BackTable Urology

In this episode of BackTable Urology, Dr. Aaron Fritts talks with Dr. David Canes, a urologist and founder of WellPrept, a curated patient database that aims to improve and streamline patient education before their clinic visits.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/w9ovzr---SHOW NOTESFirst, Dr. Canes explains his motivation for starting WellPrept. Because he was always interested in entrepreneurship, he primed himself to look for problems in healthcare. One big problem he noticed that he and his colleagues were experiencing was burnout from explaining the same procedures over and over again to his urology patients. He found himself going through the motions, feeling disconnected from his patients, and not being able to have deeper conversations about their care. This realization motivated him to start sending basic information about procedures and conditions to his patients before their clinic visits. After initial success within his own practice, he decided to create WellPrept, a central hub for patient information from resources curated by individual physicians. Individual physicians or whole departments can pay for a subscription and share information with their own patients. Since its inception, WellPrept has encouraged physicians at a variety of institutions to create their own web pages with trusted content for their patients; some doctors have even created their own videos to explain procedures to patients.Next, Dr. Canes speaks about the future direction of WellPrept. Although it is growing in popularity within the urologic community, he wants to expand WellPrept to other fields of medicine as well. He is also working on developing a shared library, or packages of crowdfunded patient education that every physician can share with their patients. Additionally, he is working with special societies and other databases to share more already published content through WellPrept, which he views as an effective delivery system.He also discusses the adversities he has faced, such as reluctance from some colleagues. However, he has found a great start up community via social media platforms like Twitter and mentorship from venture capitalists and other entrepreneurs. Finally, Dr. Canes shares tips for work-life as a physician-entrepreneur.

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses methods and benefits of smoking cessation in urologic oncology patients with Dr. Christian Fankhauser from Luzerner Kantonsspital and Dr. Richard Matulewicz from Memorial Sloan Kettering.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/3iSSef---SHOW NOTESFirst, the doctors discuss the role of urologists in taking charge of smoking cessation. Because smoking cessation directly minimizes surgical complication and increases longevity in urologic oncology patients. It is beneficial to have other medical professionals, such as physicians in other specialties (e.g. cardiology) and PAs, working to encourage smoking cessation as well.Next, they discuss the initial intake of a smoking patient. Screening patients for smoking is not happening as commonly as it should. Additionally, it is important to use non-judgmental phrasing and tone in order to make the patient feel comfortable with sharing information. When screening for smoking, the 5A Model can be used: ask, advise, assess, assist, and arrange smoking cessation therapy. However, this method can take up a lot of time during the clinic visit. Thus, pre-visit questionnaires are efficient. When counseling a patient to quit smoking, it is best to set a quit date within 2-3 weeks before surgery. Some evidence-based benefits to smoking cessation include: inhibition of bladder cancer progression, increases in longevity, minimizing perioperative complications, prevention of erectile dysfunction and infertility, and the promotion of wound healing. Dr. Bagrodia also mentions that bladder treatment outcomes from adjuvant chemotherapy and intravesical therapy will improve with cessation. Some common cessation techniques are nicotine replacement therapy and stress reduction techniques.The urologist can take the lead on smoking cessation or refer the patient to a counselor. In Europe, Dr. Fankhauser sends the patient to their general practitioner to initiate cessation therapy, while Dr. Matulewicz encourages urologists to learn how to document cessation encouragement as a separate billable service. Finally, the doctors share resources for urologists wanting to help their patients quit smoking. All three urologists agree that there should be more formal education initiatives about cessation for medical students and residents and that society guidelines should emphasize the importance of smoking cessation more strongly. Dr. Matulewicz encourages his patients to call the number 1-800-QUIT-NOW- to connect to state health departments, which provide nicotine replacement medications and trained counselors. Finally, Dr. Fankhauser discusses his smoking cessation research and emphasizes that it’s never too late for patients to stop smoking.

