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BackTable / Urology / Podcast / Transcript #46
Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Initial Evaluation of Bladder Cancer Patients
(2) In-Office Cystoscopy Approach and Tips for Patient Comfort
(3) TURBT Procedural Tips & Considerations
(4) Important Post-Operative Documentation and Communication
(5) Approaching Extensive Carcinoma In-Situ (CIS)
(6) Approach to Bladder Diverticula and Non-Invasive Cancer Management
(7) Prostatic Urethra Sampling Criteria & Postoperative Catheterization
(8) Selection Criteria for Postoperative Installation Chemotherapy
(9) Selection Criteria for Additional or Repeat Resection Patients
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[Aditya Bagrodia MD]
Hello everyone. And welcome back to the back table podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and@backtable.com. This is Aditya Bagrodia as you host this week. And I'm very excited to introduce our guest today, Sam Chang from Vanderbilt University, where he is the chief of urologic oncology. And, to me personally, I've really just enjoyed knowing Sam over the course of my career. Sometimes you'll come across people that despite never having worked directly together, you get the sense that they're rooting for you. They're kind of in your corner. Sam, you really embody that for me. So thanks for coming on. How's it going out there in Nashville?
[Sam Chang MD]
Well, NashVegas misses you and appreciates any warm words like that. We always welcome visitors like yourself. I don't hear words that often with our residents. Because usually we have conversations back and forth, and they understand that I am trying to support them, but you know, we sometimes have tough love here too. But I just want to say from my point of view, it's easy to be supportive of individuals who are really trying to move the field forward and are good people. And we're lucky in our field to have so many good people. And, you’re definitely ranked high on that.
[Aditya Bagrodia MD]
Well, thanks Sam. And I'm certainly looking forward to learning from you. Sam is first author for the AUA non-muscle invasive bladder cancer guidelines. And today we'll kind of try to focus on intermediate and high risk bladder cancer patients. So let's just, let's just jump on into it, Sam. So, you know, one-on-one with any new bladder cancer patients. What are the kinds of critical elements that you're going to intake in terms of history exam and so forth?
(1) Initial Evaluation of Bladder Cancer Patients
[Sam Chang MD]
Yeah. I mean, to be honest, my history focuses on not necessarily a lot of symptoms, but a little bit in terms of voiding symptoms, that type of thing. But I have gotten better, although I'm still not perfect, getting into their smoking history. Are they active smokers? If they are, are they trying to quit? If they're not trying to quit? So really trying to focus on, hopefully trying to get them off of the cigarette bandwagon here. Second thing then after that is, if we talk a little bit about the symptoms. Then we dive into what kind of evaluation they have had? What's been done? How has it been done? When’s it been done? And, just today, we were at the end of the day on Thursday and we saw a number of patients. Some have treatments spot on that you totally agree with and some have treatments that you are totally unfamiliar with. And so you really want to get an idea and it's something that I really tease out with the residents.
I want to know when the procedure was, when they got their treatment, what kind of treatment they got, et cetera. And so that to me is the key in terms of history, for anybody who has recurrent disease. The first timers, the ones that we diagnose that focus on their smoking history. And then I say, we've got to go to the operating room. So it kind of differentiates until, those that are initial cancer diagnosis, versus those that have recurrence.
[Aditya Bagrodia MD]
All right. So maybe we'll start out with the initial diagnostics. So generally I'm assuming they're coming in with some type of imaging, hematuria, workup, et cetera, something suspicious. If it's suspicious enough on their imaging, do you do an office cystoscopy or is that patient going straight to the.
[Sam Chang MD]
That is a pet-peeve of mine. Why do a procedure over again, other than you just want to charge that patient for a procedure and have them go through the discomfort of an in office cystoscopy. That's for lesions that are obvious. I mean, you've gotten scans, you've gotten some ultrasounds where there's a papillary lesion or multiple papillary lesions or multiple solid worsened lesions or there's calcifications and something. You know, you're going to take that individual to the operating room. So in all honesty, I don’t do an office cystoscopy. If there's any doubt. You'll get referrals for bladder lesions, bladder, mass, that type of thing. Yeah I’ll definitely cysto those people and do office cystoscopy in order to try to avoid that in anesthetic procedures down the line. But, there are times where you don't know and yeah, you need an office cystoscopy but I think if it's pretty clear on imaging, then I really don't like doing an office cystoscopy.
I really liked it and explained to the patient, “Hey, I'm going to take some pictures in the operating room”. I'm really big into that. I really think that's important. They're awake seeing it, in the office cystoscopy, if they are under anesthesia, I really like to take pictures. And, then I really like to share those pictures with the patient as well as their family, just so they have an idea of, okay, this is what we've got. And I usually take a before and after, right? Here's the, before this is what it looks after, and now we'll figure out what we need to do based upon the pathology.
[Aditya Bagrodia MD]
Yeah, I like that.
[Sam Chang MD]
What do you do? Do you do the same thing?
[Aditya Bagrodia MD]
The short answer is yes, for a new diagnosis coming through my hands. If it's outside referrals, that's pretty much a trust, but verify type of phenomenon, you know. How many complete resections have you been referred that they've got a tumor. Sometimes, if the imaging suggests that it's really close to the UO. I don't really do this, but conceptually, if they may require a resection and a stent, et cetera. I might like to know that information, but it's not really going to change things. And we'll, we'll kind of get to this a little bit down the way.
