A transurethral resection of bladder tumour, almost always referred to by its acronym TURBT, is both the most common procedure used to diagnose bladder cancer and, for many patients, the first step in treating it. After a TURBT, the tissue removed is sent to a pathology laboratory, where a pathologist examines it under the microscope and writes a report describing what was found. This report contains critical information that your medical team will use to determine the type, grade, and stage of any cancer present, and to plan your next steps.
TURBT reports can be confusing because they contain many technical terms and include findings that affect management in important ways. This article explains what a TURBT is, how the pathology laboratory processes the tissue, and what each part of your report means.
The bladder and its lining
The bladder is a hollow, muscular organ in the lower abdomen that stores urine produced by the kidneys. Urine travels from the kidneys through two ureters into the bladder, where it is stored until urination. Urine then passes through the urethra — a tube leading out of the body — to be expelled.
The inner surface of the bladder is lined by a specialized layer of cells called urothelial cells, which together form the urothelium. The urothelium is uniquely designed to stretch as the bladder fills and to form a tight barrier that prevents urine from leaking into the surrounding tissue.
Beneath the urothelium, the bladder wall is made up of several distinct layers, each of which plays an important role in the pathology report:
- The lamina propria. A thin layer of connective tissue lies just beneath the urothelium. It contains small blood vessels, lymphatic channels, and scattered muscle fibers called the muscularis mucosae. When cancer spreads into the lamina propria, it is classified as T1 disease.
- The muscularis propria (detrusor muscle). A thick layer of muscle that makes up the main wall of the bladder. Contraction of this muscle causes the bladder to empty. Whether or not cancer has reached this layer is one of the single most important questions in bladder cancer pathology, because muscle-invasive disease requires a fundamentally different treatment approach than non-muscle-invasive disease.
- The perivesical fat. The fatty tissue surrounding the outer surface of the bladder. Cancer extending into this layer represents advanced local disease.
What is a TURBT?
A transurethral resection of bladder tumour is a surgical procedure performed by a urologist. It is done through the urethra, which means no cuts are made in the skin. While you are under anesthesia, the urologist inserts a thin instrument called a cystoscope — a tube with a camera and light at the tip — through the urethra and into the bladder. The urologist first examines the entire inner surface of the bladder, noting the location, size, and appearance of any abnormal areas or tumours.
The tumour or abnormal tissue is then removed using a small cutting loop that passes an electrical current through the tissue. The resected tissue falls into the bladder and is flushed out at the end of the procedure. Depending on the size, location, and appearance of the tumour, the urologist may remove the entire visible tumour or take representative samples.
A key part of the TURBT is the attempt to include tissue from the muscularis propria — the deep muscle layer — in the resection specimen. Your pathology report will specifically note whether muscularis propria was present in the submitted tissue and, if so, whether it was involved by cancer. If muscle is absent from the specimen, the pathologist cannot determine whether the tumour has invaded into the muscle, which may mean a repeat TURBT is recommended.
TURBT serves two purposes: it is a diagnostic procedure that allows pathological examination of the tumour, and it is also a therapeutic procedure that removes the tumour, providing initial treatment.
Why is a TURBT done?
Your doctor may have recommended a TURBT because of one or more of the following:
- Blood in the urine (hematuria). Blood in the urine is the most common reason bladder cancer is discovered. It may be visible to the naked eye, making the urine appear pink, red, or brown (gross hematuria), or it may only be detected on a urine test (microscopic hematuria).
- Abnormal urine cytology. Urine cytology is a test in which cells shed naturally into the urine are examined under the microscope. If abnormal or suspicious cells are found, a TURBT may be performed to find their source.
- An abnormality seen on imaging. CT scans, ultrasounds, or other imaging tests of the urinary tract may reveal a mass, thickening, or irregularity of the bladder wall that requires further investigation.
- An abnormality seen during cystoscopy. If a previous cystoscopy showed a suspicious area in the bladder, a TURBT is performed to remove and examine that tissue.
- Follow-up after previous bladder cancer. Bladder cancer has a high rate of recurrence. Patients who have had bladder cancer in the past undergo regular surveillance cystoscopies, and TURBT removes any new tumours found.
What does the pathology laboratory do with the TURBT specimen?
The tissue fragments removed during TURBT are collected and placed in a container of fixative solution, most commonly formalin, which preserves the tissue and prevents decay. The container is labelled with your identifying information and sent to the pathology laboratory.
In the laboratory, the pathologist first examines the specimen with the naked eye, recording the total amount of tissue, its colour and texture, and noting any fragments that appear papillary (frond-like), solid, or unusual. This is called the gross examination and is described in the gross description section of your report.
