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One, every everyone who's joined so far. Um Thanks for coming and signing up. We'll start in a few minutes. I think we'll expect a few more people. Can I just confirm uh in the chat if you can hear me? Mhm. Yes. Thank you very much. It's always hard to tell when you can't actually see people's faces. No, let's go from the beginning. So, welcome to my talk today. Uh, we'll be talking about bladder cancer and its surgical management. My name is Charlie. Er, I'm a course surgical trainee um UK based, er, working in the southeast of England. Um, my main passion is urology and I've been uh working with a lot of bladder cancer patients over the last, uh, let's say almost two years, I've been doing a lot of other urology stuff as well and we've got a few other urological cancer videos on our middle page as well as other stuff um related to other specialties as well. Um, and as my knowledge has grown, I've realized actually there's a lot to surgery that you can only really learn if you go to the operating room and even then realistically it can be quite challenging when there are a lot of people also wanting to learn at the same time. So I think talking through it can be really useful and I wish I'd been able to have that before, kind of having to learn the hard way. Um, but without further ado uh we'll get starting. Um, I will say I, um when presenting, I er, won't necessarily be able to see or monitor the chat very easily. Um, but keep your questions going in the chat and I'll try and answer them at the end of the session as best I can. Thanks very much. So, learning objectives today are er, to recognize the key presenting features and risk factors for bladder cancer, er, to understand the national hematuria referral guidelines. That's I appreciate we've got some people from all across the world, so that's UK national, but I can't imagine they're two different elsewhere. Um, recognizing how bladder cancer appears on cystoscopy. So I'll have some pictures as well. Uh how it's investigated following its diagnosis and how it's treated as well. Getting an understanding of flavor for how the staging and grading affects bladder cancer management and why it's so important the surgical options used to treat bladder cancer, where we're talking about some of the techniques in a bit of detail and also some of the key postoperative complications following bladder cancer surgery and given it's such a major operation, um, there can be a lot of complications to consider as well. Bladder cancer is common and it's associated with significant morbidity and mortality as well. Unfortunately, it can be particularly challenging to treat compared with other cancer. And as such, it has poorer outcomes than other forms of cancer. Surgery is a key part of bladder cancer management at a number of different stages throughout uh the cancer journey. Um, and it's important to understand um why that is, it's also important to understand why certain population groups are at significantly higher risk than others. Uh, bladder cancer has been been called sort of the poor person's cancer because the socioeconomic differences between the patients who get bladder cancer and the ones that don't. And also the stage at which these patients are diagnosed based on the socioeconomic status of the patients. It's the U K's 11th most common cancer and its incident rate is about 10,500 a year. It also results in about 5.5 1000 deaths per year in the UK. It's more common in men in women by quite a long way. It's the seventh most common cancer in men and 17th in women. Um, and that makes a massive difference to our patients population and as well as surgically as well. The good news is that bladder cancer incidence rates have fallen by about 16% in the UK in the last 10 years and its incidents are predicted to continue to fall. Er, and that's probably a large part due to, um, public health information about smoking because smoking is the biggest preventable cause of bladder cancer in the UK. Er, and 49% of all half the cases are preventable. Um, if, if patients just didn't, er, didn't have a smoking history, it's also strongly linked with deprivation. Er, and actually the women who are deprived are significantly more likely to get it than the women who are not deprived. Rates are also higher in white ethnic groups than other ethnic minorities. Um, and is unfortunately a cancer that tends to come back and can come back with a vengeance as well. So the one year recurrence rate is between 15 and 61% depending on how it's presented. So the staging grading features, um, as well as the quality of the surgery you you receive to resect the cancer if that's, you know, is, is indeed possible. Um, and also the five year survival rate is between 31 and 78% which is much larger than a lot of cancers. The five year survival rate is about 78% which is again lower than other cancers, er, but is still a lot better than other cancers too risk factors. As we mentioned, around half of bladder cancer cases are caused by smoking and you're more likely to get bladder cancer with a heavier smoking history and a longer pack year history, age and male gender also significantly increase the risk. So, a classic patient is an older man who has a smoking history and then there are some less sort of potent risk factors. Schistosomiasis, which is a tropical disease, otherwise known as Bilharzia. Um is a, is a waterborne infection and increases the risk of squamous cell carcinoma of the bladder, bladder radiotherapy, which is ironically also a treatment for bladder cancer can also increase your risk just like radiation everywhere can increase the risk of cancers. Long term catheters, um which may lead to sort of chronic low grade infections can also increase your risk. Um and then industrial exposures, which in the UK, because of our declining industry is not actually particularly common. Now, um things like dye industries and rubber industries uh make this more common. Er, and I'd be interested for some of our um, listeners abroad is this is still a common risk factor in your country. I'd like to, I like to sort of see if that was the case presenting features. Er, the classic is visible hematuria. Er, but actually many cases are asymptomatic and are found incidentally or indeed are found at a later stage when they become symptomatic, which is also part of the issue with its treatment and diagnosis. Visible hematuria. Actually, you know, no disease is found in between half and three quarters of the patients that have visible hematuria. And that's because so many other causes of visible hematuria exist. Think about anticoagulants, urinary tract infections, catheters, bleeding from other parts of the urinary tract, um, bleeding that might actually come from the vagina, for example, uh, trauma. Um, you know, all sorts of different reasons why, uh, bleeding may occur and actually only about sort of 16 to 19% of all cases investigated with visible hematuria actually have bladder cancer when it comes to non visible hematuria. Er, you know, even fewer cases have bladder cancer about three or 3 to 5%. Um, and so these are cases again, often, er, sort of incidentally found to have microscopic hematuria during investigations for other reasons and, er, are sent to urology nevertheless. And we do need to, er, look at these cases because, you know, up to 5% risk is still significant. The large majority of cases with non visible hematuria do not have bladder cancer. As you can see, 68.2 to 87.3% don't actually end up having bladder cancer. Um, so if a patient is nervous in clinic with you and they have non visible hematuria, you can say that chances are actually they're not going to find anything. But nevertheless, it is important to do this investigation, er, er, regardless patients with larger