Treatment Talk | Trans-Urethral Resection of the Bladder Tumor (TURBT)

With Dr. Yair Lotan and Patient Advocates Lori R. and Ron K.

Year: 2022

You can read the full transcript of Treatment Talks | What you need about treating upper tract urothelial carcinoma (UTUC) at the bottom of this page.

Part 1: What happens during a TURBT? A medical explanation of

Video (17 min) | Transcript (PDF)


Part 2: The Patient Experience with TURBT

Video (14 min) | Transcript (PDF)


Part 3: Question and Answer about TURBT

Video (26 min) | Transcript (PDF)


Full Transcript of Treating Upper Tract Urothelial Carcinoma

Stephanie Chisolm:

BCAN’s introduction of the Treatment Talk physicians and patients program is really designed to help you really understand more about the TURBT experience. Today, we have a special guest who’s with us from the University of Texas Southwestern Medical Center, Dr. Yair Lotan. Welcome, Dr. Lotan, It’s great to have you here. And then we also have advocates, Lori R. and Ron K., who are also here to share with you their experience with a TURBT. So, Dr. Lotan, a TURBT is a surgical procedure that’s used to diagnose and treat visible bladder cancer at the same time. And we’re delighted to have you here to explain and I’m going to turn off my camera and let you take over in terms of showing your slides and talking us through the procedure.

Dr. Yair Lotan:

Great. Thank you. First of all, I appreciate the opportunity to speak with everybody and hopefully, you’ll find this informative. It’s really meant to be fairly social. And in the sense that really, I’m mostly here to try to give you some background and then to answer questions, and really any type of question is fine. And I think it’s this is important conversation because, for the urologist, it’s such a common procedure that we really treat it as kind of a minor surgery. And yet for many patients, this is a major surgery and also results in a lot of anxiety especially since we’re talking about diagnosing cancer and the implications of the finding of the TURBT on how your cancer will be treated. So hopefully, we’ll take away some of the unknowns about this and that maybe will help you understand a little bit of what you may have already had or might have in the future.

So some of the aspects of the talk will be a little technical. I’m trying to teach you a little bit about the equipment that we have. This is obviously an atomic picture of a man and the resectoscope is really our tool that we use to go into the bladder to evaluate, first of all, what the suspicious areas are. There’s a camera and a light source, and we can look in through the urethra, look at the prostate in men, in women you go straight into the bladder and we can look around and see if there are any cancers there. Next slide.

Dr. Yair Lotan:

The real goal of the TURBT is to determine the extent of cancer if there is cancer at all by removing tissue, either using biopsy forceps or cautery loop. And the goal is to find out A, if you have cancer, and if you have cancer, how aggressive it is. Is it invading deeply into the wall of the bladder, or is it in what grade it is? Cancers of the bladder arise from the lining which is called the urothelium. And this is a lining that starts in the kidney, goes down the ureters which are the tubes that carry urine from the kidney to the bladder, go to the bladder, and then it lines the urethra. And when the cancer starts in the lining, it can stay in the lining, or it can invade under the lining into a layer called the lamina propria which is kind of a thin connective tissue with some blood vessels or it can go into the muscle, which is really the function of the bladder is a muscle that relaxes to store urine and then squeeze to empty. And then surrounding the bladder is fat and we rarely ever will scrape deeply enough into the fat because then that means we went through the whole muscle layer and we might have a hole in the bladder which is what we want to avoid. The grade of the cancer is really what the cancer cells look like under a microscope. If the cells in the tumor resemble what normal lining would be, but maybe more cells than you should have, or some disruption in the architecture, then they’re considered low-grade. But if the cells look very abnormal in appearance, or maybe they’re dividing a lot more than they should, they’re considered high-grade. And that’s something that the pathologist can tell us with a microscope we can’t tell visually. Next slide.

Dr. Yair Lotan:

Now, TURBT is a surgical procedure. Generally, it’s performed under general anesthesia which means you’re completely asleep. And in many cases paralyzed so there’s a breathing tube breathing for you. Because it’s performed under anesthesia then you’re going to get instructions to fast and most people can’t eat any solid food or liquids with milk or dairy for six to eight hours before surgery. And you’ll get direct instructions about that. Sometimes it will allow some clear fluids or coffee or water with your medicine, but you’re going to get some instructions from your urologist or from your anesthesiologist before surgery on how long you have to avoid foods. Many of our patients are older, have other medical problems, and sometimes before we recommend general anesthesia, you’re going to have to get a clearance letter from your primary care physician or your cardiologist if you have a history of heart disease, and we’ll inform you of that typically beforehand, or when we schedule a surgery. Blood thinners need to be stopped prior to surgery. And it depends on the blood thinners. Some blood thinners have to be stopped five to seven days ahead of time. Some have to be stopped two to three days ahead of time. This is typically done as an outpatient procedure. Most patients go home same day, but some patients are monitored overnight to make sure there’s no evidence of bleeding or because of issues with anesthesia and there’s some concern about sending home the same day. But the vast majority of patients will go home the same day. That means you need a ride. And so make sure you don’t drive yourself or take a cab. Most hospitals don’t want you to go home in a cab on the way after a surgery. Next slide.