The tissue is then processed, embedded in paraffin wax, sliced into very thin sections, and placed on glass slides. The slides are stained with standard dyes — most commonly hematoxylin and eosin — and examined under the microscope. Additional special stains or immunohistochemistry tests may be applied if needed to clarify the diagnosis.
Because TURBT specimens are often submitted as multiple tissue fragments, the pathologist examines all fragments together to build a complete picture of the tumour. The report reflects the most significant findings across the entire specimen.
What does a TURBT pathology report contain?
TURBT reports follow a structured format that ensures all clinically important information is recorded. The following sections explain each component.
Type of tumour
The most important information in the diagnosis section is what type of tumour was found. The vast majority of bladder tumours are urothelial carcinomas — cancers arising from the urothelial cells that line the bladder. However, other tumour types can also occur and will be identified in the report. These include:
- Urothelial carcinoma (also called transitional cell carcinoma). By far the most common type, accounting for approximately 90% of bladder cancers. This is what most patients with a TURBT report.
- Squamous cell carcinoma. A less common type arising from squamous cells. It is associated with chronic bladder irritation, long-term catheter use, or infection with the parasite Schistosoma haematobium, which is more common in certain parts of Africa and the Middle East.
- Adenocarcinoma. A rare type of bladder cancer that forms gland-like structures under the microscope. It may arise from the bladder lining itself or from a structure called the urachal remnant at the top of the bladder.
- Urothelial papilloma. A benign (non-cancerous) growth of urothelial cells that forms papillary fronds. Although it looks similar to early urothelial carcinoma under the microscope, it is considered benign. Follow-up is still recommended because of a small risk of recurrence.
- Papillary urothelial neoplasm of low malignant potential (PUNLMP). A growth that resembles a papilloma but has slightly more cellular crowding. It is considered to have a very low risk of progression, but is still followed closely because it can recur.
- Inverted papilloma. A benign growth that grows inward into the bladder wall rather than outward into the bladder cavity. It is not cancerous, but is documented in the report.
Tumour grade
For urothelial carcinomas, the pathologist assigns a grade that reflects how abnormal the cancer cells look under the microscope compared to normal urothelial cells. Grade is one of the most important predictors of how a bladder tumour will behave.
The current grading system divides urothelial carcinomas into two grades:
- Low grade. The cancer cells look relatively similar to normal urothelial cells. They are arranged in an orderly way, and their nuclei (the parts of the cell that contain genetic material) are fairly uniform. Low-grade tumours tend to grow slowly and are less likely to invade the muscle wall or spread to other parts of the body. However, they tend to recur after removal, and regular follow-up is essential.
- High grade. The cancer cells look very different from normal urothelial cells. The cells and their nuclei vary significantly in size and shape, and there are often many cells in the process of dividing. High-grade tumours are more aggressive and are more likely to invade deeper layers of the bladder wall and spread to other organs. Virtually all invasive urothelial carcinomas are high-grade.
Some reports, particularly older ones or those from institutions that use a different classification system, may use a three-tier grading system (Grade 1, Grade 2, Grade 3). If your report uses this system, Grade 1 corresponds approximately to a low grade, Grade 3 to a high grade, and Grade 2 falls in between. If you are unsure which system your report uses, ask your doctor.
Non-invasive versus invasive tumour
One of the central questions every TURBT report answers is whether the tumour is non-invasive or invasive. This distinction has a profound impact on treatment decisions and prognosis.
- Non-invasive tumour. Cancer cells are confined to the urothelium and have not grown into any of the layers beneath it. Non-invasive tumours cannot spread to lymph nodes or other organs. They are classified as pTa (papillary, non-invasive) or pTis (carcinoma in situ, described separately below). Non-invasive tumours are generally managed with TURBT followed by intravesical therapy — medication instilled directly into the bladder — and close surveillance.
- Invasive tumour. Cancer cells have grown through the urothelium and into the layers beneath it. Invasive tumours have the potential to spread to lymph nodes and distant organs. The depth of invasion is described using the pT staging system.
Carcinoma in situ (CIS)
Urothelial carcinoma in situ, abbreviated as CIS and sometimes written as Tis in the staging system, is a special type of non-invasive urothelial carcinoma that deserves particular attention. Unlike papillary tumours, which grow outward into the bladder cavity as visible projections, CIS is a flat lesion. The abnormal cells replace the normal urothelium without forming a raised growth, which means CIS may not be visible during cystoscopy, or may appear only as a subtle reddening of the bladder lining.
Despite being non-invasive, CIS is always high-grade. It is considered an aggressive form of bladder cancer because of its significant risk of progressing to invasive disease if not treated. CIS requires prompt treatment, usually with a course of BCG immunotherapy instilled directly into the bladder.
