BackTable / Urology / Podcast / Transcript #2

Podcast Transcript: Management of Bladder Cancer

with Dr. Aditya Bagrodia and Dr. Jose Silva

Dr. Jose Silva talks with Urologist Dr. Aditya Bagrodia from UT Southwestern Medical Center about the medical and surgical management of bladder cancer. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Initial Diagnosis and Workup of Bladder Cancer

(2) Transurethral Resection of Bladder Tumor: General Surgical Technique

(3) Surgical Approach to Large Tumors

(4) Blue Light Cystoscopy and Office-Based Biopsy

(5) Helping Patients Tolerate In-Office Cystoscopy

(6) Resection at the Ureteral Orifice: To Stent or Not To Stent

(7) Troubleshooting Stricture Disease and Other “Weird” Cases

(8) Management of Bladder Perforation

(9) Bladder Cancer Biomarkers: Utility and Practical Applications

(10) Bladder-Sparing Techniques

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Management of Bladder Cancer with Dr. Aditya Bagrodia and Dr. Jose Silva on the BackTable Urology Podcast)
Ep 2 Management of Bladder Cancer with Dr. Aditya Bagrodia and Dr. Jose Silva
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[Jose Silva]
Welcome to Urology Back Table. I'm Jose Silva. I'm a urologist in central Florida and today we are going to have a guest, Dr. Aditya Bagrodia, like I said, better known as Dity. He is a urology oncologist down at UT Southwestern. He did medical school in Tennessee and then he did residency at UT Southwestern, then went for a fellowship in Memorial Sloan Kettering, and now he is an attending at UT Southwestern. So, Dity, how are you doing?

[Aditya Bagrodia]
I'm doing great. Thanks so much for having me today, Oche. Really appreciate the invite.

[Jose Silva]
And you said you're in your office?

[Aditya Bagrodia]
Yep. Spent a little time in the office, knock out some work.

[Jose Silva]
What do you have in your background? You're writing on your walls?

[Aditya Bagrodia]
Yeah, those are the research projects that are in various stages of completion. When they pop up they tend to go kind of quickly so I try to get them down on my dry erase wall back there.

[Jose Silva]
That's great. That's great. So Dity, you did a fellowship in cancer in oncology. What made you go into a fellowship in the first place rather than just going straight to work?

[Aditya Bagrodia]
Sure. Yeah, it's a great question and I think something that everybody needs to individually identify for themselves. Fortunately, I think as urologists, cancer is part and parcel of what we do on the day-to-day and I would say for most U.S. residents, getting exposure to prostate cancer, kidney cancer, bladder cancer is an expectation of most residencies. Some of the rarer tumors, penile cancer, testis cancer, urethral cancer, upper tract cancer, you may not have that much exposure. I felt pretty fortunate, being in Dallas, a large volume center, that the clinical fundamentals were there.

But, certainly, I think if you really want to be involved in understanding some of the biology, pathophysiology, really keeping your finger on the pulse in terms of multimodal management and really what's coming through the pipelines in terms of next steps, fellowship could be a good option. And whether you ultimately decide to go into academics or private practice, having that additional training, I think, is valuable.

[Jose Silva]
Okay. And what made you go into academics? Did you want to go into academics prior to the fellowship? Is that something that you had in mind when you started all this process?

[Aditya Bagrodia]
Absolutely. I think I decided fairly early on that I liked the research aspect of it, I liked the teaching part of it. I liked the thought that through an academic path I would be able to focus on oncology only. That was certainly my plan going into it. With that being said, I know plenty of people go into fellowships and go into practice and I'd like to think that there is still value in that route as well.

(1) Initial Diagnosis and Workup of Bladder Cancer

[Jose Silva]
Okay. So Dity, today we are going to talk about bladder cancer. In your practice, do you see a bunch of bladder cancer? What's the most that you see down there in UT Southwestern?