The steps, typically you’ll come to the hospital two to three hours before surgery. Generally, I will meet with every patient right before my surgery and my anesthesiologist will meet with them, in most hospitals I suspect that’s a case. You’ll go to the operating room, you’ll get an anesthetic. In most cases, as I mentioned, a general anesthetic, rarely a spinal anesthetic. After anesthesia is delivered your position usually you’re lying on your back with your knees bent and legs apart. So there’s room for us to maneuver and place a cystoscope or resectoscope. So if you had prior hip surgery or knee surgery, or have difficulties bending your knees or your joints, you may want to let your doctor know just so it’s not a surprise the day of surgery. Next slide.

So again, in a moment, we’ll watch a video and we’ll let you know before we turn on the video, I don’t think these tend to be particularly problematic for people to watch, but if you’re squeamish, we’ll let you know so that the video is going to come on. But as mentioned, we put a resectoscope which is basically a hollow sheath with a camera and a lens and a light source. And we look around the bladder and make sure we find the openings from the ureters where the kidneys drain. So we don’t injure that. We’ll look around to see any signs of any tumors. Then we have a couple of different instruments to remove cancer. We either have biopsy forceps, which are just graspers, which remove relatively small pieces of the tissue. Or we have a cautery loop which is a half moon which you’ll see on the video.

Dr. Yair Lotan:

And it uses heat or an electricity to cut through tissue. And once we remove all the tissue, we’ll coagulate burn the area so it doesn’t bleed. Some cases we’ll leave a catheter and sometimes we don’t know if we’re going to leave a catheter until after we do the resection because we want to determine how deep we resect and whether or not there’s a big raw area. We may leave a catheter for a few days to let the bladder heal. And sometimes depending on the aggressiveness of the cancer and what we find we may actually put chemotherapy in the bladder for an hour after surgery to decrease the risk for cancer coming back. And that’s very dependent on the type of cancer you’ve had. All right, next slide. Okay. This is important disclaimer that if you think you might be uncomfortable watching a video, I promise you it’s not particularly bloody video. I want to note that many of you may have watched your own cystoscopy, it’s very similar. But if you do feel like you’re going to be uncomfortable, then I’ll let you know when we start the video.

Okay. Yeah. A quick transition here to the video. Okay. So what you’re looking at here is a very typical bladder cancer. It has a typical papillary appearance. This one is kind of broad, but and when you look at the adjacent bladder, you can see that the normal lining doesn’t have any growth to it. But the tumor itself is kind of broad. Parts of it are kind of more carpeting, and this is our cautery loop and it has sort of this half moon. And our job is to scrape out this tumor without making a hole in your bladder. And so you’re going to see that we turn on the electricity and the cautery loop is basically moving towards us. And we’re trying to gently shave the cancer off of the bladder in a way where we’re not going too deeply and hopefully in a way where we can control the bleeding as we go. And so we’re going fairly methodically here and okay. And this is, we skipped ahead. I don’t want you to watch all five minutes of this. And so, as you can see, oh, we’ll watch a little bit more of this, if it’s okay. The goal is at some point to get comfortable that you cut deeply in enough so that you’re under the tumor. And here you can see that there is some areas that we’ve already removed the tumor completely and cut below what we think is to the wall of the bladder. One of the challenges for us is that once you cut off the tumor, you can’t always distinguish the layers. It’s not light the nice cartoon diagram where the muscle looks different than the lamina propria. And the one thing that you can tell is if you’re cutting into fat, but you can’t always tell exactly how deep you are, especially after you cauterize the area.

Dr. Yair Lotan:

And that’s sort of the art of the resection is we want to make sure we remove all the cancer, but again, we don’t want to make a hole. And this cautery loop, as you can see we can cauterize the areas so it doesn’t bleed. And, and you can see that I’ve already resected the vast majority of this tumor and just cleaning up areas that I feel like maybe they’re not completely as deep as I would like, but again, for the most part, we always think we can come back and get more tissue if we need to, it’s hard to fix the hole and these are the three pieces, and we’re going to remove those later and send them to pathology. All right. So hopefully nobody got too squeamish, but that’s generally what a TURBT looks like. And I think it’s kind of nice to be able to see what those look like to have a good idea. So if we don’t leave a catheter, we want to make sure you can urinate after the procedure so that you’re less likely to find out later that you can’t urinate, need a catheter and have to come back to the emergency room. You do need a driver after anesthesia. Now, even though when we finished the surgery, you could see there wasn’t really a lot of active bleeding. And for us, everything looks real good. The problem is that for us, your bladder is paralyzed and not squeezing, but once you actually start urinating, you’re actually squeezing your bladder and increases the pressure and you have this raw area and it might ooze a little bit. And so it’s normal to see the urine look a little bit pink could be, look, burgundy can look tea-colored, that can actually happen for about a week or two after surgery.