[Sam Chang MD]
I do want to talk to you about a disease at the ureteral orifice, and kind of your strategies and your goals, but we'll save that if you want. Cause, I'm an outlier I think, in my group. And so I'd love to kind of hear what you have to say about that.
[Aditya Bagrodia MD]
All right. So a quick question. So office cystoscopy tips and tricks. I mean, you know, it's a straightforward procedure. Do you do anything to try to make this better or more tolerable for patients?
(2) In-Office Cystoscopy Approach and Tips for Patient Comfort
[Sam Chang MD]
Ah, you know, studies have been done showing that the viscous Lidocaine really doesn't help. Other studies have been done talking about putting pressure on the bag to help open and decrease discomfort. Even if studies have shown that they haven't necessarily been helpful, we do everything we can to make it a little bit easier, a little bit more tolerable. So we do viscous lidocaine. We do put pressure as the scope is being passed, we do everything we can to try to explain. We have really gotten into patient videos and educational videos. This is one where we've really avoided it because we think it would cause even more anxiety and more worry about, oh, you're going to put that in this. We've really tried to talk through things. Let me tell you the best preparation and decrease anxiety technique we have in our clinic. And that's our nurses. So we have dedicated four or five folks that are procedure nurses and there are LPNs, a couple RNs there, even some MAs that help set things up.
I tell you what, they're the ones that really will be doing all the, I don't want to say dirty work, but when we do all the counseling before you walk into that room, they're the ones that are really helpful. Within actually then passing the scope in and doing anything technical, you develop your own technique, honestly. Your first or second or third year in practice, you're going to spend 10 times longer than you do after your fifth year and six year old practice in terms of how carefully and what you look at within the bladder. You know, it depends on certain situations regarding other tricks. We do not have in office blue light cystoscopy flexible cystoscopy. You guys may, and that's something you may want to bring up. We don't have that. We haven't bought the equipment, but I will say that scope is probably the best scope I’ve used. Has a wonderful irrigation and suction combination that you can use. The optics are fantastic and you can use both white light and blue light.
But we still use a plain in office white light cystoscopy. And we have just started using it literally today. It was the first day that I used a flexible disposable scope because of the issues with the storage recall. And so we bought more than a hundred thousand dollars worth of disposable, flexible scopes. And we knew that this was happening and I didn't know it was going to be day one. Actually in my clinic until about halfway through the clinic. I acted like I knew exactly how the scope worked. The optics are really pretty good are honestly better than I thought.
[Aditya Bagrodia MD]
Yeah, we have them here. And, certainly if I was a resident, I wouldn't mind having a couple of those around for putting in complex catheters, et cetera. Certainly I got the job done. The working channel, I thought, is a little bit clunkier. And of course the deflection is kind of opposite from a typical, but certainly I think a adequate by any metric.
[Sam Chang MD]
For sure. And again, like anything there's no substitute for experience. And so the more you do the better you get. What we did do is we do have, you know, the residents will be doing certain procedures in the clinic. We've made sure that at least early on where we're going to have the residents not use that flexible scope, that's disposable early on. Just until they kind of get a little bit more comfortable with it.
[Aditya Bagrodia MD]
Yeah, I totally. I agree with you. We have some light music playing and go with the bag, squeeze. I mean, our colleagues across the pond, the EAU actually have it within their guidelines now to do a little bag squeeze. But I think these small things certainly can't hurt.
So now, you know, you've kind of made the decision. Patient's got to go to the OR. Talk to me a little bit, you know, so obviously you had an academic medical center. I've kind of got my spiel with the residents that they hear every time we would first do something like a TURBT. And what are your kind of tips and tricks for, for that initial TURBT. And are you doing these with blue light?
(3) TURBT Procedural Tips & Considerations
[Sam Chang MD]
Yeah, so would say probably blue light. I would say, 80% are done with blue light, just all comers, initial diagnoses, followup diagnosis, that type of thing. There are certain scenarios where we always use blue light. For instance, recurrent disease, multifocal disease. Those with positive cytology. We haven't been able to find something. Those always get blue light. We know patients with invasive disease that we're doing bladder sparing that we're doing basically a maximal TUR prior to initiation of, chemotherapy and radiation therapy, trauma modality. I don't do blue light. I'm resecting invasive disease. I don't see a huge benefit of finding a small papillary area somewhere else. But, some of the tricks, again, it's like anything that we do in medicine. This is one where you really need to see a couple. And then you need to kind of see what happens? Well, then the transition is to someone with a papillary tumor. That's not too deep, it's not too large. The residents start resecting kind of basically superficial. So they get an idea and then I gradually then employ them into okay. We start, and I always like to start a resection in normal appearing bladder. And it's a combination of both speed and sense of judiciousness so you can go both ways.
You can be so careful you get so much cautery artifact. You really don't have a good specimen and it gets massery or whatever. Or you go too quickly and you get a hole that's much larger than you'd like. So I really focus on a combination of speed and judiciousness. I want to start in normal tissue. I want to resect and I want to resect in a way that I'm removing as much tissue as possible with each resection bite. So early on, everyone tends to get small bites and feel comfortable. And that's a good start, but I really want to emphasize to them. Look, we need to get tissue specimens that are helpful for a pathologist. Let's actually get a real specimen bite and go through there. I'm very much into separating specimens when I can. Sometimes you can't do that, but I really like to resect normal deep, send that off. If it's a large tumor, then resect as much as I can of the superficial stuff, send that off. But then I send separate specimens, hopefully of good quality, less cautery artifact of the kind of mucosa, T1, hopefully T2 kind of combination, just to help our pathologists out as much as possible. So I think those are just some initial tricks.