[Aditya Bagrodia]
Absolutely, absolutely. It's obviously one of the big four - kidney, prostate, bladder, testis - and we do see quite a bit in various stages. We take care of patients at both the safety net hospital, a VA hospital and then an academic tertiary referral center. Each of those populations, I would say, especially with the baby boomer population, being here in Texas a lot of folks smoke, unfortunately. In my practice, I would say that I see about four or five patients at any given clinic with bladder cancer and anywhere from about four to six cystectomies a month.

[Jose Silva]
That's a big volume. I wanted to start with just the basics. First, when you start in the process of diagnosing that patient with a bladder cancer....the patient starts with hematuria, you do a cystoscopy. What's the next step?

[Aditya Bagrodia]
Sure. And even before that, I think it's mandatory to review the imaging yourself if it's been done. Oftentimes, our patients are referred. And if they've got a clear-cut tumor in the bladder, oftentimes we'll just save them the whole experience of an office cystoscopy and go straight to the OR. I think that's a decision that you make on the front end.

And, with respect to office cystoscopy, really looking at the level of suspicion, looking at the imaging and certainly looking at patient comorbidities, many times I think it's a good option to actually perform a flexible cystoscopy with biopsy fulguration in the clinic. If you can save some of these elderly patients with significant comorbidities an anesthetic, I think that's very, very nice.

And also, with respect to office cystoscopy, if you have the capabilities to do any type of augmented, enhanced cystoscopy whether that's NBI using Olympus infrastructure or whether that's using blue light enhancement with the Karl Storz infrastructure, I think those can be nice options. They are in the guidelines. I wouldn't say it's mandatory.

But, going back to your initial question. You've got a suspicion for a tumor, whether based on office cysto or whether based on your preoperative imaging, the next steps are going to be taking them to the operating room, establishing a tissue diagnosis. And I actually like to get a cytology just so I have a sense of what I'm getting into, what I'm working with. If it's high-grade, that may impact my decision to use any type of postoperative intravesical therapy.

(2) Transurethral Resection of Bladder Tumor: General Surgical Technique

[Aditya Bagrodia]
We've gotten to the operating room. I always counsel my patients for a transurethral resection of bladder tumor along with possible postoperative installation of a chemotherapeutic. I personally would go with gemcitabine over mitomycin routinely. It's cheaper. It's got a better side effect profile, and oftentimes the issues with calcifications that you see with mitomycin are essentially non-existent with gemcitabine.

In the operating room, of course we're the captains of the ship there and I think it's important that you are in contact with your anesthesiologist. If it's a lateral tumor, a posterior tumor, that you do have the capability to have the patient paralyzed, checking the irrigants, whether you're using monopolar or bipolar. This is just kind of my preference, I will typically still do monopolar. I think bipolar is a perfectly fine option. Certainly if you have a larger tumor, I think it could be a good option to use bipolar technology. I also will try not to hang the fluids overly high. While that does help out with the visibility, I do think you can over-distend the bladder and put yourself at a slightly higher risk of a perforation.

Then, jumping on into it, as soon as the patient is prepped and draped and the timeout is performed, I'll put in 26 or 28 French sound into the meatus just to passively dilate the fossa. I think this is nice for accommodation of the resectoscope and as well as mitigating any issues or problems with postoperative strictures. If I am fairly confident that there's a tumor, I will oftentimes just go in with the 26 French resectoscope visual obturator and skip the standard rigid cystoscopy with the 21 French 30 degree lens.

As soon as you get in, I think you're trying to get information from time point zero, what does the urethra look like? What does the prostate look like in terms of are there any masses, lesions, anything suspicious, obstructing lateral lobes. Are you potentially going to be running into any issues with postoperative retention? So, careful look at the prostate and, again, a second careful look at the prostate when you come back out.