And sometimes patients will call me and say, then they’ll send me a picture of what they think looks like fruit punch, or maybe it looks like a Merlo and they say, “Is this okay?” And unless it looks like ketchup or you see a bunch of clots or you can’t urinate, I usually just tell them, drink more fluid and it’ll clear up. But if you see clots in the urine or you can’t urinate, that’s when you need to let us know and you have to come in and sometimes we have to irrigate out the bladder and usually, we’ll wait it out and it’ll be fine. And once every year or two, I’m going back to the operating room to cauterize areas that I thought I did a good job in the first place. And it turns out that it was something started bleeding that was some small blood vessel, and it’s not stopping on its own. And I have to go cauterize it again.

Dr. Yair Lotan:

Next slide. So what are the complications with bleeding? Usually stops on its own. Infection, and usually you’ll get a urical before surgery and you’re given antibiotics. Some people give antibiotics after surgery to reduce the risk for infection, but that is a risk. Bladder perforation is probably the thing that we are most afraid about. If you make a hole in the bladder, we don’t have a needle and threat to be able to sew in the bladder. Usually, we can just leave a catheter and the bladder will heal itself. The body is very good about healing things. Very rarely, you actually have to make an incision and close the bladder. We all have a few of those stories after 20 years. I think I’ve had to do that three or four times. That’s okay. That’s once every five years or so when you do something a lot, but it’s obviously disconcerting for everybody involved. And usually, you end up being in the hospital for a few days. Then there’s also risk for anesthesia. And those are rare. There’s usually not a lot of bleeding, not a lot of fluid shifts, but anytime somebody who is normally on blood thinners to prevent a stroke comes off a blood thinner. That’s a risk. And it’s something that we obviously are worried about and something to consider anytime you go under any anesthetic for surgery. So what I usually tell of my patients, I tell people, take it easy. If you think you’re going to do something strenuous, probably don’t do it. I don’t know that you need to worry about how much something weighs or not. But if you’re thinking twice about whether or not it’s too much, it probably is. You really want to give a couple of days for bladder to heal and you want to make sure that you don’t do things that might lead to bleeding.

If you go home with a catheter, you usually get instructions about how to take care of it and when it should come out. And normally once you get over the aesthetic, you can go back to your normal diet. There’s not really usually dietary restrictions. Going back on blood thinners is really up to the urologist. I usually tell people, wait two or three days and make sure your urine stays clear before you can go back on the blood thinner and generally you should have a follow-up arrange to go over the pathology report. I usually will give a patient a follow-up appointment 7 to 10 days after the procedure. Before the surgery even happens some urologists will set up a follow-up after they do the surgery but you do want to know what the pathology report showed. Good. Well, that was a formal presentation. I think Stephanie is going to lead some of the discussion with the patients.

Stephanie Chisolm:

Absolutely. So Lori, if you could put your camera back on, that would be fabulous. Great. So I have a couple of big questions that I wanted to ask you. So I guess we can start with you first Lori and then the next question, we’ll start with Ron. But Lori, could you just give us a brief description of your experience leading up to your TURBT procedure. How many did you have and how prepared were you in advance of that? And what do you think you could tell people that you wish you had known prior to your first TURBT?

Lori R.:

Sure. Thank you for inviting me to participate, Stephanie. I was pretty much dragged to a urologist taking and screening by my primary care doctor after I had blood in my urine for the third time. And she refused to take my excuse that it was just a UTI and just give me an antibiotic and please leave me alone. I was absolutely terrified to have a cystoscopy. And I think part of that fear was that I had been very healthy. I had given birth to two children, but somehow I put that in a different category. I had not had any medical issue. I had not had any medical procedures. I had not had surgery. I had not seen a specialist. So, and I think in the back of my mind, I knew something was wrong. So, the urologist did this cystoscopy and said, I could wait and biopsy this but you have bladder cancer. And I think at that point there’s sort of a truism that it’s like, somebody puts a metal bucket over your head and starts banging on it once you hear that cancer word. And I really couldn’t focus on much, but I think he did prepare me and he was very compassionate. He said, “You can wait to 10 days until I get back from this conference.” And I told him, I didn’t think I’d live that long. Quite frankly, I was too anxious and upset. And he said, “Or you can go to the emergency room right now. I’ll admit you through the ER, I’ll do the TURBT tomorrow, it’s my last day here before I leave and I’ll fit you into my schedule.” So he was extremely compassionate not just to my medical situation which didn’t really require that sort of urgency, but to my mental state which was not good. And he also prescribed Ativan for me in the interim. So I was able to manage. So I had the TURBT the next morning.

Lori R.:

That was the only one I had. Physically, I think I was prepared. I did go home with a catheter which is uncomfortable, but bearable. Like Dr. Lotan said, “You don’t do much the next day. So it’s not a terrible impediment.” Although it’s nothing to look forward to. I didn’t have any bleeding, I didn’t have any cramping. I didn’t have any physical problems. The thing that was most troubling to me is that, and my urologist told me this. He said, “I wish I could tell you that this is a one-and-done experience.” He said, “Most of the time it’s not, and you’re going to be under very regular surveillance and we’ll discuss treatment options once we get the path report.” And waiting for that pathology report is a unique kind of torture as anyone who’s waited for one knows. So the idea that I was about to have an experience of some grave uncertainty to me was particularly difficult. And I don’t know that I could really absorb that at the time. I just wanted to get through the TURBT, go to the next step of getting pathology. But I think I was prepared. I just don’t think sort of the gravity of the situation of I wasn’t able to really process that. And I really appreciated Dr. Lotan saying that this is such a typical routine surgery for urologists, not always for patients, as he mentioned. For me, this is the first surgery I’d ever had. So and the first time I ever felt at risk for any type of cancer. So acknowledging that and with the sort of compassion with which I was treated was just really made it bearable.

