TURBT within two months of MI/stents

[Gas you down]

Hey guys,
I'm an anesthesiologist. I'm curious about the progression of bladder tumors. I've just finished a case where the patient had an MI less than two months ago, requiring a DES for RCA occlusion. Sent home on dual antiplatelet medication, ASA + Brilinta. Thereafter, he had some hematuria.
Sent for cysto. Urology curbsided Cardiology, who just hears the word "Cancer" and says, ok go ahead with it, and ok to stop antiplatelets for 3 days.
If this were completely elective, it would be against ACC/AHA guidelines. I understand that if he's bleeding, so it needs to be done. Off antiplatelets on the day of surgery, his urine looks clear in the urinal.

i'm just worried we may fix his bladder tumor, but kill him in the process. Can anyone elaborate on the progression of bladder tumors in this particular situation?
Normally, I would ask the urologist, but this one guy is a little...different.

the only thing i would have changed is please don't stop the ASA/Brilinta.

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[cpants]

Hey guys,
I'm an anesthesiologist. I'm curious about the progression of bladder tumors. I've just finished a case where the patient had an MI less than two months ago, requiring a DES for RCA occlusion. Sent home on dual antiplatelet medication, ASA + Brilinta. Thereafter, he had some hematuria.
Sent for cysto. Urology curbsided Cardiology, who just hears the word "Cancer" and says, ok go ahead with it, and ok to stop antiplatelets for 3 days.
If this were completely elective, it would be against ACC/AHA guidelines. I understand that if he's bleeding, so it needs to be done. Off antiplatelets on the day of surgery, his urine looks clear in the urinal.

i'm just worried we may fix his bladder tumor, but kill him in the process. Can anyone elaborate on the progression of bladder tumors in this particular situation?
Normally, I would ask the urologist, but this one guy is a little...different.

the only thing i would have changed is please don't stop the ASA/Brilinta.

It's an interesting question, and certainly not uncommon in our world. Bladder cancer is a disease of the elderly, and often they have imperative indications for antiplatelets or anticoagulants. We frequently diagnose bladder cancer due to hematuria after initiation of these drugs and stent placement.

I have a couple of comments about the situation. High grade and low grade bladder cancers are completely different animals, and we can reliably tell the difference with a bedside/office flexible cystoscopy. Depending on tumor burden and appearnce of the tumor, it may be reasonable to do something less invasive (eg. tumor fulgeration while on blood thinners). If we are dealing with high grade, muscle invasive cancer, unfortunately it it is probably worth cardiac risks to undergo resection and definitive treatment. These cancers are bad actors and we have good evidence that delaying treatment >12 weeks results in worse survival in these patients. As long as everyone has their informed consents in line this shouldn't be that bad of a situation. It's not anesthesia or the urologist's fault that the guy is a vasculopath. Just explain the risks, document like hell, and have him sign the form.

 

[mestielest]

Really depends on the co-existence of CIS and grade of the bladder tumor. In this patients, flexible cystoscopy would be a sensible initial choice. In small, papillary tumors resection or biopsy + fulgration is possible without cessation of antiplatelet therapy. For large or solid tumors the situation should be discussed with patients again.

Take care.

 

[Gas you down]

Really depends on the co-existence of CIS and grade of the bladder tumor. In this patients, flexible cystoscopy would be a sensible initial choice. In small, papillary tumors resection or biopsy + fulgration is possible without cessation of antiplatelet therapy. For large or solid tumors the situation should be discussed with patients again.

Take care.

I like to know as much as I can when discussing matters like this with patients. It's kinda the Wild West out here, and I want the patient to actually know their options and the risk involved.
this guy has burned me badly in the past, so I approach his patients with caution. thank you both for the replies and info!