Then I will oftentimes go ahead and switch out from my visual obturator to a resectoscope if I know that there's going to be a large tumor that I'm 100% going to be resecting. You get better in-flow, out-flow, better visibility. First thing, of course, is just to take a systematic look around the bladder. I think everybody's kind of got their rhythm, to make sure that you're visualizing all your critical elements, including the ureteral orifices, the trigone. And if you can't get a good look at the entirety of the bladder neck with a 30-degree lens, I would say it's 100% worthwhile to spend the extra 30 seconds to put in a 70-degree lens and really investigate that bladder neck. Once you've got an assessment of the entirety of the bladder, then I think it's time to begin the resection.

[Jose Silva]
For a simple resection or a small tumor, you would just straight up resect it. How far or how deep do you go into that muscle or bladder tissue?

[Aditya Bagrodia]
Oftentimes it is these smaller tumors - half a centimeter, one centimeter - which I think can be challenging. If you go in with your resectoscope and you've engaged your resectoscope a little too quickly, the bladder is undistended...next thing you know, you've cauterized the tumor, you've annihilated your ability to get a pathological diagnosis. Something I certainly iterate and reiterate to the residents is, especially for these smaller tumors, you want to be careful and you want to give the pathologist something to work with.

So what I will do is actually get the bladder decently distended. When it's under-distended, I think to actually get your loop within the bladder wall can be difficult. And I'll generally start about two to five millimeters beyond the tumor, engage my loop, get it into the wall, and then I use a stutter step technique resecting towards myself, trying to get under the tumor, sample muscle - and I realize that I may be overly dogmatic about this- I want to know is the muscle sampled, both visually and then, of course, by the pathologist. But I'm trying to get under the tumor and almost do an en bloc resection for very small tumors. I think that this gives the pathologist something to work with. It minimizes cautery artifact. You can feel good that you've completely resected the tumor.

In general, I am at least getting through the lamina propria. I want to have muscle, and beyond that, if it's a low-grade papillary solitary tumor, I'm not trying to resect down to fat or anything beyond that.

[Jose Silva]
Okay. Do you usually get a cold cup biopsy of that base or that area where you just resected? For bladders that are thinner, that you don't want to go in that deep, what's your process with those?

[Aditya Bagrodia]
I think a cold cup is a great option. Of course, there's tumor location and tumor height. The dome can often be difficult to resect, and I think you're at a higher likelihood of just cauterizing the entirety of the tumor. If it's a small tumor, certainly, elderly females or you're suspicious of a thinner bladder wall, I think a cold cup biopsy with fulguration can be a complete resection. Of course, you can take multiple bites in the same area. I would absolutely say that that should be something that you use in your armamentarium. Clearly, there's not going to be any cautery artifact.

I always tell the residents if there's multiple tumors, it may sound obvious, but if you take several cold cups, you need to keep track of how many cold cups, where you took them and make sure that you cauterize and get hemostasis at all of those.

(3) Surgical Approach to Large Tumors

[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.

(4) Blue Light Cystoscopy and Office-Based Biopsy

[Jose Silva]
And you had mentioned the blue light cystoscopy. Do you have blue light both in the office and in the OR, or just in the OR?

[Aditya Bagrodia]
Yeah, we have it for both.

[Jose Silva]
For both? Okay. And has that changed... Or let's say let's put it this way, has that made you take more patients to the OR because you see something more suspicious with the blue light? Have you been able to diagnose more patients with that technique?

[Aditya Bagrodia]
It's a great question and, honestly, I would say in my clinical practice, and I think the field in general, there's been this kind of parallel emergence of flexible office blue light cystoscopy and just an increased adoption of office-based biopsy fulguration. I would say that I am diagnosing more suspicious lesions and, at the same time, biopsying those in the clinic with the idea being that many times these are going to be early dysplastic low-grade lesions or they're going to be carcinoma in situ.

And, as we know, one of the trickiest, most challenging bits of this is to sort out BCG changes from tumor recurrence. So net, I would say that I actually end up taking a lot less patients to the operating room and it's a little hard to parse out what's the contribution of blue light cystoscopy and what's the implementation of more office-based biopsy.

