BackTable / Urology / Podcast / Episode #46
Techniques & Maneuvers for Optimal TURBT
with Dr. Sam Chang
In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Sam Chang, chief of urologic oncology at Vanderbilt University, about surgical tips and tricks for intermediate and high risk bladder cancer.
BackTable, LLC (Producer). (2022, July 20). Ep. 46 – Techniques & Maneuvers for Optimal TURBT [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Sam Chang
Dr. Sam Chang is the chief of urologic oncology at Vanderbilt University in Nashville, Tennessee.
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.
First, the doctors discuss important considerations during the initial patient visit. Dr. Chang emphasizes that reviewing previous evaluations and treatments is important for patients with recurrent disease. Also, if the patient is a current smoker, smoking cessation should be encouraged. Dr. Chang will not perform a cystoscopy if the lesion is obvious. However, he acknowledges that this procedure may be necessary if the imaging is ambiguous. Some tips and tricks he shares for blue light cystoscopy include: using lidocaine, applying pressure when passing the scope, and training effective procedure nurses. He notes that residents will greatly improve their cystoscopy skills as they gain more experience.
Next, Dr. Chang shares his tips for a transurethral resection of bladder tumor (TURBT). He usually employs a bipolar TURBT and starts resecting in a normal-appearing bladder, being sure to balance speed with judiciousness when resecting. Additionally, he tries to obtain pathologic specimens from various tissue sites and the appropriate tissue layer orientation in order to facilitate pathological analysis of the tumor. Further, he notes that thorough OR dictation matters greatly, especially if the patient transfers to the care of a different provider or if a revision surgery is needed. He encourages urologists to give as many details as possible about the appearance, location, size, and nature of the tumor. For bladder carcinoma in situ, Dr. Chang cauterizes the tumor instead of resecting it in order to spare the specimen from destruction. For tumors involving the diverticulum, he obtains his sample with extra caution, as this location increases the possibility of tumor spillage. Then, the doctors compare and contrast different types of intravesical therapy.
Finally, the doctors discuss postoperative TURBT care. Dr. Chang usually does not place a postoperative stent because most of his patients do not develop stenosis. However, in cases of CT-proven hydronephrosis, a stent is necessary. He will also leave a catheter in all his patients for 3-4 days to prevent clot retention during recovery. Finally, he prescribes post-operative maintenance gemcitabine. Revision resection procedures if there was lots of tumor left behind after the first surgery or if the tumor was present in a difficult anatomic location. Dr. Chang repeats the resection before administering intravesical therapy. Lastly, he emphasizes that in cases of muscle-invasive bladder tumors, he would rather get rid of all the tumor than worry about preserving muscle.
[Sam Chang MD]
I hate partial cystectomy and diverticulectomy for bladder cancer and tumor and a TIC. When was the last time I did it, I haven't done it in 20 years. Do I believe it's effective therapy? No. What does it say in the textbooks? That's what you should do. I don't believe in it. So my algorithm is you sample as carefully as you can the tumor. If it looks papillary, you know, if it looks worried, I advocate cystectomy, because it's tumor there, that's worrisome is just like tumor somewhere else that's worrisome, that you cannot completely resect. So think of a T1 tumor that you can't completely resect or high-grade TA you can't for whatever reason, you cannot completely resect. I recommend cystectomy so wildly that's our number one or path split cystectomy. The other is I tend to treat these with intravesical therapy and aggressive TUR in full duration and the majority of patients end up doing fine. I really counsel them saying, look, if you want to try to save your bladder, we're taking a real risk here. And I have had a handful of patients that have tried intravesical therapy that have exploded. And would that have happened if I'd taken out their bladder or done a diverticulectomy? I think disease trumps everything, I think probably so but, I don't know for sure.
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