Ashish Kamat: Welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, I'm a professor of urologic oncology at MD Anderson Cancer Center in Houston, Texas. And it gives me great pleasure to welcome today, Dr. Makarand Khochikar, who is Chief Urologic Oncologist at the Siddhi Vinayak Ganapati Cancer Hospital in Miraj. He's also a past President of the Urologic Society of India - West Zone. More than just that, he is a good friend, and a true expert when it comes to urology and uro-oncology, in general. He has a huge case file that he has collected over the years that have some pearls as far as educational value, and when it comes to bladder cancer. I'm really pleased to have him join us today for this session. Dr. Khochikar, please take it away.

Makarand Khochikar: Thank you, Ashish. It's been a great pleasure to be part of this UroToday symposium. It's wonderful to be back here.

I'm going to present to you an interesting case. A 28-year-old lady was pregnant for the first time. She was in the second trimester. She presented with hematuria and clots. Many times the gynecologist would put it down as a urinary tract infection, and 9 out of 10 times, it does happen. But this was something alarming, and the gynecologist wanted to investigate it further, and when he investigated further, he found that urine has plenty of RBCs. The cytology was negative. This was initially treated by UTI as identified by one of the gynecologists, and they just did a pelvic ultrasound like most of the gynecologists would do. Eventually, when she had an abdomen ultrasound, abdomen and pelvis, this was seen on the ultrasound. I'm sure the picture speaks for itself.

That's the pregnant tubules at the back. You can see the bladder here. And almost a more than three-centimeter tumor, which was sitting just on the posterior of the bladder. This shows neovascularity, a highly vascular tumor. Maybe the pregnancy had compounded the vascularity of the bladder as well.

And these are fascinating pictures. I was fascinated by these pictures. Many times you get these pictures for the fetus. So this is how the picture looks like. And the baby looks fine and healthy, without many congenital anomalies, and fairly large tumor. Now you can see the vascularity with the color dropped out. Fairly, a highly vascular tumor.

Ashish, I know you have a large series of patients, pregnancy with bladder cancer. Now, what do you think about this case then, and what do you think we should be doing in this case?

Ashish Kamat: These are always tricky situations because we have to obviously weigh the health of the mother, and the health of the fetus at the same time, and factor the potential aggressiveness of the tumor in place. This is one of those prime occasions where the experience of the urologist looking in the bladder, the cytology that you obtain, a small biopsy that it might be able to do in the clinic without anesthesia, or with minimal local bladder anesthesia clearly helps to drive how you manage these patients. Because if it's a low-grade or a very early stage, even if it's high-grade noninvasive tumor, you can clearly wait and allow the patient to proceed to pregnancy and normal delivery, or early delivery. If it's a higher grade tumor, which is already invasive, then sometimes you have to have difficult discussions with the mother. I know, Dr. Khochikar, you actually have written on this topic, and I'm excited to see how you manage this patient.

Makarand Khochikar: The question was, when and how we will be operating on her. And Dr. Kamat has told us that we have to be very careful, try and do under regional anesthesia, or minimal anesthesia. Very careful, because you are worried about the pregnancy, the baby. The big stuff, anesthesia, and the surgical drama itself.

So second trimester was fairly reasonably set up, a good time to operate on this. We decided to do under epidural anesthesia. The tips and tricks, I think, if you have a smaller tumor, and especially it if is in the back of the wall, or the trigone, or the base, it usually doesn't bother you. This is a very easy job to do, but if it is there on the posterior wall, where the uterus is just behind the bladder, but probably the entry wall, I think there's going to be a tricky situation.

I'm just going to run through the video here, a really short video. This is showing you the bladder there, and you know the bladder has been sort of pushed. And there you are, that's the tumor. It's a papillary tumor, no doubt about it. The rest of the bladder looked normal, but it's there on the posterior wall. Once you go inside the bladder, you are actually looking at the tumor itself, and just behind it is the pregnant uterus. I'm just going to make sure there is nothing seen elsewhere also. There is no tumor elsewhere as well. Both the ureteric openings were normal. There were few clots. We just took it away.