And for those of you that maybe don't do office-based biopsy, I must say it's really, really actually quite simple to implement. And whether you do blue light or not, putting in a catheter, a solution of a local anesthetic plus some saline, letting it dwell for 20-30 minutes and, to be perfectly frank, even if you use lidocaine gel, patients tolerate these very, very well. Uniformly it's preferred versus general anesthesia, the whole experience of coming in two hours early, general anesthesia, making sure you void, X, Y and Z. It takes it from being a half day affair with two or three days of lingering effects to literally a 15-minute procedure.

There's plenty of great information in terms of implementing an office-based biopsy program. You buy a little generator, get a flexible cold cup biopsy forceps and a Bugbee and you're home free. That's something I would say it may sound intimidating but it's actually quite, quite easy to implement.

[Jose Silva]
For surveillance cystoscopies after BCG, you start doing the cold cup biopsy of that base or where there is scar tissue, you do that in the office?

[Aditya Bagrodia]
No, I haven't gone that far. Office biopsies I think have a role but it's not the same. I would liken it to... It's better than trying to biopsy a lesion in the upper tract, but it's not the same as a rigid cold-cup biopsy. When you're doing a second-look resection staging biopsy etc, you really need to make sure that you have that muscle sample then. And the tools are just not quite as amenable to that with the flexible setup as they are to the rigid. I will still do my second looks in the OR, typically.

[Jose Silva]
Okay.

(5) Helping Patients Tolerate In-Office Cystoscopy

[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 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.

[Aditya Bagrodia]
Yeah.

(6) Resection at the Ureteral Orifice: To Stent or Not To Stent

[Jose Silva]
So, Dity, let me ask you this. Let's say you are there in the OR. The bladder tumor is located right in the ureter orifice, right on top, not coming out from the orifice but just right on top. What's the next step? Do you do a stent prior to the resection or what would you do?

[Aditya Bagrodia]
I will typically try to resect everything other than immediately over the UO. That's going to be my last bit. And then I will try to take a rapid swipe using cut only. And if I visualize the mucosa of the intramural ureter and I see efflux of urine, then I'll typically not stent them.

[Jose Silva]
Okay. Sometimes you start doing the resection and then you lose either the angle to put something inside and then it gets more tricky. What I'm doing, I'm putting at least something, an open end there just to have visualization of that orifice and then if I see that it's not damaged, that everything is okay afterwards, I would just remove it. But I usually start putting an open end just because sometimes I have had difficulty putting the stent in afterwards. I don't know if they need it, but it's just not at the same location that once I started the procedure, it doesn't look the same. In that sense, I started preventing that and putting an open end just prior to everything.

[Aditya Bagrodia]
I think it's perfectly reasonable. Clearly, once you've resected the UO, it's not always a foregone conclusion that you can find it. That can be stressful. And if you can't what I'll typically do is admit them overnight, monitor for symptoms, get ultrasound the next day and then oftentimes they need an antegrade stent. And that is an affair. And even if you do see it and you see it effluxing, it's not a guarantee that there couldn't be some post-procedural inflammation requiring an adjunct procedure.

I think what you're describing is perfectly reasonable. It's also mandatory, obviously, that you resect the entirety of that tumor which can sometimes be a little bit trickier with either a stent or a wire or open-ended in place. But having your UO clearly demarcated is never a bad thing, as I think any urologist would tell you.

[Aditya Bagrodia]
But to take this one step further, if they've got hydronephrosis and I'm worried about a muscle invasive tumor and that they're going to be getting chemotherapy, I think there's actually decent data that a nephrostomy tube may be a better option than a stent in terms of mitigating upper tract recurrences as you move forward. I totally get it and respect it that patients would like to not have an external appliance. And if I can see the UO after a large resection, I still will often put a stent but I certainly don't think there's any reason to feel ashamed if you ultimately wind up putting in a nephrostomy tube.

