Cystoscopy with TURBT (Transurethral Resection of Bladder Tumor)
Bladder tumor, [papillary / sessile / solid], [X] cm at [lateral / posterior / trigone / dome] wall, noted on [CT urogram / office cystoscopy]
Same
Cystoscopy with transurethral resection of bladder tumor (TURBT), [monopolar / bipolar] technique [with fulguration]
[***, MD/DO]
[Nurse/tech name]
General endotracheal [/ spinal / MAC]
The patient is a [age]-year-old [male / female] with a [X]-cm bladder tumor identified on [hematuria workup / surveillance cystoscopy]. CT urogram confirmed the lesion without upper tract abnormality. TURBT was planned for diagnostic and therapeutic resection. Risks including bleeding, bladder perforation, ureteral injury, and anesthesia risks discussed. Informed consent obtained.
Cystoscopic examination demonstrated a [X]-cm [papillary / broad-based / solid] tumor at the [lateral / posterior / dome / left / right] wall [at X o'clock position, X cm from the right / left ureteral orifice]. The remainder of the bladder was [normal / with X additional small papillary lesions at (locations)]. The ureteral orifices were [bilateral normal position / uninvolved / right orifice adjacent to tumor — stent placed]. No carcinoma in situ (CIS) was apparent [/ suspicious flat erythematous areas were biopsied at (locations)].
The patient was positioned in the dorsal lithotomy position. The genitalia were prepped and draped. A [26-Fr] rigid cystoscope was introduced transurethrally. A complete cystoscopic survey of the bladder was performed: all walls, trigone, dome, ureteral orifices, and bladder neck examined.
The tumor was identified at [location]. A [26-Fr] resectoscope with [monopolar cutting loop and glycine 1.5% irrigation / bipolar loop and normal saline irrigation] was introduced. [For a lateral-wall tumor, full neuromuscular blockade was confirmed with anesthesia (and an obturator nerve block was placed) prior to resection to prevent the obturator reflex.] The tumor was resected systematically from the exophytic top to the base, including [3-5]-mm margins of normal-appearing mucosa. The base was resected separately to include detrusor muscle for staging.
Specimens were sent separately: exophytic portion labeled "[location] exophytic" and base with muscle labeled "[location] base with muscle — separate specimen for staging." Hemostasis was achieved with the [coagulating loop]. [Additional cold-cup biopsies were taken from [locations] for CIS mapping and sent labeled by location.]
[The right / left ureteral orifice was adjacent to the resection — a Double-J ureteral stent was placed for protection.]
A [20 Fr] 3-way urethral catheter was placed for continuous bladder irrigation. The bladder was irrigated with [glycine 1.5% (monopolar) / normal saline (bipolar)] until the effluent was clear.
None
Bladder tumor, exophytic portion, [location]: pathology (SEPARATE)
Bladder tumor base with detrusor muscle, [location]: pathology (SEPARATE — required for staging)
[CIS mapping biopsies: labeled by location — right lateral, dome, etc.]
Minimal
[20 Fr 3-way catheter for continuous bladder irrigation]
The patient was taken to the PACU in stable condition. Continuous bladder irrigation was maintained until the effluent cleared. [Single-dose intravesical [mitomycin C 40 mg / gemcitabine 2 g] was instilled within [X] hours of surgery for low- to intermediate-risk NMIBC per AUA guideline — administered after confirming no perforation occurred.] Pathology results to guide adjuvant intravesical therapy.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Bladder tumor, *** cm at ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cystoscopy with TURBT, [monopolar / bipolar]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm bladder tumor on ***. TURBT planned for diagnosis/treatment. Consent obtained.
FINDINGS: *** cm *** tumor at *** wall/o'clock position, *** cm from ureteral orifice. Remainder of bladder ***. Ureteral orifices ***.
PROCEDURE:
Dorsal lithotomy. Genitalia prepped. 26 Fr cystoscope. Complete survey: findings above. Resectoscope introduced [monopolar/glycine / bipolar/saline]. Tumor resected top to base, *** mm margins, muscle included in base. Specimens sent SEPARATELY: exophytic portion (*** location) and base with muscle (*** location). Hemostasis coagulating loop. [CIS mapping biopsies: ***.] [DJ stent placed right/left ureter.] 3-way catheter *** Fr for CBI, irrigated until clear. [MMC/gemcitabine instilled *** mg, *** hrs post-resection.]
EBL: Minimal
SPECIMENS: Exophytic tumor and base with muscle, separately labeled, to pathology
COMPLICATIONS: None
DISPOSITION: PACU, CBI until clear. [Intravesical agent instilled.] Pathology to guide further treatment.
