Blue Light Cystoscopy in Bladder Cancer

[Jose Silva]
Okay, definitely. For larger tumors, the tumors that you go in, you're seeing it from the bladder neck, you see that it's encasing the entire bladder, what's your next step? Do you try to completely remove them and leave a possible non-functional bladder? Or do you just try to get some samples, try to get tissue samples, pathology, and then go straight for the cystectomy?

[Aditya Bagrodia]
I think this is one of those things that people struggle with all the time. And once we answer this, I think it would be nice to come back and revisit using blue light enhanced cystoscopy. Based on what you're describing, my suspicion for this being a muscle-invasive bladder cancer is going to be high. And, first things first, looking at patient comorbidity, looking at the clinical picture - are they having gross hematuria with clots, etc? If it's a very large tumor, sick patient, clearly muscle invasive, hydronephrosis, extension beyond the fat, a lot of this is going to depend on the relationship with your medical oncologist as well.

If I've got a tumor like that, I would almost say that I would be fine doing an office cystoscopy, obtaining a cytology, getting a biopsy, because I don't want to run into any operative misadventures - persistent gross hematuria, bladder perforation, something that could be a catastrophe. If I know it's locally advanced, clearly T2 through T4, our medical oncologists here I think are very, very into being aggressive with multimodal therapy. In a patient like that, that’s sick, I would have a very low threshold to try to go with the less is more philosophy.

The other half of this is determining resectability. We know that patients that are ultimately pathological T0 after neoadjuvant chemotherapy and cystectomy or after cystectomy alone, do better. So if you can safely get it out - if it's in an area that's amenable to a complete resection, you don't think you're going to put the patient at a risk for a perforation or anything along those lines - I do like to completely resect, both for increasing the chance of them ultimately being pathological T0 and then also just to make sure that if they're going to be receiving chemotherapy that we don't run into issues with recurrent hematuria.

[Jose Silva]
Okay. In terms of the technique, when you did a fellowship, did you have any difference from what you learned in residency in terms of the pure surgical technique?

[Aditya Bagrodia]
I feel like in my residency, I was fortunate that most of our oncologists - actually all of our oncologists - were fellowship trained at reputable, prestigious centers, so I felt like we got a really nice state-of-the-art training. One of the areas that was a little bit more aggressive in terms of resection... This is kind of straightforward from the Harry Herr school of thought, would be radical resection of carcinoma in situ. That was something that in residency if your suspicion that they had diffuse carcinoma in situ, oftentimes we would just make sure we were establishing a diagnosis with multiple cold cups or several swipes, get your hemostasis and get out.

And in fellowship, there was much more emphasis on complete resection of all visible disease. That was something that's nuanced. Coming back full circle, when I came back to UT Southwestern as an attending, our institution was one of the first early adopters of blue light enhanced cystoscopy, so really making sure that we're trying to resect not only the tumor but anything that looks like peri-tumoral dysplasia or carcinoma in situ.

In a lot of ways, I think those are kind of merging, but this idea of a deep, radical resection, understanding that you may have perforations into the fat and that kind of happens part and parcel of radical TUR, was a notion that I would say was a little bit more emphasized in fellowship.

[Aditya Bagrodia]
And Oche, while we're on the topic of flexible cystoscopy, I think another very easy to implement set of maneuvers when you're doing these cases in the office, whether that's standard surveillance, initial diagnosis or relatively simple moves, and I may ask you from your perspective as well what you do. In our clinic... And of course they all get lidocaine jelly instilled. Then when I'm at the sphincter and about to go through the sphincter and the prostate, I'll ask the patients to take a deep breath, relax, act like they're urinating and then I'll have the assistant actually squeeze the irrigant bed to kind of passively dilate the sphincter and the prostate as well.

There's actually data that patients do better in terms of tolerating their office cystoscopies. And, again, these are going to be super simple things to implement. Really trying to keep that lumen visualized actually as you're going through the prostate and not just pass it in blindly as a catheter. Anything that you do at your end?

[Jose Silva]
I do exactly that. I tell the patient to take a deep breath. It was three months ago, this patient told me that his urologist started out and always tells him to cough.

[Aditya Bagrodia]
Mm-hmm (affirmative), okay.

[Jose Silva]
Have you heard that? I started doing that to see. I didn't see any difference, but it was the first time that I have heard of people... because this was a patient with just surveillance cystoscopy. He had bladder cancer and his urologist retired, or I think he just moved to Florida. But that's what he told me. He told me his urologist told him to cough. I didn't know about that technique. I usually just tell the nurse to just push the bag, have the patient take a deep breath. I use the lidocaine lube. But if the patient starts complaining, I just tell them to cough to see if that helps also. But I haven't had any changes for now.

[Aditya Bagrodia]
And extrapolating from prostate biopsy, if it's easily implementable, I think even playing some music. Everybody can pop in a wifi speaker, or if somebody's got their Spotify or YouTube, whatever. Just pop on something relaxing that the patient may enjoy. These are very simple things that I think we can do to just make the whole experience a little bit more tolerable.

[Jose Silva]
Yeah, specifically for vasectomies. Definitely, you need to put something on for the patient to be more comfortable. Usually cystoscopy is so fast that I don't think about that. But the more comfortable the patient is, the better.