[Aditya Bagrodia MD]
Cold cups at all?
[Sam Chang MD]
Yeah, I think I use cold cups as much as anyone. Cause I tend to, when I'm concerned about a tumor, I tend to use both a loop and a cold cup. So what I like to do is actually resect the tumor and then an area where I think there might still be some tumor might resect maybe before the last resection. I like a combination of mucosa, hopefully laminate propria muscle, right at the edge of your previous resection site. It takes several of those biopsies to give pathology a noncauterized specimen. And hopefully one that has orientation of mucosa, lamina propria and muscle.
[Aditya Bagrodia MD]
I think that sounds great. I totally agree with you. The art of it, and I think the perfect amount of distension to keep your loop cutting through it. Like, a knife through butter. If it's under extended, you're gonna cauterize the crap out of your specimen. If it's over distended, particularly in a thin-walled bladder, et cetera. That you know, comes around with its risks. But I think that perfect amount of distension. And then, I've actually kind of gone back to a staccato type of resection, to minimize some of that cardio artifact. And I always tell the residents, if anything feels off, just take your foot off the gas first things first, you've just gotta let go. And you know, you're not going to have a big hole or a perforation or something terrible like that.
[Sam Chang MD]
Along those lines. I think your point of the perfect amount of distension is one of the most difficult things as residents go through this procedure to, understand and to pay attention to. So when residents spend time with me, it's the twos, the PGY two. So the first year urology residents spend a day with me in the cystoscopy room. And then I work with chiefs and fellows on bigger pieces. But it's that, they either will get a false sense of security because we'll have a continuous flow in terms of just an open bottom stopcock and they think, oh, everything's fine. And then what, what ends up happening is they're overdistended and they don't appreciate that. Or because they have continuous flow the bladder hasn't filled up enough and they think everything is okay. And just, as you say, you have a combination of char or when your bladder is under distended and you take a big bite. Your bite is much bigger than, you've anticipated, the bladder folds on itself. And then when you distend the bladder, there's some fibers or fat layers. And so that combination of constant recognition. And so I think appreciation is really important.
This staccato method, we just, I actually just talked to a chief about that yesterday. Honestly we were resecting laterally and just went over. What are ways we can avoid an obturator reflex and you know, there were some struggles. I was like, you know, it's been a few years since we did this. And it's one of those things where we're probably not as good as programs should be in terms of really working on resection. And so we talked about staccato and just, as you said, look, by doing that staccato, if there's a kick, if there's an issue you're not constantly jammed on that electric cautery burning a hole where you don't want it to burn. So I love both those points.
(4) Important Post-Operative Documentation and Communication
[Aditya Bagrodia MD]
So checklists for me, it's, size number of vocality, completely resected, presence of carcinoma in-situ, was muscle clearly sampled, do they have to have a previous recurrence or exam not under anesthesia. Are these all, you know, especially for settings where the residents are dictating VA county, hospitals, et cetera. Sometimes I'm like, you know, your dictation needs to be completely reproducible. So that if it is three months later and your colleague and your partner in your co-residency, and that they know exactly what transpired in the, or what to look out for any comments on the.
[Sam Chang MD]
Yeah. You know, I think you might, you might've been there when Chris Anderson actually, after while he was in Memorial, worked with Harry Her. Going over what do expert endoscopists do, what their thought process is and they query different folks in terms of what's important and what’s not. That was the basis for, in the guidelines to talk about all those things. Did you say to make sure that's included in the operative note? So I don't harp on that as specifically as I should. What I do harp on is when you dictate your operative note for a bladder tumor, I want, whatever way you describe it, it can be systematic, but in a way that it's, as if you were looking in the bladder and you know, what's going on.
Okay. I need to know what's going on at the dome. Is it near the urethral orifice? What does it look like? You don't have to use the exact terms. Just give me terms that tell me, you know, and so I tell them I'll use terms like carpeted and covered. You know, just so you would have an idea of exactly the points that you raised regarding location size, the nature of the tumor, all those things are essential. And then at the end of the procedure, what do things look like? You know, completely resected or, you know, concerned about residual disease. All those things I think are important because you're going to be the next individual back in that bladder or evaluating the bladder you want to know. And undoubtedly, one of the things that I've done more now than I've done in the past is I've done stage resections. When I know that I'm going to come back, I want to clear out as much of the bladder in an area safely as possible. Because then I will have an idea of the stage of the tumor. So if at that point I understand I've gotten an invasive disease, I want to move forward. If not, then do tend to come back within a couple weeks or so and do a repeat resection. I worry about perforation. I worry about poor visualization, those types of things. And so have done that, especially with high volume tumors.
(5) Approaching Extensive Carcinoma In-Situ (CIS)
[Aditya Bagrodia MD]
Yeah, that's critical. So, if you're worried about extensive carcinoma in-situ, do you try to resect all of it, Sam?
