Jeremy Teoh: Thank you. My pleasure to be here.
Ashish Kamat: So, Jeremy, at ASCO GU this year, you gave an outstanding presentation on optimizing surgical management of non-muscle-invasive bladder cancer. And I think this is something that has been a pet peeve in some ways of mine over the years that people don't pay much attention to, TURBT. And, of course, you've championed the use of optimal techniques in TURBT, such as en bloc and now, of course, the robotic platform. And in general, you've been a champion of improving techniques for TURBT in non-muscle-invasive bladder cancer. So, really, first of all, kudos to you on the presentation and looking forward to seeing what you have to share with us today.
Jeremy Teoh: Sure. Again, I think surgical quality, in terms of TURBT, as you mentioned, has been largely neglected. And I would argue that's probably one of the most important aspects for an upfront cancer control. So, I'm really glad I'm able to give this presentation at ASCO GU and also talk about it in this presentation. So, as we all know, TURBT is a procedure that has been here for many, many years, from the first attempt about 200 years ago trying to visualize the bladder, and then 100 years ago, that's really the first historical resectoscope that was designed to have a single-handed resection of a tumor. So, I always think this is a revolutionary technology, especially back 100 years ago, but you can also imagine that, at that time, probably we can't see the bladder very well, probably can't resect very well. So, as a urologist, we need to do everything we can in order to remove the tumor. And we decided to do it in a piecemeal manner, and that has been how we have been doing it up to this day. And I guess the issue is there are two main problems. Number one, it's really dependent on the surgeon's experience and the judgment as to whether a complete resection has been achieved.
And especially in those larger tumors, lateral tumor, when you experience an obturator reflex, for example, then I realize that surgeons might err on the safe side and sometimes it's prone to under-resection and there's always a risk of residual disease. And, secondly, this is probably the only surgery that would actively demolish the tumor and resulting in floating tumor cells, which might be prone to a tumor seeding afterwards. And that's why I, myself, have been dedicated to improving the surgical quality by procedure called en bloc resection, essentially respecting the cancer principles, defining the margins, getting the right layer from the beginning from periphery to central, ensure that we have a uniform resection at the detrusor muscle layer, hoping we can improve the recurrence rate in long run for non-muscle-invasive bladder cancer. So, previously, we published a randomized trial comparing between en bloc versus conventional resection, 350 patients with a primary outcome of one-year recurrence rate.
So, 13 hospitals in Hong Kong, we realized that using the same bipolar system, same surgeons, but then just adopting a technique of en bloc resection, we're able to reduce one-year recurrence rate from 38.1 to 28.5%. But, I think, as a researcher, I also learned something from a trial. So, in particular, patients with one to three centimeter tumor, single tumor TA disease, these are the tumors that will benefit a lot. But, what strikes me is really on the actual risk profile of the bladder cancer patient. So, patients with low-risk intermediate disease, good surgery alone already can confer a benefit. So, I think it makes sense because low-risk disease, a good surgery should cure. But, on the other hand, patients with high-risk disease, multifocal disease, carcinoma in situ, to those with an unhealthy bladder to begin with. Even when you do a good surgery, it's not good enough, you need something more. And going back to the Kaplan-Meier curve on the left, if your attempt is trying to have a good surgery, the benefit should occur quite early. So, we found that the two curves separated quite early at three to six months' time, but in the en bloc group, we also found that at 12 months' time, there's a jump in a recurrence rate.
And I believe these are later recurrence, probably related to the tumor biology more, multifocal disease, et cetera. So, I think when we dissect into details, we learn a lot more on how these tumors can recur and what's the implication in the future. And one of the subgroup analyses on the use of BCG together with en bloc, without BCG, I think the recurrence pattern is pretty much the same, but on the right, there, patients with conventional TURBT plus BCG one-year recurrence rate is 26.3%, but all the recurrences across 30 patients occur quite early at three to six months' time. So, I believe these are probably more surgically related, but if we do en bloc resection for a good upfront control, together with BCG, then we hope to have a longer control of the disease. And bear in mind, we're talking about 5% recurrence rate at one year for patient with high-risk non-muscle-invasive bladder cancer is very low. And that's why we're planning to do more trials on that. All the other secondary outcomes are very similar, while en bloc has a slightly longer operative time, but it's on average 10 minutes longer, so it's not clinically important. So, we concluded that en bloc resection should be considered as a first-line approach in dealing with bladder cancer of less than three centimeters. So, the take-away message is really like this.
So, a good surgery, important for an upfront cancer control, both in terms of residual disease and tumor seeding, but I think a good adjuvant, as simple as BCG or other novel agents will be important for the longer term control and therefore a combination, in my opinion, should be the way forward. And we're really aiming for an actual cure for most patients with non-muscle-invasive bladder cancer. So, I hope urologists would agree that surgical quality is most important to ensure upfront cancer control. En bloc by its name is removing one piece, but I think most importantly is how we can standardize it, how we can do it systematically, how we can ensure we get the right layer throughout the whole procedure. So, en bloc is just a way to ensure that the whole resection quality is maintained, and en bloc plus BCG seems to be conferring very good outcomes even in the case of high-risk diseases, and I certainly look forward to more trials looking at this aspect. And just now, as I just mentioned about a robotic system, this is also a system that we have done. We have conducted a first-in-human trial in Hong Kong, and, certainly, it did a lot of noise in the field, and initial results were great. So, it's just in parallel, we're trying to develop something that is easier for surgeons to adopt and also, hopefully, deliver full-quality surgery, and I look forward to more discussion as well. So, without my team, this will not be possible. So, just, thank my team for everything that they've done. Thank you.
