1.What is electrosurgery for bladder cancer and how is this procedure done? Electrodesiccation for bladder cancer requires the use of a set of equipment called electrodesiccoscope, which is similar to cystoscope. This is a set of metal tubular instrument, which is a little thinner than a pinky finger. This tubular instrument is inserted deep into the bladder through the urethra, and then a special electric knife is used to follow the sheath of this tube into the bladder, and at the same time, a slender mirror of optical fiber is probed into the bladder, and with the help of this observation mirror, the bladder tumor is removed by the electric knife. 2. Is it true that cutting more tissue during the surgery can reduce the probability of recurrence of bladder cancer? Transurethral bladder tumor electrosurgery has two purposes, one is to remove all the tumor visible to the naked eye, and the other is to remove tissue for pathological grading and staging. The bladder tumor should be completely removed until the normal bladder wall muscle is exposed. After tumor resection, basal tissue biopsy is recommended to facilitate pathological staging and determination of next treatment plan. Is it true that cutting more tissue during surgery can reduce the probability of recurrence of bladder cancer? Theoretically, yes, but the bladder is a cavernous structure and the bladder wall has a certain but limited thickness, so it is not better to cut as deep as possible. Bladder cancer is usually done superficially by electrodesiccation, but there are some cancers that invade deeper, even to the superficial muscle layer. Cutting deeper into the muscle layer can easily cut through the bladder wall. The consequence of cutting through is very serious. In bladder cancer surgery, the doctor needs to keep filling the bladder with water to see the lesion clearly, and many tumor cells may be suspended in this filling water, which can easily spread through the wound; this requires the doctor to cut as deep as possible when doing the surgery, but not to cut through, which has high requirements on the doctor’s surgical level. 3.Whether to perform multi-point random biopsy of bladder mucosa at the same time? There is no consensus on whether or not to perform a multi-point randomized biopsy of the bladder mucosa at the same time as the electrosurgery. Given the multifocal nature of bladder tumors and the possibility of TaT1 tumors with carcinoma in situ or atypical hyperplasia, some scholars suggest that random bladder mucosal biopsies should be routinely performed. The literature also reports an abnormality rate of less than 10% for random mucosal biopsy and less than 2% for low-risk tumors, and most scholars do not advocate routine random mucosal biopsy. High-grade G3 tumors have a high abnormality rate on biopsy, with 41% of concomitant carcinoma in situ reported in the literature, and mucosal biopsy of the bladder can be performed selectively. Random biopsies should include the right and left lateral walls, anterior and posterior walls, the apex of the bladder, the triangle and the urethra of the prostate. A biopsy of the prostatic urethra may be performed in the presence of cyst neck tumors, or if in situ cancer is suspected, or if the prostatic urethra is abnormal. We advocate that pathologic biopsy should be performed for high grade tumors and suspicious abnormalities of the bladder mucosa. In recent years fluorescence cystoscopy has been used in clinical practice to guide electrodesiccation, suspiciously finding lesions that cannot be found under conventional cystoscopy and avoiding unnecessary routine biopsy. 4.Is electrodesection an option for all superficial bladder cancer? Can patients with urethral malformation or urethral stricture be electrosurgically resected? If the bladder cancer is single or limited multiple, electrodesiccation should be done; if it is extensive and multiple, electrodesiccation cannot cut cleanly, total or partial bladder resection can be done. For patients with abnormal urethral structure, the electrodes can be put in as long as the patient can urinate normally. For example, patients with urethral strictures can have their urethra cut open and then have the scope inserted for surgery. It is not recommended to temporarily open another surgical channel to do resection, such as trying to do cystocentesis when it is difficult to put in the electrodesiccope, or opening the bladder through laparoscopy, which will lead to a very high risk of tumor cell overflow. 5.If the tumor has invaded the muscle layer, is it still possible to choose electrosurgery? This kind of patients will have certain risks if they choose electrosurgery. In principle, no tumor spread is the bottom line of bladder preservation surgery, total bladder removal has a great impact on the patient’s quality of life, so every effort should be made to preserve it if possible. For bladder cancer that invades the muscular layer, the first step is to observe and determine whether there is lymph node metastasis on imaging. If lymph node metastasis occurs, then it means that the tumor is no longer confined to the bladder and it is meaningless to do local resection, and the whole bladder should be removed and then lymph node dissection should be done. Some doctors also try to do bladder preservation surgery for patients with bladder cancer that has invaded the muscle layer. Radical TURBt combined with radiotherapy plus chemotherapy is the most used regimen today. Several studies, including the MGH and the University of Paris, have found that radical TURBt combined with cisplatin-based radiotherapy for muscle-invasive bladder cancer has an overall 10-year survival rate of 60%, which is similar to the gold standard, and a success rate of nearly 50% for bladder preservation. In