Ashish Kamat: A warm welcome to all of you from the UroToday studios. I'm Ashish Kamat, Professor of Urologic Oncology at MD Anderson Cancer Center in Houston, Texas, and we're live at AUA 2025 in Las Vegas. It's a pleasure to welcome to the UroToday studios two exemplary individuals when it comes to the field of bladder cancer. Dr. Vig Packiam, Mark Tyson, welcome to the studios.

Mark Tyson: Thank you, Dr. Kamat.

Vignesh Packiam: Thank you.

Ashish Kamat: So you guys are doing a lot of stuff at the AUA obviously, but right here, for this discussion, we're going to have you-- mini debate the issue of what constitutes the best TURBT in 2025, and this is part of the IBCG AUA forum that we have every year and that you have faculty on. So let me start with you, Vig. In your mind, today in 2025, what are the factors that make the optimal TURBT?

Vignesh Packiam: Yeah, I think right now it's really important to stick to strong surgical principles. There's been increased education about what elements are important within a TURBT. And obviously, that has to be stuck to. But I think technology is really important too. We've seen outcomes for non-muscle invasive bladder cancer improve over time. And I think part of that is from improved technology, bipolar TURBT, blue light cystoscopy, and other modifications.

Ashish Kamat: And Mark, what's your take on that?

Mark Tyson: Yeah, I don't disagree with that. I think that the technology has been enabling. But at the end of the day, I liken it a little bit to a torpedo bat, which is all the rage right now in Major League Baseball. They put the mass of the bat right in the center, but at the end of the day, the batter's got to hit the ball square on the bat. And that's how I feel about TURBT.

At the end of the day, a high-quality surgeon is going to do all the things that we need them to do to get a good outcome for the patient. She completely resects the tumor, gets muscle, doesn't perforate, gets all the disease out, gives peri-operative gemcitabine for low-grade appearing tumors. All of those factors, I think, are more pertinent to a good long-term outcome than, say, getting a little bit of CIS with blue light.

Ashish Kamat: Yeah, no, I think both of you are pretty much on the same page. And we're having this artificial debate because that's what we're doing. But I really think that it's a mesh of the two. TURBT is one of those procedures that have, in many centers, relegated to the junior resident. Junior resident teaches the next level below him or her.

And in many practices, the junior faculty do all the TURBTs and the senior faculty are doing the cystectomies or what have you. I think that needs to change, right? Because it clearly is the most important thing that we do for any bladder cancer patient. The TURBT—that's what gives you the diagnosis, the variant histology, complete resection even if you're doing TMT, et cetera.

So let me have you first, and let me go to you, Mark. When you have a patient you're taking to the OR for a TURBT, what are some of the things that you will tell your trainee or yourself or thinking of like a checklist as to this is what I'm going to follow?

Mark Tyson: It starts in the pre-operative area, by reviewing the scans, by reviewing the data, knowing exactly what the patient has had done in the past and what we're thinking about for them in the future. And I think reviewing the scans is very important, and having pre-op scans that are up to date, I think, are also very important.

But after that, the residents, our trainees, know to use the checklist that's been developed by you and others, actually, where the patient has clearly delineated history in the operative note. And then all the things that we want to see—complete TUR, muscle is visualized, maybe even sent a deep specimen separately, document that, a bimanual examination, peri-operative chemo, and then commenting on whether there's been concern for perforation or not. All of those elements, I think, documentation, that is, is really key to planning and executing a high-quality TURBT.

Ashish Kamat: And Vig?

Vignesh Packiam: I'm not going to argue against any of that. And I teach that almost every day. But it's interesting that I use blue light cystoscopy in almost every TURBT that I do. I'd say 80% to 90% of the time I turn to the resident and say, “Aren't you happy we had blue light?” We always pick up something extra that is easy to miss on white light cystoscopy. So I think in this day and age, that should be a part of a really optimal TURBT.

Ashish Kamat: Yeah, no, I think using the best technology you have available is critical, right? I also think that, and I'm a big proponent of blue light, but I think what's also happened is that our scopes and our screens have gotten so much better that we can almost see things now in high definition that maybe we couldn't see, or I know I couldn't see, 10 or 15 years ago, right? So I think using whatever we have, using the latest loops, bipolar, monopolar, whatever you have, but using what you have that's the latest generation is absolutely critical.

Since you're on the tech side of things, let me ask you, do you have a preference between what type of electrocautery? The settings? Do you have any tech tips that you impart to your trainees?

Vignesh Packiam: Yeah, those are important points. I personally have a preference towards bipolar TURBT. I think especially if you're doing an extensive resection, there's less risk of electrolyte imbalances since you're using saline instead of water.

I personally find the char to be a little more beneficial, but I think that that's surgeon-specific. I have some colleagues that love monopolar technology. The obturator reflex is a little diminished using bipolar resection, but I think with a good surgeon, you can make modifications with either technology. So those are my preferences.

Ashish Kamat: And our good surgeons—look to you. I'm not implying that he's not a good surgeon, right? But when you're doing a resection, how often do you use en bloc resection for bladder tumors?

Mark Tyson: I haven't been using it at all. Like Vig, I use bipolar blue light for most of my resections. It's not that I don't find the technology to be helpful, it's just that I think that if you were to look at a model explaining a good outcome, and you had the two variables—surgeon and technology—most of the explained variation is going to be attributed to the surgeon. Even a blue light TURBT can be performed very poorly. And so it's not that I'm against the technology. Even en bloc resection, where I think there's probably some advantages in terms of preparation of the tissue, I just haven't been using that particular technique lately.

