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Sam Chang: Hello everyone. My name is Sam Chang. I'm a urologist at Vanderbilt University in Nashville, Tennessee, and we are quite fortunate to introduce Dr. Max Kates. Max is an associate professor at Johns Hopkins University and actually leads their division of urologic oncologists. He's the director of also their bladder cancer program there and has really become quickly one of the leaders in the treatment and diagnosis and evaluation of bladder cancer. And we wanted to discuss today an upcoming course that he is introducing, at the AUA in 2023, which is looking at techniques of cystoscopic evaluation and resection of bladder tumors. Probably one of those areas that we discuss all the time and probably don't do as great a job of teaching as we should along the residents and fellowship levels. So first of all, I want to welcome Max. Max, thanks so much for spending some time with us and tell us a little bit about your course.

Max Kates: Well thank you Sam for that wonderful introduction. The origins of this course really is exactly what you just talked about, which is that TURBT is a extremely common procedure performed all over the country and really the world. We give lip service all the time to how important it is for the diagnosis, staging and treatment of bladder cancer. And yet we have limited discussion and there's limited teaching regarding techniques in TURBT. And really if you look as we look over the last several years, there have been a lot of innovations that have happened in TURBT. So the real origins of this course was to say, well, how can we take what we know, which is the, that TURBT is this very important aspect of bladder cancer management and care and really hone in on what are the techniques that can maximize our outcomes for our patients.

Sam Chang: So give us a brief outline of what you do with this course in terms of the introduction and then do you talk about specific different techniques? Do you have videos? Tell us a little bit about the actual kind of nitty-gritty of the course.

Max Kates: Yeah, so I'm glad you asked. So the course is first and foremost going to be on Friday, April 28th at 1:30 PM at the AUA and I'll serve as the course director and I'm really excited about our faculty. Our faculty are international. Dr. Maria Ribal from Barcelona, Dr. Jeremy Teoh from Hong Kong, and Dr. Jen-Jane Liu from OHSU. So between the four of us, the format of the course is essentially going to be taking a 15-minute topic, so for example, one of the 15-minute topics will be TURBT best practices. Another 15-minute topic will be TURBT in the guidelines. And then the last topic will be en-bloc TURBT, which Jeremy will be discussing. And then intermittently I'll be showing video cases and case-based videos and we'll be discussing the techniques used to employ specific situations that will have been highlighted in the rest of the talks. So it'll be a 15-minute talk, cases for 15 minutes, 15-minute talk, cases for 15 minutes. And so I think that breakup will be very lively and there'll be a lot of audience participation and discussion.

Sam Chang: That outline I think, really will propel this course to become one of the can't miss courses actually at the AUA. First of all, your faculty. International experts, social media in terms of their presence and their ability to deliver kind of the latest and greatest in dealing with different forms of urologic cancers, but specifically bladder cancer. Fantastic. And that integration of a didactic in a video session to me is outstanding. So with that, are there ... I don't want to give away the whole course because there's no way we can because there's going to be so many, I think, important and interesting facets, highlight some of the key areas. As you were putting the videos together or as you were accumulating the videos, tell me some points that you actually learned as you were putting these videos together.

Max Kates: Yeah, well, I mean think when you do a course this, it's very sort of easy to sit on what maybe we have, we think about TURBT as years ago. So I think the challenge in this course was the word contemporary. What is contemporary? And when you put a course like that together you realize the technologies have really improved. Bipolar technology that that's been around a while, has really made subtle changes in how tumors are managed. So for example, we'll be discussing a lot scenarios of tumor ablation rather than necessarily resection. And what bipolar technology allows for tumor ablation in, for example, low grade recurrent bladder cancer. Another example would be the use of lasers, which is something that's done some in the United States, but it's done a lot more out of the United States for en-bloc resections and how laser technology has really enhanced the ability to do that in more of a precise way for those that are interested in employing that in their practice.

And then some subtle things like that I think we don't necessarily do as good of a job of teaching things like resecting your ureteral orifice or managing a tumor diverticulum and how some of the technologic changes in the last five to 10 years have maybe changed how we might even think about doing that. So those would be a couple examples of different techniques we'll touch on in the course.