Stephanie Chisolm:

Thank you so much, Lori. It’s really helpful to get that perspective from your lived experience. And now, Ron if you don’t mind sharing a little bit about what led up to your bladder cancer and going into your first TURBT, and I know you said you’ve had more than one to TURBT, how prepared do you think you were? What do you think you’d like to tell other people before they have a procedure if they haven’t already had one?

Ron K.:

Well, I find that bladder cancer is it’s a continuum of treatment. I’ve been treated now at the clinic for over 10 years. I’ve had four endoscopies and biopsies. I’ve had chemotherapy insertions at the clinic some of which were uncomfortable. But I feel much the same way as the other patient that once you leave the day surgery, especially if you don’t need a catheter, the recovery is easy. You stay home for a couple of days and do light activities for a week. So I just think that it’s the thing that’s hard to digest is that it’s not one and done. It’s the continuum of treatment and you may have multiple cystos over the years and you just have to follow up very closely. I have a friend who did not follow up for a year and a half, and unfortunately, he has invasive cancer and it has spread to his lungs. And you can’t leave it alone. I argue with Dr. Lotan each time when he says, “Come back in three months.” And I say, “How about four?” And we negotiate for three and a half but you have to do your clinic follow-ups. It’s very important.

Stephanie Chisolm:

So, Ron, do you do anything mentally or physically when you know you’re going to have another one of those TURBT procedures, is there anything that you do to prepare yourself for that?

Ron K.:

Not really. You have to be prepared that you’re going to have a day surgery procedure. I pray they don’t have to put in a catheter when I go home because it gives me pretty bad spasms. And the last couple I’ve had, I’ve had no catheter after, and I’ve had very good recoveries that after four or five days of light bleeding, I feel very normal.

Stephanie Chisolm:

Dr. Lotan, I have a question for you because Ron just talked about having a bladder spasms. How frequently, what percentage of patients have problems like a bladder spasm as a result of having that TURBT?

Dr. Yair Lotan:

A lot of it does depend on whether or not you leave a catheter. It also depends on the extent of the resection and the location of the tumor. But I mean, I would say it’s probably 10 to 15% probably have some, maybe not specifically bladder spasm, but they have some sense of urgency, maybe frequency, like early on, they feel like they have to go to the bathroom more. And sometimes people have some burning and discomfort. And the good news is that we do have medications that help with that. And so if you are having symptoms, don’t be shy, especially in how it is with electronic medical records, people will send me something and I can give them a variety of medications whether or not it’s perdium to help with burning, detropen or detrol, or they’re probably about six or seven medications that help with overactivity. I just don’t like to start off patients with too many medications, especially the antispasmodics, and cause dry mouth and constipation. And so I don’t like to just immediately start you with it, but if people have symptoms, we certainly do have some remedies that can help with that.

Stephanie Chisolm:

Okay. So everybody should make sure that they’re telling you what’s going on after they have their procedure because there might be something that you could do to mitigate some problems and make them feel a whole lot better, right?

Dr. Yair Lotan:

Right. And usually I give my cell phone to my patients who are having surgery, so they can always text me and they don’t have to go through some of the rigmarole, but we have MyChart through Epic and it’s relatively straightforward. It’s just, it is important. There’s no reason to suffer. If we have medications to help, then we’re happy to provide them.

Stephanie Chisolm:

Thank you. So, Ron, I’m going to start with you. So are there any lessons learned or challenges from your experiences with the TURBT procedures that you want to share with the 50 people that are on this call?

Ron K.:

Well, it’s a day surgery. It’s the discomfort is really minimal and the recovery is not difficult. I’ve had four and I don’t say I look forward to it. I just know when the doctor wants to do it, it’s because he’s seen something that he can’t handle in the office and he needs a patient under anesthesia. And you just got to do it. This is a tumor that keeps popping up at multifocal and it’s just you have to do your due diligence and you have to do the procedure.

Stephanie Chisolm:

Sure. And again, I’m just going to remind all of the viewers that are on this program, there’s a lot of information about this on the BCAN, bcan.org website as well. So, Lori, what about you? Do you have any lessons learned after having your first TURBT or what challenges did you have that you might want to share with the listeners?

Lori R.:

I think that there’s something to be said for having your first surgery be something that’s very routine that the medical staff is very comfortable with, that they do all the time that serves the dual purpose of staging and treatment. So in that sense, I would say it’s like Ron said, you wouldn’t look forward to it, but it’s not something to dread or fear. And to realize that whatever comes after is there are people like the wonderful doctors that have been in my life that will help you through it. And I think for me, and the thing that I needed, in addition, was physicians who understood how emotionally challenging this was for me. I just was not at all prepared. And so I really appreciated every doctor who didn’t say, “Oh, come on, we do this all the time. Buck up.” And treated my anxiety as an important thing to manage.