[Jose Silva]
For those patients that you already know that they have hydronephrosis prior to the dissection, do you go and put a nephrostomy first? Or would you just do your part and see if that alleviates the obstruction? Sometimes it's just like a valve effect that the tumor is not entering the UO, it's just the mass effect that is causing the obstruction, and once you remove it you should be fine. Or do you go straight into the nephrostomy first?

[Aditya Bagrodia]
I'll typically, unless there's any evidence of renal dysfunction, would go in and do my resection first to see if I can unroof it, to see, exactly like you said, if it's a ball valving effect or something along those lines. I think that outside of renal dysfunction or, of course, some type of obstructive pyelonephritis situation, I would generally try to do my resection first.

(7) Troubleshooting Stricture Disease and Other “Weird” Cases

[Jose Silva]
I had this patient two or three weeks ago, a history of prostate cancer. He had radiation. He comes with hematuria, a bunch of blood clots. When I went in he had very small papillary lesions in the right lateral aspect of the bladder. I tried dilating the urethra...I went in just with the 21 cystoscope just to take a look inside. I liquidated all the blood clots. But I couldn't get in the... At our hospital we have a 27 and a 29 French...I couldn't get in a resectoscope, so I ended up doing a bunch of cold cut biopsies and then we did Bugbee and just fulgurated the area.

But it came out high grade. Now I'll probably have to go back in and do a resection. I'm trying to see if we can get a smaller resectoscope, a smaller French. What's your thoughts on that, on patients that you cannot for either history or just bad strictures, what's the next step for those patients?

[Aditya Bagrodia]
These are tough cases. These are challenging cases, and oftentimes we have to kind of work closely with your reconstructive urologist. Another example is going to patients that have urinary sphincters in place. You want to make sure that you don't go in and cause more harm than good. First and foremost, you've got to do what you've got to do. It sounds like you did exactly that. You got in there with a 20 French scope, established the tissue diagnosis and did the best you could, and I think that's perfectly reasonable.

The resectoscope, were you able to get it into the level of the prostate? Was it kind of a fixed prostate post-radiation or was this more of a meatus, urethral issue?

[Jose Silva]
It was the urethra. Usually I have the Goodwin Sounds so I put a wire inside, and then I don't like to ligate blindly so I use that one to dilate and I got up to a 24 but then it just got stuck. Nothing. It was just going to rip the entire urethra. Very, very hard. I would say I got into the penile urethra, two or three inches inside, but that was it.

[Aditya Bagrodia]
Broadly, I've started moving more away from Sounds and more towards balloon dilation. And in this patient we were unable to get into the bladder, what I would probably do is sequentially use a 4 cm 26 French, almost like a NephroMax balloon and just dilate step-wise all the way in. Start with that. And if that got you there, great. It's certainly not a foregone conclusion.

Some of these patients post-radiation, fixed prostates, I get nervous about using Sounds to go in. In our M & M conferences, you hear every year or so about somebody who had a perforation or he came in through the prostate, undermined the bladder. And if you don't have somebody who knows what they're doing, the perfect amount of back tension on your wire, things can get kind of out of hand.

I would try to dilate first. These are going to be extreme cases where, if you've got diffuse pendulous, bulbar urethral stricture disease, you're even considering maturing a perineal urethrostomy so you can make sure you can access the bladder. If it's more at the level of the sphincter prostate bladder neck, that's obviously not going to be sufficient.

I am very, very reluctant to put in a suprapubic tube and access the bladder in a patient with active bladder cancer. But I would say that in these cases, you've got to do the best you can. You get in there with a flexible or a rigid, you get your biopsies, you get your fulguration, you carefully characterize the bladder, the size, the location, is there any evidence of carcinoma in situ? Is it a nodular, sessile-based tumor? Is it diffuse? Because those are going to be the bits of information, in addition to the pathology, that are ultimately going to be driving your decision. And this may absolutely play into how you ultimately manage a patient like this. And if you've got a patient with terrible stricture disease, diffuse high-grade cancer, that might be somebody that may be benefiting from more aggressive early intervention.

