(TURBT)

TRANSURETHRAL RESECTION OF
BLADDER TUMOR
Prepared by:

Bolibol, Renz Marion

Cruzado, Jomark
Gamaro, Windelyn
Lopez, Hera
Maghirang, Claudine Mae
Introduction
The bladder tumor is most common in
people older than 55 years of age that
more in men than women. It can be
cancerous or not. In this TURBT is done
to facilitate removal of the mass to avoid
malignancy or for biopsy purposes. We
choose the procedure because it is new
for us so that we could gain knowledge
about the procedure and the process it
will take.
ANATOMY AND
PHYSIOLOGY
Introduction to the urinary
system

 The urinary system consists of all the

organs involved in the formation and
release of urine. It includes the kidneys,
ureters, bladder and urethra.
 Kidneys and Ureters

 The kidneys are large,

bean-shaped organs
towards the back of
the abdomen (belly).
They lie behind a
protective sheet of
tissue within the
abdomen. It help the
body produce urine
to get rid of unwanted
waste substances. .
 The kidneys regulate the amount of
water in the body. Humans produce
about 1.5 litres of urine a day.
 The kidneys also produce renin (a
hormone important in regulating blood
pressure) and erythropoietin (helps
produce red blood cells).
Bladder

 The bladder is a
pyramid-shaped organ
which sits in the pelvis
(the bony structure
which helps form the
hips). The main
function of the bladder
is to store urine and,
under the appropriate
signals, release it into a
tube which carries the
urine out of the body
Urethra

 The male urethra is

18–20 cm long, running
from the bladder to
the tip of the penis.
The female urethra is
supplied by the inferior
vesical and middle
rectal arteries. The
veins follow these
blood vessels. The
nerve supply is via the
pudendal nerve.
Appearance of the obstructed water passage due to
bladder tumor
How do the kidneys and urinary
system work?
 The body takes nutrients from food and converts them to
energy. After the body has taken the food that it needs, waste
products are left behind in the bowel and in the blood.
 The kidney and urinary systems keep chemicals, such as
potassium and sodium, and water in balance and remove a
type of waste, called urea, from the blood. Urea is produced
when foods containing protein, such as meat, poultry, and
certain vegetables, are broken down in the body. Urea is
carried in the bloodstream to the kidneys, where it
is removed.
 Other important functions of the kidneys include blood
pressure regulation and the production of erythropoietin,
which controls red blood cell production in the bone
marrow.
 CLINICAL
DISCUSSION
Bladder tumor
 Bladder tumors
usually arise at the
base of the bladder
and involve the
ureteral orifices and
bladder neck.Visible,
painless hematuria is
the most common
symptom.
Definition

 Transurethral resection is the piecemeal

removal of prostatic tissue and/or lesions
of the bladder or bladder neck
transcystoscopically
Sign & symptoms
 Hematuria
 Dysuria
 Frequent urination
Risk factors
 Increasing age  Previous cancer
 Being white treatment
 Being a man  Chronic bladder

 Smoking inflammation
 Personal or family
 Exposure to certain
chemicals history of cancer
Diagnostic tests
 Cystoscopy
 Biopsy
 Urine cytology
 Imaging tests
Prevention
 Don’t smoke
 Take caution with chemicals
 Drink water throughout the day
 Choose a variety of fruits and vegetables.
PATHOPHYSIOLOGY
Bolib’s Great PATHOPHYSIOLOGY

Non
Modifiable:
modifiable
- Lifestyle:
factors: Preexisting
smoking, does
•Age (77) condition:
not urinate
•Gender Chronic
even urge is
(Male) bladder
felt.
inflammation
↓
↓
Causing
muscle to
↓

Urine stay in contract

the bladder

Increase in
muscle size.
(Hypertrophy)
PATHOPHYSIOLOGY (CONTINUATION)

Obstructs the
outflow of
urine.
Microorganism will colonize
the bladder.
↓ (The patient can possibly
develop UTI if not treated)

Urinary retention as
manifested by patient:
Hematuria
dysuria
Normal urine flow. Urine flow with bladder tumor.
 Surgical
preparation
DEFINITION WHAT IS
TURBT?