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses radiation therapy for favorable intermediate-risk prostate cancer with radiation oncologist Dr. Amar Kishan, Chief of the Genitourinary Oncology Service for the Department of Radiation Oncology at UCLA.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/r17OQG---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESFirst, the doctors discuss important patient factors to consider when designing a radiation therapy regime. Dr. Kishan emphasizes the importance of considering the patient’s baseline characteristics and preferences. Because favorable intermediate-risk prostate cancer is curable, his top priority is optimizing post-operative quality of life in areas such as urinary function, bowel function, and sexual function. In order to measure baseline characteristics, he uses various questionnaires, such as the IPSS questionnaire and the SHIM score. Additionally, he takes a thorough patient history in order to screen for any contraindications for radiation, such as a history of pelvic radiation, active inflammatory bowel disease, radiosensitivity syndromes, and lower urinary tract symptoms (LUTS). He mentions that TURP and HoLEP procedures are not contraindications for radiation therapy, but recommends waiting 12 weeks after the operation to start radiation because of the risk of hematuria. He also recommends MRI for imaging.Additionally, he discusses the option of combining radiation therapy with adjuvant androgen deprivation therapy (ADT). Because the likelihood of curing favorable intermediate-risk prostate cancer with radiation monotherapy is high (90% over 7-10 years), ADT is often not required. However, he considers ADT if the Gleason score and volume of disease point to a more aggressive prostate cancer. He also uses the Decipher test, a molecular test that helps him decide whether or not to include ADT in a patient’s treatment regime. Dr. Kishan notes that de-intensifying conventional therapy must be based on evidence and towards a goal of reducing the absolute risk of the patient.Dr. Kishan also explains the different radiation therapy options. There are two main categories: external beam radiation and brachytherapy (internal radiation). External beam radiation delivers an X-ray dose daily. The conventional timeline is 9 weeks of therapy but a shorter 5-day SBRT course can be used. Brachytherapy is a surgical procedure in which the surgeon places radioactive pellets inside the prostate. The pellets are left inside the patient in low-dose brachytherapy, while they are removed after 15-20 minutes in high-dose brachytherapy. Dr. Kishan believes that an extra boost of brachytherapy is not required and can in fact introduce more toxicities. Contraindications to brachytherapy include bleeding risks, anesthesia risks, larger prostates (large median lobe), and pubic arch interference. For external beam radiation, spacers for patients with rectal problems and fiducial markers may help with narrowing margins needed for treatment, since the prostate is a mobile organ.Finally, Dr. Bagrodia and Dr. Kishan delve into a discussion about recent radiation therapy trials and briefly discuss the field of radiogenomics, an area that is developing DNA screening tests to predict idiosyncratic reactions to radiation therapy.

In this episode of BackTable Urology, Dr. Jill Buckley, professor of urology at UC San Diego, interviews Dr. Jack McAninch, professor emeritus of urology at San Francisco General Hospital and an international leader in the field of genitourinary trauma and reconstructive surgery.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/N3Mbe5---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESFirst, Dr. McAninch delineates his path to becoming a doctor. He grew up in Merkel, a small Texan town, and worked on an oil rig after high school to save money for college tuition. He attended Texas Tech University and majored in animal husbandry. After college, he received a master’s degree in animal science from the University of Idaho. However, during his time in graduate school, he was required to take various pre-medical classes and discovered a passion for medicine. He applied to and received an acceptance to the University of Texas Medical Branch in Galveston. During his time in medical school, he worked as a research assistant in the plastic surgery department and discovered his interest in surgery and reconstruction. However, he chose urology as his specialty as the hours and training were less demanding than plastic surgery. He decided to enlist in the army and was sent to Letterman Army Hospital in San Francisco to complete his urology residency. During his time there, he operated on many Vietnam war soldiers and gained valuable insight in acute care