Cystoscopy and Transurethral Resection of Bladder Tumors with Stent and Foley Catheter Placement

CHAPTER 1

Hi. I'm Tullika Garg. I am an associate professor of urology at Penn State Health in Hershey, Pennsylvania. And we're going to be talking about a 62-year-old gentleman who came in with visible blood in his urine, and he was found to have some masses in his bladder. And so the operation we're going to do today is a cystoscopy and a transurethral resection of bladder tumor. And the key steps of the operation are first to take a very thorough look around the bladder, using both 30- and 70-degree lenses to identify all of the tumors that are present in the bladder. And then the next step is to introduce the resectoscope into the bladder, which is the scope that we use to remove the tumors and thoroughly scrape out all of the tumors that are present, and then to cauterize the base of the tumors to ensure that there's good hemostasis at the end of the procedure.

CHAPTER 2

All right, so we are... Getting started. Starting and entering the urethra. His meatus is a little tight, so, okay. Can we get the Van Buren sounds, please? All right. So we're going to use the Van Buren sounds to dilate the urethral meatus. And usually try to get these in order by size. We're gonna start with a 16 French. Next we're gonna go to the 18, and then the 20, and then to the 22. And this is just so we can fit our scope into the urethra. And it's a sequential dilation and we typically dilate to a little larger than what our scope size would be. So we're gonna go up to 28. That was the 28, right? Yeah. Okay. And we'll give the scope a try again. And this is just our regular rigid cystoscope. So I always start with that to get a good look at the bladder and kind of plan out what tumors are there, where they're located, and how we're going to resect them. And coming through the prostatic urethra here. That's the verumontanum. It's a little tight. I wonder if we're gonna need the extra long for him. I might. Is he doing okay? Yeah. Okay. I just heard his heart rate go up. Oh. A little bit. And so now we're just examining the bladder. And we do a systematic examination. And here we're seeing some tumor right at the bladder neck. It has that kind of cauliflower appearance to it. Hmm. Some more tumor on the kinda left and anterior lateral wall. What were you saying, Austin? Yeah, we definitely, yeah, don't want to stir it up too much. So we always start with the 30-degree lens. That's kind of our workhorse lens. I look back there, there's a couple little tumors there too. Yeah. Did you see the UOs? Not really. We'll probably need to find them with the 70. Ooh. Is that one there? Maybe. It's close. We're also trying to find the ureteral orifices. Oh, geez. Okay. Move this thing out. Sure. And there's the other ureteral orifice on the right side. And we always wanna know where those are so that - they are good landmarks for resection. Some tumor in training there. Yes. Is he doing okay? Yeah. So now we're gonna switch out for the 70-degree lens and that gives us a little sharper angle to be able to look around in the corners of the bladder. I was just emptying him out. Oh, actually, sorry. Yeah. I was emptying out the side during that. Yeah. I would just empty it. Yeah. So we're just looking in the bladder with the 70-degree lens here. And those are just air bubbles at the top of the bladder. We can use those as a landmark as well. And here we're seeing the bladder neck tumors. And then this one on the left lateral wall. That looks kind of dark in there with the 70, doesn't it? So a little something on the right bladder neck there. Yeah. Yeah. Yeah, there's definitely some tumor there. There's a little tumor there. He's got quite a bit of tumor around his bladder neck. Careful, careful. Bit torque too much. Yeah, it is stirring up bleeding. Yeah, it's gonna be on the inside. It's right in there. Yeah. There is one. Might have to resect that. You all will see. Yeah. Okay. Wanna take a look at this one? Yes. Thanks. It feels really tight. Got high bladder neck. Yeah. We might want the extra long. Do we have the extra long resectoscope in the room here? No, but we can call for it. Yeah. Can we call for it? Can we call for the extra long resectoscope, please? Can we call for the extra long resectoscope? So you wanna be really gentle on the bladder neck. Otherwise that's why you have all this bleeding now, 'cause, you know, and try not to torque on it too much. He is fully relaxed, correct? He's fully relaxed. Okay. I think it's just his bladder neck is really tight, but that has nothing to do with anesthesia. Okay. All right. Let's get our resectoscope in. So we will again use the 30-degree lens now with the resectoscope. And then can we open up the loop, please?

