Rikiya Taoka: Thank you very much for the introduction. So I will start the consensus-based TURBT surgical checklist and an initiative of JSUO. I will cover the two parts. First, our experience using the TURBT checklist in Kagawa University. Second, I will introduce the new JSUO TURBT surgical checklist. As you know, TURBT is the first procedure for bladder tumor. The quality of TURBT is important for correct staging and treatment. One key point is detrusor muscle in the TUR specimen. So we started the surgical checklist in 2016 to improve muscle collection. This is our nine-item checklist used in clinical practice since 2016. The aim is simple. Better tumor assessment, better planning, and complete resection including detrusor muscle. Here is a first outcome. Detrusor muscle sampling improved. With the checklist, the detrusor muscle rate increased from about 70% to 92%. In multivariate analysis, checklist use was an independent factor. Next is recurrence. The intravesical recurrence rate was lower with the checklist. It dropped from 49.6% to 19.2%.
In multivariate analysis, not using the checklist was an independent predictor of recurrence. This graph showed two points. First, recurrence-free survival was better with the checklist. Second, perioperative complications did not increase after checklist use. We also reviewed published studies. Many levels show better documentation of TURBT. Some show better muscle sampling rate and better outcome. But not all studies are the same. Overall, using the checklist during TURBT can improve documentation and muscle sampling. It may also reduce intravesical recurrence. But effects vary across the studies likely because checklists are different. So we need a standardized checklist. And in Japan, TURBT is one of the most common Urologic operations. About one third of patients are 80 years or older. So we need not only better cancer outcome, but also a strong focus on safety.
This is why we decided to create a standardized TURBT checklist that can work in real-world practice. Now, I will introduce the JSUO TURBT surgical checklist. Firstly, we made an initial draft vote as a committee. Finalized 22 items and revised based on expert review and public comment. Then we completed the final checklist. The final checklist has 22 items in four sections. Perioperative patient and tumor information, perioperative planning, intraoperative tumor and resection details, and complication and postoperative management. You can also scan the QR code to use the checklist. So section one covers the basic patient and tumor information before surgery. This item help bladder cancer assessment and surgical risk evaluation. Section two is about the plan. Surgical intent, technique, imaging, biopsy, and anesthesia. It also includes step two, prevent obturator reflex when needed. Section three is the core TURBT information during surgery. We record the tumor number, size, shape, possible CIS finding, completeness of resection. This is the mass visibility and suspicion of muscle invasion. And section four focuses on safety. We record intraoperative complications, how we managed them, and whether immediate single instillation was given. We also use the bladder diagram for visual mapping. This makes a tumor location and resection area easy to understand and compare later. This slide shows how we use the checklist in practice. We prepare it before surgery, share key item during surgery, and enter information after surgery.
Then we review cases all in surgical conference for education and feedback. There are limitations. This checklist still needed prospective validation in multicenter study, and some items are subjective and may differ by surgeon and imaging. Therefore, our next step is multicenter implementation and validation. We also want to work with IBCG, the World Bladder Cancer Patient Coalition, and other groups to harmonize key items and spread the standardized checklist worldwide. The final goal is better TURBT safety and better outcome for patients. Thank you very much for your attention. We look forward to your comment and discussion. That's all. Thank you very much.
Ashish Kamat: Thank you very much, Rikiya, for that presentation. Really excited to take this forward. Let me ask you or Mikio, if you want to chime in. How do you see this being implemented in different parts of Japan and then globally?
Rikiya Taoka: So this surgical checklist is very valuable for patients and surgeons. So next month and two months later, we can see the checklist in English version worldwide. So I hope urologic surgeons can use the checklist. And I would like to collaborate with the IBCG and brush up the new checklist for worldwide. Thank you.
Ashish Kamat: Great.
Mikio Sugimoto: How often in the US, Ashish, is a checklist usually used?
Ashish Kamat: So here in the US, most of us will use a checklist at large academic centers. But as you saw recently, there was the Burst data that was published recently from a multinational checklist initiative. And what it actually showed was that just the fact that surgeons know they're being observed improves the quality. So the checklist certainly helps. But even just letting people know that they're being observed will increase the quality of the resection. And I think something such as what you proposed with the newer technology and the QR code and all of that will be extremely useful. And certainly we can incorporate this into different arms of what we're doing in international places. Especially as you mentioned through the IBCG or the World Bladder Cancer Patient Coalition. Professor Sugimoto, you have led the JSUO and you have of course been part of many initiatives like this. Where do you think this would take the Japanese Urological Oncology Association over the next three to four years? Do you see this being adopted within Japan?
Mikio Sugimoto: Yeah. Really, I hope so. But JSUO, many hospitals participating in the JSUO, not only academic, but also peripheral hospital. So this checklist is adopted mainly only in academic hospitals, I think.
Ashish Kamat: And do you think if it's rolled out to non-academic hospitals in Japan, some of the urologists would be interested?
Mikio Sugimoto: Yes. Very interesting. Many doctors are interested in this checklist. But actually very, very busy as you know, it's very busy, so hard to introduce completely.
Ashish Kamat: What do you think would make people use it? Like how can you convince people to use it? Because like you said, in academia, we use it, people have had such efforts. But what do you think is the best way to get people in countries like Japan to use this outside of academia?
Mikio Sugimoto: Simpler and we have to obtain further good outcome, so more simple. And peripheral hospital has very, very few doctors. Some insurance experiment, maybe some reward is needed.
Ashish Kamat: Yeah, I think one of the big rewards, of course, is better outcomes, but I understand what you mean, right?
Mikio Sugimoto: Yeah.
Ashish Kamat: I mean, clearly people have to be willing to take the time and effort. Speaking of time and effort, I want to thank both of you for taking the time joining us today. This was very helpful and congratulations once again.
Mikio Sugimoto: Thank you.
Rikiya Taoka: Thank you so much.