Ashish Kamat: I use en bloc technology, and I teach my residents more because it's a cool thing for them to learn and have in their armamentarium. But I agree with you. I think the surgeons that do en bloc are better surgeons anyway, and that's what's reflected in the outcomes rather than the actual en bloc.

But the pathologists love it, right? Because they get one specimen. They don't have to go looking through the different things. So I think it's being more friendly to the pathologists. But what you said, or I forget who said, but taking a deeper section and sending it separate also helps the pathologists, right?

Now, walk me through—you are in the OR now, and you are doing a TURBT, right? Plan the resection. It's multifocal, multiple areas. Do you go for the dome first? Do you go for the one that looks like it could be muscle invasive first? What's your thought process there?

Vignesh Packiam: That's a really good question. Some of it depends on the trainee, to be honest. If I have a high-level trainee that I'm walking through the operation—

Ashish Kamat: For this, let's assume no trainee. It's you.

Vignesh Packiam: Oh, sure. Absolutely. I'll typically try to do whatever lesion is most straightforward first, so I get a feel for the bladder thickness and how deep I need to resect in that patient. If you go for the dome right away, I think you could be surprised with how thick or thin the bladder is, which is an unnecessary variable for that part of the case. If it's a muscle-invasive tumor, I think go for the main pathology first, because you never know if there's going to be issues during the resection, and then you can attack the satellite lesions later.

Ashish Kamat: Do you always try to get a complete resection if it's a muscle-invasive tumor? Or do you say I think it's muscle-invasive. I've got what I need. Let's move on to discuss treatment.

Vignesh Packiam: If I'm able to get a complete resection, my bias is to do that. I think there's only some retrospective data suggesting that there may be a benefit for patients to get neoadjuvant chemotherapy followed by cystectomy. But I think that data is somewhat compelling. Obviously, for trimodal therapy or bladder sparing, doing a maximal resection is going to be beneficial.

Ashish Kamat: The folks in the UK would strongly disagree with you because they're claiming you can just do a biopsy and an MRI and go to TMT, or they don't call it TMT. It's radiation. I don't agree with that, so I'm glad you said that. What's your feel?

Mark Tyson: I agree. I generally resect as maximally as I can, get all the tumor out safely without perforating, making sure to send muscle separately, deeper specimens separately. And I usually start with those tumors first for that very reason. If there's a complication at that point and you need to stop, at least you've made the diagnosis. You can leave the catheter and potentially get that patient on to chemotherapy sooner, as opposed to having to bring the patient back for the rest of it down the road.

Ashish Kamat: You brought up catheters. And this question is more—it's obviously US-based because overseas, they're able to keep patients in the hospital for overnight, et cetera, and watch the patient. Here, with our system, we tend to get patients out the same day. Share with us your thought process as to when do you leave a catheter in? How long do you leave it in? What are some of the factors you're considering when you're doing that?

Mark Tyson: I do my best not to leave one in for two reasons. One, every single patient asks me not to leave one in. But the other reason too, is just environmental sustainability. It's just a little bit harrowing to think that we're sending all of these catheters to the dump. And so if a patient can go without a catheter, I tend to lean more towards that.

If someone needs peri-operative chemotherapy, obviously we leave a catheter. If somebody is a little deep or if it's a big resection or they have a big prostate, I'll leave a catheter generally for one to three days. If there's a perforation, which is obviously rare, then I'm going to leave one for a week and do a cystogram a week later.

Ashish Kamat: And Vig?

Vignesh Packiam: Yeah, I agree with those principles. I think the environmental angle is laudable, not something I've thought about before. Catheter sizes have evolved. Traditionally, our teaching was to leave big catheters in, 22, 24 French, make sure they don't get clogged. But I think it's more patient-friendly to leave as small a catheter as you can, too.

Ashish Kamat: Yeah, I think the patient-friendly part is important because from a patient-friendly aspect of things, yes, I leave a small catheter in, but also a lot of patients are driving 3, 4, or 5, or longer hours to get home or taking a flight. And what I've found is if I take the catheter out, and they go into retention in the car or on the plane, it's horrible.

So I actually tell them, leave the catheter in until you finish your journey, right? Whether it's the same day or the next morning. But that's again factoring those soft factors that come into play from the practicalities of what we have to deal with. Again, we could talk forever on TURBT, one of my favorite subjects, but in closing, I want to offer you gentlemen both a closing statement, so to speak. So let me have you go first, Vig, and then you, Mark.

Vignesh Packiam: Sure. I think you said it well, where we should use the maximal technology that we have available to us. Bipolar technology and Cysview with blue light—these are things that most urologists do have access to, although cost can be prohibitive to some practices. In my practice, there are many, many cases where I find blue light to be helpful, and I think that is responsible for a lot of the improvement in outcomes that we're seeing over time. So that would be my main take-home point.

Ashish Kamat: Is that why you're wearing a blue suit today?

Mark Tyson: I'd leave your viewers with the notion that the high-quality TURBT starts in the pre-operative area—starts with good planning, good counseling, a good pre-op CT, good documentation of what you've done during the case, following a checklist, for example, hitting all of those high marks with getting muscle, getting all the tumor out, maybe using some type of imaging technology, narrowband, or blue light, to get all the tumor out, as much of the tumor as you can, not perforate. All of those things. But at the end of the day, I think that those are probably going to be far better explanations of a patient's good long-term outcome than the technology itself. I think it's the surgeon.

Ashish Kamat: Great. Great points, both of you. Thank you so much for taking the time.

Vignesh Packiam: Thank you.

Mark Tyson: Thank you.