tumors, um, that are significantly infecting the bladder capacity can have lower urinary tract symptoms, the frequencies urgencies, incontinence leaking may present with retention, particularly if it's causing bladder outflow destruction. Um, but actually, yeah, as I say, you have to have pretty large tumors to have this. Er, and um, because a lot of cancers are not large enough to cause these kind of symptoms. Many cases are asymptomatic. Er, it should be noted though that your carcinoma in situ patients are more likely to present with your um, urgency and frequency type symptoms. So it's important to be aware of that. Again, classically with all cancers, your weight loss, bone pain, headaches, confusion, appetite loss, fatigue are also important to ask about your history. Taking. These patients may have sort of later stage advanced cancers. So we investigate bladder cancer. Um, well, we have to get patients in with a two week wait referral, er, or if they can have an urgent review in hospital, we can do that as well, but it classically occurs in a hematuria clinic which is dedicated to investigating this symptom. Um, all investigations, um that is er, the history taking the flexible cystoscopy, the urine dip, er, and the scans that you need, er, should be done within two weeks of referral. And as a result, most centers employ a one stop shop system where they can have all investigations in one sitting. Um, the issue with not having this is that it's all well and good getting them the, er, in person investigations with the doctor within two weeks that usually is done quite well. But then if you're then referring them for a scan on that day, um, chances are it's probably not gonna happen within that two week period from the time of referral, um, particularly if they've rated at the latter end of that two week period. So when you get patients in your hematuria clinic, this is the standard thing that they should all receive so thorough history, abdominal examination, men generally speaking, should have a digital rectal examination. Um because the prostate can lead to uh bleeding but also, er, because actually, uh you can feel fixed tumors during the dre by manual palpation as well. And the same goes for women with um, bimanual er PV examinations, a urine dip with or without a um culture and sensitivities, flexible cystoscopy. And that is if they don't have an active clear infection that might make them at risk of developing a worse infection at the time. Uh A CT urogram, um, generally speaking, for your visible hematuria patients, we'll go over what a urogram actually is in the moment. Um, but this may also be in the form of your ultrasound, um K UB in your lower risk patients. And I put in brackets urine cytology because this isn't always done and it's not particularly sensitive in a lot of cases. Er, I know it's a large range, um, you know, with 100% sensitivity in some cases but that's, that's very rare. Um, a lot of the time it won't come back with much at all and, and many don't see the point in doing it very often unless there's a clear contraindication to other investigations or it's a case where you think it might be likely to come back as sensitive flexible cystoscopy. Er This is the gold standard investigation for bladder cancer as it allows for the direct visualization of the urethra and bladder mucosa. It also in men allows for the visualization of some sections of the prostate. Bladder cancers typically appear as papillary, solid tumors or as red patches. Um And you can see in that diagram over there, what exactly I mean? And we'll go through that in a moment. Um Some of them can be very subtle and easy to miss. Um something to try and look, look at if you're on your urology placement or um rotation is just how tiny some of the lesions can be. I was really surprised when I went to one particular clinic and so many tumors that were so small that they'd actually be very difficult to see if you didn't have AAA trained eye. Um bladder carcinoma in situ can be very difficult to visualize. And there's something called narrowband imaging can be used to help find tumors. So what do I mean? What do I mean by Hillary? Well, it's a sort of soft leafy er kind of visualization that you see poking out of the mucosa. And there's a fairly good diagram as to what they look like with a cross sectional image. Um You've got your cis which is usually flat. And obviously, you can see why that might be difficult to see during your cystoscopy. Uh And then you've got your solid tumors, which do look more classically like a, a hard irregular craggy mass that you might associate with cancer. So mention that narrowband imaging and you can see here on the image on the left hand side um that that is pretty subtle, fairly easy to miss um and very difficult to actually map out the extent of the tumor. So that's your normal cystoscopy picture. But with your narrowband in your imaging, the sections in red are much easier to see and those are the sections that represent cancer. So you can see how that might be very useful CT urogram. It's used actually to diagnose cancers of the upper urothelial tract, not for bladder cancer. Er but it can also be used to detect uh bladder cancer as well. It involves doing the CT scan with contrast with a delayed phase. What do I mean by that? So we inject contrast into the veins, we allow it to travel around into the er right er cardiac system through the bronchial system, into the left system, through the arteries and then through into the glomeruli and then into the nephrons of the kidney, it goes through the nephrons that's excreted and then the contrast is visible in the collecting system of the kidney in the ureter. And then if you wait long enough you can do a cystogram and it's visible in the, in the bladder as well. So that allows you to actually highlight what the ureters and the collecting system uh actually appear like. You can therefore hopefully see filling defects uh and aspects that may represent ureteric cancer or cancer in the renal pelvis as well as potentially bladder cancers as well. Um not gonna touch much more on upper urothelial tract cancers as we do have a separate session on that. Um But you can see without the contrast with an ultrasound, it's much more difficult to actually detect a uh upper urothelial tract cancer. Um Because of the importance of that contrast, incidentally, these er delayed phase images can take around 40 to 45 minutes to an hour after the contrast is injected to get into the system. So the scanner is done after that period of time. So the initial scan with a plain film and then they wait that time to do it again so that they can highlight the ureters. So our first case, I thought I'd break down um bladder cancer into a series of cases. There's a 65 year old male who attends the hematuria clinic. He recalls having a few episodes of blood in his urine in the last month. He has no uti symptoms and his urine dip showed er that there was plus plus plus blood, it was negative for any signs of infection. His past medical history for his hypertension and asthma. His performance status is zero. That means he's fully independent with his activities of daily living and he has a 20 year pack history. His digital rectal examination reveals a small, smooth and mildly enlarged prostate ct urogram showed no significant findings. His flexible cystoscopy however, reveals three papillary lesions on the posterior wall of the bladder, the right lateral wall and the anterior wall. So I'd like to ask what you think should happen next. I'm just gonna stop sharing whilst people just answer in the chat, what we think should happen next? Yeah, well done, Josh Tur Bt, correct. So, so CTCA P is also um chest Abdel S for anyone that's not sure about uh C ap it's also very sensible um because the patient will need staging as well. So