CHAPTER 3

Here you go. This is not the extra one. You want the regular? Yeah, I want the regular, please. The extra loop? Yep. I got it. Thanks. This is the resecting loop and this is what we use to resect the tumor. Going in okay? I need that 28 again. The 28? Okay. Yep. There we go. The resectoscope is a larger French size, so sometimes we need to dilate a little more. And can you turn our energy down to... Yeah, tap on saline, bottom left. And drop the cut down to 60, please. I'm sorry, to 100. 1200? 100. There you go. Okay. And hit return. Yep. Do you want me to take a look or you good? Yep. All right. Yeah, we'll take a look. We'll see what we can do with this because we may need to switch. Why don't you put this in? So now we're switching out for the visual obturator for the resecting loop. And I always resect on lower energy for the bladder because it's more delicate tissue. Just check that loop and make sure that it's sliding okay. Are you getting any dragging? No? Okay, good.

CHAPTER 4

So I think we should start by resecting the lateral wall tumor. I usually like to start with that versus the bladder neck because it's just gonna keep, we're just gonna keep rubbing against it. Yeah, makes sense. So I would start with that and I always start at the top and work my way down and just keep a close eye on where the ureteral orifice is because of course it looks like it might be involved. Do you mind if I just take a quick peek? Yeah, please. Okay. I think it might be hard to get there too. Let's take a look. Yeah. So since we can't really see the base of it on the more like higher-up lateral side, is this one where you would like cut off the top just so you can get down to it or, like on that edge? I'm not sure I understand what you're saying. So I couldn't see like the base of the tumor on the top, like the lateral part of it. Yeah. Around it. But I just wondered what you tactic is. Because you don't want to just like shave off the top of the tumor. Yeah. So I like to shave it down kinda layer by layer and work my way down. And I also like reduce some of the fluid in the bladder to try to bring it closer to me. It's kind of a fine balance here. Yeah. I'm just gonna go ahead and start this... Okay. Yeah, this is not a straightforward one. I got my foot pedaling. Okay. Are we on 60 or, sorry, 100? I'm always think about the gyrus. The gyrus is 60, but this one is 100. Wow. All right. So I'm gonna start resecting this tumor. Just take my time through the tissue because it helps to cauterize the tissue as well. I try to push away the specimens so I know what I've already resected. Of course, we're already seeing a little bit of bleeding from kind of the center part of it. You always wanna try to avoid working in a hole because it's tougher to find the bleeders and always be cognizant of where the bladder wall is. I'm sorry, what's that? Oh, thank you. Thank you for warning us. No surprises, Doctor. Thank you. Appreciated. And I always like to kind of pull the tumor towards me so I know where the back wall is so I don't resect any normal bladder as well. I just take my time through it and I kinda shave layer by layer so I avoid that whole working in a hole aspect. And then in this way, the tumor also sort of reveals itself and what it's doing. This looks pretty sessile. I don't think it's really on a stalk. Some of these tumors have kind of a fibrovascular core that bleeds more centrally. Seems to have something like that here. And it's helpful to resect around where it's bleeding so we can see it a little bit better. Not gonna be able to see it. I'm getting close to the bladder wall there, so I just wanna be careful. I'm gonna find this bleeder. Let's try to clear this out a little bit. I'll find it. I'm just trying to, as I empty the bladder, to kind of clear the vision, try to make sure that the specimens are flowing out as well. Not out of fluid, are we? Okay. And sometimes emptying gives us a new perspective on what remains and what still needs to be resected. Again, I'm just trying to figure out where the edge of this tumor is and get the back end of it and pulling it again towards myself to stay away from the wall. So this part is kind of, like it might even be kind of a tumor alongside this main tumor. So we're getting pretty close to the wall now, so I to get really careful in this area to make sure that there's no perforation. I get some of these bleeders to try to see a little bit better. My lens is fogging a little bit. Let me just grab a little... Yeah. Thanks. All right, so definitely have a bleeder somewhere in here that we probably need to get so we can get good visualization. Looks like it's coming from right in here. Let's just try to... And I just use a light touch on the tissue to get it to stop bleeding so that the loop doesn't stick and pull off the cautery. And this area looks a little bit more sessile in here. So we're pretty close to the wall here, Austin. I'm just trying to kind of take more superficial bites here. Just look at this again. It's kind of like growing before our eyes. Looks like there's another little satellite lesion right there. And again, now that I kind of know where the wall of the