TURBT recap

Yesterday I had the TURBT at GW hospital.  It was supposed to be at 2 pm, but we didn't get going until about 3:30 pm because Dr. Hendricks' other procedures were taking longer than scheduled.  I was told that it would likely be on an outpatient basis, and I would go home that evening.

I woke up in the recovery room at about 6 pm.  The doctor reported that is was a particularly angry tumor, about the size of man's thumb, with lots of blood vessels.  He also saw several other lesions of carcinoma in-situ (or Tis, short for tumor in-situ).  It took about 2 hours to cauterize, resection, and remove the big tumor.  The doctor says that the tumor has been completely removed.  He was most concerned about removing the tumor, and trying to remove the portion of the bladder muscle wall that also was infected with the cancer, while trying to be careful not to go all the way through the muscle wall.  After a couple of hours, there was enough swelling and blood that he chose to end the procedure after removing the tumor and what he thought was the right amount of the muscle wall, while leaving the other surface cancers in place.  He knew that with this type of tumor, there was a risk or metastesation, so he ordered the follow-up CT scan and wanted to wait for the pathology analysis for definitive staging.  He said that, after the pathology report, we'd meet, but that he'd probably schedule another TURBT to remove the rest of the little surface cancers.

He also kept me in the hospital overnight.  The catheter (#24 in size) felt like a fire hose emerging out of my penis, and was incredibly uncomfortable to sleep, not that hospitals are where one goes to get rest in any event. 

I was discharged after eating breakfast and showing I could walk and pass gas (although not at the same time - that's only for advanced patients).

It seems this cancer is more advanced than the doctor had initially indicated.  I've decided that I'm going to get a a second opinion.

Following is an email that I sent to my extended family, as well as an exchange between my brother, and my daughter, as second year med student at GW:

Dear family:

I'm home from the hospital.  I'm in no pain, fortunately.  I have a Foley catheter; it will be removed on Monday.  The cancer was more extensive that expected. They got the large tumor out of the bladder but smaller lesions were left for later. They are waiting on the pathology to determine the next steps. It's at least Stage II, maybe Stage III cancer.  They also will do more tests on Monday (CT scan, etc) to see if it has spread to the lymph nodes or elsewhere. They don't yet know what other interventions are needed. I'll almost certainly have another surgical procedure, either endiscopically to get out the rest of the in situ carcinoma, or to do a partial or radical resection of the bladder.  I'll probably need chemo and/or radiation, although if I'm lucky it will just be an immunosuppressant. Chelsea has been talking with the doctors and has been acting as my patient advocate. Below is an exchange that she had with my brother with more info. Feel free to circulate to other family as appropriate.  Thank you for your thoughts and prayers.

Love, Ken

> Dear Chelsea,

> Your dad wrote a short note explaining the results of the surgery.  He suggested writing you to ask questions.  I understand that you have been there practically non-stop.  No doubt you are worn out.  I hope you can shed light on some of the following:

> Is the tumor-type papillary or non-papillary (sessile)?

Chelsea's answer:  The large invasive tumor which they removed was papillary. The other small foci scattered around the bladder were flat, superficial lesions - carcinoma in situ.

> Will they wait for pathology reports before further treatment or move aggressively to chemo and/or partial or full bladder removal?

Chelsea's answer:  The pathology will be back next week, and will have important information including the staging and aggressiveness of the tumor. The results of the pathology will then dictate the next steps that need to be taken. For example, if the tumor went only partway into the muscle wall, they may not need to do surgery again and can do localized chemo in the bladder. If the tumor spread deeper into the muscle wall, they will need to go back in and take out a larger chunk of bladder. If the tumor spread past that, more systemic treatment will be required; etc.

> As I understand it, the cancer has progressed past stage I.  Have they been able to determine if it is stage II or if it has progressed to stage III?

Chelsea"s answer:  The staging system is based on how far the tumor has invaded. The tumor is assigned the highest stage for which it meets the criteria. I included 2 different descriptions of the same staging system below, but to summarize: there are 4 layers to the bladder (see http://www.lab.anhb.uwa.edu.au/mb140/corepages/urinary/images/ure10he.jpg). The inner layer, which is a sheet of "transitional epithelial" or "uroepithelial" cells, is the site of origin of bladder cancers. All of the small, superficial lesions scattered around the bladder are superficial enough that they only involve this layer, so they are stage 0. The second layer is called the lamina propria; it contains some blood vessels, fat, lymph nodes, and white blood cells. If the cancer has spread out to this region, it is Stage 1. The third layer is the "muscularis propria", which is the thicker muscle layer of the bladder; this muscle layer is what squeezes to expel urine from the body. Dad's tumor is at least out into this layer, meaning it is at least Stage 2. The fourth layer is the "serosa" or "adventitia," which is a very thin sort of sheath around the bladder. The pathologists will take the tumor they removed from dad and slice it into little sections, then examine it under the microscope. They will be able to tell where exactly the tumor invasion stops - whether it is somewhere in the muscle layer, or whether it made it all the way out to the serosa (serosa cells look different than muscle cells; cancer cells look different than both of those). If the tumor has reached the serosa, it almost definitely has invaded other organs around the serosa that it is adjacent to, making it Stage 3. Next week Dad will get a pelvic / abdominal CT to see if the tumor cells have made it into the bloodstream or the lymphatic system and spread elsewhere, which would make it stage 4. The CT will also show uptake in areas like the prostate (meeting stage 3 criteria).

* Stage 0: The cancer cells are found only on the surface of the inner lining of the bladder. The doctor may call this carcinoma in situ.

* Stage I: The tumor has grown deeper into the inner lining of the bladder. But it hasn’t invaded the muscle layer of the bladder.

* Stage II: The tumor has invaded the muscle layer of the bladder.

* Stage III: The tumor has grown through the muscle layer to reach tissues near the bladder, such as the prostate, uterus, or vagina.

* Stage IV: The tumor has invaded the wall of the pelvis or abdomen, but cancer is not found in any lymph nodes. Or, the cancer cells have spread to at least one lymph node or to parts of the body far away from the bladder, such as the liver, lungs, or bones.

Ta: Noninvasive papillary carcinoma

T1: Tumor invades lamina propria

T2: Tumor invades muscle

T2a: Invades superficial muscularis propria

T2b: Invades deep muscularis propria

T3: Tumor invades perivesical tissue (= tissue around the bladder)

T3a: Microscopic (= visible only on microscopic exam) perivesical fat invasion

T3b: Macroscopic (= visible with the naked eye) perivesical fat invasion (extravesical mass) (= visible mass outside of the bladder)

T4a: Invades adjacent organs (uterus, ovaries, prostate stoma)

T4b: Invades pelvic wall, abdominal wall

> Have they been able to rule out stage IV?

Chelsea's answer: Not yet. They will be doing an abdominal / pelvic CT scan next week which will pick up any metastases to the lymph nodes or other organs in the area.

>