So I would say like Dr. Lotan encourages patients, “Don’t be afraid to say I’m really scared. I’m really anxious. I don’t know what’s going to come next.” And get a referral to a mental health professional, get on a low dose of some medication that can be helpful. There’s no reason to suffer whether it’s with bladder spasms or anxiety and that as much as you don’t necessarily want the lessons that a cancer diagnosis is going to have for you, try as best as you can, to trust, to be grateful for the care that you get, advocate for yourself, ask questions, don’t be embarrassed. I mean, I couldn’t even say the word bladder cancer for about six months. I didn’t tell anybody but my family. And in retrospect, that’s the way I had to deal with it, but it’s nothing to be embarrassed about. It’s just something to get the help you need, however that looks.

Stephanie Chisolm:

Okay. Great. So let’s go to some questions that have come in from our participants. How important is drinking water and walking after that procedure? Dr. Lotan, do you want to provide some comments? You mentioned that earlier and do they do anything to rinse the bladder once you’ve done all of the tumor removal to get that part out, or?

Dr. Yair Lotan:

Well, for sure, we’re going to remove all the cancer that’s floating around there as best as we can. And we use sterile water or glycine, which lysis cells, which is hypotonic, but we’ll definitely irrigate all the floating things. It’s one of the rationales for putting chemotherapy wash in the bladder to kill any cells that are floating, but that’s been shown to be useful in some patients. But if you have a large raw surface area, we don’t want you to absorb the chemotherapy. And certainly, if there’s concern that you may have made a small hole in the bladder. So it’s not something that’s used every single time, but just in general, yes.

Dr. Yair Lotan:

After anesthesia, when you get home, we definitely want you to drink plenty of fluid so that you make a lot of urine so that if you are having some slight oozing from the raw area, you don’t form clots. The worst-case scenario is if you are not making much urine and your bladder, and if you have some oozing, then you might form some clots and we’d rather the bladder gets washed out. As far as walking. I think it’s good to stay active. We don’t want you lying in beds. You don’t form clots or get pneumonia or something strange like that. I wouldn’t walk a marathon the next day. I think it’s certainly good to be up and about. But again, I would say avoiding strenuous activities, and if you normally walk five miles, I’d say one would be enough the next day and build back up.

Stephanie Chisolm:

So Ron and Lori, how about you, as far as getting back up to your normal activity levels post-procedures when you had a TURBT? Did you jump right back into life as usual when anything kind of settled down or how did you deal with that?

Ron K.:

I think I spent 48 hours or so at home and or just walking in the neighborhood. And after that, just going out for dinner was fine, and going out for a longer walk is fine. I love to play golf, but I wait about six or seven days before I do that. And within a week I’m back to normal and within a week I think every time I’ve had a procedure within a week, the bleeding’s gone. So I really feel pretty normal after a week.

Stephanie Chisolm:

Good. And how about you, Lori?

Lori R.:

Yeah, as soon as well, I still had the catheter, no, nothing was normal. It was very uncomfortable. But once the catheter came out which was like two days later, I felt pretty good. I didn’t have cramping or fatigue or bleeding and that was a big relief. So yeah, I definitely second the drinking water and moving around to the extent that you feel up to it. But yeah, the recovery was not difficult.

Stephanie Chisolm:

Okay, great. Thank you so much. Here’s another question from our participants. Why do they not send the entire tumor to the pathologist? I understand that it cannot be removed in one piece. When determining mixed grade tumors, how would a pathologist determine the percentage of high-grade versus low-grade to determine the overall grade, if they don’t have the entire tumor to analyze?

Lori R.:

They do.

Dr. Yair Lotan:

Well, we send the entire tumor. It’s just, we send it in pieces because if you have a large tumor, it’s deceptive because on the resectoscope when you look, you see, I mean, you see the entire screen, but the tube is not that wide. You wouldn’t be able to fit a tumor more than two centimeters anyway, even if you tried through the urethra or through the resectoscope. So you do have to cut into smaller pieces, but we send every piece to the pathologist. Now, in terms of the question, if 50% of is high-grade and 50% is low-grade, you don’t have a low-grade tumor. You have a high-grade tumor because your cancer will behave similar to the most aggressive aspect of it. If you have four tumors and three of them are low-grade, and one of them is an invasive high-grade cancer, we don’t consider you as a mixed tumor.

Dr. Yair Lotan:

You have an invasive high-grade cancer. You just happen to also have some low-grade or some non-invasive component. So for us, it’s not important the percentages. Now I do rarely see some patients with focal high-grade and a background of low-grade. And that sometimes does impact my decision on what to do but the pathologist will tell me that. They’ll say almost every piece I saw was low-grade and I saw a small area that I think is high-grade, and I will treat that patient a little differently, but there’s nothing that we, I don’t take anything home with me. It’s all going to the pathologist and they’re going to look at all of it.