bladder is and where the tumor is, I'm just trying to get everything flush with the bladder wall. And when I'm trying to find the bleeders, I just look for these open sinuses and put my loop right on it and then coag in that area. So I try to be precise to avoid damage to the specimen. Oh. Is he fully paralyzed? He just... That was like kind of posterior. Yeah, he moved. He twitched a little bit. His obturator fired there. I was pretty far from his obturator. Yeah. Sometimes the batches of rock can be bad and they chew through it. I always like to make sure that the patient has full neuromuscular blockade, especially for these lateral wall tumors because you can stimulate the obturator reflex. That's part of the reason why I also resect on lower energy is to try to reduce the amount of stimulation of the nerve. Okay, perfect. Thank you. Yeah, I'll start over here a little bit. Let's see. I'm doing... This looks... I'm worried this is invasive. Yeah. Okay. Looks like we're pretty flat there. I always watch how full the bladder is and make sure that we're not flattening out the tissues too much because that increases the risk of perforation. So I tend to empty and fill quite a bit. I'm just gonna try to grab some more of these specimens out. Gosh, he's got some tumor in training like everywhere here. Now I'm just going to try to clean up some of these edges here. Need to figure out what's going on with the ureteral orifice too. We will get there. I am kind of seeing where my depth is and trying to maintain the same depth throughout. I always check kind of what the fluid looks like that's coming out of the bladder. That usually gives me a sense of if there's ongoing bleeding or how brisk it might be so I can address it. I think we should send some deep resections to, probably from this spot right here. I think I'm gonna have to resect right over the UO here. Ugh. Go ahead and have them open wires and stuff for a stent? We might, yeah. I think... I guess it looks... It's close. Bad. Yeah. We'll see how it looks. Probably, yeah. I mean, it's squirting right now, but... We'll take a look at that area. I think we should put a wire in. Just put a stent up. It's getting a little full again. So I just resected the left ureteral orifice because he has tumor sitting right over it. And we wanna make sure we try to get all of the tumor out. There's the orifice right there. Let's see. I'm gonna try to get some of this stuff and then we'll get our deep and then we'll put a stent up. Okay. I think that looks like all of that tumor. I think I'm just gonna take a deep specimen from right in here. It looks kind of chunky there. It does. And then we will put our wire up and then we will turn and burn. So now we're just gonna collect our specimens. So we're sending the superficial tumor first. I'll take a deep resection 'cause that will help us to figure out if this tumor is invading into the muscle layer of the bladder wall. And I like to send it separately 'cause it makes it a little easier for pathology to figure out the different layers. Of course, we try to handle the specimen really carefully so that there's no crush artifact when the pathologists are looking at it. Let me just double check to make sure we got all the specimens out. Yep. We can go ahead and send that one then. Oh, actually, hold on just one second. I found one more. Actually, let me take a look in the... Sometimes the specimens fall into the prostate, so I have to just double check. Sometimes when there's a high bladder neck, the specimens fall behind the bladder neck and I basically just fill up the bladder and then stop filling and let the chips fall down and then grab them. All right. I think that's it for that specimen. And then take a deeper resection in this one spot. Left lateral wall bladder tumor is our first specimen. Do we have more Telfa? No. Send more Telfa as well. So here I'm taking the deep specimen from this middle area. It looks... This area looks a little concerning for more invasive tumor into the bladder wall. So I'm going to send these specimens separately. And it's kind of a fine balance to get a deeper resection while not perforating the bladder wall. And then here's one of our specimens and I think both of them came out. Let's see. So our next specimen is going to be left lateral wall, bladder tumor deep. I think those are the two main ones we already got. All right. So now we're gonna take a look at that ureteral orifice. The key with resecting the ureteral orifice is to, if you need to resect it, to just go ahead and resect it. And then you just want to avoid using any cautery, any coag on the UO. And then I typically like to leave a stent to allow that area to heal up. And I don't cauterize until after the stent is placed. So I know exactly where the UO is when I'm cauterizing. So I think we're gonna need to use fluoro. We're going to use X-ray, everybody. So we'll need to put on some lead. Try to... Oh, here's a little bit more specimen, actually. So now we're gonna switch out for a different instrument for the resectoscope. And that is our working channel. This will allow us to put a wire through without having to switch for the regular cystoscope again.