[Sam Chang MD]
Yeah, I don't try to resect it to be honest. CIS if I’m really concerned about it. CIS is one where I really tend not to resect I tend to get cold cut biopsy forceps because I think you get the best specimens. Any char on that superficial mucosa you worry about. But then I do full gray, all areas that look worrisome. I have no idea. And I would love a study to look at this, if it makes any difference. The problem is there's so many ways that CIS presents and you're missing areas unquestionably. Even with the light areas with microscopic CIS. On the flip side, I hear Dr. Her’s voice in my ear. “What good does it do for you to leave it there?”. You know, it's superficial and you cauterize it. If you cauterize it, you're only talking about five cell layer thick. You've destroyed that you haven't destroyed it all, but you've removed a lot of tissue now, does that change the carcinogenesis of the tumor at all? I don't know, but it sure doesn't hurt. And I tend to do that. I am curious to hear what you say cause, there are zealots to say “That's one of the stupidest things you've said Sam?”. And there are many who say, “Oh, absolutely. I try to remove all the tumor”. So I wonder what you do.
[Aditya Bagrodia MD]
I'm with you. I mean, I kind of feel a little guilty every time. Let me backup. Is there a maximum resection, full duration surface area, estimated of the bladder that you kind of call it a day at. And I feel like sometimes I'd heard these like kind of random stats that once you get up upwards of a third or a half of the bladder that's been cauterized or resected, you really run into contract all bladders and so forth.
[Sam Chang MD]
Wow. No, I have heard that. I don't now I've not resected more than half. Okay, but have I cauterized two thirds of a bladder? Yes I have. Has that contributed to changes in bladder volume size, et cetera, et cetera. You know what, I don't think it's that as much as a combination of everything of intravesical therapies of multiple scopes and different things like that. So I mean, to me in the end, rid someone of their tumor and discard quickly and or with combination of intravesical therapy. It's worth to me a small risk of bladder contracture vis-a-vi bladder removal. And so I think I have tended to be aggressive, but at one setting, if things are going well, you know? Yeah, I try to eradicate everything I can see, but I did tell you, if I need to come back in a separate setting. I'm fine with that.
[Aditya Bagrodia MD]
Yeah, and I don't resect all the CIS, I do cauterize it. Anything visible, white light, blue light, try to get rid of it. But, I dunno something like, get my loop, you got a good thing going, or just kind of working enough current or getting a good, you know, full duration. It's like mowing the lawn or vacuum cleaning. I also just kind of hear Harry Her in the background kind of explaining the exact same thing. What about diverticula if you've got a tumor and diverticula, how do you approach that?
(6) Approach to Bladder Diverticula and Non-Invasive Cancer Management
[Sam Chang MD]
Okay. So were you in my clinic today? What are you, what are you some kind of, psychic or whatever? I just
[Aditya Bagrodia MD]
My favorite thing about this podcast, I get to ask about the odd ball stuff that happened earlier.
[Sam Chang MD]
I just got off the phone from someone who came up and, long story, short, healthy, except he had a heart attack. Got put on blood thinner, had hematuria, someone scoped him. Oh, you've got something going on in your bladder. you should have something done, but just had stints in. In the meantime, he had done research and he came up here and he wanted to have blue light cystoscopy et cetera. So low and behold, he ends up having CIS and a TIC and tumor in the rim of the tick. So here's my, take on bladder diverticulum and noninvasive cancer or T1 disease in a TIC. 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. You know, these folks with disease in the diverticulum, you don't give them neoadjuvant therapy. So it's cystectomy would I have changed those people that really had widespread nodal disease quickly? I don't know, but I've definitely successfully treated diverticular disease with BCG or intravesical chemotherapy and endoscopic resection. And that's what I'm going to do with this gentleman I'm going to try. We just did a resection. I just talked to them. We're going to do BCG and we'll, we'll take a careful look.
[Aditya Bagrodia MD]
Yeah, I don't know that I'm quite as I don't like partial cystectomy and a diverticulum for cancer because. I mean, just the tumor spill part of it is so freaky to me. Like how do you actually get that fellow out without spilling tumor, you know, suppose steers by the UO like
[Sam Chang MD]
The answer is you don't, it's just.
[Aditya Bagrodia MD]
Exactly.
[Sam Chang MD]
There's spillage, there’s no doubt.
[Aditya Bagrodia MD]
So I, that part I don't like at all one bit whatsoever. I totally agree with you, you know, you have to look at it and assess it. If it's chock full of tumor, you know, the die is cast. If it's not, intravascular therapy would be my, my first-line opinion. And, the only thing is in surveillance, I will pepper in, axial imaging a little bit more, and I like a bladder MRI just to see, you know, make sure you're not being fooled, that the urothelium looks okay. And something's going gangbusters out of the backside.
[Sam Chang MD]
That's a great point. And so I haven't done that, but I think I might now. I think that's a great point. I do. In terms of treatment. I think that, or endoscopic treatment, I almost never loop within the diverticulum. To be honest, I tend to cold cup everything within the diverticulum, and then I'll roll a ball or I’ll full grate. I just think, especially with a diverticulum with a more narrow mouth. I don't think I can have as good a purchase and distension. And so that is one alteration. Now along the rim of a diverticulum where you've gotten from, I'll be aggressive and I'll resect that rim and almost open that diverticulum up more. But then, within the TIC, I tend to use cold cut biopsy forceps.
[Aditya Bagrodia MD]
Yeah, same. I mean, I think the rims are a little bit more forgiving and you know. Almost like by definition you have some muscular hypertrophy right at the rim. So not quite as freaky. Okay, great. So what about, diesel monopolar or bipolar?
[Sam Chang MD]
Both actually probably 85% monopolar, 10 to 15% bipolar?
[Aditya Bagrodia MD]
Kind of what's available or do you feel strongly?