Signed: .ME, .MYDEGREE
.TODAYVariants
Blue light cystoscopy / photodynamic diagnosis
Cysview (hexaminolevulinate 100 mg) instilled intravesically 1 hour before the procedure per protocol. Cystoscopy performed first under white light then blue light fluorescence. Under blue light, additional [flat CIS lesions / satellite lesions] were identified not visible under white light and were resected/biopsied. Blue-light cystoscopy improves CIS detection over white light alone and is recommended by AUA for initial staging TURBT and high-risk surveillance.
Re-TURBT (restaging resection)
Perform within 6 weeks for T1 disease, high-grade Ta, or when detrusor muscle was absent from the initial specimen (AUA guideline, strong recommendation). Document that this is a restaging resection, the result of the prior pathology, and that the goal is to confirm depth of invasion and completeness of resection. 0-day global on all TURBT codes — no modifier needed for the repeat procedure. If upstaged to muscle-invasive disease (T2+), document and initiate pathway for radical cystectomy vs. chemoradiation discussion.
En bloc TURBT (ERBT)
En bloc resection of the tumor using monopolar/bipolar loop, thulium laser, holmium laser, or water-jet — preserves tumor architecture and lamina propria orientation for better pathologic staging assessment compared to piecemeal resection. Particularly useful for small-medium papillary tumors (typically <3 cm). Document approach and that the specimen was submitted en bloc for improved T-staging accuracy.
Tumor near ureteral orifice
Resect tumor at or adjacent to the ureteral orifice with pure cutting current and avoid coagulation/fulguration over the orifice, which causes stricture. Cold-cup biopsy is appropriate when only sampling is needed. Prophylactic stenting for orifice protection during TURBT is generally bundled. Monitor with post-op retrograde pyelogram or renal US if stent placed.
Charting Tips
- Obturator reflex on lateral-wall resection: electrocautery near the lateral wall can stimulate the obturator nerve, causing a sudden adductor jerk and bladder perforation. Mitigate with general anesthesia plus full neuromuscular blockade, or an obturator nerve block; keeping the bladder partially filled and using short resection bursts also helps. Document the strategy used for any lateral-wall tumor.
- Send the base specimen SEPARATELY from the exophytic specimen. Staging requires detrusor muscle (muscularis propria) in the base sample — a combined specimen may prevent the pathologist from determining invasion depth. Label each specimen by anatomic location and document 'base with muscle submitted as separate specimen' in the operative note.
- Document tumor location by clock face and distance from the ureteral orifice. Tumors within 1 cm of the orifice alter management and should be documented: 'tumor located [X] cm from the [right / left] ureteral orifice.'
- Document irrigation fluid used. Monopolar resectoscope requires non-conducting electrolyte-free solution (glycine 1.5%, sorbitol, or mannitol). Bipolar resectoscope uses normal saline. Document explicitly — this is relevant if TUR syndrome is suspected postoperatively.
- Document intravesical instillation timing and agent. AUA 2024 guideline recommends single-dose intravesical chemotherapy (MMC 40 mg or gemcitabine 2 g) within 24 hours for low- and intermediate-risk NMIBC. Document the time from TURBT to instillation, dose, and that no perforation occurred. Contraindicated with confirmed or suspected bladder perforation.
- Document depth of resection and completeness. State whether the base included visually confirmed detrusor muscle, whether resection appeared complete, and whether any areas of concern for perforation were noted. Bladder perforation must be documented — extraperitoneal perforations are typically managed with catheter drainage alone; intraperitoneal perforations require operative repair and preclude intravesical instillation.
Documentation & Reimbursement Considerations
- Report Cystoscopy with TURBT (Transurethral Resection of Bladder Tumor) as the primary service when it is the definitive operation performed.
- The 0.5 cm lower bound matters — fulguration of tiny papillary lesions <0.5 cm is integral to diagnostic cystoscopy and not separately billable. Document the largest tumor dimension explicitly in the operative note.
- Multiple tumors: for Medicare, bill the code corresponding to the single largest individual tumor — smaller tumors do not aggregate to a higher tier. Many commercial payers allow aggregate sizing (sum of multiple tumor dimensions); verify with payer before submitting aggregate claims.
- The biopsy site must be clinically distinct, not simply the resection margin.
- Global period is 0 days for all TURBT codes. There is no post-procedure global; follow-up cystoscopies and office visits are separately billable from the date of service.
- The drug is instilled intravesically 1 hour before the procedure.
- Intravesical mitomycin C (MMC) or gemcitabine instillation: administer within 24 hours of TURBT for low- and intermediate-risk NMIBC per 2024 AUA/SUO guideline. Contraindicated if bladder perforation occurred, if extensive resection was performed, or if gross hematuria is present. The drug administration generates a separate pharmacy/nursing charge but does not add a separately billable surgical reporting options for the surgeon.
- Re-TURBT within 6 weeks is a strong AUA guideline recommendation for T1 disease, high-grade Ta, or when detrusor muscle is absent from the initial specimen.