TURBT (Transurethral Resection of Bladder

Tumor)

• Transurethral Resection of Bladder Tumor is a

relatively straightforward operation to remove a
tumor from the bladder. It is done using a
telescope that is passed along the urethra
(water pipe), so there are no incisions or cuts
on the body.
DESCRIPTION OF THE PROCEDURE

There is NO
external
Incision.

•The surgeon
reaches the
prostate by
inserting an
instrument
through the
urethra.
Discussion
 The procedure is performed when the
patient is a poor surgical risk, thereby
eliminating the need for open
prostatectomy. In the immediate hours
after the procedure, there is often blood
left over from the procedure that
inevitably will color the urine bright red.
Also, small clots may be produced and
evacuated in this time period. Usually this
bleeding will clear in 1-2 days
Procedure
 The urethra may be dilated.
 Cystoscopy is performed to assess the hypertrophy and inspecting the
bladder.
 The resectoscope complete with sheath and obturator is passed.
 The irrigation tubing, fiberoptic light cord, and cautery cable are
connected.
 The obturator is removed and the operating element with the
fofroblique telescope and cutting loop is inserted through the sheath.
 The bladder is continuously irrigated.
 The urethra and bladder trigone are examined.
 Electrodissection is employed to remove pieces of prostatic
hypertrophied tissue.
 At intervals the fragments of tissue is desired. When resection is
complete, the bladder and prostatic fossa are examined for residual
unattached fragments of tissue.
 Adequate hemostasis is ensured, and the resectoscope sheath is
removed. A foley catheter with 30 ml bag is inserted into the bladder,
filled with 5 to 10ml of fluid, and then drawn into the prostatic fossa
where an additional 12 to 25 ml of fluids is introduced to provide
additional hemostasis
How is it done?

 The tumors can be

removed through a
probe passed up
through a
cystoscope. The
tumors are then
removed through the
cystoscope and sent
for microscopic
exam.
TURBT
 During surgery, a Foley catheter is placed in
your bladder to drain the urine. After
surgery, your urine may be bloody and there
may be some clots in it. Continuous bladder
irrigation (CBI) may be needed to clear your
urine if you have a lot of clots. With CBI, a
special Foley catheter is used to irrigate or
flush the bladder continuously while your
urine and the CBI fluid empty into a drainage
bag.
CONTRAINDICATION
•Unstable cardiopulmonary status and history of
uncorrectable bleeding disorders.
•Patient with recent myocardial infarction or
coronary artery stent replacement must no have
elective TURP surgery for at least one month
because of increase risk of cardiovascular events and
other complications. A reasonable minimum delay
for 3 months is suggested but 6 months is still
optimal.
•Patient with myasthenia gravis, multiple sclerosis
and Parkinsonism have their external sphincter
dysfunctional, it can cause intractable continence.
INSTRUMENTS NEEDED IN
TURP
CYSTOSCOPE
It is the instrument inserted
through the urethra
in order to visualize the bladder
and the prostate.

RESECTOSCOPE
It is the instrument inserted to the
cystoscope.
It consists of a loop at the distal
portion which is
being used in resecting tumors.
CYSTOSCOPY
Is the use of a scope
(cystoscope) to examine the
bladder. This is done either to
look at the bladder for
abnormalities or to help with
surgery being performed on
the inside of the urinary
tractA (transurethral surgery).
 AREAS THAT CAN BE
EXAMINED:

•Urethra or urinary channel,

which includes the prostate
in men
•Bladder, which collects and
stores urine
•The 2 ureters, which are
small internal tubes that
conduct the urine made by
each kidney into the bladder.
PREPARATION FOR
CYSTOSCOPY