Stephanie Chisolm:

Okay. Well, that’s good to know. I’m very happy to hear that. So can you talk a little bit about enhanced cystoscopy, whether it’s with the blue light, with SIS view or narrowband imaging. What’s the difference from your perspective and is that better if it’s available to a patient, is it going to allow the doctor to do a better job? What is the story behind that?

Dr. Yair Lotan:

Right. So normally I give a talk, I have disclosures page. So I will give you a disclosure that I do consult with Photocure, which is a company that makes blue light. And I have done research with STORZ and but, which is the company that makes the blue light scope. That aside though, there are many, many randomized trials where half the people just got white light, half got white light plus the blue light and found that the blue light improves detection of cancer especially a flat tumor called carcinoma in situ, but also improved the ability to find additional tumors. In fact, the American Urologic Association Guidelines actually recommends that if you can get blue light as urologist if you have it available, that you should use it because it does improve detection and reduce recurrence rates for patients. And the reason it reduces recurrence rate makes quite sense.

If you had three tumors and they only found two then the other tumor is not going to go away on its own. You’re just going to find it later and then that’s going to be considered a recurrence, but it really truly wasn’t a recurrence. It was always there in the first place. And if you had removed it at the initial TURBT, you won’t have to remove it as a subsequent TURBT. Now, biologically speaking, the way SIS view works and blue light is SIS view is the substance that gets taken up more often by cancer cells than normal cells. So when you shine a blue light, the cancer cells look pink. Narrowband imaging is actually incorporated with different scopes. And what it does is actually highlights blood vessels. And since cancers attract blood vessels, it’s easier to your eye would naturally go to the area with more blood vessels.

So you’ll see additional tumors. It’s actually also recommended in the guidelines. Just has a little bit lower level of evidence because the studies that were done didn’t show quite as much of a difference. But obviously, if you have a scope that has narrowband imaging, it’s actually made by Olympus, then you can do that. And I do it periodically in my clinic as well. But the vast majority of TURBTs in the US are done without either blue light or narrowband imaging. But if you have it available, then I think it does help in some cases, not in every case, but in some cases, it does add value.

Stephanie Chisolm:

Great. Thank you. I have another question, a little more of a technical question. What are the indications for fulguration versus excisional biopsy and pathological examination? What you talked about with the wire was the fulguration, correct?

Dr. Yair Lotan:

Well, fulguration just means you’re burning something. So we sometimes will take patients with, especially in the office setting where a patient, for example, may have eight small tumors, and they always only have low-grade cancer. So you already know that they’re a person who usually makes low-grade cancers and patients who have current low-grade cancers, less than 5% of them will have high-grade cancer. So if you have a patient who’s got multiple small tumors, I might biopsy one or two of them, but I won’t biopsy eight of them because that will just lead to more bleeding and discomfort for the patient. So I can actually just burn the other ones, knowing that probably if they’ve always had low-grade, they’d probably still have low-grade. So fulguration literally just means burning a tumor. We sometimes do it in the operating room too if you have a patch of tissue that looks abnormal, you might biopsy it, but you may not resect or cut out the whole patch because you don’t want to have as big a raw area, as much bleeding as much discomfort. So you might just biopsy part of it and burn the rest of it. And that’s called fulguration.

Stephanie Chisolm:

So when you’re looking for a physician to do this level of examination, can a general urologist, I’m sure they could do this, is it better to go to a general urologist or to somebody who’s really been doing a number of these procedures over the long term?

Dr. Yair Lotan:

So there are 80,000 cases a year diagnosed with nearly new bladder cancer. And there are about 500,000 people in the US living with bladder cancer. So as much as Dr. Smith and I like taking care of patients, there aren’t enough academic urologists to do every TURBT in this country. Do I think there’s a value in doing it repeatedly or having experience? Well, I’d like to think that experience helps with any procedure you do, but it’s such a common procedure that people in training probably do a large number of them. And some most urologists would feel comfortable doing it. The truth is that both Dr. Smith and I see patients who have larger tumors or multiple tumors or some complexity that the urologist didn’t feel comfortable doing the procedure, in which case they do refer them to us because they think that we would have an easier time. I don’t know that we have an easier time. It’s just, we don’t really have other people to send it to. So we end up doing them, but at the end of the day for straightforward TURBT, the vast majority of urologists in the country, it should be a more than capable of doing them.

Stephanie Chisolm:

Okay, excellent. Hold on. Let’s see. The pathology report on this individual’s last TURBT stated muscularis propria present, but it was not the same report on their first procedure. What does that mean? Does that mean that they got a deeper sample the second time?

