Open Journal of Urology, 2013, 3, 253-255 Published Online October 2013 (
Tips for Office-Based Transurethral Biopsy and
Fulguration as a Treatment of Tiny Bladder Tumors*
Teiichiro Aoyagi1#, Isao Kuroda1, Masaaki Tachibana2
1Tokyo Medical University, Ibaraki Medical Center, Inashiki, Japan
2Toky o Medical University, T o kyo, Japan
Received August 8, 2013; revised September 6, 2013; accepted September 14, 2013
Copyright © 2013 Teiichiro Aoyagi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Among the patients who underwent outpatient cystoscopy as a follow up of bladder cancer, quite a few patients are ob-
served tiny papillary lesions suspicious for tumor recurrence. Tran surethral biop sy and/or resection under spinal or gen-
eral anesthesia in a hospitalized setting are the usual procedures for th is kind of patients, even thou gh these procedures
are simple and brief. We tried transurethral biopsy and fulguration as a treatment for very small bladder tumor in an
outpatient setting and here describe tips for these procedures. Olympus CYF-VA flexible cystoscope, a 3 Fr. diathermy
probe, monopolar electrosurgical unit were used. No additional anesthetics except for 10 ml of 2% Xylocaine gel ap-
plied to (male patient’s) urethra as an initial flexible cystoscopic procedure, was required for tumor treatment. Distilled
water was used as an irrigation fluid. Experienced tips of the procedures to avoid tumor recurrence are as follows: tu-
mor should be one location, size of the tumor should be less than 5 mm, bladder should be washed several times after
the fulguration with hundreds ml of distilled water. We conclud e that outpatient biopsy and fulguration for tiny bladder
tumor is effective and less invasive procedure as a treatment of bladder cancer patients.
Keywords: Transurethral Surgery; Bladder Cancer; Office Urology; Fulguration; Biopsy
1. Introduction
Office-based cystoscopic examination is a usual estab-
lished method as an initial and postoperative surveillance
of bladder tumor [1]. During the follow up period, small,
low grade and superficial bladder tumor recurs in quite a
few patients [2]. Although experience and efficacy of
office-based fulguration for low grade papillary lesions
has been reported previously, this procedure does not
performed routinely in the clinical practice, presumably
because there is no precise explanation on actual meth-
odology and safety [3-5]. However, considering increas-
ing comorbidities, use of anti-coagulation medication,
economic restriction and so on, ambulatory treatment for
these lesions should be beneficial both for patients and
surgeons [6]. Here, we present the tips of ambulatory
biopsy and fulguration treatment for tiny bladder papil-
lary lesions with some improvements after experiences of
failure cases.
2. Patients and Methods
Fourteen patients, 19 procedures were enrolled in this
report. The patient profiles are listed in the Table 1. All
the patients had the history of transurethral resection
(TUR) or nephroureterectomy surgery under spinal or
general anesthesia previously, and followed with repeat
surveillance flexible cystoscopy in an outpatient setting.
Safety to use diathermia for these patients was confirmed
by previous surgery, and informed consent on the treat-
ment of ambulatory procedures was made by patient’s
signature. This report does not violate ethical standards
of the Declaration of Helsinki and its revisions. No addi-
tional anesthetics except for 10 ml of 2% Xylocaine gel
applied to (male patient’s) urethra as an initial flexible
cystoscopic procedure, was required for tumor treatment.
Olympus (Tokyo, Japan) CYF-VA flexible cystoscope
and Versa Pro unit, Takei (Tokyo Japan) monopolar
electrosurgical unit B-1, Olympus flexible biopsy forceps
and 3 Fr. Takei Bugbee ureteroscope electrode were used.
Normal saline was used for observation, and distilled
water was used for treatment as irrigation fluid (Figure
*The authors declare that they have no conflict of interests, no funds
and no grant on thi s project.
#Corresponding author.
opyright © 2013 SciRes. OJU
Table 1. Patient profiles and results.
Pt Age Previous TUR Tumor Pathoogy Result Comment
1 71 6 m Dome 1 trigonum 3 UC G1 3 m relapse Treated with re-TUR
72 1 y Dome 1 UC G1 4 y free
2 82 Primary Trigonum 3 UC G1 4 m relapse Treated with office-based re-TUF
82 4 m Near left orifice 1 UC G1 4 y free
3 77 3 m Trigonum 1 UC G2 3 m relapse Treated with office-based re-TUF
78 3 m Bladder neck 1 9 m relapse Treated with re-TUR
79 7 m Trigonum 1 10 m relapse Treated with office-bas ed re-TUF
80 10 m Trigonum 1 6 m free Severe Alzheimer disease
4 60 8 y Dome 1cm × 2 UC G2 5 m relapse HD patient, Treated with re-TUR
5 83 6 m Left orifice 1 UC G2 2 m relapse Other location treated with re-TUR
6 80 6 m Left wall 1 UC G1 5 m relapse Other location tre ated with re-TUR
7 62 3 m Left wall 1 3 m relapse Other location treated with re- TUR
8 76 3 y Right wall 1 UC G1 4 y free
9 71 1 y Bladder neck 1 UC G1 > G2 4y free
10 66 2 y Anterior wall 1 2 y free
11 81 2 y Trigonum 1 2 y free
12 68 6 m Bladder neck 1 UC G2 7 m free
13 71 1 y Anterior wall 1 6 m free
14 69 16 m Bladder nec k 1 UC G1 2.5 y free Post nephroureterectomy
m: month, y: year, re-TUR: Transurethral resec ti on of bladder tumor after adm i s sion, HD: hemodialysis, UC: urothelial carcinoma.
Figure 1. Examples of biopsy and TUF (#2 patient, second procedure of biopsy and TUF, (a), (b), (c), (d). Cystoscopy after 12
months showed no recurrence, (e)).
3. Experiences
The first patient (Pt #1) had recurrent small tumor around
the fulgurated tiny tumors after 3 months, presumably
due to multiplicity of tumors and insufficient irrigation
after treatment. Second patient, had maintenance hemo-
dialysis (Pt #4), also recurred probably because the tumor
was too big (about 1 cm × 2) to treat in this setting. So in
treating the following case, we indicated this procedure
for a sole papillary lesion. In addition, after the fulgura-
tion, wash the bladder enough for several times until all
fulgurated white debris were completely cleaned out,
because living tumor cells might still exist in the debris.
As shown in the Table 1, although some patients re-
curred at other location, many of the treated patients
showed tumor free for more than 6 months in the treated
area. Patient #3 suffered severe Alzheimer disease, and
though tumor recurred several times, office-based treat-
ment was beneficial for both patient’s family and sur-
geon as much.
4. Conclusion and Tips
Office-based biopsy and fulguration for tiny bladder tu-
mor is thought to be effective and less invasive procedure
as a treatment of bladder cancer patients. Tips of the
successful transurethral biopsy and fulguration for tiny
bladder tumor are as follows: 1) sole lesion; 2) less than
5 mm in size; 3) wash bladder enough after the procedure
with distilled water.
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