All right. Do you see the UO there, Austin? Yeah. Okay. All right. Everybody covered that wants to be? Let's see. We need to get our fluoro pedal in. Here. Do you wanna see if you can grab it? All right. Do you wanna just take a spot? Try that. Hmm. Okay. All right. So let's turn that UO. Yeah, just be careful with this level of distension 'cause I'm not... Okay. Here we go. Okay. Okay. Spot there. All right. Actually, yeah, let's do a retrograde. Yeah. Let's pop that in there. Yeah. Okay. I'm just gonna sheath our wire. You've got the catheter. So we're just finding the ureteral orifice. We're going to do an X-ray test called the retrograde pyelogram. And that's just to kinda give us a roadmap for where this stent is going to go. You're good. You're good. Yeah. Just saved it. Oh, thanks. Yeah. Okay. Spot. All right. So that gives us a picture of the left kidney and ureter. Looks good. Now we're gonna get our wire back up there. Can we get a 6 by 24, please? Got one. Okay. And this is our stent. It usually comes with a pullout string, but we're not going to leave a pullout string on here 'cause the stent is going to stay in for about four to six weeks to allow everything to heal up. So now we're just threading the stent over the wire. There you go. These stents tend to be kinda slippery. Do you wanna just angle towards the... Angle yours. There you go. It was actually why I moved this, so I could... Oh. Adjust the lens part of it. Yeah. That way. Yep. Okay. You need a pusher. So we're just pushing the stent up to the kidney. Yeah, I don't fluoro until the end to try to reduce the radiation doses. Okay, and then come on back to the bladder neck and push a little further right there. Yep. Push a little further until you see that orange. Just we got our little air bubble. You coming out? Yeah, that's good. Okay. Spot there. All right. I'm gonna burn the wire here. Okay. Spot again. Ooh. I should have gone with the 26. That's the magic. I mean, it looks like it's... Is it up in the... I think so. I think it's going. Yeah. Oh, yeah, I see. Okay. I think it'll fall back. Yeah, it will. Yeah. I'm glad I went with a 24. Yeah. Okay. And it's draining. All right. Yeah. Yeah. Okay. Now, do you want to burn those areas, Austin? Okay.