a long-term follow-up cohort at MGH (348 cases), cystoscopic biopsy + urinary exfoliation cytology evaluation was performed after induction radiotherapy, with follow-up consolidation radiotherapy for patients in complete remission and immediate radical total cystectomy for those in partial remission or with tumor progression during follow-up. After a median follow-up of 7.7 years, 70% of patients eventually had successful bladder preservation, while overall survival rates at 5, 10, and 15 years were 52%, 35%, and 22%, with disease-specific survival rates of 64%, 59%, and 57%, respectively. In contrast, 29% of patients who underwent radical total cystectomy had a prognosis similar to that of the initial cases where the gold standard was used. 6.Why do some patients with bladder cancer need a second electrosurgery? In the past decade, the concept of secondary electrosurgery has been gradually introduced at home and abroad, i.e., electrosurgery is performed again within 2-6 weeks after the initial electrosurgery. The main reasons are: ① The residual positive bladder tumor rate after the first electrosurgery is very high, even in large cancer centers in the United States and Europe, this figure is as high as 30-52%, so it is necessary to perform a second TUR to remove the residual tumor tissue. ② A comparative analysis of pathological specimens after secondary TUR and those after the first surgery revealed that the pathological staging after secondary TUR was higher than that of the initial surgery in 10-20% of patients, especially those patients whose initial TUR did not reach the muscular layer or whose muscular layer was not seen in the specimen. Inaccurate staging can also affect the choice of subsequent treatment options and prognostic assessment of the patient. Why is such a high rate of tumor positivity found within a short period of time (2-6 weeks) after the resection? These factors may be related to: (1) the multicentric and multiple biology of bladder cancer, the ease of missing latent early tumors, the high malignancy of high-grade tumors, the ease of tumor implantation and intravesical metastasis, etc.; (2) of course, the quality of the initial electrosurgery is also crucial, and if the initial electrosurgery does not reach the muscular layer or if no muscular layer is seen in the specimen, the rate of positive tumor detection by repeat electrosurgery increases significantly. Therefore, for the first TURBt is not sufficient; there is no muscle layer tissue in the first electrosurgical specimen, except for TaGl (low grade) tumor and simple carcinoma in situ; T1 stage tumor; G3 (high grade) tumor, except for simple carcinoma in situ. Secondary electrosurgery is recommended within 2-6 weeks after surgery for accurate staging, reduction of postoperative tumor recurrence, and better control of bladder tumors. At present, secondary electrosurgery is unanimously recommended in domestic and international bladder cancer treatment guidelines and has become the current standard treatment method. 7.If the tumor recurs repeatedly, should I still choose electrosurgery? Theoretically, as long as the bladder cancer is superficial, it can be electrosurgically removed after recurrence. However, whether the bladder can be preserved or not and whether the bladder is worth preserving are two concepts. Superficial bladder cancer should be preserved if it can be preserved, but if bladder fibrosis occurs after repeated electrodesis and the quality of life decreases, it is actually to the extent that it is not worth preserving and can be completely removed. 8.How long does it take for a patient to urinate normally and be discharged from the hospital after electrosurgery treatment? Generally speaking, you can remove the urinary catheter and urinate in about three days after electrodesiccation, and you can be discharged if the bleeding is not serious. Some patients with deeper incision should not urinate prematurely because the bladder wall of such patients will be thinner and urine will spill out when the bladder expands and contracts, which may cause the cancer cells remaining in the urine to spread to the blood. Therefore, the urinary catheter will be left in place for a longer time, maybe 1-2 weeks. 9.Why should I have bladder perfusion chemotherapy after bladder cancer surgery? Bladder tumors are multiple in nature, and the so-called multiple has two meanings. One meaning is manifested in spatial multiplicity; multiple tumors growing in the bladder at the same time. Another meaning is temporal multiplicity. A large number of clinical studies have confirmed that the recurrence rate of non-muscle invasive bladder cancer using transurethral bladder tumor electrosurgery without subsequent bladder perfusion therapy is about 70-80% within 5 years. The main reasons for recurrence are: (1) the primary tumor is not excised; (2) the tumor cells are shed and implanted during surgery; (3) it originates from the pre-existing metastatic epithelial proliferation or atypical lesions; and (4) the bladder epithelium continues to be stimulated by intra-urinary carcinogens. If the correct bladder irrigation treatment is used, the recurrence rate can be reduced by half, usually to about 30%. Regular bladder perfusion chemotherapy after surgery can effectively prevent tumor recurrence and inhibit tumor progression to infiltration, and it is simple to operate and has few adverse effects, which is an important part of treatment for non-basal invasive bladder uroepithelial carcinoma. 10.Post-discharge precautions ①No smoking (the occurrence of bladder tumor is closely related to smoking); ②Regular bladder perfusion; ③Regular review (cystoscopy); ④Bladder tumor is prone to recurrence, if there is discomfort such as hematuria, seek medical consultation in time.