Ashish Kamat: A warm welcome to all of you from the UroToday Studios. I'm Ashish Kamat, Professor of biological oncology at MD Anderson Cancer Center in Houston, and we're live in Las Vegas at AUA 2025. It's a great pleasure to welcome to the studio, Professor Morgan Rouprêt and Laura Bukavina. Thank you for being here.

Laura Bukavina: Thank you for having us.

Morgan Rouprêt: Thank you.

Ashish Kamat: So there's a lot of stuff going on at the AUA, but one of the things that we are featuring here today is your contentious debate on what is the optimal management for patients with low grade Ta disease. Active surveillance, yes or no? So, Morgan, what do you think?

Morgan Rouprêt: Well, actually, we should put a frame around it because these cases of bladder cancer are quite, I would say, impressive. When I look at the data in the US, we have 25,000 cases per year. We have a lot also in Europe. And this is a real daily practice of the urologist.

So at the moment, we have good criteria to select the patients that are in this category and to follow up on them with active surveillance, trying to avoid to do too many endoscopic procedures and TURBT that are going to impair the quality of life. And I think the question here is for how long we can maintain the active surveillance and what are going to be the exit criteria.

Ashish Kamat: So, Morgan, what are your exit criteria for patients who--

Morgan Rouprêt: Actually, I will follow your IBCG criteria. When the patient has no hematuria, and then you have hematuria goes out of active surveillance. The number of tumors is increasing, so usually, the cutoff is five. The size is increasing. The cutoff is below one, and you are over one centimeter. Or you have all of a sudden a positive cytology.

Then each one of these criteria, when it's coming during the follow up, then you can decide to trigger, I would say inactive treatment. But you can see that there is a high proportion of patients that can remain under active surveillance for at least one, two years, which is a solution that can, I would say, avoid overtreatment or other endoscopic procedures.

We have to bear in mind that the quality of life is also decreased by several TURBTs as we do it, usually in Europe, because the treatment is always, and so on. So the tradition in Europe is to do TURBT, and TURBT can decrease the quality of life.

Ashish Kamat: Yeah, and I think it's a trade off between what's right from a cancer perspective and what's right from a morbidity standpoint, but there's obviously a downside to active surveillance when you're counseling patients. So Laura, what's your take on it?

Laura Bukavina: Generally, when I talk to patients about surveillance, I always tell them tumors are like people, and people have different personalities, and tumors have different personalities. So you can't just contextualize and put every low grade into the same category. So people are different and their recurrences are different. Their actual genetic differences within the tumors are different. So what may appear as low grade initially might not always be low grade a year after in terms of recurrences.

So that's where the IBCG criteria really comes into play in terms of how I stratify people. And I tell them right away, we might be able to observe, but there's very stringent criteria about when I am intervening.

And we also have to look at health care systems. So within different health systems and the resources available, yes, potentially, we might be able to delay that TURBT a couple of months, but are we just delaying treatment and diagnosis of high grade disease and potentially underdiagnosing the progression of disease?

So you can't just say every low grade is the same. You have to look at individual patients, their risk factors, their inability or ability to undergo TURBT, and then think about the patient. They're going home. They know they have a tumor in their bladder. They're thinking about it constantly from the patient perspective.

They're thinking about it's growing, and some people can't tolerate it. It's very similar picture to people who are in active surveillance of small renal masses. How many people come off surveillance just because they cannot tolerate the anxiety that comes with knowing that there's cancer inside of their body?

Ashish Kamat: Yeah, I love the fact that both of you are putting the patient at the front because when you talk about treatment of any cancer, especially bladder cancer of this kind, the patient is at the forefront. So patient anxiety, clearly, if a patient is going to be so anxious that they can't sleep, that treatment for active surveillance is not good. But both of you touched upon the downsides of a TURBT as well.