All right, so now we have our stent up. So we're going to just burn the areas that we resected. Yep. All right. Yep. We'll get that one out of the way now and bring this one in. Okay. Coag only. And just watch how full he is getting. Yeah, there you go. Make sure you burn all the edges and burn the base. Just be careful around the ureteral orifice because of course we don't wanna coag that. Coag only. And you just need to touch the tissues. Yep. Yep. So now we're just cauterizing the base of the tumor and the resection site to make sure that there's no bleeding. Yep. It's okay. And we're gonna have to maneuver around the stent, but it's helpful to have it in place because then we know exactly where the ureteral orifice is so that we don't coagulate it. Yep. You can distend a little bit more to see the distal edge there where it's close to the bladder neck, just enough, but not too much distension. Yep. It's always a little challenging to maneuver around the stent, but... Yep. Get all that kind of pink stuff. Look on the other side, I think. Yep. Yep. We just watch the UO there and stay away from that area. Yep. Yep. And yeah, exactly. You are pushing the stent away with the nose of your scope. Yep. Yep. And that's really good, like to be very precise like that. You're just touching the tissues. No need to dig in. Yep. And then always let the fluid down 'cause the distended bladder puts pressure on the vessels and so seeing the area without the extra fluid helps to identify any vessels that may still be bleeding and that may have been tamponaded by the fluid. And that resection site looks pretty dry. Is there still a little- Yeah. There's a little satellite lesion right there. Tumor up there? Yeah. Yeah. Okay. And you can see that there's urine draining from that stent, which is good. Do you wanna tackle that up there? Yeah. Probably need to distend a little bit. You want me to take a look at that one? Yep. I'm gonna have you resect all the bladder neck stuff, okay? Ah, yeah, I see it. Boy, it's right around the corner, isn't it? Did you bump him there or is that... Oh, okay. I just moved the table right here. Okay. Okay. Let's try to bring this a little closer to myself. I don't know. Is he... He's still fully paralyzed? Yep. I just redosed it two minutes ago. Okay, perfect. Thank you. No twitches? Yeah, no twitches. Okay. This is in theory pretty close to the bladder neck, so... Ugh. Really tough. I might just have to coag this one. It's really, gosh. Okay. All right. So I think let's take a look at what we've got at the bladder neck here. Oh, quite a bit of tumor here. So, Austin, I'm gonna have you resect all this. So, you know, the key here is that it's gonna kind of be a moving target. Yeah. Use the nose of your scope to get you where you need to be. Okay? And then I got a little bit of stuff over here and... And then shaving it down. Yep. I can do the other one. Exactly. And then, 'cause I'm not exactly sure, the question is going to be how far inside of the bladder neck is this? Yeah. And we probably won't be able to tell until we start shaving this all down. Right? Because again, you know, we don't wanna perforate at, you know, the anterior bladder wall. And so as you shave this down, you'll get a better sense and this will all kind of move and fall into your face as you're resecting and you'll be able to see a little bit better. Okay? Yeah. Yeah. And just again, watch how distended he gets because we still have a thin area on the other side. Yeah. You just wanna be cognizant about your other resection sites as well. And we'll probably just burn those little satellite lesions that we saw on the posterior wall. Okay. Let's make sure the pedal is where you want it to be. Okay? Mm-hm. Coag that bleeder. You're gonna get more bleeders at the bladder neck, of course, because it's the bladder neck and there tend to be more bleeders there. Yep. And then just kinda, and again, just watch your distension. Use the nose of your scope to kinda... Push up. Push up so that you can see the tumor a little bit. It's a fine balance