staging CT tap and the Tr BT. So, well, them guys you nailed it. Um I'll start sharing again. Ok, brilliant. So I think so as was mentioned by er the guys in the chat, all patients should have a staging. CT. Counseled about Tur Bt, if this patient, this patient's fit and well, so they should be able to have it very few significant comorbidities. Um They should be given the bowels leaflets regarding the procedure. So, bowels for anyone again, who doesn't know is British Association of Urological Surgeons. Um again, which whichever leaflet is used uh where you were. Um the purposes of Tr BT are both for resection, uh which may be curative, it may be for debulking. Um but it's also to acquire a tumor sample for staging and grading as well. So it has a dual function. The risks and this should be on the consent form include dysuria. Basically, everyone will get that infection failure to cure, uh which is pretty common bladder perforation and other damage to structures, urethral stricture, bleeding, anesthetic risk. So mention you're I always standardly uh put AMI VT stroke uh and, and, and not make it through the operation for all in all my consent forms need for a catheter and need for an additional surgery as well. So, the first stage of TR BT involves performing your rigid cystoscopy. And so that should be the first thing you try and master after your flexible cystoscopy in clinic after you've done that, er, to do that, what you need to do is you need to first set up your cystoscope. So you need to know the anatomy of your cystoscope after you prep and drape your patient as well. Uh You need to identify the urethra, you need to pass the scope through the urethra, meatus and the urethra and sometimes in some patients, uh you can't do that because the urethra is too narrow. In which case, you might use cluttons dilators in order to dilate it up to the appropriate size as well. That's generally in men, more than women hold the penis vertically in men to age, the centralization of the lumen, you don't want to be scraping the lumen as you're going in cos that can cause damage to the urethral mucosa er and can cause strictures, it can cause false passages and all sorts of unnecessary damage. As you enter the prostatic urethra and the urethral sphincter, lower your hands. Again, this is obviously in men to enter the bladder as well. That's something key because of the er curvature of the urethra. Obviously in women, um, the urethra is much shorter and the main issue is just identifying the urethra and being able to safely insert it into the blood. So that, that's when you need to do your rigid cystoscopy, you need to identify the ureteric orifices. These are your key anatomical landmarks. If you're resecting those. Unfortunately, what you're gonna do is you're gonna resect, um the ability to er drain the kidney and that's not gonna be good, identify your tumors and empty the bladder. You've then got to load the receptors cope, which is not the same as your cystoscope um with the working elements and connective bipolar diathermy. So that's a lot of things that we'll go to through in a second resect the tumor superficially and up to the muscle layer because you need to get full staging for the tumor. You need to include muscle. Otherwise the patient's just gonna have to go back to theater just because you weren't able to get muscle layer from your initial resection. So you need to go deep enough to get the muscle but not too deep as to perforate the bladder. So, what do I mean by all this receptors cope business? Well, actually, we have to realize that your scope is just the initial innermost layer. It's a bit with the camera, it's the bit where the light lead goes on to uh your cystoscope. When you're doing cystoscopy, we will also have your visual obturator and your outer sheath. Er, but that's not the same as resectoscope, which is, er, er, larger ball, er, and it also includes your working element here. So that's probably seen it in theater. It's the section that we use to resect, er, where you, you use with your hands, you need to add the loop or the roller ball and depending on what instrument you need at the time for Tr BT, it's the loop. Er, and you need to attach that in that er, smaller, er, cylinder on the working element, then need to load it up with the outer sheath for resectoscope and you need to go back in um, er, and perform a cystoscopy here. You can see it quite well, but the resectoscope sheath has one tap that's er closer to you. I imagine you're the other way around, er, than the other one. That's where your inflow of water should be going in, it shouldn't be going in the other one. That's your outflow and the benefit of a receptors cope is that a, the vision is better, but also you can have continuous er inflow and outflow with the fluid. And so that is obviously helpful for emptying the bladder, making sure the bleeding that you will cause from resection is being drained away, being replaced by fresh fluids. Uh going into the bladder surgery on the lateral wall of the bladder, which you know, remember our patient had right lateral wall lesion can stimulate the obturator nerve and this can lead to what we call the rapid er, the obturator kick, which is rapid er, leg abduction to mitigate this, what we can do is use bipolar diathermy, er, which has a lower current, er, and generally the er, er, current going through is staying between the two ends of the um, diathermy rather than going through the body. And then to the diathermy pad, that's the difference between bipolar and monopolar. Discuss the need for paralysis at the theater brief, you can't do paralysis if the patient is not er, under general anesthetic. So, if this is being done under spinal, due to anesthetic risks that can't happen. Um, but also, er, if it's being done under general anesthetic and you need to think about paralysis, mention it to the anesthetist, make sure it's done. Um, and then you can hopefully resect safely with the patient breathing safely under anesthetic as well, avoid overfilling the bladder, which is the temptation that all uh junior trainees have, er, because if you overfill the bladder bladder is under more pressure and you're more likely to cause a perforation. Uh But obviously you don't want to underfill the bladder because you need to have space to actually work. So you need to get that balance with your fluid, right? You need to have your inflow and outflow balance correctly, um, and, er, avoid doing anything like that. Uh, my consultant, er, that I was working with today, er, has told me twice actually. Now that when she was supervising an sho in the past, um sho overfilled the bladder and just with the bladder biopsy. So, which is not as, er deep as a bladder resection. And at O BT that caused a bladder rupture, er, just from that. So it's really important, it's also really important to read the patient's clinic notes preoperatively because they'll be able to tell you where the cancer is and so where to focus. And it also means that you're less likely to miss any tumors as a, as a result as well. Last but not least, uh ensure adequate re hemostasis through what we call cystic diathermy. So apply the diathermy buzz all the areas that you can, that's usually best done with the roller ball, which you can see in the bottom here. Um, and um, you're able to apply that heat to the mucosa safely, er, whilst burning all of the bleeding vessels, um, from my experience when you resect the pilary lesions, it's actually only gonna have adequate bleeding control once you actually resect all the way down the um initial mucosa down to muscle. If you try and do cystodiathermy, before that, it's just gonna keep bleeding. So actually, you just need to uh keep resecting as, as so, so long as it's safe to do so up until you reach the muscle layer as well. Fine. In