Transurethral resection of a bladder tumor (TURBT) is the first step in bladder cancer management for new and recurrent tumors. For urologists, it is a highly rewarding procedure as it cures most patients of the disease and provides valuable prognostic information. However, incomplete initial resection is not uncommon, particularly for high risk nonmuscle invasive bladder cancer (NMIBC), resulting in persistent disease at future surveillance cystoscopy despite the administration of adjuvant intravesical therapies. These observations are then wrongfully characterized as recurrences, undermining the patient’s therapeutic response. A complete TURBT is imperative. An enlightening study including more than 2,500 patients from phase III European trials with Ta and T1 bladder cancer determined that the high variability in tumor recurrence rates at the first surveillance cystoscopy was most influenced by the quality of the TURBT performed by the individual surgeon and not other tumor factors that were studied.¹

TURBT is a technically challenging procedure influenced by patient and tumor characteristics. Patients who are obese, a high riding bladder neck, and larger tumors that are multifocal and located on the lateral or anterior wall or the dome of the bladder pose greater challenges to accomplishing a “high quality” TURBT. In addition to these factors, recent studies suggest surgeon education, experience and surgical resection technique also influence TURBT quality. Therefore, there is an important need to develop and implement tools that teach and measure TURBT quality beyond the conventional mentor–mentee (apprentice–expert) relationship. An early effort in this area was a multi-institutional collaborative that developed and implemented a 10-item surgical checklist (Appendix 1) of factors that could influence and demonstrate the quality of the TURBT and perhaps patient prognosis.² In this study, the implementation of a prospective surgical checklist significantly improved the 10-item reporting and likely resulted in a higher quality TURBT, although it did not significantly increase the presence of muscularis propria in the surgical specimen. As sampling of detrusor muscle is considered a requisite goal in bladder cancer management, it is commonly evaluated as a surrogate of the quality of TURBT. Bos et al retrospectively reviewed 463 TURBTs and determined that urology resident involvement was associated with less likelihood of detrusor muscle in the surgical specimen of high risk patients.³ The finding was similar to previous studies that also suggested less surgical experience was associated with higher operative times, and higher readmission rates and predicted for higher rates of recurrence of Ta and T1 bladder cancer.⁴ However, other studies have reported that surgeon experience and tumor location had no correlation with likelihood of detrusor muscle in the specimen, suggesting there is an opportunity to improve TURBT quality for all surgeons.

Surgical education is the fine balance between maximizing procedure efficiency, treatment efficacy, patient safety and the need to train the next generation of urologists. Surgical simulation provides the opportunity to develop requisite procedural skills before engaging in patient care. Certainly, surgical simulation is a growing area of study for many surgical procedures including TURBT when one considers advancements in virtual simulation and the potential benefits that artificial intelligence may present. The first step in the development of procedural skills curricula is to define the intended and desired outcomes of training. Learning objectives, including procedural steps and pitfalls, are identified by a training needs analysis (TNA), where the objectives close the gap between the actual needs of the learners and the desired outcomes of training. Once the TNA is established, a suitable surgical simulator is required and validated to ensure trainees acquire the intended operative skills. Individual feedback and interventions can then lead to improved performance.

A group in the Netherlands recently developed a TNA focused on all procedural steps and technical and nontechnical pitfalls of TURBT: Test Objectivity Competency (TOCO)-TURBT tool.^4,5 The Simbla TURBT simulator (SAMED GmbH, Dresden, Germany) was used to conduct the prospective, observational and comparative study in 7 teaching hospitals. Participants were recruited equally into 3 groups based on TURBT experience: novice, intermediate and expert. The participants performed 2 standardized TURBTs on the simulator with bladder substrates depicting anatomic details of the bladder and tumors in different locations with real life continuous flow resectoscopes and biopolar diathermy. The simulator was judged to be most useful in learning eye–hand coordination and least useful in learning to avoid complications. Overall, all aspects of the simulator were rated above the acceptability threshold and demonstrated face and content validity. Importantly, the simulator also reliably demonstrated construct validity, assessing the simulator’s ability to differentiate between different levels of surgical experience.⁴ During the validation phase of the study, participants were blinded to the items measured on the TOCO-TURBT tool by independent expert urologists during the preparatory, procedural and completion phases of the simulated TURBT. The procedural phase focused on 3 areas: 1) applies systematic and prioritizing strategy in tumor approach 2) resects strokes of adequate depth and length 3) has adequate speed/progression of tumor resection. The study clearly established the feasibility, content and construct validity of the TOCO-TURBT tool.⁵ The authors suggested the tool has the potential for high stakes assessment such as certification of residents and relicensing of urologists but needs clinical validation.

At our center, we have adopted the 3 procedural areas of focus as part of our resident assessment strategy. We have recently developed and piloted a skills assessment tool that uses a 5-point Likert scale to assess 11 features of the TURBT procedure (Appendix 2) in addition to denoting the case complexity (low, medium, high) and whether preoperative technical preparation (video, simulation, other) was undertaken in anticipation of the procedure. We use a Qualtrics based survey that is accessible via web or mobile phone using a smartphone link that is stored on one’s phone and essentially appears as any other application. It is generally completed in 1 minute and serves as a tool to direct specific resident feedback. We believe that the iterative combination of evidence-based curricula, effective simulation and tools to assess and provide feedback will provide an outstanding foundation to teach this important operation.