•NPO after midnight, the

evening before the
surgery.
•For procedures being
done with only a local
anesthetic, no fasting
requirement is necessary.
• Notify your doctor if
patient is taking any
blood thinners, including
warfarin (Coumadin),
aspirin, and ibuprofen
CYSTOCLYSIS
•Post operatively the patient will be inserted three way
catheter for urination and bladder drainage. Distilled
water will be used as irrigating solution to the
patient’s bladder. The purpose is to wash out the blood
and wastes that have been accumulated during the
procedure.
POSITION
• The patient is positioned with the buttocks flush with
the end of the cystoscopy table.
•LITHOTOMY is suggested position for better
exposure of the organ.
•TRENDELENBURG can also be used.
ANESTHESIA
SPINAL ANESTHESIA
It is a type of extensive conduction nerve block that is produced
when local anesthetic is introduced into the subarachnoid space t
the lumbar level, usually between L4 and L5. It produces
anesthesia of the lower extremities, perineum, and lower
abdomen. For the lumbar puncture procedure the patient usually
lies on his side in a knee-chest position. Sterile technique is used
as a spinal puncture is made and medication is injected through
needle. As soon as the injection has made, the patient is
positioned on his/her back. If a relatively high level of block is
sought, the head and shoulders are lowered.
 ANESTHESIA

The spread of anesthetic agents depend on:

•Amount of fluid injected
•Speed with which it is injected
•Positioning the patient after injection
•Specific gravity of the agent-
if greater than CSF, it will go to
dependent position if lower than
CSF it will move away from the
dependent part.
ANESTHESIA

ANESTHETIC AGENTS can be:

•Procaine (Pontacaine)
•Lidocaine (Xylocaine)
•Bupivacaine (Marcaine)

COMPLICATIONS
•Spinal headache- leakage of CSF in the injection
site.
•Hypotension- anesthesia acts on the
parasympathetic nervous system which stimulate
relaxation of smooth muscles.
 Biographic data
 Case no: 6828
 Patient’s name: Patient P
 Add: Brgy. Soledad San Pablo City Laguna
 Age: 77 years old
 Gender: Male
 Date of birth: December 20, 1934
 Religion: Catholic
 Nationality: Filipino
Nursing Health History
 Date of Admission: November 9, 2012
 Time: 10:15am
 Admitting Physician: Dra. Maghirang
 Attending Physician: Dr. Ernesto Valdez
 C/C: Dysuria
 Admitting Impression: R/O urolithiasis
 Operation: cystoscopy, transurethral
resection of bladder
tumor, transurethral
incision of prostate
VITAL SIGNS UPON ADMISSION

BP: 130/80mmHg
PR: 66bpm
RR: 20bpm
Temp: 36.4 C
O2 Sat: 99%
PHYSICAL
ASSESSMENT
 General Appearance: Lethargic due to
sedative and anesthetics administered
 Skin: dry, sagging and scaly all over
 Head: normocephalic, thinning hair and a bit
dry scalp
◦ Eyes: anicteric sclera, pinkish conjunctiva, no
abnormal discharges seen
◦ Ears: no discharges, prior to induction of
anesthesia the patient is able to hear what is being
said and responds correctly
◦ Nose: no obstruction, with O2 via nasal cannula at
2-3L/min
◦ Mouth: dry lips, pinkish mucosa, tongue at midline
 Neck: non-palpable lymph nodes, good
ROM: pt. is able to turn his head from side
to side
 Thorax and Lungs: symmetrical lung
expansion, no adventitious breath sounds
heard, RR: 20bpm
 Abdomen: flabby, no tenderness noted
 Upper Extremities: no contractures,
arms are restrained
 Lower Extremities: legs are in lithotomy
position, swollen scrotum
GORDON’S
FUNCTIONAL HEALTH
PATTERN
 Health PerceptionPattern – the client was informed by
the attending physician prior to the procedure regarding his
condition and was offered the option of undergoing TURBT
in which the client agreed to undergo.
 Nutrition/ MetabolicPattern – prior to manifestation of
signs and symptoms the patient’s usual diet includes meat
and fruits but he had fewer intakes of vegetables. After the
procedure the attending physician instructed the patient to
avoid consumption of food high in sodium.
 EliminationPattern – dysuria and oliguria were the
primary signs presented by the client and it was due to the
intense pain that was felt by the client that the relatives
decided to bring the client to the hospital. The patient had
passed a stool once the day after the procedure (dark
colored stool); Post op urine output: 800 cc (with foley
catheter)
 Activity/Exercise Pattern – The client
reported that his only activity prior to
hospitalization was “pamamakyaw ng
lansones.” After the procedure the patient was
confined to bed for convalescence.
 Sleep/Rest Pattern – Sleeping pattern of
patient was normal being that the client was
able to sleep for 6-8 hours but during
hospitalization the client complained of not
being able to sleep continuously unlike before.
 Self-Perception Pattern – the client’s self-
esteem doesn’t seem to fazed by his condition
as he often smiled at us during the interview
and he doesn’t show any embarrassment with
the tube hooked on his private area.
 Cognitive/Perceptual Pattern – the client
has intact sensorium and responds coherently
to questions.
 Role/Relationship – the client has one
daughter and a grandchild staying with him and
his wife while the rest of his six other children
live away from them but maintains
communication with them
 Sexuality/ Reproductive Pattern – The
client and his wife had 7 off springs and the
client is no longer sexually active. At the
moment he has cystoclysis for irrigation and a
foley catheter.
 Coping/Stress Pattern– during the
operation the patient seemed anxious but
while he was resting in the ward he seemed
more at ease.
 Values/Belief – during the interview the
client told the student nurses that he is a
catholic. He said that he did believe in
‘albularyo’ and he was a bit upset that they
didn’t consult one before they went to the
hospital.
Laboratory
LABORATORY
FINDINGS
Results
Ultrasound of the kidneys, urinary
bladder and prostate
(November 9, 2012)
Impression:
Benign Prostatic Hypertrophy, isoechoic
mass, lesion on base of urinary bladder,
neoplastic process is highly entertained.
Normal ultrasound of the kidneys non
dilated proximal ureters.
DRUG STUDY
PRE MEDS
GENERIC NAME BRAND NAME CLASSIFICATION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING
RESPOSIBILITIES