theory, if there's small lesions um that you can er destroy, you can do that with the assisted dim. And the roller ball depends partially on the purpose of the tur bt. Um how fit this person might be for cystectomy, for example. And also to what extent do you think the tumor is gonna come back in if they're fit for radical surgery in the future as well? That's um because if the tumor is around the bladder, there's no way you can resect it all. At least one thing you can do is try and, and kill off and, and reduce the bulk of whatever is there uh through cysto dither. Um So that's one thing to consider as well, is one thing you might see. And again, we have techniques and theater um photodynamic er er therapy and imaging that can help us er identify lesions. Just look at the one on the left. I'll be honest, I've, I've compared this presentation, I've seen plenty of tumors. I wouldn't be able to tell where a tumor is there. It's a very subtle change but look how clear it is on the PDD um imaging, it's much um better. So, photodynamic diagnosis is. What's that, what that's called intra Zyc or mitoMYcin? So, mitoMYcin is a chemotherapy agent very potent and can be given at the end of ATU R BT. It's given via a catheter in theater at the end of the procedure. Um It's mixed in theater um as, as uh the um decision is being made to install it. Um and then it is uh put into the bladder with as much exposure to the um mucos as possible. So you want a fairly empty bladder to it. Um, and then you attach a valve that you can turn on and off and that valve, um you put it on closed once it's in um, and then it can stay in the bladder for about an hour or so, er, to prevent it leaking out. And then once the patient's safe and back on the ward, er, you can turn the tap on again, flush the bladder out, er, and get rid of the chemotherapy agents. It's shown to reduce the risk of bladder cancer recurrence. Um And that can be up to 44% risk reduction within 12 months. It's recommended as standard practice following TR BT for new and recurrent cases, er, in which there is no, er, t to or above disease because once it's in the muscle, it's not effective giving it in theater is also ensuring that it, er, is given quickly and in a safe environment, er, rather than somewhere where people might not be experienced with chemotherapy agents. Um and it's also given as a six week course er, after tr BT for your non muscle invasive ca er cases. So they can also be given in a dedicated urology clinic as well, bladder cancer staging. So in with regard to T staging, it can be divided up into two sections, nonmuscle, invasive and muscle invasive. Er and that's the key difference um often when it comes to deciding what exact treatment they can have. So, non muscle invasive includes carcinoma in situ er for anyone that needs a reminder that is cancer that's not spread beyond to the basement membrane. Ta So that's noninvasive er beyond the innermost urothelium. So just within that innermost epithelial layer, T one embedding it a bit deeper into the underlying connective tissue, the lamina propria then getting into muscle invasive T two into the muscularis propria. T three into the tissue immediately surrounding the bladder. Er so um up towards the serosal er er serosal layer of the bladder, um and then t four directly invaded directly into the surrounding organs. Er, classically things like the prostate, um the rectum er and er the um gynecological organs as well. Patients with T four disease, you may find that they have a frozen pelvis and they're the ones that you can feel on your bimanual PV, palpation in women and dre in men as well. Nodal staging. Er It's fairly simple. So N zero, no mets into the lymph nodes. N one, there's a one single pelvic lymph node involved, N two, multiple pelvic lymph nodes involved, then N three into the common iliac nodes or beyond. And then M staging is just whether or not there are metastases at all tumor grading. So I should say at this point that the vast majority of cancers in the UK are transitional cell carcinomas. So T CCS um so your bladder mucosa and your ureteric renal pelvis, mucosa. Uh That's transitional cell urothelium. Um I mentioned squamous cell carcinoma as well. So, squamous cell carcinoma more likely in the schistosomiasis cases, but over 90% are TCC two systems of grading tumors. Um So grades 12 and three, there's also low versus high grade. Um All grade one cancers are low grade, all grade three cancers are high grade and all your grade two cancers depends on the other features of the cancer as to whether they are um high or low risk. All carcinomas in situ are high grade and that is uh a difference between bladder cancer and other forms of cancer. For example, breast cancer, er where your carcinomas in situs may not be um er higher grader grader than your actual t er one cancers, for example. So relook Tur bt you may have seen on a list, you may have been to, er, that a patient's actually having a Ta Rook Tur Bt. And that goes back to my point that Tr BT is not the best operation in the world, it's not the most effective. And that's why we need to go back and do it again in a lot of cases. Um, and in a lot of cases are standard as well. That's, um was always gonna be the case based on their disease. Sometimes it's also because the resection is insufficient. Er, for example, if there's no muscle can't do proper staging, if there's no muscle. For example, also the reason why it's necessary is, is bladder cancer is just often multifocal er and not all the tumors um are, are seen and not all the tumors are resected. Yeah. Rook is recommended for all patients with T one disease, all patients with T with grade two or above grading incomplete resection. Er, and so that's if there's positive margins um around the cancer. But, and also if there's no muscle found on the histology, you should be able to see the areas of previous resection. When you do your cystoscopies, you can see the scar tissue compared to that pink healthy epithelium from before as well. So that's where you can aim your, er, er, aim your resection and your relook to your R BT. You may also see that there's just tumor there. That's obvious and that's where you need to assess, obviously resecting in, er, scar tissue, er, believes a greater risk of bladder perforation and things like that. So, it's best done with a senior clinician, er, doing the operation really should be done within six weeks. Um, in low stage, high grade patients, bladder cancer has high rates of tumor being left, left behind. Uh, and local recurrence is around 50% within 12 months, which is massive. Um And that's because actually, you know, we say you do your cystoscopy, you be all, you know, professional and you've got experience, but actually it, it's just as difficult to identify all the tumors as we've shown with some of the images. Um and reality is effective at leading to disease upstaging in a lot of cases, your, your cis patients have a particularly high rate of recurrence and progression rates uh just because of your er inability to see them as well. So I'm not, I'm gonna read off all of these er risk stratification criteria. Um This is taken from the European Association of Urology, but the reason I include this, this diagram, this picture is just to appreciate the stratification group. So low intermediate and high and to appreciate actually anyone who's t one staging or above is automatically high risk. All your grade three patients, er your carcinoma in situ patients er are all high grade by definition. So that is, that is a la high risk sorry, by definition. And, and that includes a very large percentage of the patients that are treated for bladder cancer. In order to be low risk, it has to be a primary and solitary small lesion with low grade. And so you can see that's not actually gonna be a large