because you don't wanna push up so much that, you know, you're causing trauma to the area. Okay? Yes, exactly. Mm-hm. Yep. There you go. Yep. And yep. Pull the tumor towards you a little bit and kind of see where it is. Yep, in space. Yep. There. That was nice. Yep. Yep. Whoa, whoa. Just grab it with your loop and pull it off because it's already resected. You don't need to resect that part. Well, it'll... Yep. There you go. Pull it towards you. There you go. Yep. So you know exactly where it is in space. One more in here. Gonna get this one more little bit and I'll just cauterize that. Yep. There. Yeah, that's good. Yep. Mm-hm. You might just wanna grab that and pull it off 'cause it's, that little part is resected. Bladder neck is actually pretty challenging, especially when they have kind of a high bladder neck 'cause you're kind of fighting it all around. Yep. Your specimens. Yeah. Yeah. It's pretty good stuff. I think the main lesion is actually that left lateral wall lesion. Yeah. Mm-hm. Yep. It's okay. If it's kind of mostly cauterized, I mean... Yeah, that's good. That's okay. You can take a little bit of that area. You just don't wanna get too deep 'cause, you know, it's the anterior prostate, of course. So there's always, you know, dorsal vein there. Yeah. You're almost there. It's just that. Yep. Yep. Yep. That's really nice. Yep. Just empty him out again. He still doing okay? Yeah, he's doing well. All right. Mm-hm. Yep. I think you got it. You can probably just coag that stuff. Yeah. Really sit on it. You can see all those vessels there. You really wanna make sure. That's always the toughest spot because it does tend to bleed, and when we put our catheter through, it may irritate it some too. Yep. So there's still some tumor on the... Yeah. Right side there. There still some there, but I feel like I'm torquing on it a lot to get to that. You want me to take a look at it? Yeah, just it's like... Yep. It looks just a little bit of fluff on that's very small. Sure. Yeah. I would probably just coag some of this stuff because it's just gonna be really tough to resect. To torque, you know, just enough, but not too much, right? Like it's... Oh, is this? So I think this is just a little bit of tumor. I think this is like a one swiper here. I think it was on the, was it down here? It's on there, but I thought it was bladder neck. Over here, you mean? Yeah, there was like... We'll look again with the 70, I think, 'cause... So we got, those are the couple little tumors there I think that we need to get. We'll probably just coag those, but yeah, I think... So that one swipe right there and... Yeah. And then, yeah, and we'll get those in the back and then we'll take a look with the 70 again 'cause, yeah. Yeah. So I think it's just this, it's more, it's almost like a tumor in training. Yeah. But it certainly looks suspicious. So do you wanna take that one? Our next specimen is going to be bladder neck tumor. Yep. Okay. We'll take a look at that whole area one more time before we exit the bladder too. Yes. All right. So we can grab those specimens. Okay. Is there anything else in there, Austin? No. Specimens? Just little teeny-tiny things. This is our next specimen. Should I just put it in here for ya? Yes, please. Okay. Bladder neck tumor. Thank you. Thank you. Yeah, let's be careful. Let's kind of carpet it. Carpet it with your coag. Yeah. There you go. Yeah. Okay. All right. You wanna coag those couple things in the back? I fill and empty a lot. I think it just kinda helps to clear the deck little bit. All right, so yeah, they were kind of almost kind of right posterior. There's your UO, right? Right ureteral orifice. There are couple of very small satellite lesions there, so we're just going to thoroughly coagulate them. You see how small they are compared to the loop, which is, I always sort of guesstimate the size of the loop as about a centimeter. So those are even smaller than the loop. Yeah. Get the back part, a little bit of it. Yeah. Yep. That looks good. Okay. All right. Let's get our 70 in there and take another peek.