The ureteric openings were perfect and fine. As far as the insertion is concerned, I think we have to be very, very gently. And there you are, I'm just trying to do a reverse tool. I'm trying to do an envelope one, so I'm not going to go deeper as such. I'm just trying to do an en bloc resection in this lady. Just went to the base, and just never, ever wanted to go deep because that can be counterproductive. It's a really sharp scope, I must say. It looked like a broader tumor, and there was no contact tumor. Slowly and gently, bring it out.

Obviously, the tumor wasn't the lack of side, we have to be a bit careful about alter the jerks, keeping the bladder deflated. It was slightly flattened at an angle loop here.

Ashish Kamat: Let me ask you one question here. In patients who are pregnant, one of the things that I've found to be useful is to use bipolar energy. And this looks like a monopolar loop, or is this bipolar?

Makarand Khochikar: It's monopolar. I think that's a good idea to use a bipolar. The other thing, what we're done, I think rely mainly on our endoscopic impression. You know what it looks like. I refrain from taking deep muscle, right, like they do at the previous cycle path. And I'm sure that's the treatment, and I'm sure you will also agree with me, Dr. Kamat. So if it looks like endoscopically, it's like a low-grade, and low stage disease, in the en block, if you see the muscle, that's fine, but I really don't chase it, go deep to take the deep muscle. You agree, Dr. Kamat?

Ashish Kamat: Absolutely, absolutely. In fact, we have a publication that just came out from the International Bladder Cancer Group making this exact same point. It's a point that Dr. Soloway has been preaching for many years, and people are sort of understanding. Now that we don't need to mutilate the bladder with deep, deep biopsies in patients that have TA low-grade tumor, because a deep resection, while it may look heroic, is actually more harmful in these situations. Getting the tumor out, confirming it's TA low grade, and then sparing deep biopsies, is exactly what I would recommend.

Makarand Khochikar: Sure. So everything went off well. We reported hemostasis, she went home in a couple of days' time. The final histology as expected, not to be a low grade. No inappropriate invasion. It looked fine, and she continued with the pregnancy. Now, future course of treatment. I'm sure the AUA guidelines would suggest low-grade disease, perhaps would not need any sort of invasive treatment at this stage.

One would have talked about giving perioperative cross cycle mycomycin but not certainly in pregnancy. That's my personal opinion. Dr. Kamat, do you agree? No end cross cycle mycomycin, in this case?

Ashish Kamat: Absolutely. I would not do it in a pregnant situation.

Makarand Khochikar: Yes. So this was done. As Dr. Kamat mentioned to you, we have nearly about 30 odd patients with different cancers during pregnancy. This we published in Nature's Review, and just give the guidelines when to operate these patients. So we have to look at the earliest intermediate risk, according to the guidelines. And the idea is, what you do in the first trimester, second trimester, and third trimester.

This actually helped the bladder cancer itself. And so far to me, we nearly have done about 18 patients so far. Ashish, I must say that once you start doing this, more people, bits of urologic cancers and pregnancies start coming to you. Start attracting more and more patients.

The last patient I had, I thought it was likely a tumor. We did a plexus cystoscopy, because I'm not very happy with an ultrasound pictures, as such. It looked like more of a solid tumor. I was really lucky, we did her urinary VMAs, and sort of another workup, because she was very hyper significant there [inaudible 00:09:52] and believe me or not, these turned out to be explained [inaudible 00:09:56] sacrum in the bladder in a pregnant tumor.

So we continue with the pregnancy and thereafter, we did a partial cystectomy. Quite interesting as such. And I thought pregnancy, the bladder cancer, was interesting enough. And this was all about this case. Thank you very much.

Ashish Kamat: Absolutely. And again, you raise very important points and things that would be very useful for our audience. I do want to thank you once again, for sharing this interesting case and sharing your pearls of wisdom. Always a pleasure chatting with you, Dr. Khochikar.

Makarand Khochikar: Thank you. Same here, Ashish.