percentage of patients. Unfortunately, your intermediate risk tumors are just the ones that don't fit into, er, the other two groups neatly. And that includes a lot of, er, tumors which you can have a look at on the E AU guidelines. So, what do we do after tr BT? Well, it depends on the risk, of course. So low risk, they have a surveillance, flexible cystoscopy at three and 12 months and if there's no recurrence, uh many of them can be discharged uh intermediate risk patients, we can consider intra zo called BCG or mitoMYcin. So we'll talk about BCG in a moment and the high risk patients can get, er, intra recycle BCG or actually, even though they might have um non muscle invasive bladder cancer, we still consider them for cystectomy and then there's very high risk and they need a radical cystectomy or if they're not fit or willing to have that they need to have BCG. And BCG is a form of immunotherapy. It's given in six rounds. It's a form of live attenuated mycobacterium bovis, um, which is not similar to tuberculosis, um promotes the ability of the immune system to identify and kill cancer cells. Um, and it's shown to, it has been shown in, studied to lead to a 27% risk reduction um of recurrence. Of course, if it's, er, increasing the risk of the immune system attacking um, cells cancer cells, it also can attack to our own cells. So it can lead to significant side effect and many patients have to come off the six week course. Um, for example, the other day, there was a patient who uh unfortunately suffered reactive arthritis type symptoms, er, leading him to have aspirations of his knee, lots of pain, very difficult er, immobilization. And we think it's due to side effects of BCG, we can't prove that, but it probably is given that he didn't have er, issues with that before. Er, and so he had er, five rounds of BCG. Er, and so we decided he shouldn't be for his sixth round. Um just due to the risks, given his development of symptoms after that fifth round, it's given after your T ABT but not too soon after. Er, and it cannot be given in patients with a UTI or bladder trauma. Uh uti obviously because of the immune effects that I've mentioned, but obviously, bladder trauma, um that's actually the same for mitoMYcin, er, just because it will leak out of the bladder and then cause systemic effects which uh uh we don't want um mitoMYcin being a chemotherapy agent uh can be significantly er, damaging to the body. If it leaks outside can affect the immune system, it can affect large parts of the body. So, if there's a risk during your resection, um, that, uh, you have caused a perforation, maybe you've taken a swipe, that's too deep. Either you're sure there is a perforation because you can see it or you're not certain, better to not give the mitoMYcin, er, in theater, as I mentioned before. Just because, um of that risk should also say. Actually, I've heard that, er, those who do get um mitoMYcin through a perforation of the bladder, apparently it is one of the most painful things and they have severe abdominal pain. So that to consider as well on to our next case, which is a 60 year old lady, er, who presents to hematuria clinic, she has a performance status of one. So she's pretty, er, fit found to have a large solid mass on the left posterolateral wall of the bladder and two papillary tumors on the posterior wall. She undergoes a TBT and that successfully resect the tumors, er, and includes muscle. The staging ct reveals no distant metastases. His histology comes back. However, as a grade two P two B cancer, she's happy to undergo further treatment. What are her treatment options? So, I'm gonna again, stop sharing. So I can see the chat, er, and just ask you guys, what do you think her treatment options are? Remember she's had um all of the investigations that she needs, let me know if you need me to go over the case again as well. So, the suggestion about Rook to your R BT, um, why would I not go for a rook to your R BT intra cycle BCG is an option? Um, so she's had at O BT already and we've got the, uh, I've got the histology back. Uh, just a reminder. It's P two B cancer. Um, so it's muscle invasive. She's in that muscle invasive, a few suggestions. So we'll go through what we do in these cases. So her options, radical cystectomy, er, we can't do much in the form of local treatment in patients with muscle invasive disease. Once it's reached down to that layer, we can't do er, curative er, treatments through tur BT anymore. Radiotherapy, which I saw someone suggests. Uh So it's very good. Um, is another option. Um, generally for patients who either are not fit for er, cystectomy or can't have cystectomy and palliative care. So, when we think about treatment options, let's not forget about palliative care. So, intravesical treatments like BCG and mitoMYcin at this point, er, will be ineffective. Um just because it's reached down to that muscle layer. So fortunately, these intravesical therapies, if you think about it injecting them, having them go around the mucosa, um is all well and good because it can treat the mucosal disease. But once it's past that mucosa, it can't get to the muscle. Er, and so, er, we need to think about more, er, radical methods. Um, and these include cystectomy and radiotherapy realistically with radiotherapy as well. Um, the ability to lead to curative treatment is limited, er, but there are other, er, benefits to having radiotherapy potentially as well cause a lot of side effects as well. We should also think about neoadjuvant chemotherapy. So, neoadjuvant being before surgery, um, and that can help debulk tumor. Er, it can also help er get rid of cancer within the er lymph nodes as well. It's been shown to boost cure rates, but of course, chemotherapy uh can lead to significant effects on the body. It's not an easy thing to go through. So it may affect patients fitness, which is just something to consider as well. So, radical cystectomy can be performed er via the open or robotic approach. Generally, there's also laparoscopic approaches as well. It involves removing the tumor, the surrounding organs, the lymph nodes and of course, it needs to have urinary diversion as well. We can't just have uh the urine leaking into nowhere because of the surrounding organs being different. In men and women. The operation is different between the two genders. Er, and so in men, um we obviously remove the bladder, the distal ureters, er, but we also removed the prostate prostatic urethra seminal vesicles and ejaculatory ducts. So you may see it called a cystoprostatectomy. Er, but in men, it's, it's always er, involving the prostates, er, as well. It differs from a simple cystectomy which you may see, er, in that terminology you use that only removes the bladder and creates the divergent. Er, some people, for example, have really bad interstitial cystitis, for example, or leading to significant urgency and, and lower urinary tract symptoms. And one way of treating those patients is kind of, you know, when they get to the end of the road for any sort of medical management, uh they can have a simple cystectomy. It's not a common thing. Uh but it's just something to be aware of. So, when we remove prostate and prostate cancer and you can watch the prostate cancer video that we produced a while ago. Uh it can significantly affect erections. Um And so some people think about nerve sparing approaches and that's because the neurovascular bundles that control erections run sort of just posteriorly and inferiorly to the prostate uh bilaterally. Um So these nerve sparing techniques, um they've been shown to have equal effectiveness of preserving erections. Um It's not always very easy to do technically, er, and it kind of also depends on the extent of the disease, er, in terms of um how deep the cancer is going into um the bladder and, or surrounding