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Ashish Kamat: Hello, everyone, and welcome to UroToday's Bladder Cancer Center of Excellence. We are here in San Antonio at AUA24. I'm Ashish Kamat, and it's a pleasure to welcome once again to the forum, folks who really need no introduction, Professor Badri Konety and Professor Jeremy Teoh. Thank you for taking the time and spending it with us today.

Jeremy Teoh: Thank you.

Badrinath Konety: Thank you.

Ashish Kamat: We're going to talk about a topic that is in the guidelines, but it's still controversial. People often wonder, well, I'm an expert urologist. I've done a TUR for a patient. There's TA high-grade disease. I've gotten muscle. I don't need to listen to the guidelines. With that in mind, let me ask you, Badri, first, what's your response to the question when you are asked, "If an expert urologist does a TUR, do they need to do a reTUR for TA high-grade disease?"

Badrinath Konety: Depends on how you define expert because that's part of the problem. If you look at all the data out there, you need to do about a hundred TURs to officially start noticing a considerable decline in the number of specimens with no muscle in it. If you use that as a measure of a thorough TUR so that you've got enough muscle, then you can say that's a good TUR. There are actually studies from England which show that even in somebody who is a junior consultant, meaning they finished their full training, their performance in the number of patients who have muscle in the specimen is actually worse than resident trainees because they really want to be thoughtful and careful and get adequate samples. If it's somebody who's really experienced in general, not necessarily TURs, but it's 10, 15 years out, and they go in and resect the tumor, and they take a couple of small bites using a cold cup of the base. There are all different ways to say what is a thorough TUR, and who's judging that it's a thorough TUR, and who's judging that this person is experienced?

Ashish Kamat: Let me stop you there for a little bit and flip it over to you, give us a little bit of an international perspective. If you look at Hong Kong or you look at other parts of the world where you've been active, is that the same experience as far as the expertise of a urologist? How long does it take, for example, in your training program for you to say so-and-so is an expert?

Jeremy Teoh: I think in our training program, generally we have a lot of exposure. Endourology will have at least 50 to a hundred cases every six months. In the six years of training, pretty much you would have done a few hundred cases. I would say in general, I think the Asian urologists, by the time they got qualified, they're pretty much very experienced. Therefore, in the notion of whether a repeat TUR is needed, I think in our situation it's probably not the case.

This is actually one of the biggest questions that was in my mind when I was in training because it appears a little strange in a way that you would recommend a second surgery to compensate for the limitation of a surgery. Why do you need it? If you think it is needed, why do you think a second surgery will be easier than the first one? The immediate intuition is we should do it the right way the first time. Instead of thinking whether a second surgery is needed, I think the more logical way and the right direction is really how we can optimize the training and make sure the quality is up to standard in the first place.

Ashish Kamat: Both of you raised great points, but let me play the devil's advocate a little bit. The guidelines are to help our patients.

Jeremy Teoh: Sure.

Ashish Kamat: It's to help us help our patients. If the guideline says if you have a high-grade tumor, you should do a repeat resection, in some ways, it's to protect the patient from a poor TURBT. Comments, Badri, on that?

Badrinath Konety: I agree. I think it's meant to be really patient-focused, and what's the downside of the repeat TUR? That's the other thing we have to think about too, and also, what's the context? Repeat TURs can be done because you didn't resect everything the first time. This happens quite often in community practice. That's a different ... That's an inadequate resection, and knowing fully well that you didn't do a complete job, but the most common reason we're doing repeat TURs nowadays is because you don't have enough muscle in the specimen. You want a thorough diagnosis. I don't see a downside to doing that. How is one going to defend if one did an inadequate sampling or wrongly classified the patient, because understaging is a big issue. I think it's going to be hard for us to make a case why not to do something, especially when it's in the guidelines.

Jeremy Teoh: I think most of the cases probably there's not much disadvantage per se, but I think there's still a need for anesthesia. I think sometimes, especially when you're not the one doing the first surgery, you don't really know how deep the resection is, and then obviously, the resection is not so uniform across the resection bed. Sometimes you would have resected, and then suddenly you see fat coming out. In a way, I don't completely agree that there's no downside. There are certain risks. It might be minor to correct some cases, but then again, I think the more important thing is really ensuring doing it properly instead of finding a way to compensate for it later on.