Dr. Yair Lotan:

Yes. In general, we would like to see that the muscle is present and not involved in the majority of patients. Now, the truth is that because we cannot see, I mean, we see what we think are muscle fibers, but that doesn’t mean that we get enough muscle fibers that the pathologist feels comfortable saying that there’s muscle or that when we cut through with a loop that has electricity, it causes charring that the pathologist has a hard time saying that there is muscle. Now bladder cancer does not skip through layers. So if it’s not going into the lamina propria which is the layer under the lining, then it’s not going to suddenly show up in the muscle typically. So if you have a noninvasive tumor that’s not going into the lamina propria and there’s no muscle, then we don’t necessarily feel like, “Oh, we’ve got to back and get more tissue.” But if it’s going into the lamina propria and we didn’t get muscle, then we usually want to go back and try to get muscle. Are we successful a hundred percent of the time? No. We don’t necessarily like to go a third time. So we really try to get that tissue if we can, but it’s not always so easy because like I said, visually, it’s not like a Neopolitan ice cream where part of it’s vanilla and part of it’s strawberry and chocolate, and then you go, “Oh, I’m in the right layer. I did a good job.” So we do our best to try to get the kind of tissue we need. Again, we are a little concerned because we don’t want to make a hole and then have cancer cells spill out and you need a catheter for 7 to 10 days to let the bladder heal. So that’s the challenge.

Stephanie Chisolm:

Another question from a participant, this person had two emergency fulguration after having their TURBT because clots had prevented him from urinating. How common is that?

Dr. Yair Lotan:

Thankfully not very common. A little more common on patients who are on blood thinners because at some point they have to resume blood thinners and many patients are taking aspirin, or Plavix, or Coumadin, or any of the variety of these blood thinners because our patients are getting older and have heart disease, or have a risk for stroke and their primary care physicians like to put them on these blood thinners. And so that is a risk. Is it common? No, it’s not common thankfully, but if you do enough to TURBTs, you’re certainly going to have some patients who are going to have bleeding, and sometimes it’ll stop on its own. And rarely we have to go back to the operating room and to fulgurize some vessel that we didn’t see or that wasn’t bleeding at the time of surgery.

Stephanie Chisolm:

Okay, Let me go back to the video for a minute. What the tumor looked like on that video was very large. And what’s the size of the wire, the little moon that you were talking about?

Dr. Yair Lotan:

Oh, a loop.

Stephanie Chisolm:

Was that a typical size tumor? Was that a large tumor? People were wondering about that.

Dr. Yair Lotan:

That would be a medium tumor. We don’t really have a ruler. Yes. That loop probably is and Dr. Smith might correct me. I think it’s about five millimeters or something. So this tumor is probably the nice thing about it was, it’s not a perfect sphere. So yeah, maybe three and a half centimeters, an inch and a half in diameter, but I’ve seen when they’re much bigger volume. We’ve seen tumors over five centimeters which is what we would consider large. This would not be considered large. I mean, and sometimes it’s a bit of a misnomer. The whole video is about five and a half minutes from, and that’s basically how long I’m scraping from start to finish. Sometimes patients, well, it’s an hour procedure, but some of it’s going to sleep and getting positioned and all that. Now I have scraped for 30 or 45 minutes and get a little workout. It’s rare for me to be doing, so for us to have to resect for more than an hour, that would be unusual.

Stephanie Chisolm:

Right. Well, that was a very obvious tumor, because you could see all the little papillary things kind of swaying in the fluid. What do you do under somebody who’s got a carcinoma in situ, so a flat tumor? How much more challenging is that from your perspective and also from the patient’s recovery?

Dr. Yair Lotan:

Well, first of all, there’re two issues. I would not do carcinoma in situ patient without blue light. That was a white light, not blue light. I have many blue light videos. I picked this one specifically just because I thought it was kind of a nice view of a typical TURBT. But for carcinoma in situ a blue light is for me sort of a must. So I can see where the cancer is. Otherwise, you just don’t know what you’re doing or where you’re doing it. Now, carcinoma in situ is also a strange cancer in the sense that we don’t necessarily think we’re going to be able to resect all of it and we depend on BCG or other treatments to help eradicate all the cancer. I will sometimes if it’s a reasonably sized patch takes several biopsies and then burn the rest of it because I know it’s not invasive. By definition, carcinoma in situ is not. But if it’s occupying a third of the bladder, I’m not going to burn a third of the bladder. There’s no point to it. I’ll biopsy several areas to get the diagnosis and then I’ll rely on BCG to get rid of the rest which actually I’m relying on the immune system to get rid of the rest. I’m going to use BCG to attract the immune system to the bladder, to fight the carcinoma in situ.

Stephanie Chisolm:

Okay, great. Thank you so much. In a follow-up TURBT, is it possible that the cuttery, effect the scarring that comes from previous TURBTs could be mistaken for cancer cells, or obviously you are a very expert in doing this. So, you know what you’re looking at, but from a regular urologist who might only do one or two of these a year, or three or four, would they know the difference between potential scar tissue and another possible tumor?