CIS may appear as the only finding on a TURBT report, or it may be found alongside a papillary tumour. When CIS is found concurrently with a papillary urothelial carcinoma, it indicates a higher risk of recurrence and progression, and your urologist will factor this into treatment planning.
Pathological stage (pT)
The pT stage describes how deeply the tumour has penetrated the bladder wall. It is one of the most clinically important findings in the report. The pT stages for bladder cancer are:
- pTa — Non-invasive papillary carcinoma. The tumour grows as a papillary (frond-like) projection into the bladder cavity but is confined strictly to the urothelium. It has not grown into any layer beneath the surface. pTa disease, regardless of grade, is classified as non-muscle-invasive bladder cancer (NMIBC).
- pTis — Carcinoma in situ. A flat, high-grade tumour confined to the urothelium. Also classified as non-muscle-invasive bladder cancer. The significance and management of CIS are described in detail above.
- pT1 — Invasion of the lamina propria. Cancer cells have grown through the urothelium and into the lamina propria, the connective tissue layer lying just beneath the surface. pT1 disease is still classified as non-muscle-invasive, but it carries a higher risk of progression than pTa disease, particularly when high-grade.
- pT2 — Invasion of the muscularis propria. Cancer cells have grown into the deep muscle layer of the bladder wall. This is the critical threshold that separates non-muscle-invasive from muscle-invasive bladder cancer (MIBC). Muscle-invasive disease requires a fundamentally different treatment approach, typically involving radical cystectomy (surgical removal of the bladder) or a bladder-sparing combination of chemotherapy and radiation.
- pT3 — Invasion of the perivesical tissue. Cancer has grown through the full thickness of the bladder wall and into the fatty tissue surrounding the bladder. Note that pT3 disease is rarely staged definitively on a TURBT specimen, as resection does not usually include the outer bladder wall.
- pT4 — Invasion of adjacent structures. Cancer has spread into neighbouring structures such as the prostate, seminal vesicles, uterus, vagina, or pelvic wall. Like pT3, this stage is rarely fully assessed on a TURBT specimen.
Why the presence of muscularis propria in the specimen matters
Your pathology report will explicitly state whether muscularis propria — the deep muscle of the bladder wall — was present in the submitted tissue and, if present, whether it was involved by cancer.
This is so important that it is considered a quality indicator for TURBT. Without muscularis propria in the specimen, the pathologist cannot confirm that the tumour has not invaded the muscle. For high-grade non-invasive tumours and any tumour in which the depth of invasion is uncertain, the absence of muscularis propria typically indicates that a repeat TURBT should be performed to stage the tumour adequately before treatment decisions are made.
If your report states that the muscularis propria was present but not involved by the tumour, this is a favorable finding, indicating the cancer has not yet reached the muscle layer. If it states that the muscularis propria was present and involved by carcinoma, this confirms muscle-invasive disease and will significantly change your treatment plan.
Lymphovascular invasion
Lymphovascular invasion means that cancer cells have been found inside the thin-walled channels of blood vessels or lymphatic vessels within the bladder tissue. When cancer cells enter these channels, they gain a potential route to travel to lymph nodes and other organs.
In bladder cancer, lymphovascular invasion is associated with a higher risk of the cancer recurring, spreading to lymph nodes, and progressing to a higher stage. Its presence in a TURBT specimen is considered a high-risk feature and may influence decisions about additional treatment, such as early radical cystectomy or intensified surveillance.
Variant histology
Most urothelial carcinomas have a typical appearance under the microscope. However, in some cases, the cancer cells show a pattern that is different from standard urothelial carcinoma. These different patterns are called histological variants, and they are important to recognize because some variants are more aggressive than typical urothelial carcinoma and may require different treatment approaches.
Common variants your report may mention include:
- Squamous differentiation. Areas where the urothelial carcinoma cells look similar to squamous cells, the flat cells that line the skin, and some other body surfaces. This is the most common variant and is seen in approximately 20% of urothelial carcinomas. It is associated with a more aggressive course.
- Glandular differentiation. Areas where the cancer cells form gland-like structures. Like squamous differentiation, this is associated with more aggressive behavior.
- Micropapillary variant. Cancer cells are arranged in small, tight clusters surrounded by empty spaces. This variant is associated with a high risk of lymph node involvement and an aggressive clinical course, even when the tumour appears to be at a low stage.
- Plasmacytoid variant. Cancer cells that look similar to plasma cells, a type of immune cell. This variant is associated with an aggressive course and a tendency to spread along tissue planes, making it difficult to achieve clear surgical margins.
- Sarcomatoid variant. The cancer shows features resembling a sarcoma (a cancer of connective tissue). This is one of the most aggressive variants of urothelial carcinoma.