organs because, er, clearly if it's a larger tumor, you're going to have to d resect, er, deeper and you may not be able to preserve those nerves. And that's the same in prostate cancer. Also. Uh again, based on that these methods risk even positive tumor margins because you're not quite going as deep as you would otherwise. So consider that as well. Um clearly, obviously, the cancer may be bigger on one side than the other. So you can have bilateral nerve sparing or you can have unilateral nerve sparing. Um which is a decision that uh will be made after really appreciating the size staging and everything related to the tumor intraoperatively as well. Women, of course, bladder and distal ureter is removed, the entire urethra regional lymph nodes. Uh but of course also the er, ovaries, fallopian tubes, uterus anterior vagina may also be removed. It does depend on what uh er is seen, it depends on the extent of the cancer. Er, it depends, of course, on what's happened before for the patients as well. So they don't always have to remove all of the gynecological organs, clearly removing the ovaries and making someone menopausal who's not already menopausal er, is an issue. Er, but again, of course, most of the patients we deal with are older and therefore unlikely to have already been menopausal women with a family history of breast or ovarian cancer should also er undergo bilateral sampo oophorectomy. Um So that's because of the er, genetic associations with these cancers urinary diversion. Like I said, you can't have urine just draining into nothing. Otherwise you just get urine leak collections forming in the abdomen, which is no good. Er, and again, we can divide up the forms of urinary diversion into two. So, incontinence, urinary diversion, that's where the urine flows and the patient can't control it. The first one, I've listed cutaneous ureterostomy, that's where the ureters are brought out into the skin. Um, and you have a stoma bag and they, and they leak the urine, um, that can be very uncomfortable and lead to sort of bad outcomes for the patients. We don't see it very often anymore in most cases. Um, the one that you do see most often is the second one. So ileal conduit formation and this involves using a 15 or so centimeter section of the mid ilium on a vascular pedicle. So it has its own blood supply. The ureters are joined together in an anastomosis point and they're er, stitched together onto the section of ilium to form a conduit through which the urine can flow and then it becomes a standard ileostomy um, as you would see in general surgery. So you have a distal end that's spouted, um, because urine is irritating to the skin, um, and it's stitched down and then a stoma bag is applied to it. And so you have to think about all of the things that we would think about and think about where to place a stoma um, for your general surgery cases. So, is it around the belt line? Er, it has to be within the rectus sheath, er, because otherwise the, um, the stoma is just gonna prolapse. Uh It has to be in a place you have to consider the size of the patient's abdomen. Um And how, how large they are as well. Um Is it in somewhere where they can see? So, is it somewhere where they can actually see and manage the, er, stoma as well? Um And then it also you have to think about all the risks associated with stomas um that you might see there are two techniques, there's intracorporeal and extracorporeal. Um So this is more intracorporeal is more related to your limited um limited invasive techniques like your robot techniques to where they form the stoma whilst er in the body, er whereas the extracorporeal will bring the section of abdomen outside of the body like you would again in a in a laparotomy, for example, uh it's been shown in, in various studies that the intracorporeal technique is less likely lead to lead to post Optum eyelids. We replace stents er often um through the conduit into the ureter into the kidney to ensure patency. Um And these stents are often removed either uh just before discharge or maybe one or two weeks after discharge if it's safe to do so. Some of the patients remain stent dependent er because of the high risk of ureteric slash anastomotic stricture. Um And a catheter may be placed through the conduit to facilitate the drainage of urine and some patients need to have that all the time to ensure urine drainage. Some patients have it stitched onto the um ileal conduit mucosa continent urinary divergence. That's when patients do have some control over when they do and don't pass urine. Um So this the these techniques can lead to issues with water reabsorption because ultimately, we use sections of bowel in order to hold the urine and act like a new bladder. Er, but obviously, bowel is not bladder, it has absorptive capacity and so it may actually lead to water reabsorption, er, rather than just storing the urine as the bladder would. So there's the continent cutaneous version that forms a reservoir out of the sec segment of bowel er and requires intermittent self catheterization that's isc via a stoma. Uh and then there's neobladder formation which creates a section of which the new bladder out of appendix, uh bladder is connected to the urethra and the patient can void voluntarily as well. Er And so these er, you know, major operations clearly, er but can be much more beneficial than uh than being incontinent of urine effectively and having a stoma bank, these obviously been more technically difficult though, carry greater risk of complications and you have to weigh out the benefits, benefits and risks of that. These patients may also have ureteric stents in uh in place just like the er Ileo chondroit patients. So, because cystectomy is one of the most long and complicated operations in urology. Morbidity rate is very high. It's been quoted as being 30% may even be higher depending on the risk of the patients. You've obviously got your general risks, bleeding, infection, unintentional damage, disease, recurrence AK I um but then you've got unique ones like anastomotic strictures, anastomotic leaks issues related to the stoma. So prolapse or um stenosis of the stoma or the stoma becoming uh devascularized and needing to be um refashioned as well as just being uncomfortable. POSTOP ili. I mentioned a few times already. There's one study that I read that said that cystectomy was the operation most associated with postoperative ili and not um bowel operations um that purely focused on the bowel um postoperative collections. Um you know, er ureter stitches and damage hydronephrosis, AKI, et cetera, et cetera. So these patients will often come back with issues. There should be a low sort of threshold for investigating them again if necessary, thinking about all of the issues that can go wrong um and admitting them just for monitoring if they do come back. That being said, um some patients manage very well. There was a lady I met last year who had her cystectomy something like 20 years ago and was managing well. Um She needed to have a catheter in her um stoma to allow its drainage because it was becoming a bit strict the or conduit. Um But other than that, actually, she was managing very well and had many years of good life after her cystectomy. Um, and so it's not all necessarily doom and groom for these patients enhanced recovery. Um, that's something that we've adopted more within the last 10 to 15 years in urology. Um, you may see it be called, er, so enhanced recovery after surgery. Er, and it's now in most UK hospitals, um, first adopted in 2003. Um, er, and that's where the first guidelines were written by the ES Society. And realistically in urology, it's kind of since 2013, 14 that this has been standard. Um so a relatively slow approach, it's something that was actually developed for uh uh you know, large bowel operations, so