and reconstructive surgery. After being stationed in Germany for 3 years, he returned to San Francisco and was recruited to San Francisco General Hospital to start a reconstructive urology program. As the only reconstructive urologist, he worked closely with the general and trauma surgeons to manage a high-volume caseload. He then went on to start the first fellowship in reconstructive urology at UCSF.Next, Dr. McAninch explains his different leadership roles throughout his career, including being an original board member of the Society of Genitourinary Reconstructive Surgeons (GURS), the president of the American Board of Urology, the president of the American Urological Association, and an important leader representing the urologic field in the American College of Surgeons. Finally, Dr. Buckley and Dr. McAninch end the discussion by reflecting on the phenomenally rapid technological advancements that have been made in the field of urology.---RESOURCESSociety of Genitourinary Reconstructive Surgeonshttps://societygurs.org/

In this episode of BackTable Urology, Dr. Bagrodia discusses erectile dysfunction (ED) in the setting of post-prostate cancer treatment with Dr. Mike Hsieh and Dr. Darshan Patel, two urologists from the comprehensive men’s health clinic at UC San Diego Health.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/WWNMHR---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESFirst, the doctors explain their typical workup of post-prostatectomy patients. They widely use questionnaires, especially the Sexual Health Inventory for Men Score (SHIM Score) to coordinate with oncology colleagues and keep their ED assessments standardized. Because ED treatment should be tailored to the goals and expectations of each patient, taking a thorough social history is also important. Both doctors concede that robotic surgery has improved post-procedure urinary symptoms but emphasize that not many therapies are able to lower the rate of ED as a post-operative complication. Additionally, a combination of radiation and androgen-deprivation therapy can lower libido. For this reason, an early sexual function rehabilitation approach is important. Dr. Hsieh equally prioritizes both goals of resolving a patient’s prostate cancer and preventing postoperative incontinence and sexual dysfunction.There are many ED therapies available for prostate cancer survivors. Patients can be started on a vacuum erection device and low dose of PDE5 inhibitor (Cialis, Tadalafil) even before their prostatectomy procedures. Dr. Patel notes that timing of the PDE5 inhibitor is one of the most important factors to consider in penile rehabilitation. Vacuum erection devices are viable options to preserve penile size for single patients or patients who are not having sex. Next, the doctors discuss injection therapy. Dr. Hsieh and Dr. Patel usually show patients how to inject the first dose of Trimex in the office and advise patients against making big dosage jumps to prevent the development of priapism. Dr. Bagrodia mentions that pelvic floor physical therapy and sex counseling as good non-invasive and non-pharmacological options as well. Finally, the doctors discuss less common penile rehabilitation therapies, such as hyperbaric oxygen and shockwave therapy.Lastly, they discuss how to manage patient expectations. Although early spontaneous erection and fullness is a good sign of recovery, the urologist should set three-, six-, and nine-month milestones for their patients. Usually, 80% to 90% of patients usually graduate from therapy within a year of their prostatectomy, and it is beneficial to use as many non-surgical options as possible to regain erectile function at first.

In this episode of BackTable Urology, Dr. Silva interviews Dr. Katie Murray, a urologic oncologist from the University of Missouri, about management of high and low-grade upper tract urothelial cancer.---CHECK OUT OUR SPONSORJELMYTOhttps://www.jelmyto.com/hcp/?utm_source=BackTable_Podcast&utm_campaign=Jelmyto_HCP&utm_medium=audio&utm_content=podcast_link---SHOW NOTESDr. Murray prefaces the discussion by explaining that historically, upper tract urothelial cancer (UTUC) has been treated similarly to bladder cancer, but the two malignancies are actually very different. For this reason, there are no set guidelines for the management of UTUC in the United States. Then, she describes her typical workup of a UTUC patient. ALthough most of her referrals are from general urologists who already diagnosed UTUC in patients, she sometimes gets referrals for patients with gross/microscopic hematuria that leads to a de novo diagnosis of UTUC. Dr. Murray will perform a routine cystoscopy and a ureteroscopy on her patients; she prefers the Olympus scope with narrow band imaging and a