TURBT Operative Note Preoperative Diagnosis: 1. bladder mass Postoperative Diagnosis: 1. Same Procedure(s) Performed: 1. cystourethroscopy with transurethral resection of bladder tumor less than 5cm 2. pre-operative instillation of cysview with blue light cystoscopic evaluation 3. instillation of intravesical gemcitabine 4. foley catheter placement by MD Surgeon: Dr. Louis Krane Assistant: Dr. William Hughes Anesthesia: general Indications for Surgery: Patient is a 73 year old male with incidental finding of bladder mass on MRI of his lumbar spine in early 2019; patient underwent CT urogram which demonstrated a discrete lesion of the left posterior bladder wall, approximately 2cm in diameter. Of note, patient is also currently treated with xarelto for atrial fibrillation which he stopped 72 hours prior to his procedure. He also has a history of low grade, low volume gleason 3+3 prostate cancer and is currently on active surveillance. Operative Findings: left lateral wall bladder tumor, papillary in nature, approximately 2cm, just beyond the left ureteral orifice two punctate areas of intensity on blue light cystoscopy successfully fulgurated. Procedure Details: Prior to the intiation of the procedure, the patient's bladder was instilled with cysview medium via in/out catheterization per protocol 1 hour prior to scheduled procedure. The patient was correctly identified in the preoperative holding area where written informed consent as well potential risks and complications were reviewed. The patient was brought back to the operative suite where a preinduction timeout was performed. After correct information was verified, general was induced via endotracheal intubation. The patient was then placed in dorsal lithotomy position. Sequential compression devices were placed for VTE prophylaxis. The patient was prepped and draped in the usual sterile fashion and appropriate periprocedural antibiotics were administered. A second timeout was performed for which Dr. Krane was present. We began with a 26 French resectoscope. We entered the bladder via the urethra using the visual obturator and a 30 degree lens. Some stenosis of the fossa navicularis was noted but able to be bypassed with moderate pressure and adequate lubrication We performed pan cystourethroscopy using the blue light technology. We visualized a large papillary bladder tumor as expected on the left bladder wall just beyond the left UO. We switched to our 26 French resectoscope with Iglesias working element and electrocautery loop with which we performed transurethral resection of the bladder tumor. Paying careful attention to avoid the ureteral orifice's, we carefully resected down to a depth of muscularis propria. We achieved satisfactory hemostasis along the way using bipolar electrocautery. Once complete, we irrigated and evacuated the patient's bladder several times using bladder filling and evacuation. All resection chips were sent for Pathology labeled bladder tumor We then fulgurated the periphery of our resection site circumferentially. We then ensured satisfactory hemostasis with the bladder relatively empty. At this point, we elected to utilize the blue light technology, and two punctate areas of fluoresence were noted at the trigone. These were easily fulgurated taking care not to injure the ureteral orificies which were well away from our fulguration. We again visualized the ureters bilaterally and they both demonstrates an appropriate ureteral jet without hematuria. The bladder was emptied again and upon repeat inspection it was deemed that no further pathologic specimen remained in the bladder. We next placed an 18 french coude catheter and irrigated the bladder using a 60cc syringe until the urine was noted to be light pink. Finally, we emptied the bladder and instilled 2 grams gemcitabine in 100cc normal saline, after which the catheter was plugged and all chemotherapeutic agents and involved equipment was appropriately disposed of. The patient was then awoken from anesthesia and taken to recovery area. After 1 hour of exposure to intravesical chemotherapy, the patient's foley was uncapped and drained by gravity. The catheter was removed and he sent home after being deemed medically stable and demonstrating ability to urinate. Estimated Blood Loss: 50cc Drains: 18fr 2-way coude catheter (removed in PACU) Total IV Fluids: See anesthesia record Specimens: bladder tumor chips Implants: none Complications: None Disposition: to be discharged home today Condition: stable Post-Op Plan/Instructions: 1. discharge home after urinating 2. RTC 1-2 weeks for pathology results