large colon cancer removals, for example, it, it can involve dedicated ES teams and most centers that perform cystectomy will have dedicated ES nurses that are able to um carry out these regular reviews both pre per and postoperatively as well. So, rehabilitation, which is really important and also postoperatively ensuring that they're having the right diet, mobilizing, making sure their psychiatric care is good. Can they manage the stoma? Um and, and having regular reviews as well? Fine optimization is, is also key to making sure they're actually prepared for surgery. Furthermore, optimizing analgesia, actually, it's really important, it may involve um maximizing your opiate sparing options to promote your bowel function. Cos obviously, if you're having lots of R and more for oxyCODONE, you're gonna be de decreasing your bowel movements after this operation. So there can be um guidelines in place to er reduce the use of opiates and of course, things like antiemetics fluid regimens as well. So making sure that uh the er es teams are as up to date with the best possible care that these patients can receive from that perspective. And this is sort of the general sort of logo seen um for one of the er S teams as well. So pre post um and pairs of care. So a very brief note on radiotherapy. So I'm not, I'm not an oncologist. Um but uh it would be remiss of me, not to mention this other option. Um It's not as effective as surgery, but it can be given to patients who cannot have a radical cystectomy. It can also have a palliative role. So it can be very useful at stopping bleeding if given to targeted carriers that are bleeding. And so that can be highly effective. Um It should also be I, you know, I should also mention the side effects so you can have things like radiation cystitis um which can give patients low urinary tract symptoms um afterwards, uh it can also cause bleeding as well. Um So we need to be aware of that. Um And I've seen that in one case where a patient had very nasty bleeding after having um radiation cystitis. So um worth being aware of. So our final case, an 88 year old female patient who attends the hematuria clinic, she's had a previous diagnosis of non muscle invasive bladder cancer. She underwent tur bt five years ago, diagnosed with a G ONE PTA cancer. So that is in our low risk category. She's been cancer free on previous follow ups and on a flexible cystoscopy. Today, there are three small areas of recurrence that are shown, she's previously been shown to have a high risk for general anesthetic. And that decision's been made. Can we think of what options we can do for her? So, again, let me know in the chat. Sure. And let me know if you want me to go through the case again. So, palliative treatment, which is a fair enough answer. BCG Mitamycin, er, conservative management in Paris. Yeah. So Josh has gone for a few options. Um, radiotherapy, palliative, you know, these are all sensible radiotherapy, let's say. So let's say she's not having any bleeding. Um, and so let's say, er, radiotherapy is not gonna help control any bleeding. And let's say the lesions are very small and so they're quite hard to target with radiotherapy. Um, because, uh, that's given external to the body, there's one other option and I'd be very impressed if someone, um, get it. So dual diathermy, maybe if, uh, if, if there was bleeding, um, we might consider some diathermy, but again, she's, she's high risk for anesthetic. So we're not gonna be able to put her to sleep and so we're probably gonna struggle doing diathermy in that case. Um I, yeah, I'll be very impressed if someone gets uh what I am gonna talk about chemotherapy again for this, for this lady. Um, again, BCG, things like that, that lead to quite significant side effects. Er, so we need to think about the side effects for a for an 88 year old who's quite frail. Um may you know, we're thinking more about quality of life. So we are thinking about that palliative technique, but there is one other thing that we can consider, er, and I'm going to talk about it now, we will follow NADA, we will follow her up. Um Yeah, er, Ellen's made, made a good point using spinal as an alternative to general anesthetic. That again, that is, er, is something sensible. Er, obviously spinal, you can't paralyze them. So you have to have that risk of obturator kick. Um So we need to think about that. Um But also actually how you know, what are we looking to actually achieve for this patient? Um Are we thinking about resection? I cos it's still a significant operation even if you do it on the spinal. Um you have to think about uh you know that as well, active surveillance is more something that we do for prostate cancer um because of the low risk of prostate cancer progressing in some cases. Er, and not all depending on the risk stratification. So I'm gonna just talk about one more type of treatment that we haven't mentioned. Um, brachytherapy is, again, it's not really something we do in bladder cancer and more something we see in prostate cancer, cervical cancer. Uh but it's a good, it's a good suggestion. It's a form of treatment but just not, not bladder cancer based. Um or at least not widely anyway, Saturday. So two of so transurethral laser ablation, that is where we can do in the outpatient setting with a flexible cystoscope, not a rigid cystoscope. So it can be, generally speaking, it can be tolerated in the clinic setting just with a local anesthetic and not with any spinals or any general anesthetic. Um, and we can apply a laser through the cystoscope, er, and laser up, er, and ablate small tumors that are superficial. So it can be highly effective for your small papillary, low risk recurrent tumors. And if we go back to her case, er, she's got a G one PTA cancer uh previously shown at least and she's got three small areas of recurrence. So this is why she's a candidate for tla whereas other case, let's say she'd shown something massive and big and it maybe looks too big to be done with laser because the laser is very small, you can only do small cases, you can't ablate large areas of the bladder with a laser just because of the tininess of this laser, it's, you know, thinner than, you know, thinner than, um, you know, anything you can imagine. Um, and, er, because it can be done in multiple sittings and multiple settings. If there is recurrence, we can, we can follow her up again if we feel the need to, if she, if that's something she'd like, er, and it's not, you know, this, if this is well tolerated as a procedure, er, and then she can have it again if necessary. Furthermore, the laser actually has a hemostatic effect. Um And so the risk of bleeding is um usually low and so patients don't always have to stop their antiplatelet therapies. And so I know some people who allow patients to have this treatment while still on aspirin and Clopidogrel's dual antiplatelet therapy. Um I think if you're on an anticoagulant like a Warfarin or Apixaban, you probably should stop that, but obviously, it depends on what on the reason why you're on those medications as well and you have to think about the risk benefit ratio. Um Obviously, we can, we can assess the hemostatic effect of this er, treatment during the operation, er, because we can visualize the bladder directly as we're doing it as well. Um So I just wanted to talk about uh this, I think it is gonna become more and more common er, in some patients where we can prevent having significant symptoms, um significant bleeding, for example, um or er, you know, unnecessary urinary tract infections with, again, I'll, I'll say again with the small papillary, low risk recurrent tumors that we see in some patients as well. Again, not suitable for patients with more solid, larger, more deep tumors. And so that's the main body of the tour. Er, and in summary, we can talk about