[Sam Chang MD]
I think if I know that there's a large bulky tumor, I then tend to start off the case bipolar. Just, cause I think I'll be resecting longer. those types of things. My default is monopolar mainly for visuals. Looking at it with water and the license and visualization I think is better. I still think things cut better monopolar, but maybe that's just because I'm more used to it. But for high volume disease that I know. The reason why sets actually come with both monopolar and bipolar instruments in our trays, but I've always found it a little bit cumbersome to switch the bags and this and that. So I tend to when I start with mono and this is just, I would say laziness. I tend to do monopolar if I’ve started it I'll keep it monopolar. Knowing something high-volume disease you see on imaging, you see it on a cystoscopy. I'll start off with bipolar and stay with bipolar because I know I’ll be resecting longer. I think some places have gone and maybe you guys have, you know, some places exclusively do bipolar. And there's no question bipolar gives a better pathologic specimen. But, there've been some small comparative trials looking at bipolar and there's, there's actually no significant benefit that these small studies have shown. There's no significant benefit in terms of less blood loss, less obturator reflex, less issues with hyponatremia, even the smallest studies. Clearly all of it showed less cautery artifact at the time for special evaluation, by our pathology colleges.
[Aditya Bagrodia MD]
Yeah, totally with you. You know, it's despite the fact that these technologies are available. What's the irrigant available? What's kind of the set? What kind of devices are there when you enter the room? For TURPs I'm pretty into bipolar. I liked that, preferably just for some kind of TUR syndrome. But for a non bulky bladder, I'm not very particular and I kind of prefer monopolar. What about if they’ve got a tumor around the UO, how do you kind of approach that Sam?
[Sam Chang MD]
So I would say the majority of my colleagues here will resect and place a stent. I am of the ilk. Again, voice in my ear. There's tumor there resect it. Doctor I just remember distinctly, I would be spending all this time trying to find the ureteral orifice and he'd be like, Ooh there's a tumor. You’ve got to resect it.
[Aditya Bagrodia MD]
That’s gotta be Dellbagni
[Sam Chang MD]
Well, yeah, exactly. Delbagni would walk in and go, huh? What are you doing? What do you do? So I resect and what I do then is if I can see the ureteral orifice, if I can see urine coming out of it, if I have not. And I really try to avoid charring around it, but I will point, cauterize around it. I don't place a stent and knock on wood. I haven't had a high stenosis rate. There's unquestionably, some patients that have developed stenosis, but I think it may be due to a number of resections and or therapy, intravesical therapy afterwards. And I've had in, follow-up I've had to put up stents and then I worry about disease, sometimes disease, but a lot of times it's fibrosis. And I've had some luck dilating, those and that. but at the time of, if there's a tumor at the ureteral orifice, I resect the ureteral orifice and try to get rid of all disease. Point cauterize areas. Don't leave a stent. If I'm really worried, then I will have them come back. You know, we could discuss their pathology. I'll get an ultrasound on that day or in the clinic. I'll have our resident just put an ultrasound probe on that side, make sure that they haven't developed stenosis and that type of thing. But knock on wood. I think we've been okay without putting up a stent, totally different from most of my partners here.
[Aditya Bagrodia MD]
And what about if you can't see the UO?
[Sam Chang MD]
I resect and I just keep resecting. And most of the times I'll have a CT scan and I'll know if they have hydro or not before the resection. And if they don't have hydro, then I just resect and I keep resecting until I've gotten rid of all the tumor, then I'll look for the UO again. And if I don't find the UO sometimes I'll get a fluorescein or it gives something or, you know, with the blue light, the urine looks yellow and I'll look for it. If I don't find anything, I don't put a perc. I don't stop. Most of the time, if they didn't have hydro before, you're not going to cause hydro to see them back. Those folks almost for sure. If I didn't see the UO. I'll see them back within a few weeks. And I'll get some kind of upper tract imaging. If I'm really worried, I'll get a scan if I'm not worried I’ll get an ultrasound, because if they didn't have hydro before it's unlikely, you've caused hydro.
[Aditya Bagrodia MD]
Yeah, I agree. I don't know, maybe I'm a little bit more nervous Nelly about it. If I see it a hundred percent, don't stent it, urines coming out. I think they're going to be fine. And, you know, haven't really been burned in that department. If I don't see it, I'll keep him overnight, get an ultrasound the next day, make them NPO at midnight with the possibility of a perc integrated stent placement. I don't really know that a week of hydro that was iatrogenic would change much. I think doing it when they follow up is totally reasonable and if they get flank pain, et cetera, you kinda got, gotta handle it. But that's, you know, it was just kind of a different way.
[Sam Chang MD]
I know, I love the safety of that, honestly, and you have instant, you know? Okay. We're okay. We're okay. So I'm good with that.
[Aditya Bagrodia MD]
What about, um, if they're getting a TURP, they need to outlet procedures say it's like a long-standing page. Do you have any issues or problems? Just handling the TURP at the same time as TURBT.
[Sam Chang MD]
No. And, and studies been done looking at that in terms of is there increased seeding rate here? Issues with that in terms of recurrence and none have been shown. But I'll be honest I have tended not to do that because our HoLEP people are so much better than me doing a loop TURP. They remove a lot more tissue and it really doesn't bleed. And we still get tissue, you know, from a HoLEP. And so If they really need a real outlet procedure. Then I tend to say, okay, we're going to do separate procedures we'll do it that way. If they have a median lobe or something that like, okay, this is the real issue. We can remove some of that. I have no problems doing it at the same time and I'll do it. But if they have really issues, with voiding and it's clearly from the prostate, I set them up for HoLEP.
