TURBT with severe CCF

89yo male with known severe HFrEF and recurrence of bladder cancer causing haematuria and urinary retention.


  • Bladder cancer – previous TURBT (2019) and palliative radiotherapy. Symptomatic recurrence.
  • Significant cardiac disease
    • Biventricular PPM for sinus-brady, PPM-dependent.
    • IHD – CABG 06, NSTEMI 18, angina 2-3x per week.
    • HFrEF, admitted with decompensation Nov ’20, EF~30%
    • PAF – anti coagulated.
  • CVA post CABG (nil deficit)
  • CKD eGFR 42
  • Hypothyroidism
  • Borderline exercise tolerance 4.6METS DASI
  • Distant ex-smoker


  • Severe HF + ongoing angina
    • Nil clinical e/o HF on examination.
    • Known severe dx, TTE relatively unchanged from 2018 – now.
    • Known to cardiologist, reviewed recently.
    • Discussed with that cardiologist – nil room for further optimisation.


  • Should surgery proceed?
    • Palliative procedure for symptom-relief
    • Low risk, low physiologic stress surgery.
    • Palliative radiotherapy an option? – possibly, but the patient cost (emotional, physical, QoL) of a weeks long course of daily radiotherapy at 89yo and with his comorbidities should not be underestimated. Overall seemed that the TURBT was the most patient-centred option.
  • Any optimisation possible?
    • Cardiologist feels that patient is optimised. Further Ix/Mx of IHD would be invasive, low yield and may have secondary consequences with negative impact (such as delays to his symptom relief from TURBT; the need for additional anti platelet therapy which would cause further bleeding issues and be problematic in the perioperative period).