- Nested variant. Cancer cells are arranged in small, irregular nests that can appear deceptively bland under the microscope but are associated with significant invasion and an aggressive course.
If your report mentions a variant histology, your urologist will take this into account when discussing treatment options, as some variants warrant more aggressive initial management.
Other findings that may appear in your report
Beyond the main tumour findings, the pathologist may note other observations in the TURBT specimen:
- Inflammation (cystitis). Inflammatory cells are commonly found in bladder tissue, either as a reaction to the tumour itself or as a sign of concurrent infection or irritation. This is usually incidental and does not change cancer management.
- Reactive urothelial changes. The urothelium adjacent to a tumour or area of inflammation may show reactive changes — cellular alterations that are a response to injury rather than signs of cancer. The pathologist will distinguish reactive changes from true dysplasia or carcinoma in situ.
- Urothelial dysplasia. This describes abnormal-appearing urothelial cells that are concerning but do not meet the criteria for carcinoma in situ. The significance of dysplasia found on a TURBT specimen is that it may indicate a field of abnormal urothelium at risk of progression, warranting careful surveillance.
- Von Brunn nests and cystitis cystica. These are normal variations in bladder tissue architecture — small nests of urothelial cells that have grown into the lamina propria, sometimes forming small cysts. They are benign findings and are not a cause for concern.
- Cautery artifact. The electrical current used during TURBT can cause thermal damage to the tissue edges, making it difficult to evaluate the cells in those areas. The report may note cautery artifact in areas where assessment is limited, and this is a normal consequence of the procedure rather than a separate finding of concern.
What happens after the TURBT pathology report?
Once your urologist has reviewed the pathology report, they will discuss the findings with you and explain what they mean for your treatment and follow-up plan. The management of bladder cancer after TURBT depends primarily on three factors from the pathology report: the tumour type, the grade, and the pT stage.
Non-muscle-invasive bladder cancer (pTa, pT1, and pTis)
If the pathology report shows non-muscle-invasive disease, the TURBT itself is the primary treatment. However, because bladder cancer recurs in a significant proportion of patients — roughly half of patients with low-grade tumours and even more with high-grade tumours — additional treatment and surveillance are standard:
- Intravesical therapy. Medication is instilled directly into the bladder through a catheter, either immediately after TURBT or in a scheduled course of weekly treatments. The two most common agents are Bacillus Calmette-Guérin (BCG), an immunotherapy, and mitomycin C, a chemotherapy agent. BCG is typically used for high-grade tumours and CIS. It stimulates the immune system to attack residual cancer cells and reduces the risk of recurrence and progression.
- Surveillance cystoscopy. Regular cystoscopies are performed on a schedule determined by your urologist, typically every three months for the first year after diagnosis, then less frequently if no recurrence is detected. If a new tumour is found, it is treated with another TURBT.
- Repeat TURBT. For high-grade non-invasive tumours, or when the initial TURBT did not contain muscularis propria, a second TURBT is often recommended within four to six weeks. This is both to ensure complete resection and to more accurately stage the tumour.
Muscle-invasive bladder cancer (pT2 and above)
If the pathology report confirms muscle-invasive disease, the treatment approach changes significantly. Muscle-invasive bladder cancer carries a substantial risk of spread to lymph nodes and other organs and cannot usually be cured by TURBT alone. The standard treatment options include:
- Radical cystectomy. Surgical removal of the entire bladder, along with the surrounding lymph nodes and, in men, the prostate and seminal vesicles. In women, the uterus, ovaries, and part of the vagina are also typically removed. Neoadjuvant chemotherapy — chemotherapy given before surgery — is recommended for eligible patients because it improves survival outcomes.
- Bladder-sparing treatment. For patients who are not suitable for or do not wish to undergo cystectomy, a combination of maximal TURBT, chemotherapy, and radiation therapy (trimodal therapy) may be offered. This approach can achieve bladder preservation in selected patients.
Questions to ask your doctor
- What type of tumour was found in my TURBT specimen?
- Is my tumour low-grade or high-grade?
- Is my tumour non-invasive or invasive, and what is the pT stage?
- Was the muscularis propria (the deep muscle layer) present in my specimen?
- If muscle was absent from the specimen, do I need a repeat TURBT?
- Was carcinoma in situ (CIS) found? What does that mean for my treatment?
- Was lymphovascular invasion present?
- Did the report mention any variant histology, and does that change my treatment?
- What is my risk of the tumour coming back?
- What treatment do you recommend, and why?
- Will I need intravesical therapy, and if so, which agent?
- How often will I need follow-up cystoscopies?
- Are there any lifestyle changes I can make to reduce the risk of recurrence?
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