(7) Prostatic Urethra Sampling Criteria & Postoperative Catheterization
[Aditya Bagrodia MD]
If it's indicated positive, persistent, positive cytology, et cetera, how do you sample the prostate urethra?
[Sam Chang MD]
Yeah, I think, maybe I have a bit of an overkill, but I'll actually do cold cut IC bites at both five and seven o'clock. So there's some slides that I've seen that show that the majority of ductal acini are basically concentrated in those areas on the clock. And so I'll do cold cut biopsies. Bladder neck, boom, boom, clean, sent off. And then I'll loop basically five o'clock, seven o'clock from the bladder, neck out to the verumontanum. And I usually take a few slight swipes in those areas and that's what I do with the initial evaluation. I think the next question is, okay, now you find, urothelial carcinoma, maybe glandular involvement, maybe ductal. What do you do? And that's a question that we debate about here. I tend to be again, a try to save kind of person and I'll want to rule out stromal invasion obviously, but then myself I'll go back and I'll do a TURP 360 degrees, bladder, neck, fearu. I don't remove all the adenomatous tissue, but I try to get fairly deep in a circumferential manner and then send it off. Then get an idea of “Where are we at”. And I still tried BCG in those patients, if there's no stromal involvement,
[Aditya Bagrodia MD]
Gotcha. Postoperatively catheter insertions. How do you make that determination? Who needs a catheter?
[Sam Chang MD]
If there's any doubt leave a catheter in. That's a good question.
[Aditya Bagrodia MD]
When you say doubt, you mean doubt that you have, so a couple of micro perfs or doubts like whether they're going to be able to pee?
[Sam Chang MD]
Yes.
[Aditya Bagrodia MD]
All of the above.
[Sam Chang MD]
Yes. How bloody are they? What does it look like? You know, all those things. And you know, I'll be honest early on. I tried to not leave a catheter in anybody. I really tried to limit that. Okay. Control the bleeding, this and that. Now I'd probably leave catheters in more than I have ever, because like anything in medicine you want to be evidence-based. But if you just had a couple recently, they've come back with a clot retention or went into retention for whatever reason. And they're in an outside ER or our ER. I tend to almost leave a catheter and everyone for the recovery room. And just to add a lot of them are getting perioperative chemotherapy different that they have a catheter. For women it has to be pretty deep and pretty extensive for me to send them home with a catheter or pretty bloody. For older men my kind of threshold for keeping a catheter in is pretty low. Now I think the more difficult question is how long? I don't want to leave it in three weeks, two weeks. I usually leave it in. I usually resect Mondays and Tuesdays, those are my main OR days. So usually I get the catheter out early in the morning Thursday, or early in the morning Friday. So they don't have to worry about a catheter over the weekend. And if they get into trouble, we can deal with it before the weekend.
[Aditya Bagrodia MD]
Sounds totally reasonable. I mean, I think it, some patients ask for, especially, you know, repeat TUR folks, just like “Doc’ can you put a cath in”? I didn't want to screw around with it and I respect it.
[Sam Chang MD]
Really good point. Or people who are traveling from far away who know that I'm going to have some frequency and urgency, right? Just leave it in. And then those patients with more frequent visits, you know, they're the ones you're comfortable with. Here's your syringe, take your catheter out. And, you know, they already have a built-in kind of, educational system where they can utilize their learning and, facilitate safety as well as convenience,
(8) Selection Criteria for Postoperative Installation Chemotherapy
[Aditya Bagrodia MD]
So you mentioned postoperative installations, who are your patients that are, let's say initial diagnosis, suspected bladder cancer, who are the patients that are getting, postoperative gemcitabine?
[Sam Chang MD]
You know, in all honesty, very few at that point. If it's the initial diagnosis for different reasons. One, if it ends up being high-grade, I want to give that individual BCG. If it ends up being low-grade, you know, honestly the majority of those patients, I want to see how they do without any therapy. So for the initial diagnosis, it's not common that I give perioperative chemotherapy very different from European guidelines. A bit different from what our guidelines say is in terms of an option. But in my practice, I tend not to give it at the initial diagnosis. For those patients with recurrent disease, recurrent low-grade disease, then I use it quite liberally quite often. The question that was brought up, which I think is a good question, is, if you have higher volume, low-grade disease. And it's the second time and you've given peri-operative gemcitabine. You know, multiple tumors. Right. You know, what do you do now? Do you give an induction six week course? Do you resystem them in a couple months? Do you put them on maintenance and then cystoscopy them in the office? And you know, I don't think the guidelines are very clear regarding that scenario. I just got that today from our fellow. Like, well, you would give this patient induction BCG. I said, you know, that wouldn't be wrong, but actually I'm going to scope them in a few months and see how they do. Because it's the first time that patient got a perioperative dose. And maybe that's all that. And I'm going to go with that, but I'd love to hear from you if you've got someone with intermediate risk disease. That you've given perioperative chemotherapy to. The pathology is not high-grade it's low-grade or, and you've given them. What makes your next decision tree? What do you do?
