Ashish Kamat: Hello, and welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, Professor of Urology and Cancer Research, MD Anderson Cancer Center in Houston. I'm joined today by one of my colleagues from the UK, Mr. Hugh Mostafid, Consultant Neurologic Surgeon at the Stokes Centre for Urology at the Royal Surrey County Hospital in the UK. Dr. Mostafid, or Mr. Mostafid, as he likes to be called across the pond, has really pioneered a lot of things, but especially the improvements in transurethral resection of bladder cancer, which many don't realize needs a lot of improvement. And I would like to thank you, Hugh, for taking the time to join us and speak on this very important topic today.

Hugh Mostafid: Thanks, Ashish. It really is a great pleasure to be speaking to you and talking about this very important topic. So there's a couple of important points that I wanted to start with. I think these pictures really summarize one of the basic problems with TURBT because we're basically trying to use an instrument that was developed many years ago for resecting the prostate to do a completely different job. And it's a bit like using a hockey stick from ice hockey to try and play a good game of golf.

The other problem I think we have is that if you look at the resectoscope, the original Stern-McCarthy resectoscope for 1935, and then look at the current model, I mean, they basically look pretty much the same. Anyone looking at those two would be able to identify them as exactly the same thing.

And then I think the third problem that we have is that, unlike some other operations where there's essentially one technique, TURBT is not really one single technique, it's a number of different techniques. You can look at these three tumors. There's a solitary one on the left. There's the sort of flat carpet, and then the large tumor. And they all have very different approaches to resecting them.

And I think this really led to an evaluation of TURBT probably around 20 years ago. These are probably the two really landmark papers, I think, that made us rethink TURBT. So on the right, we have Harry Herr's very important paper from 1999, which made us realize that we were probably under-staging and under-treating a lot of patients by not getting muscle in the specimen. That really made us realize there was some sort of drawbacks to the TURBT technique. And then the Maurizio Brausi paper on the left showed that there was a really surprising amount of variability in TURBT outcomes amongst different surgeons. And really, from then on, we've started to really look at TURBT and particularly some of its imperfections.

So, how can we go about improving and optimizing TURBT outcomes? I think, first of all, we can look at improving the operation. And we already know that there are ways of improving the image, including photodynamic diagnosis and narrow-band imaging, high definition cameras. We can improve the equipment that we use. One of the ways that the resectoscope has been improved recently is using bipolar energy with the improvements that that brings, including better quality specimens which, of course, is important. And then there is the development of new tech techniques, such as en bloc resection, where you cut around the tumor and remove it in one piece.

But I think those of us who are interested in improving TURBT outcomes also realize that one of the greatest improvements we can make is to improve the quality of the urologists' approach to the operation. And we can do this with better training of our trainees. We could have more courses. There are surprisingly few courses for what is probably the commonest cancer operation that we do. We know that checklists improve outcomes in TURBT, but they're not widely used. We should audit our results. And I think also just the general awareness that we are doing a cancer operation, and we should apply the same criteria for our bigger cancer operations to TURBT. And perhaps one other thing is my personal feeling is that just because we can do a TURBT doesn't always mean that we should when there is probably someone with more experience who could do it.

Just a quick mention of en bloc resection, most urologists will have heard of it where we remove the tumor in one go. But one of the questions that always arises is, is if I was to start using en bloc resection, how adaptable is it? And this is some data we're in the process of publishing between myself and Jeremy Teo from Hong Kong. We looked at this in terms of an intention to treat analysis. So essentially every single patient that needed TURBT, we started off by doing en bloc resection. And I think the information that I'd like to pass on is that if you adopt this technique, about three-quarters of every single tumor that you've come across can be done using en bloc resection. And in particular, when you're looking at smaller tumors, which form the majority of the tumors we deal with, 94% of tumors less than one centimeter, 82% less than two centimeters, can all be done with en bloc resection.

In terms of minimizing adverse events, I think it's important to adapt the technique to the patient. So we all know that elderly females have very thin wall bladders, and we need to be very aware of that. Sometimes having the knowledge of the previous history of non-muscle invasive bladder cancer is very helpful. For patients with low-risk tumors, you can probably maybe take a slightly more conservative approach, particularly if they're elderly.

There's the issue of just being aware of where you are and what's happening during the operation. If you think you've made a perforation in the bladder, you should really try and stop as soon as possible. And when you're operating on the lateral wall, just be very aware that the obturator nerve is close by and be thinking in advance that there may be an obturator jerk and how you could deal with it. And sometimes just when you're dealing with large tumors, very large multi-focal tumors, I think it's important just to accept that sometimes complete resection may be impossible.

And then finally optical diagnostics, as we said before, PDD photodynamic diagnosis, narrow-band imaging, and then the STORZ system SPIES, you can see from the slides, they all help to improve the visualization of the tumors. As yet, there's been no head-to-head comparison between these three techniques. I think they're all very promising, and I'm sure that in the years to come, we will be using enhanced visualization in every single TURBT that we do.

So really my conclusions are that, almost to go back to that golf analogy that I used earlier, we need to have a better awareness of our TURBT outcomes so that we know exactly what kind of outcomes we're getting individually. And then based on that, I think we can review our technique as it is already about how we can improve our TURBT techniques and get better results. And then I think the third aspect is that if we have better imaging and instrumentation, we will also get better outcomes for our patients.