So share with me, first, you, Laura. I mean, you guys are both expert resectionists, but a TURBT is not one of those procedures that we can just take lightly. So what are some of the things you do when you're resecting a low grade tumor, say single, small, solitary, low grade tumor? What are some of the principles you follow?

Laura Bukavina: So principle, as always, is not overdistend the bladder. So whenever I teach the residents, depending on the size and where the tumor is, so it's a lateral wall, don't overdistend the bladder. So you're not getting the obturator your risk of perforation. Always talking about how many tumors there are. Can you cold cup this? Can you minimize the time under anesthesia without having to intubate? Is LMA enough?

Talking about potentially what we do call is fast track a patient, which means they get minimal sedation for small tumors. We can cold cup it without having to do an extensive TURBT, minimize the risk of perforation, and get the patient home within one hour. So all those little things make sense. If you approach this patient with an eight centimeter mass, the same as a patient with a one centimeter mass, you're overdoing it at some point, so having a protocol for these patients where you can get them in and out within one hour and get them home.

Ashish Kamat: And, Morgan, your practice?

Morgan Rouprêt: I'd say we'll make a difference between a primary TURBT and those patients where there are recurrences. And we all know that, I would say, the prognosis of the bladder is not at stake, and so we can minimize, as much as we can, the morbidity of the procedure. And of course, as Laura mentioned, even in Europe, there is a lot of development of the day care patient, so it is important to see that maybe you can do a cold cup biopsy on one of the lesions, electrocoagulation or fulguration for the other spots.

If you are quite sure that, of course, the muscle is the surrogate of the quality of the TURBT, but we are not in a primary TURBT situation. We have used a lot for BPH, the thulium laser, very recently, and we have implemented the technology and the use of this thulium in the treatment of these small spots of tumor. So I think it can make a great deal of difference at the end of the day.

And also, I would cite the physical ablation of the tumor. We should also, in the future, maybe in these patients, to consider the chemo ablation, which could be a solution. And we have seen at the AUA and in many recent conferences that the concept is there, maybe not suitable for every tumor. In case of FGFR mutation, for instance, why not consider locally erdafitinib with TAR-200?

Ashish Kamat: Yeah, and I think that's a great concept because, again, we're trying to avoid overtreatment of patients, but at the same time, there are some patients that have multiple, multiple recurrences. So we have to have that balance between overtreating even with chemo ablation versus doing what you said earlier, which is active surveillance. Now, if you had to pick the ideal patient coming to your clinic for active surveillance, since you started out with no, let me ask you, who is your active candidate for active surveillance?

Laura Bukavina: So this would be a patient who perhaps is older. The risks of anesthesia are higher. Patients who had a low grade small tumor maybe two years ago, doing great without any additional therapies, showing up to your clinic, and they have a small recurrence within their bladder.

One to two tiny tumors, and this is their first recurrence. That would be the ideal patient where we can say, let's surveil. Let's see what happens. If they get more tumors, we can always say, we'll address it. If there's more than a couple at the same time with a TURBT.

Ashish Kamat: And, Morgan, for you, which patient do you strongly recommend against active surveillance?

Morgan Rouprêt: I would agree with Laura on the definition at the bladder level stage and outside the bladder, the human being, the quality of the discussion that I have with the patient. The more the patient is able to understand the situation, to accept, to be involved, to be an actor of his disease or her disease if a patient is a woman, then we will consider the possibility to go into that direction.

Some patients, they are not really involved. As you mentioned, there is this sword of Damocles. The word cancer is triggering anxiety and so on, and outside, what Laura has depicted in the term of disease by itself, the behavior of the patient is going to influence my decision.

Laura Bukavina: Yeah.

Ashish Kamat: Yeah, and I mean, again, for the debate at the forum, you guys have sides, but it's great that you guys agree on it, which is what we all do. It's patient centric care. So once again, thank you so much, Laura and Morgan, for taking the time and being with us today.

Morgan Rouprêt: Thank you.