Management of Bladder Cancer
with Dr. Aditya Bagrodia and Dr. Jose Silva
BackTable, LLC (Producer). (2021, April 17). Ep. 2 – Management of Bladder Cancer [Audio podcast]. Retrieved from https://www.backtable.com/urology
Dr. Jose Silva talks with Urologist Dr. Aditya Bagrodia from UT Southwestern Medical Center about the medical and surgical management of bladder cancer.
In this episode of BackTable Urology, UT Southwestern urologic oncologist Dr. Aditya Bagrodia joins our host Dr. Jose Silva to discuss the diagnosis, surgical treatment, and post-operative management of bladder cancer.
The episode opens with a brief overview of the initial workup for a suspected bladder tumor with imaging and cystoscopy, then quickly moves into the OR for definitive treatment and establishment of a tissue diagnosis. Dr. Bagrodia walks us through his surgical approach for transurethral resection of a standard bladder tumor and explains some of his techniques for optimal visualization, resection in challenging locations, and minimizing cautery artifact in smaller tumors to provide the pathologist with enough tissue for a pathological diagnosis.
The conversation then turns to more complex or unusual cases, starting with the approach to particularly large tumors that are likely to be muscle-invasive. Dr. Bagrodia emphasizes the importance of working closely with medical oncology in these cases requiring multimodal therapy, then discusses how he balances the risks and benefits of aggressive resection versus a “less is more” philosophy based on the overall clinical picture. When aggressive resection is appropriate, blue light cystoscopy is particularly helpful in resecting not just the visible tumor but also peritumoral dysplasia and carcinoma in situ. The pair also discuss when to place a stent or even a nephrostomy tube when resecting at the ureteral orifice, how to troubleshoot significant urethral stricture disease, and approach to hemostatic control in difficult cases.
The episode ends with a discussion of bladder-sparing techniques for muscle-invasive bladder cancer, a guideline-directed option still largely regionalized in the United States. Dr. Bagrodia first reviews some of the relative contraindications to a bladder preserving approach, then emphasizes that it can be an efficacious option in appropriate, motivated patients so should be a treatment option included in the conversation with these select patients.
AUA Guidelines, Non-Muscle Invasive Bladder Cancer - https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-muscle-invasive-guideline
AUA Guidelines, Muscle-Invasive Bladder Cancer - https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-metastatic-muscle-invasive-guideline
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?
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.
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