Ashish Kamat: Thank you so much, Hugh. That was really an excellent overview of the topic. A couple of questions that often come up and, obviously you know, and you and I are on the same page, and we have a couple of editorials and articles coming up in press on this topic. So let me preface this for our audience by saying some of the questions I ask may sound like they're questioning what Dr. Mostafid said, but they're more to help our audience understand certain issues. So, the first one, Hugh, is people go, "Well, TURBT is really such an easy operation. We have our junior residents do it." What do you think about that mentality and teaching paradigm?

Hugh Mostafid: So, I mean, I think that I certainly grew up in an era where after maybe half a dozen TURBTs, we were left to get on with it. I think all of us who have looked at the evidence all agree that really you need to continue to supervise trainees for quite a long time because I think it's quite an easy technical operation to understand, but to get the best results requires a lot of supervision and a lot of practice to use the resectoscope in the best possible way to get the best outcomes.

Ashish Kamat: Yeah. I agree with you. Handing the resectoscope and getting the 3D and, in some ways, the four-dimensional perspective, is really hard for some of the younger trainees. I have trainees with me all the time, and I let them do a lot of the procedure, but I do not leave the room. I know there are several folks that leave the room or let them go about it. I will sit there, and there's always an opportunity to teach and guide and improve techniques, even if the trainee's done 400 of those. So I agree with you on that point.

Just as a matter of curiosity, when I was a resident, it was exactly the same way you said. And then I started doing a fellowship, and most of the attendees were the same way, they would leave the training in the room. But I had one professor, and I shall not mention his name, but he said, "No, a TURBT is an attending level case. You sit and watch." And I found that really curious until I started on my own as faculty 20 years ago.

The second question, Hugh, is the optical enhanced technologies that you mentioned. Do you feel that there's a clear winner amongst the different optical enhanced cystoscopy technologies? Do you think they're all similar and comparable?

Hugh Mostafid: Yeah. I mean, I think it's really hard to say without there being any clear head-to-head comparisons. What I can say is that I've used all of them, and I think probably going forwards, just my personal view is that being able to flick a switch, as you can do with narrow-band imaging is much easier than having to pre-instill a Cysview® into the bladder upfront. So, I think visually the results of PDD are really quite striking. You can really see it, but whether the logistics of ensuring that every patient you want to do it on can get it, that's the difficulty in practice. The advantage of narrow-band imaging, and I think the STORZ system, of course, is that you just flick a switch on the cystoscope or the flexible cystoscope, and the changes are there to see. And I think probably going forwards, it's some kind of digital enhancements of the image that may be the long-term way to go for, for this.

Ashish Kamat: Yeah. It's curious because all, obviously, the Level I evidence is of a particular technology with the white light. There haven't really been any robust trials comparing one against the other. Are you aware of any in the UK looking at narrow-band with, say, blue light cystoscopy or others?

Hugh Mostafid: No, I mean, we reviewed the evidence when we were doing the NICE bladder cancer guidelines, and there were no head-to-head comparisons. And we kind of came to the conclusion that any kind of visual enhancement is probably better than white light. So all of the techniques probably do pick up more cases than white light on its own, but whether one is better than the other, I think we couldn't say.

Ashish Kamat: Right. Tell us a little bit about the checklist, and how would you recommend that someone listening to this video and podcast essentially says, "Well, I want to implement the checklist." How should someone go about it?

Hugh Mostafid: Well, I think there's a number of predesigned checklists. One is by Professor Soloway. Another one was described in European Urology by Francesco Soria and colleagues from Vienna. And essentially they have a list of about eight to ten items that you almost have on a printed sheet. And every single TURBT that you do, you would go through this checklist, almost like a pilot would have a checklist to make sure that you've ticked off every single item. And it's just simple things like being aware of the patient's previous cystoscopy results, whether there was any imaging available. And then during the operation as well, making a note of all the tumors that you see a bladder map, for example, so that you make sure that you don't forget any of the tumors. The really important thing is that people have published pretty good data that using a checklist does really improve outcomes with this operation.

Ashish Kamat: Yeah, absolutely. I think the checklist helps not only to improve the outcomes of the operation, but also to help in the whole teaching process because one of the steps I do with the trainee before we start any case, and it takes literally 30 seconds even while you're gowning, is to say, "Well, so what are the things you're going to look for? What are you going to map? What are you going to do?" And it's amazing the number of times there's that "aha!" moment before the case starts, it was something that, in their minds, is as simple as, "Oh, just the TURBT," but as you very appropriately recognized during the talk is one of the most critical steps in the management of a patient with bladder cancer.

Any closing thoughts, Hugh? I mean, you and I could chat forever, but in the interest of time, we will have to close in a couple of minutes. Any closing thoughts for our audience?

Hugh Mostafid: Well, I mean, I think it's something that we all discuss at meetings when we bring this up, which is that, yeah, of course we could do with a better operation for non-muscle invasive bladder cancer, but we still have a lot of room for improvement in general with the current operation. And I think it's easy to blame the instrumentation and so on and so forth, but all of us can look at our outcomes, learn from our outcomes, and really think very hard about how we can improve our current technique to achieve better results.

Ashish Kamat: Well, once again, thank you so much for taking the time for you at the end of a busy day in the UK. Stay well and stay safe.

Hugh Mostafid: Great. Thank you, Ashish. Always a pleasure.