Surgical checklist adherence across urology expertise levels impacts transurethral resection of bladder tumour quality indicators

Abstract

To address the association of perioperative surgical checklist across variable surgical expertise with transurethral resection of bladder tumour (TURBT) accuracy and oncological outcomes in non-muscle-invasive bladder cancer. Patients and MethodsWe relied on our prospective collaborative database of patients treated with TURBT between 2012 and 2017. Surgical experience was stratified into three groups: resident vs young vs expert consultants. The association of surgical experience with detrusor muscle (DM) presence and adherence to the standardised peri-procedural nine-items TURBT checklist was evaluated with logistic regression models. A Cox regression model was used to investigate the association of surgical experience with recurrence-free survival (RFS). ResultsA total of 503 patients were available for analysis. TURBT was performed by expert consultants in 265 (52.7%) patients, by young consultants in 149 (29.6%) and by residents in 89 (17.7%). Residents were more likely to have DM in the TURBT specimen than expert consultants (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.03-2.99, P = 0.04). Conversely, no differences in DM presence were seen between young vs expert consultants (OR 1.09, 95% CI 0.71-1.70, P = 0.69). The median checklist completion rate was higher for both residents and young consultants when compared to experts' counterparts (56% and 56% vs 44%, P = 0.009). When focusing on patients receiving a second-look TURBT, the persistent disease was associated with resident status (OR 4.24, 95% CI 1.14-17.70, P = 0.037) at initial TURBT. Surgical experience was not associated with 5-years RFS.

A surgical checklist for optimizing the quality and outcomes of transurethral resection of bladder tumors: A literature review

“…The omission of records of risk factors related to recurrence and progression is expected to be reduced while the quality of resection will be improved by checking these items during surgery. All reports on statistically evaluated risk factor record rates found significant improvements after the implementation of the surgical checklist 10,21,25 . In addition, all checklists, except the two surgical checklists that did not include the presence or absence of muscle layer 22 and were introduced after a muscle collection rate of over 90%, 23 were associated with an increase in the rate of muscle collection, and the two reports showed a statistically significant improvement 10,25 .…”

“…Surgical experience and volume are associated with complications, recurrence, and survival risk 20 . However, a study reported that the experience of the surgeon was not associated with the presence of the DM in resected specimens and the 5‐year recurrence‐free survival (RFS) after TURBTs in the case of adequate perioperative surgical checklist implementation 25 . On the other hand, excessive attention by a surgical checklist to the presence of the DM in the resection specimen and excessively deep excision may increase the risk of bladder perforation.…”

“…Finally, we extracted seven reports that evaluated the surgical checklists for TURBTs (Figure 1) and compared them, including the surgical checklist presented in the EAU guideline (Table 1). 10,18,[20][21][22][23][24][25] The items on the TURBT surgical checklists can be categorized into (1) pre-operative, (2) intraoperative, and (3) post-operative. Most available surgical checklists consist only of intra-operative items.…”

“…10,21,25 In addition, all checklists, except the two surgical checklists that did not include the presence or absence of muscle layer 22 and were introduced after a muscle collection rate of over 90%, 23 were associated with an increase in the rate of muscle collection, and the two reports showed a statistically significant improvement. 10,25 Furthermore, two reports demonstrated using a surgical checklist significantly reduced intravesical recurrence rates after transurethral resection of bladder cancer. 10,22 Surgical experience and volume are associated with complications, recurrence, and survival risk.…”

En-bloc resection of non-muscle invasive bladder cancer: does it really make a difference?

“…The presence of detrusor muscle in the specimen is a recognized surrogate parameter for the quality of the resection [3]. The reported rate of detrusor muscle obtained with conventional TURBT (TURBT) ranges from 54 to 95% [4 ▪ ,5 ▪▪ ], and is also dependent on surgical experience [6,7]. TURBT is based on tumour fragmentation and separate resection of the exophytic part of the tumour, the underlying bladder wall and the edges of the resection area [1].…”