PREOPERATIVE DIAGNOSIS: Bladder tumor.
POSTOPERATIVE DIAGNOSIS: Multiple bladder tumors.
PROCEDURES PERFORMED:
1. Cystoscopy.
2. Transurethral resection of the bladder tumor.
3. Fulguration of bladder tumor.
SURGEON: John Doe , MD
ASSISTANT: None
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 100 mL.
INTRAVENOUS FLUIDS: Crystalloids, 1.6 liters.
SPECIMENS: Bladder tumor.
DRAINS: A 22 French 3-way Foley catheter.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the cystoscopy suite. He was placed in the dorsal lithotomy position and given IV sedation. His penis was prepped and draped and 2% lidocaine jelly was injected retrograde per urethra. Flexible cystoscopy was performed. The anterior urethra was normal. Prostatic urethra with mild bladder neck elevation. The bladder was entered and a very large bladder tumor was immediately encountered on the right side of the bladder towards the trigone. The cystoscope was then removed. Anesthesia was informed of the findings and the patient was then placed under general endotracheal anesthesia with muscle paralysis. Van Buren sounds were passed from 20 to 26 French. The dilation was snug distally and I opted not to dilate any further. Instead of the 28 French continuous flow resectoscope, I used a 24 French bipolar resectoscope with saline irrigation.
The resectoscope was placed and the bladder was briefly inspected. The left orifice was identified and a small cautery mark was placed distal to this. The right orifice could not be seen due to large overlying tumor. The tumor had very coarse papillary features. Very large submucosal blood vessels could be seen coursing through the posterior bladder and the bladder neck area. The tumor was systematically resected carrying it down to the level of the bladder wall. Towards its proximal extent and lateral extent, it was resected down into the muscle layer. In between this, deep resection was not performed because I was concerned about the underlying ureter. Bleeders were cauterized as they were encountered. Eventually, the entire tumor could be removed. The tumor fragments were evacuated and submitted for pathology. The patient was given indigo carmine. Clear blue efflux was seen from the left orifice. Eventually, blue efflux could be seen just distal to the area of resection. The bladder was inspected further with the resectoscope. Numerous small papillary fronds were noted around the anterior bladder neck and these were cauterized. Some of them appeared to be just out of view around the inner aspect of the prostate, on the bladder neck side.
The resectoscope was removed and replaced with a regular 22 French cystoscope. With a 12- and 70-degree lens, the bladder was more fully inspected. Three lesions were encountered across the posterior wall. These were broad-based with coarse papillary features as well, each measuring under 1 cm in size. These were fulgurated with a Bugbee electrode. Additional fulguration was performed around the bladder neck edge. There was no evidence of any additional bleeding. The bladder was free of any clots or large tissue fragments. The cystoscope was removed and replaced with a 22 French 3-way Foley catheter. The balloon was inflated with 30 mL and the catheter was started on continuous irrigation with clear blue output. A size 15 B & O suppository was placed per rectum to manage postoperative spasms. The patient was awakened, extubated, and transported to the recovery room in stable condition.
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