flexible ureteroscope without a ureteral access sheath, respectively. She does not always perform a retrograde pyelogram because her decision depends on the patient’s comorbidities and cytology results.Then, Dr. Murray explains her surgical techniques for managing UTUC. For low-grade and small tumors, she will perform an endoscopic ablation during the biopsy if the tumor is easy to remove. For larger tumors, she will only perform a biopsy and further evaluate the patient for the next steps. She notes that all biopsies have a risk of spreading the cancer along the ureter, as urothelial cancer can implant anywhere in the tract during the procedure. Additionally, although she does not use balloon dilation during biopsies, she places a stent instead. For visualization, she uses the single action pump system (SAPS). Finally, she explains the importance of intravesical therapy after ablation.Next, Dr. Murray explains the difference in managing low versus high-grade UTUC. Low grade UTUC has a high recurrence rate (over 50%). For low grade tumors, endoscopic ablation is her first-line treatment. She also recommends a six-week course of JELMYTO, a mitomycin gel as a non-surgical option. She uses a cystoscope or nephrostomy tube to deliver the JELMYTO medication. For patients with a high-grade tumor, Dr. Murray only performs an ablation if the patient has contraindication to every other surgical procedure. For distal high-grade UTUC, she performs a distal ureterectomy with a node dissection and follows with a ureteral implant. For proximal high-grade UTUC in the renal pelvis, she will perform a nephroureterectomy. In all high-grade tumors, she emphasizes the importance of thorough assessment of pelvic nodes and chest/abdomen/pelvis imaging to accurately stage the cancer. When deciding whether to start neoadjuvant chemotherapy before surgery, Dr. Murray recommends collaborating with the oncologist.Lastly, Dr. Murray explains her approach treating a patient with bilateral UTUC, which is to prioritize surgical management of the worst side first.

In this episode of BackTable Urology, Dr. Bagrodia interviews Dr. Alexander Kutikov, chief of urology and urologic oncology at Fox Chase Cancer Center, about diagnosis, lab and imaging workup, and surgical management of adrenal masses.---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QbNUNe---SHOW NOTESFirst, Dr. Kutikov shares important general information about adrenal masses. He notes that oftentimes, referral patterns for adrenal cancers are diverse. Although multiple specialties can take care of these patients, he thinks that the retroperitoneal space is best known by urologists, who emphasize non-surgical intervention. Adrenal masses are most likely to be found incidentally on imaging on CAT scans for urolithiasis or staging for urologic cancers. Dr. Kutikov notes that adrenal masses are quite common in patients older than 70 years old as well.Next, Dr. Kutikov summarizes his typical work up of adrenal masses. Because the majority of masses are benign and non-functional, it is important to distinguish these from malignant and functional masses. To assess if the mass is metabolically active (releasing hormones, catecholamines, and aldosterone), he looks for hypertension. Additionally, he observes the patient for the classic triad of a pheochromocytoma—sweating, headaches, and tachycardia. He also notes that extra-adrenal paragangliomas are much more likely to be malignant than pheochromocytomas, but the distinction between the two tumors has to be made clinically. As for the specific lab tests he orders, he checks aldosterone and renin levels, plasma metanephrines (a more specific surrogate for catecholamine levels), and performs a dexamethasone cortisol suppression test. If any of these tests are abnormal, he recommends that urologists partner with endocrinologists to interpret the results and manage the patient.Next, the doctors discuss imaging for adrenal masses. A non-contrast CT is the standard imaging modality for adrenal masses, as it can show lipid-rich areas (less than 10 houndsfield units). If the lesion is lipid-rich, it is most likely an adenoma and not malignant. Lipid-poor lesions have a 30% chance of also being adenoma—in these cases, Dr. Kutikov recommends doing an adrenal washout study, which is simply a delayed CT urogram. If the patient washes out lots of contrast, it is indicative of lots of intracellular lipids. It is important to note that CT with contrast does not show lipid-rich areas, and MRI serves the same function as a non-contrast CT. Dr. Kutikov also adds the importance of size—tumors larger than 4.5 cm are large enough to consider resection with the appropriate clinical and laboratory data. Adrenocortical carcinomas (ACC) are malignant and should always be taken out if greater than 4.6 cm and in patients with no contraindications.Next, Dr. Kutikov explains the role of adrenal biopsies in evaluating adrenal masses. He notes that biopsies are useful because they can differentiate between ACC and adenomas if imaging was not definitive, but require careful technique as ACC is known to seed the needle tract. Finally, Dr. Kutikov outlines his surgical management of adrenal masses. Dr. Bagrodia and Dr. Kutikov discuss the pros and cons of minimally invasive and open surgeries.---RESOURCESAdrenal Mass Management Algorithms (from the Global Society of Rare Genitourinary Cancers):https://adrenalmass.org