Nalbuphine Nubain Analgesics Relief of Hypersensitivity Sedation, -Reasses

HCL (opiods) moderate to to nalbuphine infrequently patients level of
severe pain. HCL or to any sweating, GI pain at least 15-
Pre op analgesia ingredient in upsets, vertigo,
30 minutes
as a supplement nubain. dizziness, dry
to balances mouth, after
anesth, surgical headache parenteral used
anesth allergic
reactions -Monitor
patients vital
signs

-Assess patient
for any allergic

-Check the
patency of the
IV line.
GENERIC NAME BRAND NAME CLASSIFICATION INDICATION CONTRAINDICATION ADVERSE NURSING
EFFECT RESPOSIBILITIES

Midazolam Dormicum Anxiolytics Sedation in pre Premature Rarely Check for any
med before infants. cardio allergic
surgical or Myasthenia gravis Resp reactions
diagnostic adverse
procedures, events,
induction and nausea Monitor Vital
maintenance of vomiting Signs
anesth. Headache
Hiccough Provide safety
Oversedation by putting up
, drowsiness side rails.
Rash,
amnesia
episodes.
GENERIC BRAND CLASSIFIC INDICATION CONTRAIND ADVERS DOSE/R AVAILABLE NURSING
NAME NAME ATION ICATION E EFFECT OUTE FORMS RESPOSIBI
LITIES
LEVOFLOXACI Levaquin QUINOLONE Treatment Pregnancy GI 500mg Tablets -Ensure
N S of wide and disturban BID 250,500,750 adequate
range of lactation ces, mg; fluid intake.
infection including Solution, oral 25 -Stop using
including N/V, mg/mL; this
lower diarrhea, Injection medicine
respiratory abdomina (concentrate) immediately
tract l pain and 500 mg (25 if you
infections, dyspnea mg/mL), 750 notice signs
typhoid mg (25 mg/mL); of an
fever, Injection allergic
parathyroid (premix) 250 reaction.
fever and mg (5 mg/mL), -Monitor
UTI 500 mg (5 Vital Signs
mg/mL), 750
mg (5 mg/mL).
MEDICATION DURING
OPERATION
Generic Brand Classifica Action Indication Contrai Adverse Available Nursig
tion ndicatio Reaction forms considera
n tion