Ashish Kamat: Thanks, Jeremy, again for summarizing your ASCO GU talk. That talk was really great. And at that talk, you showed some videos, obviously, and some other technical points. So, let me just ask you for the benefit of our audience here. For someone that's starting off with en bloc resection, what are some of the tips and tricks that you recommend they adopt?
Jeremy Teoh: I think choose your preferred modality. For me, I use bipolar a lot because it's widely available. It's easy to have a sharp incision. You can combine both sharp and also blunt dissection as well. And, at the end of the day, if you encounter technical difficulties, it's also quite easy just to convert to conventional TURBT. Some people would prefer using laser, primarily because the incision is very sharp, not much bleeding, which is a very good option as well, especially for lateral tumors when there's no obturator reflex. But, we also need to bear in mind that lasers are end-firing. So, when you are dealing with bladder tumors, then it's quite easy to get deeper and deeper. So, choose the modality also depending on the tumor location will be a wise move.
Ashish Kamat: And any tips on... I know, obviously, the trial was three centimeters or less, but I'm sure you've pushed the envelope. So, any tips that you recommend on extraction? Because I hear sometimes, and I'll see sometimes people saying, "Oh, they did a seven, eight, nine centimeter tumor en bloc, but how do they get it out?" They morcellate it, which you lose the ability to give the pathologist a good specimen. So, any tips there?
Jeremy Teoh: So, there are a few ways to do it. Some people will use an endobag to improve the extraction. Some people will use a small laparoscopic forceps through the channel of the nephroscope because it's bigger there. So, the good grip of the tumor and take it out. Some people would do modified en bloc, meaning you try to debulk the exophytic part, but have an en bloc resectional base. And in the worst case, like seven centimeter tumor, there's no way that you can take it out. So, you need to preplan. So, I would actually put a plan, for example, removing three pieces, four pieces. I guess the argument there is en bloc, by its name, is remove one piece. But, the more we do, actually, in my opinion, the biggest benefit is to ensure a good quality uniform resection at the base. And for large tumor in particular, this is probably more important than so-called removing one piece. So, that's how I do it for really large and challenging tumors.
Ashish Kamat: Yeah. And I think that's a critical point that you make. And, again, Jeremy, you're an integral part of the international bladder cancer group, and that's one thing that we're going to be tackling and you're leading that team, really, the quality of TURBT. Any thoughts about how you are going to actually lead that team? What are some of the things you're looking forward to?
Jeremy Teoh: I guess, of course, we need to thank you so much in bringing a world-renowned panel of experts committing. The commitment is so important in order to deliver the best quality of a surgery. And, of course, we need to define how to do it systematically. People have been using checklists, but we probably need to come up with a consensus on what is considered the most important aspects of it. We probably need to make some commitment into how we can ensure quality. For example, do we do en bloc first? For example, in feasible cases, how we can ensure a good training examination, et cetera. But, I think the other important thing is, especially when we are having newer agents, newer systemic agents, and, obviously, bladder-sparing is going to be the future for many patients with muscle-invasive disease. And I just think, as a urologist, we actually play a very big role because the initial local control is so important. Achieving a gross tumor-free disease followed by systemic treatment, it makes a lot of sense. So, in this particular time, I think this is most important for us to bring this message out, not only urology, but also in oncology field, so that we work together to really benefit our patients. So, that's also a field I really look forward to.
Ashish Kamat: Yeah, no, absolutely. And that's why as part of the team, we have medical oncologists and radiation oncologists, and, of course, us, the surgeons and pathologists, everybody together, which is a great segue for me to ask you a little bit about the robotic TUR because sometimes people will hear that and think that, "Oh, I'm a good surgeon. I don't need the robot to help me do a TUR," which may be fine for non-muscle-invasive bladder cancer, but I see that there might actually be more of a role for robotic TURs when it comes to the deep resection of invasive disease. What are your thoughts there?
Jeremy Teoh: Well, again, our experience is still quite early. We have done 10 cases so far. And, interestingly, one case actually came back to be a muscle-invasive disease, and it's a solitary tumor at the bladder dome. To be very honest, endoscopically, I think the base looks so healthy and it came back to be T2 disease. We did a second surgery, which is negative. So, naturally, we go towards a bladder-sparing approach. And I think this system can really help in a sense that if we have a good assessment beforehand, larger tumors, for example, imaging with MRI scan, we know whether it can be resectable with a robotic approach. And when we do a surgery, we can certainly get deeper than usual because, not only can we excise it, but there's also a needle holding pipeline that we can potentially suture it. So, in a way, it's really helping us to achieve something that cannot be done before, namely endoscopic partial cystectomy for well-selected patient with suturing. I think it can be a game-changer for a lot of patients. Yeah.
Ashish Kamat: Absolutely. And just as you showed in the history of TURBTs, we've come a long way and bladder preservation has come a long way. So, really, I want to congratulate you for leading the field with the en bloc and for the fabulous presentation. And thank you for taking the time and joining us today.
Jeremy Teoh: Thank you very much. My pleasure.