Dr. Yair Lotan:

So generally speaking, my eyes are not that much better than any other urologist’s eyes, but if you’re going back after four to six weeks, it actually kind of looks like a volcano, the center where you resected looks kind of charred and then the surrounding area looks red and the kind of like it’s just kind of swollen. The tissue is just healing. If you come back three months later, it’s going to be flat and look white without blood vessels to it. And it’s actually kind of, it almost has like a star pattern. So it depends on the timing. So if we go back because we didn’t get muscle or because there were signs of invasion, we want to make sure there’s no residual cancer, we’re basically trying to get some biopsies of the floor where we resected and some of the tissues surrounding it. But I can’t tell what’s cancer. I can’t tell what’s inflammation. It just kind of looks red and angry to me. And there’s nothing special about my experience that allows me to distinguish that. And in fact, if you use blue light, sometimes that will light up too because and what we call a false positive, cause inflammation can sometimes take this SIS view as well. If you come back three months later, then if it looks just like a flat area with a scar, then I think most urologists can say, “Okay, it looks like a flat area with a scar.” So the timing is really important in terms of what it appears like. But in general, you can distinguish. If you come back a year later, you may not be able to tell at all where anything happened. And so, because the lining healed nicely and things like that. Sometimes you can see but you can’t always see. So a lot of it has to do with the timing more than the experience of the urologist.

Stephanie Chisolm:

Okay. Okay. I think we probably have time for one or two more questions. If you have multiple tumors that are clustered close to each other, are they measured together as one or individually? And I know what we just saw was showing how you have that wire and it’s only going to scrape out a certain width of tumor so you’re not going to get all of those particular things at one time. So do you make a best guess when you’re reporting on the tumor size to a patient if there’s a lot of tumors clustered together. Do you just call it one or do you say we have multiple tumors in a small area?

Dr. Yair Lotan:

In fairness, it doesn’t really matter because for us, I mean, for something a patient doesn’t care, for billing purposes it matters what surface area. And then you could add it together or you could not add it together. Let’s say you had two tumors that were one and a half centimeters. If you put them together, it’s three centimeters. If you count them separately, it’s a multifocal tumor. It ends up in the same risk category for us one way or another. So it’s just semantics. It doesn’t change sort of what we do for the most part. I suppose to me, if there’s a bridge of normal mucosa, I might consider it two tumors. I’m probably going to burn that little bridge because I’m going to worry that those cells microscopically may be abnormal anyway. So I’m not going to just leave a small little segment of normal lining or normal-appearing lining. I’ll just take care of all of it just because that little piece of lining is not going to help the patient anyway. And I worry them leaving cancer behind.

Stephanie Chisolm:

Thank you. One more quick question. Do you ever end up removing a tumor that the pathology report says it’s benign growth? Does that ever happen?

Dr. Yair Lotan:

Yes. I mean it happens more after BCG, you see a red area. I try to do more of these biopsies in clinic when I’m uncertain. And if it’s a relatively small thing, I mean, what you saw today will never be a false positive. That’s always going to be cancer. It’s very typical. It more often in patients, like you said with carcinoma in situ or patients who’ve had BCG, that’s have like a red patch which is not that uncommon. I usually will not take patients in the operating room and do resections. I usually will biopsy them in clinic and then I can categorize them as well. And if it turns out to be cancer. And I felt like I didn’t do an adequate job getting rid of all of it, then I might say, “Well, I’m going to biopsy these two areas. And if it turns out it’s cancer, we might still go to the operating room.” But for the most part, it’s not going to happen for a papillary or coral-looking thing it’s going to happen because somebody has something that looks atypical. And in order to avoid anesthesia that’s why I’ll do an office biopsy in many cases, and then only go to the operating room if I’m worried that there’s still a significant amount of residual cancer.

Stephanie Chisolm:

Right? So any tumor-looking material can be removed with the TURBT and then it’s analyzed to determine exactly what it all is. Because I know we had somebody asking about a particular type of tumor, but are all tumors that are in the bladder removed with that TURBT?

Dr. Yair Lotan:

Yeah. I mean, those are our tools. If you have, I mean I’ve removed melanoma from the bladder or adenal carcinoma, or squamous cell, I mean other types of tumors, there are some benign things that you’ll find as well, I suppose that are very rare but if you do enough of these, you’ll find some rare things as well. But in general, it’s the same type of procedure.

Stephanie Chisolm:

Well, thank you. This has been an incredibly informative program. I appreciate Dr. Lotan. You’re spending the time, Dr. Smith for giving us all of the information that we used in these slides earlier. Thank you so much. And, Lori, and Ron, thank you so much for sharing your stories. It really is helpful to understand what that lived experience really is. And do you have any parting words before we end today’s program?

Lori R.:

No. No. I appreciate the opportunity to participate and share my experience and anyone who I can help on this journey. I’m very happy to be able to do that. So thank you again for inviting me.

Stephanie Chisolm:

Thank you. Ron, any comments to add?

Ron K.:

I think follow-up is the most important thing I’ve learned in being a cancer patient, bladder cancer patient, you can’t ignore it, and it can keep popping up and you have to keep up with your visits.

Stephanie Chisolm:

Well, as a lot of people have said, when you have bladder cancer you form a long-term relationship with your urologist, especially. Especially with a non-muscle invasive because it does have this ability to come back. So Dr. Lotan, thank you so much for everything that you’ve done to get this program together. It’s been very informative. We appreciate everything. I want to remind everyone that we will be sending you a short survey so that you can give us a little bit of feedback. That’s always very helpful. And we use that to plan future programs and today’s program again was co-sponsored by the CISTO Bladder Cancer Study. So Dr. Smith and Lori because you’re on the advisory board for that, thank you so much.