Bupivacaine Sensorcaine Anesthetic Inhibit Prior to Hyperse Seizures, Solution Asses for
initiation and surgical nsitivity headache, for inj: systemic
conduction procedure irritability 0.25% toxicity.
of sensory anesthesia bradycard 0.5%,
nerve is given. ia, 0.75%rx Monitor
impulses by hypotensi epinephrin vital signs.
altering the on, e rx.
influx of urinary Put up side
sodium and retention, rails
efflux of pruritus,
potassium. numbness Restraint
, allergic the patient.
reaction,
fever.
Generic Brand Classificatio Indication Contraindic Adverse Nursing
Name Name n ation Reaction Consideratio
n

Diclofenac Voltaren NSAIDs Painful post traumatic and Gastric or Occasional Monitor Vital
Na post op inflammation intestinal GI disorders, Signs
Treatment and prevention of ulcer known headache,
post op pain in the hospital hypersensiti dizziness, Provide
setting. vity to Na vertigo safety by
metabisulphi rash, putting up
te or other Rare: side rails
excipients. GI bleeding,
disturbance
s of
sensation
and vision
NURSING CARE
PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
s
Objective: Risk for injury After series of Before the Before the Patient was
-Sedated related to nursing procedure: procedure: free from
Provide a safe Provided a safe
-Age: 77 years positioning. intervention environment environment
injury when
the patient for the patient for the patient positioning.
will be free by: by: Goal met.
from injury
during Identify To promote safe
interventions physical
positioning. and safety environment and
devices. individual safety.

Place patient on To lessen anxiety

a comfortable
position.
To monitor the
Assist in taking status and the
vital signs before, response of the
during and after client’s body
the operation. towards the
procedure

Check patient To prevent

for impeded damage to
vascular supply extremity and
of lower promote blood
extremities. circulation
Assessment Diagnosis Planning Interventions Rationale Evaluation
Objective: Risk for injury After series Restrain the So the needle Patient was
-Sedated related to of nursing patient’s will not free from
-Age: 77 years positioning. interventio extremity unto accidentally injury when
n the which IV is harm the positioning.
patient will attached. patient. Goal met.
be free
from injury Remove To promote
during identified safety
positioning. electrical
hazards.

During the
procedure:

Lift both legs at To avoid

the same time injury on the
when positioning ligaments
patient in
lithotomy
position.
Assessment Diagnosis Planning Intervention Rationale Evaluation
s
Objective: Risk for injury After series of Check patient’s To assure the Patient was
-Sedated related to nursing position from patient is safe free from
time to time. and comfortable
-Age: 77 years positioning. intervention injury when
the patient After the positioning.
will be free procedure: Goal met.
from injury
during Lift both legs To prevent
from the stirrups damage to
positioning. and straighten ligament
them at the same
time.

While To prevent
transferring undue fall
patient to the
stretcher have
two or more
nurses assisting
when lifting.
NCP 2
Discharge plan
Postoperative Patient teaching
 Drink plenty of fluids, 10 – 12 (8-oz.) glasses per day.
 Take your pain medicine as prescribed, when needed.
 Get plenty of rest.
 Avoid letting your bladder get too full as this would
increase the pressure in your bladder and make you
bleed more.
 Avoid straining and constipation; increased pressure
can cause more bleeding. You can prevent
constipation by drinking fluids and adding fruit and
vegetables to your diet. Stool softeners or a mild
laxative may be prescribed by your doctor.
Activity restrictions

During the first week at home

 Do not lift anything weighing more than 5
to 10 lbs.
 No strenuous activities (i.e. aerobics,
jogging, swimming).
 Limit stair climbing to 1-2 times per day.
 No sexual activity.
 Do not drive until OK with your doctor.
During the second week at home
 You may slowly increase your activity, but rest
when you get tired.
 Do not overexert yourself.
 You may resume sexual activity after the second
week.
 You may drive if you are not taking prescription
pain medicine and if it is OK with your doctor.

 You may return to work during the third week or

when your doctor allows.
When to call your doctor

 You cannot pass urine.

 Your urine becomes so bloody that you
cannot see through it.
 You have clots in your urine.
 You have increased pain in your abdomen.
 Your fever is over 100.5° F (orally) for
two readings taken 4 hours apart.
 You have severe burning, pain, and
irritation with urination.
END