[Aditya Bagrodia MD]
Yeah. So, I mean, to me, that's an inconvenient, not dangerous situation. And I certainly take into account the patient's comorbidities. If they're older, second, I'm trying to keep them out of the OR, I'm trying to really do that. So if it's a solitary, less than three-centimeter tumor, and it looks like. I'll give them a dose. I mean, just like yourself, most of these patients are coming in and referred and they've already had a resection. So that ship has sailed. I beat it into the residents and said, you know, this, you got to kind of think about this at the point of care. Because if you don't, it's gone. So recurrent low-grade tumors, status, post, and induction course of BCG.
I always think it's good to reimage the upper tracks. Make sure they're not having drop mets from the upper tracks. I think that's something I've seen at least a handful of time. One of the things with flexible blue light that I liked is, we would actually just instill lidocaine. It came at the same time as the Cysview. And my like rate of office biopsy, full operations went up you know, so I'm saving trips to the OR, I'm able, I feel a little bit, it's like a bit of a, less of a, to do to. Just be like, all right, you know what a we've already got a catheter going in let's biopsy, full grade it. And then the final bit is I'll actually scope them a little bit more frequently early on. So if I'm picking up these low-grade tumors and I've established that they're low-grade, I can kind of handle them without an anesthetic and everything that kind of comes along with that.
But yeah, I mean, with you, then it's going to be, you know, a bit of a judgment on the natural history. If there were current low-grade by definition, they're intermediate risk. And to me, intermediate risk is super heterogeneous. You know, low-grade recurrent or multifocal low-grade, like I'm not worried about that.You know, it's like mowing the lawn or spring cleaning. It's a high-grade that kind of changes the game. So to kind of summarize. Image the upper tracks, solitary low-grade tumors, older patients are really want to keep them out of the OR. That's kind of, I think, an ideal candidate for a single post-up installation. If they keep on rapidly recurring, then I try to do everything I can to save them trips to the OR. And, you know, I'm really reluctant to use BCG for low-grade disease, unless I've kind of burned through everything
[Sam Chang MD]
Yeah, agree with that. And that's my. default. you know, to add onto your points. I do use maintenance, gemcitabine.
[Aditya Bagrodia MD]
Once monthly for a year?
[Sam Chang MD]
Do it once monthly for 6 to 12 months. And what I've found in certain patients just and who do I put those on. On people who have shown me a real tendency to recur quickly with high volume, even if it's low-grade, just nuisance wise to control. And so I will put them on monthly and I'll be scoping them in between. And if they respond well and are doing well, then I'll put them on once a quarter for a year. And then if they're still doing it and people tolerate gemcitabine, I think really well. I do the same with patients that I've given gemcitabine, for BCG unresponsive disease. Now I do a little bit more gemcitabine and docetaxel.But there are definitely patients that I've salvaged that I've given gemcitabine induction done well, and I put them on maintenance gemcitabine. And they don't want to stop because they'd been through the whole BCG and they're worried about their bladders removed and I've definitely had some long-term players on maintenance therapy. So I think that's really important.
Second point that I want to emphasize, and probably we do it more because we don't have in-office ability for full duration that type of thing. I do a lot of surveillance for low-grade non-invasive. I'll see one or two, they'll see it. And I'll say you don't want to go to the operating room. I don't want to take you to the operating room. And everybody's like, yep. Well, I'll take a look in six months. All right. If you have bleeding, you have problems, we'll look at it. You know, the majority of those patients, we can go for a long time without, I wish we had an office flexible blue light system, just because the scope is good and we can do those things. Like you mentioned, we're going to hopefully get that capability at our clinic at some point. But in the meantime, I do low-grade recurrence or treatment with that for surveillance in older non-healthy patients, or even young patients. I'm good with that in six months, I'll take a look, but they have to have the pathology. You know, they have to really have benign low-grade looking lesions. And then in those patients, I do send a cytology because if that cytology is post. Then there's at least a hint that this might be high-grade, then I will take them to the operating room.
(9) Selection Criteria for Additional or Repeat Resection Patients
[Aditya Bagrodia MD]
Yeah, I think that's a good point. You know, I've basically for folks with the history of cancer I've stopped sending cytology. This is kind of consistent with the guidelines. Now, who are you taking back for re-resections? You mentioned stage resections. a couple of times. I think that's the better part of valor instead of unresectable calling it a day, your bladder is coming out, just admitting that, whether it's visibility or operative duration, et cetera. But TA high-grade patients, who are you taking back for repeat resections.
[Sam Chang MD]
When there's a lot of tumor and you just want to make sure that you've gotten all the tumor. There are bladders where there can be a lot of tumor and you feel really confident that you got all the tumor and there are others where it's bloody. It's difficult to see. Location may be difficult. Their anatomy may be difficult, all their things. And before I put them in one category or another category in terms of intravesical therapy. I'll send him up for a repeat resection in a few weeks. And so anybody that I'm worried about incomplete resection, and then obviously the T1 tumors we do. I am really a believer in repeat resection for any T1 muscle present muslin. There've been articles that have been put out there's one in European urology from a few years ago saying, you know, in certain T1 tumors, you can avoid the repeat resection. And, you know, why go through that? You know, my counter argument to that is if you're going to try to spare a bladder, you want to do everything that you can, in my opinion, to make sure it's okay to spare this bladder. And so yes, there's morbidity. Yes. There's costs. But when you still have a detectable under staging rate. Well, even the smaller you think completely resected, why take the risk? So I tend to, you know, when I do it, I tend to repeat T1’s that I've done. And I'm clearly those that others have done.