Ashish Kamat: The proper part of it, completely agree. Both of you are on the review paper that has been put out in multiple venues. This is Bladder Cancer Awareness Month, May. I want to make a plea to everyone listening, we got to learn how to do TURBTs correctly because it's the most underappreciated procedure that we do. I know this is not the topic of this, but briefly, if you could talk about the ideal TUR. How do each of you do the ideal first TUR for what looks like a non-invasive high-grade tumor? Let's start with you, Jeremy.

Jeremy Teoh: Yeah, sure. I think there are two parts, mainly, surgically. One is about the detection, how you can ensure that you have included the tumor, even if there are some subtle changes or maybe some satellite lesions around the main tumor. That's when we can use enhanced imaging, be it narrow-band imaging or Image1 S or PDD. Then it's really helping us to define the margins that we want to resect.

The second part is about the resection procedure because I always say TURBT, the way that we resect it, actively fragmenting it, in a way, it's kind of violating the usual cancer principle that we have in other types of cancer surgery.

The other thing is after the resection, whether a complete resection has been achieved is largely based on the surgeon's judgment rather than the resection margin. That's why, as you know, we have been doing a lot of en bloc resections, trying to respect the oncological principle; marking the margins, going from the periphery, incising down to the muscle layer. Then from periphery to central, from normal to abnormal, we try to get to the right layer having a uniform resection of the whole base. That's how we do it. I think there are more and more data showing that there are benefits if we do it in a more systematic approach.

Ashish Kamat: Badri, tips and tricks?

Badrinath Konety: Yeah, I agree with Jeremy largely. The blue light has really helped us in getting a better assessment of what all you do need to resect and also assessing the completeness of resection. Though I was chagrined when we went back at the blue-light registry and looked at the last run. We had about 120 patients or so. We thought we would see lower rates of muscle recovered in the second TUR. That didn't turn out to be the case. Previous data do suggest that there's a more thorough TUR using blue light.

I also agree with Jeremy about en bloc, if I can, and if it's not an enormous tumor. The other challenge with en bloc is sometimes the tumor is so big, how do you get it out in one block? Otherwise, I do think it's really ... If you do it really well, it's really helpful in making sure you're completely resected. It takes some learning, so usually, some of the early ones, you may not do a good job, and maybe for trainees, it's going to be harder to teach them, but that's going to be important.

Also, a priori, make sure that if you're going to have a lateral tumor, be aggressive about paralysis and nerve blocks and so forth because sometimes that's where you try to cut corners. I typically don't like the idea of this cold cup biopsy thing. I think that's just a random sample. I don't know how thorough that is. I know Jeremy was a little worried about the fat. As long as it's not on the dome, on the sides, I think it's okay because we've got series that've shown that you can resect, even T2 tumors, through the fat and nothing really happens. You have to leave them with a catheter for a few days, so it's okay.

Ashish Kamat: Yeah, both of you raise great points. En bloc, when feasible. Obviously, you have to train people to do it well, and if it's a large tumor, then you defeat the purpose of the en bloc per se. Of course, planning the surgery beforehand, talk to your anesthesiologist, paralyze the patient. The number of times we see patients that have a lateral tumor that was "resected" but clearly not, is shocking.

Let's get back to the topic at hand. If you, Badri, as the expert, do the initial resection, and I'm putting you on the spot right here, it's your patient. You did the initial resection. He or she comes to your clinic, you look at the pathology report, and I'm going to give you three different scenarios. It comes back TA high-grade, muscle not present. Do you do a reTUR?

Badrinath Konety: No question. I will go back and get muscle.

Ashish Kamat: TA high-grade, muscle present.

Badrinath Konety: Muscle present, questionable. I am not as convinced. Depending on how much muscle is there, I'll probably review the pathology specimen. If you just have a few slips, it's a different issue. But if you have an adequate muscle specimen, and they're pretty confident that there's no invasion, I may not go back if I've done the first TUR, and if I've done it with blue light. I've got a bias, I'll confess. T1, I probably will go back and reTUR.

Ashish Kamat: That was going to be my last situation because I don't think ... I'll ask you, you can answer independently, but I don't think there's too much debate with T1s because that's where you don't want to miss the T2. Now, you, same scenarios. T1, I presume you go in.

Jeremy Teoh: Yeah, correct.

Ashish Kamat: What about TA high-grade? If you've done the resection, you have a lot of muscle, say it's an en bloc you've done.

Jeremy Teoh: Oh, if TA, it's a very superficial tumor. If you have done it in the first place, you're pretty much sure that you're resecting a muscle layer of a whole bed, I don't offer a second surgery. I think it's reasonable to just observe and to plan for the next step. Again, if there's no muscle at all, then definitely it's an under resection. Then, we should go back in.