Sam Chang: Well no, that's incredible. And I'm already, I don't know if people can tell, I'm getting excited about this course because I love to learn from others and I can already see iterations of this continue as hopefully you'll continue to renew this course because I think about, gosh, in the future you could focus on complication avoidance or what happens after you have certain complications. What do you do? How do you manage? I can see you then focusing on prosthetic urethral disease or focusing on so many iterations and learning from each other. I think this would be fantastic.

And the amount of work ... I personally have just started to do a little bit of video work, very little bit and the time and effort that takes Max, incredible kudos to you to put something like this together. Our reconstructive folks and others that tend to tape everything all the time, it's one thing to put all that video work together is really quite an effort. As you have put this course together, tell me some of the things that you've implemented as you have trained your residents and fellows. Because there's no question that I do things differently now compared to five years ago, compared to 10 years ago. Tell me some of the key points maybe you started integrating in your education of the next generation.

Max Kates: Yeah. I mean it's such a good question and I'd love to hear what you do as well. What I do is basically when I look inside a bladder and I see a tumor, I immediately think, who am I working with? What level of trainee am I working with and what is their capacity to learn from this case? And then whatever it is, that then will go from there. So a large six centimeter mass that's in the anterior bladder neck is going to be a senior level TURBT as opposed to a one centimeter tumor on the bladder floor, which is a great intro to TURBT. So that's first and foremost in my mind. And then there's things I always teach the residents, which is for a first year resident, I want them to understand the flow of irrigation. If they can understand the flow of irrigation ...

Sam Chang: Oh hallelujah.

Max Kates: That is my thing I teach.

Sam Chang: That is so important. Okay, good. Keep going. Music to my ears. 

Max Kates: That's like before anybody's doing any resecting, I want them to understand what the bladder floors look like. Is that full, is that empty? Is it under distended? Is it over distended? And how are they utilizing flow? This is one of those small aspects of that, but until you're really a senior level resident or higher, the outflow is never turned off in my room. And that's just like a religion to me to protect the patient for the most part, because I really think that one of the hardest things as you learn, especially as a junior resident, is understanding the dynamics of a bladder related to the irrigation. So that would just be one subtle thing, but there's obviously so many. I'd love to know what are some of your major practice points?

Sam Chang: Yeah, I think that to your point, and this is one of the things that I'm trying to integrate in our residency, but honestly it's very difficult. The junior, less experienced residents tend to work with me in the endoscopic cases. And then as they go through their residency, then they spend time with ureteroscopy, with our stone folks and our reconstructive folks and then tend to do open and then by the time they're chiefs, they've gotten a very big endoscopic kind of exposure. But I'm really trying to get the chiefs to actually come back to start doing more cases that are endoscopic because I still think and the folks that do a lot of resections really will say, this is still one of the most difficult cases that we do to do well. And that's something that I think we needed a better job on. And I'm sure with some of the simulation models that we have, we're going to get better in terms of training, but your emphasis on understanding the bladder dynamics, that this is not a static system is incredibly important.

And the danger of under-distension may be just as great as the danger of over-dissension in terms of perforation and evaluation of tumor and bleeding control and those types of things. And it is an active practice in that one of the things that we really do emphasize is that this is a practice where we're in it together, understanding it, and the idea of constant flow, I'm constantly, every time I'm actually there manipulating here, we need to turn inflow in and down, up, down, and I personally still tend to use, and I'd love to hear what you do, I still tend to use, just grab the installation from an IV pole. We have certain irrigation systems that are, a lot of our endoscopers use, that set at a certain pressure and flow, which I think are very effective and they use quite well. I tend to avoid those just because there's so much trust than just built into the system of I'm not going to over pressurize the system and I'd rather depend upon my eyes and understand what's going on in the bladder.

Some bladders are very small, some are large. Understanding that that kind of nuance is something that continues to get better and better over time. And so I really appreciate that gradual integration of, okay, you feel comfortable with a tumor in a certain location, certain size, how about this tumor? How about this? And understanding bipolar, monopolar, pros and cons, all those things I think are really important. And lessons I still hear from the voices of certain of my mentors during fellowship of, be careful of this, keep an eye on this and always talking. I think I'm a little bit better at it than I was a few years ago and definitely a few years from that. So I think emphasizing the continued learning educational process of doing this. And that's why I honestly am very intrigued by the course in terms of looking at the new technologies that you guys are going to introduce that Jeremy, I'm sure will introduce with en-bloc, and learn from that.