In this episode, Drs. Aaron Fritts and Eric Gantwerker interview Dr. Tamir Wolf, a trauma surgeon and founder of Theator, an artificial intelligence company that links intraoperative decision making with patient outcomes.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/WxyvKG---SHOW NOTESDr. Wolf describes how his experience as a trauma surgeon with the Navy SEALs shaped his perspective on high acuity situations and surgical guidance. He realized that augmented decision making in trauma settings could help him and others perform better. Additionally, he had experiences with seeing family and coworkers undergoing the same procedure, but with drastically different outcomes due to variability in surgery and clinical management. With these ideas in mind, he started Theator. The company offers a software that seamlessly integrates into existing operating room video technology in minimally invasive robotic and laparoscopic procedures. The technology captures data over decision points and key milestones that have eventual impacts on patient outcomes. The data is then analyzed to find patterns and translated to best practices.Dr. Wolf hopes that this aggregate of video data from multiple surgeons and institutions can provide evidence-based training for surgeons to operate at a safer level. Dr. Wolf emphasizes that Theator’s overall mission is to increase transparency in the operating room and break out of the traditional surgical apprentice training model. Ideally, trainees who are preparing for surgeries could draw on the experiences of thousands of surgeons in different places. Additionally, hospitals could gain information about their internal processes and address inefficiencies and safety gaps.We discuss challenges in implementation, such as surgeons’ reluctance to be recorded, competition within the artificial intelligence space, and limitations for implementation in fluoroscopic imaging. Dr. Wolf also outlines Theator’s trajectory and the single most important factor to its success— the company culture. He emphasizes the need to hire competent and trustworthy people who can innovate and self-direct.---RESOURCESTheator:https://theator.io/Dr. Tamir Wolf LinkedIn:https://www.linkedin.com/in/tamirwolfOR Black Box & Trauma Black Box:https://www.surgicalsafety.com/Disparities in Access to High-Volume Surgeons Within High-Volume Hospitals for Hysterectomy:https://journals.lww.com/greenjournal/Abstract/2021/08000/Disparities_in_Access_to_High_Volume_Surgeons.7.aspxNo Rules Rules: Netflix and the Culture of Reinvention: https://www.amazon.com/No-Rules-Netflix-Culture-Reinvention/dp/1984877860BackTable Innovation Ep. 7: Improving Access to Stroke Care Using AI with Dr. Chris Mansi: https://www.backtable.com/shows/innovation/podcasts/7/vizai-improving-access-to-stroke-care-using-ai

In this episode of BackTable Urology, Dr. Jose Silva and Dr. Jamin Brahmbhatt discuss the evaluation, causes, and treatment of chronic testicular pain.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/Ed2uAQ---CHECK OUT OUR SPONSORAthletic Greenshttps://www.athleticgreens.com/backtableuro---SHOW NOTESFirst, Dr. Brahmbhatt shares his basic algorithm for evaluating chronic testicular pain. He will take a history, perform a thorough physical examination, and obtain new CAT scans and scrotal ultrasounds. He emphasizes the importance of physician examinations in order to find hernias and encourages urologists to ask their patients to name 3 quality of life activities that are affected by their testicular pain. Later, he will use these activities to document patient progress. Dr. Brahmbhatt also notes the possibility that the testicular pain is also a result of referred pain. He makes sure to explain the mechanics of the testicular nerves within the spermatic cord to the patient. He usually does not prescribe or refill pain medications unless they are required for postoperative pain.Dr. Brahmbhatt offers various procedures to alleviate testicular pain. First, he will perform a spermatic cord anesthesia block (SCAB) if no surgery is indicated. This procedure involves sedating the patient and then