[Jose Silva]
You mentioned just opening the perineum and going through there, but I've never done that. I just read it, I have read it when I was in residency but it's not something that I'm going to do on a Saturday morning and all in the hospital with no backup or anything if something goes wrong. But I was able to just alleviate the problem that he had, so I guess I'll take it from there and see if we can get... Next time I'll use the balloon dilation so that should be helpful.

[Aditya Bagrodia]
Sure, sure.

[Jose Silva]
Let's continue talking about those weird cases. What if a patient, you cannot control the bleeding? Those big masses that you start doing resection and then you run into a problem that you cannot control the bleeding? Sometimes I have seen that if you just continue resection, eventually it will stop. But let's just say that this is a bad tumor, you run into a position, it continues bleeding. What's next?

[Aditya Bagrodia]
I think we've all run into this in some form or fashion. The first thing I would recommend for the larger tumors is really starting where it's easiest in terms of access and visibility. Say if you've got a tumor extending from trigone along the lateral aspects, I'll start medially where I can see it. And what I'll actually do is, some people advocate for this haircut technique where you're just kind of mowing down - again, let's say from medial to lateral and then working your way down to the base of the tumor - I personally don't like that. I like to start at one edge, take it down from the papillary frondular aspects of it down to the base. I know where I've been and if I run into bleeding, some large dominant vessel, I at least know where it's coming from.Once I've gotten that down to somewhere that looks like it's close to the base of the bladder, then I start moving. It's a systematic resection, recognizing that I could get into bleeding, but I'm more likely to know where it's coming from.

Now, even with that technique, trust me, I get it, in some of these big tumors the orientation can be tricky. The first things I would do are just take a look at where my irrigation is hanging, try to get it up a little bit, try to get some better visualization. Take a look at the patient's blood pressure. If they're in the 150s/160s, work with my anesthesiologist to see if they can't drop that if this is some kind of large venous sinus. You don't want to resect blindly. If you're bleeding, I don't think you want to resect blindly. The only thing that's going to be worse than a bleeding tumor is a bleeding tumor where you've perforated the bladder as well.

If you have a sense of where you've been working, I think you try to resect down, get your irrigant up, try to really do the best you can. You can consider switching to a larger resectoscope. You started out with say a 26-French or a 27, pop up to a 28 or a 29, get a little bit better inflow, outflow. If you've exhausted your standard sets of maneuvers... Of course, you want to make sure the patient is stable. If you're worried about it, you want to make sure you have an active type and screen, cross match, all those kinds of things. But if you've done your level best, call for help. There's no shame in it. This is a team sport. If you've got a partner that may be able to come in, have some different ideas.

I would next get a rollerball or some type of cylinder and really just start focusing on cautery more than resecting. And if all of this is negative and it's like a TURP where you've done your resection and things are a little bit oozier than you like, I'd say get in a large catheter, start your irrigation, observe them in the OR. Put some traction on this and see if things clear up with brisk CBI and many times these will sell themselves out. But those would be my first set of maneuvers and, fortunately, I haven't gotten into a situation where with these I'm not able to get a handle on things.

[Jose Silva]
Does IR play a role in this, like an embolization of the bladder if that doesn't work?

[Aditya Bagrodia]
Yeah. I think you really have to look at the whole picture here. If you're dealing with a nasty tumor that you know is going to be muscle invasive, the patient's anemic - i.e. a cystectomy is in the cards - I wouldn't do it at that setting but I think you get through the acute phase, you start them on CBI, you get them resuscitated and you have a conversation. But, of course, if you're running into bleeding that's not controllable, if you've got good support where you can have selective embolization of superior vesicle, inferior vesicle, or branches, that would be another option for sure.

(8) Management of Bladder Perforation

[Jose Silva]
Dity, and have you ever had to open someone? Or just a perforation that you... Hey, it's perforated, you see a bowel. Have you run into that and do you take any measures to prevent any spillage?

