Transurethral resection of bladder tumor (TURBT) has been named “the neglected procedure.”¹ But a group of global urology residents is determined to change that perception. The RESECT study (NCT05154084) aims to determine if there is significant variation in practice and outcomes after TURBT surgery for nonmuscle-invasive bladder cancer, and if audit and feedback can improve this.

The study is an exciting collaboration between more than 200 hospitals and 1,400 investigators across the world representing cases performed by more than 3,000 individual surgeons.² An analysis from this study won the best poster at the “Bladder Cancer: Non-invasive” session in Chicago at the AUA 2023 Annual Meeting. The paper is titled “Global Variation in Early Recurrence After Transurethral Resection of Bladder Tumor in the RESECT Study (NCT05154084): There Is Significant Inter-site Variation That Is Independent of Tumor Factors.”

It seems that the “old refrain” about comparing surgical outcomes, “It’s down to case-mix,” does not cut it when it comes to explaining why some sites have lower recurrence rates than others.

This analysis assessed records of 4,597 first-tumor TURBT cases from 186 hospitals, including 18 hospitals from North America. A mixed-effects logistic regression model accounted for tumor size, tumor number, tumor grade, and tumor stage, with “site” as a random effect. The difference between sites was found to be highly statistically significant after accounting for tumor variables (P < .0001, intra-class correlation 0.1). Raw recurrence rates varied between sites from <10% to >40% for both low- and high-grade tumors. The analyzed tumor factors, as expected, were all significantly associated with recurrence, but this was not enough to explain the variation seen between sites.

The study is led by BURST (British Urology Researchers in Surgical Training), based out of London, UK, and led by Drs Kevin Gallagher and Nikita Bhatt (urology specialist trainees) and Veeru Kasivisvanathan (consultant and Associated Professor of Urology, University College London).

The study team is keen to involve as many of the more than 1,300 study collaborators as possible in analyzing and disseminating the work, and were delighted to invite Dr Betty Wang (who leads the participation of 3 sites in Edmonton, Canada, and is the highest recruiter in North America) to submit and present the current paper at AUA2023. Betty’s impressive presentation and adept responses earned her the best poster prize.

The RESECT study has previously demonstrated that there is significant variation in practice and markers of TURBT quality such as detrusor muscle resection rates, the use of single-instillation intravesical chemotherapy, and documentation of factors crucial for determining follow-up and adjuvant treatment schedules such as tumor number, size, location, and resection completeness. These data were presented at AUA2022 by Dr Alexander Geisenhoff, a resident from Beaumont Hospital, Royal Oak, Michigan.³

The current study now proves that there is significant variation in the early recurrence rate (first check cystoscopy after TURBT). The study benefits from granular case-by-case assessment and data entry. This means that the next burning question can be answered—what is likely to be causing this variation in recurrence rates?

Thus, the team will be able to assess other patient factors such as age, as well as surgeon experience factors, operative technique factors, perioperative management factors, and adjuvant treatment factors such as the use of re-resection and intravesical chemotherapy and bacillus Calmette-Guérin treatments to explain the variation in recurrence rates.

At study initiation, all sites completed a detailed survey about their usual practice. While in the UK 12% of sites had a routine TURBT audit, outside of the UK <5% of sites reported participating in routine audit of TURBT outcomes.

The team is interested in finding out if we can decrease variation and enhance adherence to guidelines by involving these sites in an audit with real-time feedback on their outcomes. Additionally, they want to determine if this leads to lower recurrence rates.

To answer this question, the observational study includes an embedded cluster-randomized controlled trial that was scheduled to complete data collection at the end of June 2023, aiming to report in early 2024, and already involves data about more than 16,000 TURBT procedures.

The study team has developed an online, live-performance feedback and education dashboard. The dashboard displays performance against TURBT quality indicators. In the design of the dashboard the team were keen to take a nonpunitive and anonymous approach to surgical outcome feedback. They believe that there are unmeasured reasons why performance and outcomes may vary. Thus, the goal is to provide a tool that encourages surgeons to measure and reflect—using “know thyself” as a route to improvement. The feedback provided is completely anonymous, allowing users to identify themselves if they choose to do so, and it is not shared publicly. Access to the feedback will be randomly assigned to sites once they have entered a certain number of retrospective cases, so that impact can be measured. Ultimately, all sites will have access to the feedback by the end of the study.

If cancer recurrence can be reduced by audit and feedback, this would be an exciting achievement that argues the case for better review and feedback of surgical outcome data. Watch this space!

Acknowledgments

We thank the study main funder, The Rosetrees Trust (https://rosetreestrust.co.uk/) and additional grants from The Urology Foundation, The British Journal of Urology International Charity, Action Bladder Cancer UK, Karl Storz, Photocure, and Medac Pharma.