the fact that bladder cancer risk is significantly influenced by smoking, socio economic and democratic factors um as well as being much higher risk in men. Er patients with hematuria should undergo a flexible cystoscopy and ct urogram or ultrasound. Um As the case may be within two weeks, I should say, and a caveat that they should have this if they have been also shown to have uh be in the absence of an active urinary tract infection. So, if they have an infection in the urine and they have hematuria, they shouldn't be referred to clinic because a actually doing a flexible cystic pool whilst you have an infection increases your risk of developing sepsis. But also actually the overwhelming likelihood is that this bleeding is due to the urinary tract infection. So the ones um those patients should be uh treated for the infection followed up. Um with uh you know, asking can you still see blood in the urine or having a repeat urine dipstick? And if the hematuria persists despite treating the infection, then they should be referred to a two week wait hematuria clinic. Um So just with that caveat, it's not all the patients have to look for infection, er, if that is something that is considered likely as well. So bladder cancer will be very challenging to manage and TR BT is unfortunately not um particularly good ensuring um that we get all of the cancer for staging and grading and preventing recurrence and leading to cure. And as a result, also just the general nature of bladder cancer with it being multifocal, with it being challenging to visualize with it being carcinoma in situ um and being high grade, often it has a high risk of recurrence treatment and follow up heavily depend on the disease staging and grading. Er, and that's why having our CT tap er to complete staging to see if there's metastases um is important. But also while getting all the tumor that we can having the muscle layer, if necessary is also important, we have to think also about why we're doing the T RPT. Are we doing it um realistically to gain tissue? Because we actually think this patient's probably got T two disease, muscle invasive, er, and therefore, should probably be for cystectomy or are we going in there trying to actually resect and cure all the tumor? It depends on the, the case. It's a senior led decision. Uh It's not a decision, any uh sort of junior er, doctor sho or registrar should necessarily have to make. Uh, but it's something that you'll hear your bosses talk about T two disease and above requires radical cystectomy or they, or they won't have radical treatment basically unless you can have radical radiotherapy. Um, and again, a lot of radiotherapy is not as effective as surgery. So you have to consider that as well. Thank you very much for coming. And I'll stop sharing. Happy to take any questions. Exactly. And, um, see what we can do. So, first question I see from Bernadette, what size of the cut of f fortuna? Er, very small. Um, I can't give you exact sort of millimeters and centimeters. Um, but realistically it's, it's, it's minuscule sizes of tumors that can be ablated, er, with the laser just cos it's so thin. Um, but again, it's, it's, it's meant to be for patients with very small tumors. Er, and because again, you're in there with a cystoscope, you can see all of the tumors that may occur, you can do all the multifocal tumors, um, that are low grade, er, and, er, low stage question from Ellen, is it possible to remove the bladder and any invaded muscle and then repair the pelvic floor with surrounding uninvaded muscle at this point at this point? Where is a major surgery? Um, muscle? Fine. Ok. I get the question. Um, it's not something I've ever seen discussed, I think once it's reached that level of t staging, um, it's unresectable. Um, so what's unfortunately probably gonna happen in a case like that if we resected the kidney, the kidney, we resected the bladder. We're gonna lead to very positive margins and cancer is probably gonna recur and patients gonna have lots and lots of postoperative complications. Um So it's um it's unlikely that a patient would ever receive that just because the outcomes are probably going to be poor for that patient. And the only sort of theoretical way and think that might be done is um if you had such good response to neoadjuvant treatment, that there was um a reduction in the size of the tumor to such an extent that it became likely to be resectable. But again, that's very theoretical. I've never seen that, never heard of that. Um being done, but very good question at Josh Bailey at what stage of your career can you expect to start learning to use the robot? How does training er to use at work? Yeah, so I agree with Bena that lots of training is required. So realistically, um getting on the console is kind of a later stage registrar um thing that we can be expected. Um So I'm, I'm not at the stage where I'm learning how to use the robot as of yet, in terms of being on the console. Um I have helped assist in some robotic cases. Um Just a reminder, I'm a core trainee. So CT two, um if I, you know, let's say I do go into sort of robotic surgery, I might expect to start, um getting um more experience where I'm the sort of first assistant around ST five or six level. Um And then during that year, work slowly and I do mean slowly towards um getting up to being on the console by the end of ST six and ST seven. So that's your last year's registrar. Um That would also be quite ambitious because a lot of patients, a lot of patients, a lot of people who go on to do robotic surgery as their main subspecialty will need to then also take a robotic fellowship um where they really get to grips with um robotic cases. Um and some people even take, you know, multiple robotic fellowships so they really get um to nail being a robotic surgeon and those, you know, robotic fellowships or any sort of fellowships, they're post CT. So after you've completed all your training, after you've done all your exams, after, done everything, that's when you can really sort of nail down the robot. So it's, it's quite a later uh thing that you do in your training. Um and something I'm looking forward to doing later on and yeah, simulation can be really good. Um And there are modules you can do and there's training days run by the companies that make the robots, which is really good and you say something about treatment option for bladder cancer with SCC and histology. Great question. Um So it's, it's much the same, er, so we can resect with our turbt. We'd only know it was um sec realistically with ATU R BT, you can hypothesize about the pathology, but you're only gonna know once you've taken a sample through the resection and you've looked at it under the microscope. But then you can see whether it's er, muscle invasive, non muscle invasive. That's a key distinction. It's non muscle invasive. You can hopefully keep the bladder follow them up, see if they've got um recurrence or not think about uh things like mitoMYcin. Um And if it's muscle invasive, then it will have to be um either cystectomy or radiotherapy or palliation as discussed. Thank you very much, Bernadette. Um Yeah, er, happy to answer any more questions. Um, obviously, if there's no more questions, then I, er, will let you guys get on with your evening. Er, thanks again for coming. Er, we would really appreciate filling out a feedback form, er, because it's really useful for us. Um And just to also say we'll be running a few more sessions. So, next week at 8 p.m. not at 730 but at 8 p.m. Cos I'm on call, er, we're doing one on testicular cancer, er, which should be really good demystifying that. Um, and then the week after that we'll be doing upper urothelial tract cancer at 730. So, thank you very much again, I'll stick around for any more questions, but if not have a good evening. Yes. Ok.