[Aditya Bagrodia]
I'm going to knock on wood here. In my own hands, I haven't had a bladder perf but twice over the course of my training I have been involved. And these were very difficult tumors - large, thin, frail cases.

And the first thing I'd say is one of the things that pops up in our M&M is that if you're suspecting at all, it behooves you to rule out a diagnosis of an intraperitoneal bladder perf. When there's big mismatches in fluid, when your anesthesiologist is having a change in ventilating, you can't assume that you've had an extraperitoneal bladder perf and it's time to stop, put in a catheter and get out. You've got to do what's right, which is to obtain a cystogram and sort it out. And at this point if you do have an intra-peritoneal bladder perf, the standard of care is typically going to be to do an exploration and repair it. And it's not fun. You're not prepared for it. The tissue planes are completely non-normal. Developing the space of Retzius isn't a foregone conclusion, but you've got to do it.

With that being said, it is morbid and, depending on your comfort, depending on the comorbidities, there are options. You can pop in a laparoscope, take a look, try to repair minimally invasively. That can be a game changer. And, clearly if you run into anything like that you're not going to be thinking about any type of intravesical therapy, but these are going to be cases where I think if they're muscle invasive, you really want to make sure you're considering multimodal therapy. Shockingly, it's not a foregone conclusion that you're going to have a bunch of peritoneal implants, carcinomatosis, higher rates of metastases, but it's not a good situation. It's stressful for the family. It's stressful for the surgeon, of course for the patient, and there's not a lot of wiggle room.

With that being said, I think this is again case-by-case. If you have a super sick, old patient, sometimes you've got to do what's got to be done. Put in a catheter. Put in a suprapubic tube. Put in nephrostomy tubes. Admit them, antibiotics, monitor them carefully. I'm not advocating for that, but I think it's important to establish a diagnosis, know what the standard of care is, but also refrain from being overly ultra-dogmatic.

(9) Bladder Cancer Biomarkers: Utility and Practical Applications

[Jose Silva]
Okay, Dity. The next question, Dity. Do you use any biomarkers in your practice for bladder cancer or on a regular basis?

[Aditya Bagrodia]
I would say, largely because some of my partners have a fairly significant interest in bladder cancer biomarker research, but maybe walking through them…

Cytology would be the one that I think is consistently used by me, but we at our institution have reflex FISH for atypical or suspicious cells. I personally think it's of limited added value. If you've done a clean cysto, some atypical cells and it's FISH positive and they have recent upper tract imaging and their prostate looked fine, I'm not going to take them to the OR to do random bladder biopsies. I'm not going to take them to do prostate biopsies. I'm not going to act on that. I wouldn't necessarily do their next cysto in six months, but I would probably have a little bit higher concern that something may pop up and I may be inclined to again do office biopsies.

But, beyond that, not too much. Other common ones, BladderChek NMP22, I don't think that they have the real performance characteristics at this point for me to routinely use them.

[Jose Silva]
Okay. Sounds good. We get a lot of reps in the office trying to sell all these products so I just use the cytology and I go with it.

[Aditya Bagrodia]
I guess it's a biomarker in a sense. I think there's a lot of exciting data coming through for MRI of the [bladder]. And there was actually a clinical trial in the UK, basically getting rid of cystos and going straight to management based on MRIs. We have bladder MRI here. Our experience is relatively early. I think the results are promising, but I wouldn't say that outside the clinical trial you should be making decisions whether to scope or not scope, give chemo, not give chemo or really dictate your management at this point.

[Jose Silva]
The cystoscope is a great tool that we have and I don't see an MRI changing that. Maybe it does, but for now also in terms of selling the patient, telling them, "Hey, we need to do this." So let's see how that works.

(10) Bladder-Sparing Techniques

[Jose Silva]
Lastly, you mentioned the UK, there's a trend in Europe to do more bladder-sparing techniques. What are your thoughts on that?

