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.

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SHOW NOTES

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.