So we're not able to run the loop through the 70 degree lens, unfortunately, but we'll just use the 70 to help us see if there's anything that still remains that was difficult to see with the 30. Whoa. Okay. It's the edge of the one that you did. Yeah. Wow. This guy's got a lot of tumor. That's gonna be tough to get to. Yeah. Keep looking around, I guess. Yep. Wow, I didn't see that at all with the 30. I thought that was the one you had ablated. Yeah. Goes to show why... Yeah, it's always good to look. Yep. There's your resection edge there. A little in there. Okay. So that is like at about 10 o'clock. Yeah. This lens is really dark. Yeah. That's the one we already saw. That's good, I think at least for the anterior bladder neck one. Can't really get around it, so I feel good about that. We might need the extra long to get that other one. Can I just take a quick peek? Yeah. Empty him out again. Yeah, I remember seeing like another second one or an initial one, but I thought that was the one... It's probably because the fiber optic is not good anymore. All right. So we have this. That's just some debris up there from our resection. A large air bubble. There's our right UO. And there was something right at the bladder neck right at about... Oh, there's another one up there. Geez. And there's, yeah. Let me give it a try. But we might need the extra long. We'll see. Oh, it's like way up there. There. Now I can see it. Ugh. Yeah, I think that will help. Yeah. Okay. Sometimes if the tumor is in a difficult location, we can actually kinda manually push on the bladder to help bring it into a better view for resection. When he gets full, it's like hard to reach it. Just gonna empty him a little bit. Yep. It's kind of a fine balance here again. I try to get just the right amount of distension. I'm out of fluid or something. Something's... Yeah, I'm trying to... Oh my god. Make sure I'm not too deep. Let me try to empty him again. Okay. Yeah, that's good. Yep. Okay. That was better. I've got a little bit of tumor there, a little bit right here. Let's see if I can get this. Okay. That was all right. Okay. I think that's all of it. Right? I don't see anything else. It might have been on a little stalk, actually. Yeah, you got it. Let's burn this area. Probably a little tumor in training right there. Yeah. All right, I got that. We have one more specimen. This is going to be left anterior wall bladder tumor. Left anterior wall bladder tumor. Correct. Just make sure nothing fell down in here. I don't think so. Probably a 20, like a 20 coude, I would say, for him. Okay. Oh, yeah. Oh, I see it right there. Let me just get it while in here. Push for the other one. I think I killed it. The one that was like... Yeah, right at the bladder neck there. I don't think there was... Is there anything else? There's one back there - when you were, it was like almost... Was it the same one? No, it was a different one. Or no, it was. It was... Yeah, it was definitely posterior wall right, a bit more. Sometimes it looks different on the 70, you know? Yeah. Oh, that's true. It was like when we were seeing the one that you just ablated, then like looking. Yeah. You could see it. There's so much debris in here right now. Let's look at one more time with the 70. All right, let's grab these and then let's look with the 70 just to make sure. Oh, yeah, let's take a look with the 70. So that's our next specimen. That was the left anterior wall bladder tumor. There shouldn't be another one after that. No. There's the actual specimen sitting right here. I don't know if that's what you're talking about. Yeah. So we should have left lateral wall, left lateral wall deep, bladder neck, and left anterior. Yes. You got it, boss. Perfect. Thank you. Ah, there you go. That's not even the one I thought. I know. There's another little... Yeah, there's a tumor in training up there. Okay. I thought it was like one on the one right, and then... I think that's the one I got right here maybe. I think it was that. Or is that one you just saw? That one on there? That is the one you just saw. Yeah. Wow. Okay. Gosh, he's just got tumor everywhere. Okay. So we have that one and then we had like a little one in training. That was right... Is that that guy right there? Yeah. Right there. Okay. Okay. So kind of at like 11 o'clock and right at noon there. Air bubble. Okay. All right. Let's see. We're just gonna coag those. Make sure there's nothing else. Boy, my lead is about to fall off my body. I'm running very little fluid right now to try to keep this close to me. It's gonna be really tough 'cause it's right at the bladder neck, so it's not going to move very much when you push. I'm gonna burn the heck out of it, whatever I can do. Okay. All right, and then there's that other one. Okay. All right. Let's look one more time with the 70. All right. We'll get that. Here's another one right there. Right? Okay, so this is right lateral wall. That one looks burned. Okay? That just looks like edema there. Where's the other one? So there's this little guy down here, right? In the corner there. The other one looked like kind of tumor in training. That's the UO. It was sort of more posterior. Try emptying again and see if it reveals itself. This guy. Where is that? Yeah. It's sort of like the bladder's not fully distended. It's just right posterior here, and then there's that guy. Yeah. Okay. All right. This thing. Okay. Okay. Let me see if I can find this one first. I think that's it right there. This guy. Yep. That's it right there. Oh, there it is. Yep. Yep. Okay. Uh. Okay. All right. We got that one. Now... Now, the 70 would appear more... It was sort of like... It's so tiny. Yep. Yep, that's it. At least that's different one. It's something. Let me just try to empty him again. Let's see. Is that some stuff right there or is that just edema? Just coag some of that stuff too. It seemed like it was kind of, like in this crease right here. Oh, there it is. There we are. Excellent. All right. It's definitely tumor in training. All right. That's done. All right. One last time with the 70, hopefully. Oh, you gotta be kidding me. Do you see that? Yeah. Okay. All right. We're gonna get that. And then I think that's it. I think it is. I... All right. So where is that? That is kind of right lateral wall. Two-way. Coude. Coude. Coude, 20 French two-way coude. Yep. Two-way coude. All right. Let's see if we can find... It was pretty high up here. I'm trying to empty him too. Let's see if we can pull it down for ourselves. It was pretty close to the bladder neck, wasn't it? That's true. I think I need to look at the 70 again. I just can't find it. It's right there. Okay. So if you want- So let's see. Here's a resection site. It's like right adjacent to this resection site. Let me get where on the bladder I should look to. Okay. Could get better... Yeah. I don't know if that... Okay. And it's right adjacent to this resection site, which is, yeah, I think it's one of our burning sites. Yeah. Okay.