injecting a mixture of anesthesia and steroids into the highest point of the spermatic cord. He usually injects 30 cc of the solution, saving 5 cc to inject in the most painful region. He follows up with his SCAB patients in 5-7 days and observes for pain reduction. He notes that this non-surgical procedure is very effective in many patients. Worsening pain after SCAB is a contraindication to surgery. The second procedure that Dr. Brahmbhatt offers is testicular neurolysis or microscopic testicular denervation, a procedure in which he cuts and divides tissue microscopically within the spermatic cord. This is a procedure that can be performed robotically and is very effective for resolving pain in patients with retractile testicles.Although he offers procedural-based treatments to testicular pain, he always tries to maximize medical treatment for at least 30 to 90 days. Medical options include: 7.5% Meloxicam, a short course of antibiotics (Bactrim), Flomax (for pain during ejaculation), or gabapentin. He will attempt SCAB first before prescribing a muscle relaxant, as muscle relaxant can be addictive. He also recommends specialized physical therapy for groin and testicular pain.Additionally, the doctors discuss the role of varicoceles in testicular pain. Although both doctors agree that varicoceles are not supposed to cause pain, grade 2 and 3 varicoceles can cause a stretching sensation that irritates the nerves. Dr. Brahmbhatt will continue with his standard evaluation algorithm, even in patients with a known varicocele. He notes that SCAB is very effective in patients with varicoceles. If he has to proceed to surgery to manage testicular pain, he usually includes an additional varicocelectomy as well.Finally, Dr. Brahmbhatt discusses his non-profit organization, Drive for Men’s Health, which aims to increase male engagement with health care by organizing road trips around the US and the rest of the globe.---RESOURCEShttp://myballshurt.com/

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Sam Chang, chief of urologic oncology at Vanderbilt University, about surgical tips and tricks for intermediate and high risk bladder cancer.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/yNjHKQ---SHOW NOTESFirst, the doctors discuss important considerations during the initial patient visit. Dr. Chang emphasizes that reviewing previous evaluations and treatments is important for patients with recurrent disease. Also, if the patient is a current smoker, smoking cessation should be encouraged. Dr. Chang will not perform a cystoscopy if the lesion is obvious. However, he acknowledges that this procedure may be necessary if the imaging is ambiguous. Some tips and tricks he shares for blue light cystoscopy include: using lidocaine, applying pressure when passing the scope, and training effective procedure nurses. He notes that residents will greatly improve their cystoscopy skills as they gain more experience.Next, Dr. Chang shares his tips for a transurethral resection of bladder tumor (TURBT). He usually employs a bipolar TURBT and starts resecting in a normal-appearing bladder, being sure to balance speed with judiciousness when resecting. Additionally, he tries to obtain pathologic specimens from various tissue sites and the appropriate tissue layer orientation in order to facilitate pathological analysis of the tumor. Further, he notes that thorough OR dictation matters greatly, especially if the patient transfers to the care of a different provider or if a revision surgery is needed. He encourages urologists to give as many details as possible about the appearance, location, size, and nature of the tumor. For bladder carcinoma in situ, Dr. Chang cauterizes the tumor instead of resecting it in order to spare the specimen from destruction. For tumors involving the diverticulum, he obtains his sample with extra caution, as this location increases the possibility of tumor spillage. Then, the doctors compare and contrast different types of intravesical therapy.Finally, the doctors discuss postoperative TURBT care. Dr. Chang usually does not place a postoperative stent because most of his patients do not develop stenosis. However, in cases of CT-proven hydronephrosis, a stent is necessary. He will also leave a catheter in all his patients for 3-4 days to prevent clot retention during recovery. Finally, he prescribes post-operative maintenance gemcitabine. Revision resection procedures if there was lots of tumor left behind after the first surgery or if the tumor was present in a difficult anatomic location. Dr. Chang repeats the resection before administering intravesical therapy. Lastly, he emphasizes that in cases of muscle-invasive bladder tumors, he would rather get rid of all the tumor than worry about preserving muscle.