[Aditya Bagrodia]
I think it is a guideline directed option. Thus far, there's been a fairly significant regionalization. In the United States, it's largely been the group from MGH that's done a lot of the lion's share of work in terms of bladder sparing. And what I would say that a big part of bladder sparing is patient selection, making sure that you know what you're doing. Going back to some of our initial discussions, is the tumor completely resectable, do they have extensive carcinoma in situ? Is there hydronephrosis? These are going to be relative contraindications.

On the flip side, I think this idea among urologists that bladder sparing is uniformly less effective is wrong. There's never been a randomized control trial. There was a spare trial in the UK, which closed due to poor accrual. But I really do think that it behooves us to have that conversation with our patients about, "You've got newly-diagnosed muscle-invasive bladder cancer, here are your options." And that doesn't mean cystectomy with or without chemotherapy. That means cystectomy with or without chemotherapy as well as bladder sparing techniques.

It's absolutely mandatory that you have a good working relationship with your radiation oncologist and medical oncologist. These are intensive regimens with radio-sensitizing chemotherapy along with radiation, oftentimes same day. The patients have to be motivated. And I think us as urologists need to be somewhat familiar with the data in terms of local control, bladder intact control and then distant control.

Again, I think it's really incumbent upon us to have that discussion and fast forward 10 years...I would say that I see bladder cancer management more like prostate cancer where you have an honest discussion about broad stroke surgery versus radiation.

[Jose Silva]
More options, okay. Will you do bladder neck biopsy or other biopsies of other areas in the bladder to make decisions? Do you usually do this in your practice?

[Aditya Bagrodia]
Typically not. Random bladder biopsies, prostate urethral biopsies, upper tract ureteroscopies, selective cytology, etc, those are generally going to be in unique cases of completely clean bladders, positive cytologies and I would say that that clinical scenario is less common as we implement blue light cystos.

[Jose Silva]
But I mean in a patient that you're considering a bladder sparing technique, for example. Would you do a random bladder biopsy of other areas that don't have tumor just to have more information, say, "Hey, we can do this. We cannot do this."

[Aditya Bagrodia]
Yeah, honestly if I'm considering it they're typically going to get a blue light resection, I'm going to be going for maximal resection. I feel pretty good that I've had good visualization. So in terms of the prostatic urethra, non-suspicious lesions, I probably wouldn't. But if there's anything even remotely suspicious, I think you do it. You put it to rest, and I would actually put a fiducial in if we're electing for a chemoradiation type of approach.

[Jose Silva]
Okay. Well, Dity, I guess that's it for now. Do you want to add anything? It's been great.

[Aditya Bagrodia]
No, I really appreciate you all having me. And I think, like you mentioned when we were talking before, guideline directed care is rather easy but, by all means, don't hesitate to reach out to somebody who does this a little bit more if it's outside of your comfort zone. And I again would say implementation of office cysto-biopsies can be a real benefit to patients in terms of saving them from unnecessary anesthetic cystoscopies. And I know we didn't really touch onto this but, as an office-based procedure, it can be a decent option for the urologist as well.

[Jose Silva]
Good, good. I know you're very passionate about testicular cancer. I know you do research on that, so hopefully in upcoming sessions, we can talk about that. I'll be interested to have that take on your thoughts on that and what's the future on testicular cancer.

[Aditya Bagrodia]
Absolutely, absolutely, Oche, happy to do it. We may have to pencil out a few hours...I enjoy talking about testis cancer. We'll get that one taken care of next time.

[Jose Silva]
Okay, Dity. Thanks very much. Take care, man.

[Aditya Bagrodia]
Perfect. Thank you. Appreciate it.

Podcast Contributors

Dr. Aditya Bagrodia discusses Management of Bladder Cancer on the BackTable 2 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Dr. Jose Silva discusses Management of Bladder Cancer on the BackTable 2 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 16). Ep. 2 – Management of Bladder Cancer [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Transurethral Resection Procedure Prep
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