[Aditya Bagrodia MD]
Yeah, I totally agree. I'm pretty, I mean, for T1 high grades, I think it's pretty much a no-brainer unless you're fairly confident that the bladder is coming out, then we can talk about that.
[Sam Chang MD]
Yeah.
[Aditya Bagrodia MD]
But, I think MRIs may help out a bit. I don't know if it's really gonna, you know, cause the post-treatment resection artifact, et cetera. That to me just seems like it'd be a tough thing for an MRI to sort out. So if it's, TA high-grade, no muscle, is that a reflex take-back or does it kind of depend on the size location? Completeness of resection?
[Sam Chang MD]
Yeah. Good question. No, I'm fine. If it's noninvasive. I'm fine not having muscle. That almost inevitably happens in a high volume case. We have lots to where you're trimming and you've probably given cup fulls, multiple cup fulls. There might be muscle somewhere. And in those patients, I'd rather get rid of all the tumor as much as I can. And not be so concerned about getting muscle that could actually make it more difficult for you to say you get bleeding or you're worried about a perf. Then you're not going to be really concentrating on getting rid of all the tumor. So if things look superficial, I tend not to worry too much about getting muscle. you know, the problem is, when you have a high-grade TA and it's lots and lots of tumor where you don't have. You know, should you go back and get muscle? Well, those patients, a lot of times I do repeat resection anyway, cause I want to make sure I've gotten all the tumor. But if there's a few tumors, there's no muscle, and we feel comfortable with that in terms of all the tumors removed. I don't do repeat resections for high-grade TA. Tell me, what do you do?
[Aditya Bagrodia MD]
Yeah, I agree. I mean, it's kind of like, you know, an analogy that quite quickly comes. The analogy that kind of comes to mind is that like any suspected fournier needs to go to the OR. Every trip to the OR in an older sicker patient has potential consequences. You know, multiple anesthetics in older patients. I mean, if you resect it and feel good about it, it was accessible. All the kind of things that you described. I don't think you'd have to rush back there. You know, in two to six weeks to hammer things out again. If you're a little bit more worried about if it's a difficult resection or is particularly large or particularly multifocal, I see very little downside. But I'm not dogmatic about everybody's got to go back, if there was no muscle. I think there can be harms. And, sometimes it's, it's not really a technical thing. It's a pathology issue. I mean, this is not like you and I are not the first persons I'm sure to say I, a thousand percent saw muscle and the pathologist tells us that there's no muscle present. So Sam, we have not even made it out of the, or in terms of any type of management we've basically spent, this time talking about, you know, really trying to get the diagnosis. Correct. And, I mean, I've certainly learned a lot, but I don't think it's going to be feasible at all whatsoever to talk about the management of intermediate and high risk bladder cancer during this episode.
[Sam Chang MD]
Well, Aditya, I appreciate just, you know, talking through these scenarios, as patients are in the operating room, what do you do? What do you think about? Because I think every patient presents a different sense of situation and scenarios. And so I love the fact that we're able to talk about a lot of differences. Cause that's what clinicians face every day. And I didn't get to ask you about what's behind you on the wall. Like, I want to know what that one is and what that one is, but that's where another time. and then I can tell you what's behind my wall and we'll, we'll catch up another time.
[Aditya Bagrodia MD]
This was excellent. Sam. So maybe if you could, I sometimes get the sense that TURBT is dismissed as a not important, not glamorous procedure. But to me it’s massive. You know, if you're, if you're going with bladder sparing approaches, you need to establish the diagnosis. Hopefully it's diagnostic and therapeutic. You can really hurt somebody. You know, last but least we’re oncologists, we're cancer surgeons. You want to get the cancer out. So I think, you know, digging into some of these components is, quite valuable, but any parting thoughts from your end to the listenership about, preparing yourself for a TURBT.
[Sam Chang MD]
Yeah, I think the most important thing is, before going into the case. You know, have as much of an idea of what's going on with the patient as possible. So the residents know I harp on this. I want to know, okay. Was the cytology positive? I want to know what the imaging shows. I want to have an idea of what's going on outside the bladder. I'm going to evaluate what's inside the bladder, but really want to get as much of an idea as possible, that's number one. Number two. going in you have different goals when you do resections for different patients. So I love your combination of diagnostic and therapeutic, and it varies for every patient for the older sicker patient with low-grade disease. You're trying to safely get rid of all the tumor and that's it. For someone with muscle invasive disease that you're doing a repeat resection before radiation. You want to get rid of as much of that cancer as possible. So you have different mindsets. So knowing that ahead of time is important.
And the last thing is never underestimate a TURBT, communicate with your circulators, tell the anesthesia folks ahead of time. This is going to be, you know, no LMA on this one. You know, this is gonna, I'm gonna be here for a while. You need to know, that communication and follow up afterwards to making sure the pathologist knows separating specimens. And I'll tell pathologists on the pathology note, you know, make sure that they know they've received chemotherapy. They’ve received BCG. Everything we can to try to give as clear a picture for all the treating physicians, I think will be really important.
[Aditya Bagrodia MD]
That's great.
[Sam Chang MD]
So appreciate this opportunity at ditches. It's always great. to see you virtually. Hopefully, I'll be able to see you in person at our upcoming AUA meeting.
[Aditya Bagrodia MD]
All right, Sam.
Podcast Contributors
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.
Cite This Podcast
BackTable, LLC (Producer). (2022, July 20). Ep. 46 – Techniques & Maneuvers for Optimal TURBT [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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