I think right now, one of the things, the last thing I want to bring up is one of my partners is actually working on a robotic kind of robotic instrumentation of a cystoscopic and endoscopic, a rigid scope. And like everything, it's to better visualize, better control, better manipulate the instruments. And tell me what you think would be the next important step forward for resection. Is it better visualization? Is it better hemostasis? Is it better evaluation of tumor depth, is it OCT something? Tell me what you think excites you the most about the next steps with endoscopy.

Max Kates: Yeah, I mean so much there, what you've talked about. I am very excited about, first of all, let's take a step back. If we look over the next 10 years, what's the major aspect of bladder cancer that will change? I think that will be preserving more bladders for early stage disease. When I say early stage, I mean muscle invasive and earlier. I actually think we may be doing more surgery for a locally advanced and metastatic disease, but that's a different topic. But for muscle invasive bladder cancer and earlier, I think we'll be trying to preserve a lot more bladders. What's going to allow us to do that is maybe therapeutics, I think so. But certainly it's going to be enhancing our ability to resect muscle invasive tumors. And the thing I'm most excited about with that, I think that allows us to do that, is the ability to suture endoscopically. So I want to be, I'm very excited about robotic technology that will not only allow me to cut out a muscle invasive tumor endoscopically, but suture it back essentially doing a partial cystectomy cystoscopically. So that's where I want, I want to be doing that surgery in five to 10 years. I hope I will be.

Sam Chang: You heard it here first. And it's this kind of forward-thinking that I think will really transition things because I agree with you, not necessarily with suturing, I'm going to learn from that. But the idea of, gosh, for certain tumors, we've got to be able to do less. We have to be able to preserve more bladders, be able to focus on better kind of diagnostic evaluation. And it may be imaging, it may be techniques, it may be everything. And so I find it, because we joke about it, but it is really true. The way we remove these tumors is archaic and the way we've done it for a long, long time and is really different from any other tumor that we use or any other tumor that we treat and we use this type of equipment. So Max, last points here for you, as you've put this course together and those that are looking at putting courses together for the AUA or for ASCO, other types of meetings, tell me what the most exciting part is to help putting a course together for you.

Max Kates: That's a great question. I think for me it's finding the need. Where is the need? You know, you look at the courses at the AUA and they're incredible. I know you've been a part of one with non-muscle invasive bladder cancer for a few years. And so you look at these courses and you see the amazing breadth. But believe it or not, when you look at that breadth, there are still holes there and there are still areas in which you might say to yourself, why is nobody talking about this or teaching this? And so I would say that the number one thing to do if you're interested in putting a course together or an education, is finding where the need is. And then the really exciting people is building it. For me, the most exciting thing of anything I do is always building the team. So then it's really building the team of people who know things that you don't. In my practice, I do not do laser en-bloc TURBTs. So that was the first thing I wanted to find somebody to teach because that is, I'm going to be able to learn so much.

And then I'm not on a guideline committee, and so to have Maria Ribal who's the chair of the EAU guidelines come in and have that perspective. So it's building the team based off things that you don't necessarily do or skills that you don't necessarily have. So those would be sort of the two aspects of this course and building a course in general that I find most exciting.

Sam Chang: Well Max. That's great. So Max, if people can't make it this year, I want them for sure to be on the lookout for it in the years to come. So tell us the title of the course and Max Kates is the director. So Max, the title of the course for the a AUA is ...

Max Kates: It's Contemporary Techniques in Transurethral Resection of Bladder Tumor.

Sam Chang: You heard it here first folks. If you can't make it this year in Chicago to the AUA, upcoming years to come, we do have an annual meeting and there are lots of good courses just like Dr. Kate's mentioned. But for those of you in practice, and for those of you who help train fellow fellows and residents, I can't think of possibly a better course that's cancer related. So Max, thanks so much for spending some time with us and look forward to definitely this course this year and for years to come.

Max Kates: Thanks, Sam. This was a lot of fun.