Ashish Kamat: I think that's a good thing to keep in mind. Even as experts, if there's no muscle present in the TUR, which again, is not a failing on your part. It's because sometimes the tumor looks like it's low-grade, and if it's a low-grade tumor, you don't want to do something too drastic and not be able to give the perioperative chemotherapy. Sometimes you plan for less of a resection, and you're surprised by, oh, it's 10% high-grade or it's 20% high-grade. Maybe it was mainly low-grade, but some high-grade. Even if we do the resection initially, it's not a matter of telling the patient, I did not do a good job. It's literally a matter of telling the patient we need to go in and see if there's any roots left behind, or however you want to word it. Patients understand that.

Badrinath Konety: They do.

Jeremy Teoh: Yeah.

Ashish Kamat: That's an argument that I often hear people throw, saying, my patient is going to think that I did an incomplete surgery. How do you counsel the patient for a reTUR, Badri?

Badrinath Konety: I tell them exactly what you said. I say, look, I think we got all the tumor, but I just want to make sure there's no roots left behind because we can't see that. I can tell you the tumor that's growing out of the wall, but the roots I can't see with my naked eye, and it looks like there may be a chance some roots are left behind, so we've got to go take it out. It's like you can throw Roundup on the weed on the surface, but you got to dig out the thing, otherwise it'll grow back next summer.

Ashish Kamat: What do you tell your patients?

Jeremy Teoh: For me, it's very simple. I just tell them right away, endoscopic judgment of any residual disease is inaccurate. It's prone to error. We can't see it. Because in T1 disease, for example, there's already some evidence of invasion, it's worthwhile to go back in, get more samples, making sure that it's really all cleared. That's how I counsel my patients.

Ashish Kamat: If you are going to go back and do reTUR, Jeremy, what timeframe do you schedule it for?

Jeremy Teoh: We should schedule it around four weeks. Two weeks, I find it a little early sometimes, but we don't want to wait too long either.

Ashish Kamat: Badri?

Badrinath Konety: About the same, three to four weeks at least.

Ashish Kamat: I do the same too. I usually wait three to four weeks because too early, there's a lot of edema; too late, you could be waiting too long. That's another criticism. People come up, and they say, well, you're delaying effective therapy, say BCG in this case. Why not do BCG, and then go in at the first cystoscopy and do a reTUR then? What would your argument be?

Badrinath Konety: There are at least a handful of papers now, telling you that BCG given after a reTUR begets a better response than BCG given without a reTUR in those high-grade T1, high-grade TA cases. Actually, though that's the fear, the data would not support that fear.

Jeremy Teoh: I guess the other point is there's still a chance of a T2 disease. In a way, of course, BCG, if it's just one dose or a few doses, maybe the side effect is not so much, but then it's still kind of unnecessary in the case of T2 disease. I think it's more logical to really properly stage it. Then, together with what Professor mentioned, that doing reTUR, BCG works better. I think that's probably the better way to do it.

Badrinath Konety: I would add that's probably why the response is better, because otherwise, there should be no real reason. You're culling out all the people who are not candidates for BCG, so your response looks much better now.

Ashish Kamat: Exactly. Exactly. Gentlemen, of course, we could talk about this forever, but we do have to close. Let me ask both of you for closing thoughts on this matter. Jeremy?

Jeremy Teoh: I think if it is a high-grade tumor per se, it doesn't really translate to whether TUR is needed at all. It really depends on the surgeon's experience, how confident you are doing the surgery, and if you have resected it. Presence of muscle is very important. It is a good indicator of whether there's any under-resection. T1 disease, definitely we should offer. I think at the end of the day, as a surgeon, we still need to try our best to optimize the surgical approach in order to avoid any unnecessary second surgery in the future.

Ashish Kamat: Dr. Konety?

Badrinath Konety: Yeah, I agree. I think we should take personal ego out of this and do the right thing by the patient. If you feel you did a thorough job but still don't have enough muscle in the specimen, I think you should go back. T1 for sure, you should go back to be on the safe side, and there's no data to say that you're doing anything wrong by doing that.

Ashish Kamat: Great. I'm glad there's so much agreement on this very important topic. Of course, at the forum and the debate, you guys have to stick to your side, so do that. Thank you so much for taking the time.

Jeremy Teoh: Thank you.

Badrinath Konety: Of course. Great to be here. Thank you.