All right. So we're going anterior here. So we have our two sites here. There it is. All right. Site mapping. Yeah, seriously. Let's see if I can't... Yeah, there we go. Okay. All right. Okay. Let me just make sure we don't have any bleeders here. So we were torquing quite a bit on the bladder neck here. Exactly. So we need to, since all of these may start to bleed again from the torque, we have to just double check everything and make sure that all of the areas are hemostatic. Sometimes you can use the roller ball here too. That can help. But I think that the best thing for him is just going to be having the catheter in place. You see he has kind of a narrow bladder neck too, which has made it a little bit challenging to access his bladder. I think we just put a catheter in. I don't wanna burn the - too much. 20 French coude, two-way. Oh, now we're just leaving the bladder, coming through the urethra here. Now we're just going to place the catheter. Thanks.

CHAPTER 5

You know, I mean, he looks a little pink. He looks little what? He looks a little pink. I would definitely keep an eye on him. I wonder if we should just put a three-way in. Should we just put a three-way in? I mean, do you want to...? Let's see how he does. Yeah. And if we need to, we can keep him overnight. Yeah. But we'll just, we'll see how he does. Yes. I think we're done. We're just putting the catheter in. We're on the cusp of that nick too running out. Okay. Oh, you got it. Doctor, are you wrapping it up? Yes, we are. Yep. We're just putting the catheter in. What do you think time-wise? Like five minutes. Five minutes. Yeah. I think it's all like bladder neck. Yeah, bleeding should stop. I hope it's gonna, yeah. I wonder if we should put him on a little traction for a little while. Can do the hold trick with the blue towel around it. Yeah. Just to hide it. Yes. That's all it does.

CHAPTER 6

So now we're done with the procedure and we found that there were more masses there than we expected and we found that some of the masses were in difficult-to-reach places. And we also found that the main tumor appeared to be invasive and involving the ureteral orifice on the left side. And so some of the key decision points were, number one, figuring out all of the tumors and making sure that we went back and forth and completely removed every visible tumor that was present in the bladder. A second decision point was whether or not to resect that ureteral orifice. And given that the tumor was involving it, we opted to remove that part of the tumor by resecting the ureteral orifice. And so we had an unexpected additional procedure, which was placing a stent. And that is I think an important teaching point of this case is that sometimes you do need to resect the ureteral orifice and if you're going to do it, we should go for it and really resect that area thoroughly and be sure to not use any cautery in that area because it can lead to scar tissue and obstruction of the ureteral orifice. After resecting it, I typically like to leave a stent because that helps the area to prevent, it helps to prevent any scarring in that area and it helps the area to heal. And I usually leave that for about four to six weeks after surgery. I think the other key teaching point is that sometimes it can be hard to identify all of the tumors in the bladder, given an individual's anatomy. This patient had a very high bladder neck and so looking with a 30-degree lens didn't give us a full picture of what was going on in the bladder. And so we had to switch back and forth with the 30- and the 70-degree lenses in order to make sure that we saw all of the tumors and got rid of all of them.