To achieve the best performance of transurethral resection of bladder tumor: implication of surgical checklist

Urothelial carcinoma at bladder is the 9th most common malignancy worldwide (1). It is the second most common malignancy in the urologic tract (2). According to GLOBOCAN data, 165,000 bladder cancer death occurred in 2012 worldwide (3). The clinical behavior of bladder urothelial carcinoma is quite different depending on the presence of muscle layer invasion. The involvement of muscular layer in transurethral resection of bladder tumor (TURBT) specimen is one of the most important factors for adequate diagnosis and management. Non-muscle invasive bladder cancer (NMIBC) can be easily treated by TURBT. However, up-to 80% and 45% of patients experience recurrence and progression, respectively, with long-term follow up (4,5). For this reason, current guidelines recommend repeated TURBT with regular follow-up by cystoscopy and trans-urethral resection or drug instillation for intra-vesical recurrence (6-8).

Frequent cystoscopy and TURBT increase health care cost and decrease patient’s quality of life (QOL). EAU, NCCN, and AUA guidelines for surveillance protocol recommend cystoscopy at least 5 years of follow-up with 3-month interval in the first year for low-risk disease with more frequent surveillance for higher risk bladder cancers (7-9). About 60% of lifetime medical cost of bladder cancer patients is spent on surveillance (10). This expenditure makes bladder cancer one of the most expensive malignancies to treat (11). Patient’s quality of life is another issue of NMIBC patient surveillance. A cross-sectional study using SEER (Surveillance, Epidemiology, and End Results) database has shown that the detection of bladder cancer itself decreases both mental and physical subset of patient reported QOL (12). Explicably, muscle invasive bladder cancer (MIBC) patients report much lower QOL than NMIBC patients. Disease recurrence and progression also worsen their QOL.

Just performing TURBT is simple. However, performing qualified TURBT is not that easy. Recent evidences support that surgical quality of TURBT can affect recurrence rate of bladder urothelial carcinoma (13). Brausi et al. (14) have reported inter-institutional differences in intravesical recurrence after TURBT of Ta, T1 bladder tumor using combined seven EORTC studies. Percentage of patients who needed intravesical instillation because of recurred cancer in the first follow-up cystoscopy was 0–15.4% in single tumor and 7.4–45.8% in multiple tumors. Mariappan et al. (15) have described surgical experience associated with positivity in detrusor muscle on first TURBT with early recurrence. Rolevich et al. (16) have reported that recurrence rate after TURBT is significantly different among five high volume surgeons in a single institution. The 5-year recurrence free rate was 44.2–62.9%. These differences were statistically significant. These findings supported that the quality of TURBT can be affected by surgeon’s experience and style of surgery.

There are various quality improvement strategies for NMIBC management. Repeated TURBT is still on debate. However, most methods for improving quality of TURBT are acceptable and endorsed by the EAU guideline (7). Evidence of repeated TURBT is based on incompleteness of initial TURBT and survival gain of repeated TURBT. Dutta et al. (17) have reported that about 40% of patients undergoing TURBT have risk of under-staging which is detected in radical cystectomy specimen. Badalato et al. have founded the presence of muscularis propria in TURBT is a surrogate marker of pathologic up-staging in high risk urothelial carcinoma (18) which is a marker of TURBT surgical quality (15). However, another evidence from multi-center cohort data has suggested that repeated TURBT is un-necessary because it has no clinical benefit if the muscle layer is present in the specimen of primary TUR (19). Because repeated TURBT is relatively safe (20), it is recommended in selective patients who are at high risk of bladder cancer or fail to obtain muscle layer in initial TURBT.

Surgical checklist is one of the easiest ways to improve performance quality of surgical procedures. WHO surgical checklist announced in 2009 by WHO was developed to reduce communication error by the part of Safe Surgery Saves Lives campaign (21). After WHO surgical checklist is published, it is accepted by more than 4,000 institutions world-wide (22). Although WHO checklist is developed to reduce communication error for blocking intraoperative complications (23), recent studies have shown that WHO surgical checklist itself has benefits for reducing postoperative complication of surgery (24).

Using surgical checklist in urologic field has also been studied for TURBT. Anderson et al. (13) have reported 10-item surgical checklist during TURBT shows possibility of improving clinical outcome. In their study, the completeness of resection was significantly (P<0.00001) increased after implication of surgical checklist, although there was no significant (P=0.8) change in containing the detrusor muscle in TUBT specimen. The surgeon who reported more checklist items tended to have higher chance of obtaining muscle-containing specimen in TURBT, although the difference was not statistically significant (P=0.062). Their study successfully demonstrated the increase of awareness after adaptation of surgical checklist. However, the correlation of recurrence with surgical checklist was unclear.

Suarez-Ibarrola et al. (25) have recently published a study to reveal the association between surgical checklist and recurrence free survival of TURBT. The authors applied an eight-item surgical checklist for TURBT in two tertiary referral centers. All items of the checklist were evidence-based and guidelines recommended. These checklist items were “Tumor status”, “Positive pre-TUR bimanual palpation”, “Macroscopic appearance”, “Tumor size”, “Number of tumors”, “Location, n (%)”, “TUR macroscopically complete” and “Positive post-TUR bimanual palpation”. The major hypothesis of their study was that if pre-operative surgical checklist was carefully performed through cystoscopy by surgeons, it would improve the surgical quality. For this reason, the authors predicted that “Number of tumors” and “Location, n (%)” items were the most important factors that would affect the recurrence free survival. The authors retrospectively reviewed 547 patients, including 266 (49%) of checklist implicated patients, with as recurrence free survival as target primary end-point. The performed surgical checklist was an independent factor associated with recurrence free survival by cox-proportional hazard regression analysis (P=0.02). The “Number of tumors” item in surgical checklist was also an independent prognostic factor (P=0.08) as expected by the authors. However, the presence of detrusor muscle, a surrogate marker of surgical quality of TURBT, was not significantly different after implication of the surgical checklist. The authors explained that this result was because, although the eight-item surgical checklist resulted in careful cystoscopy, it did not guarantee qualified resection. Thus, careful cystoscopy before TURBT has benefit for identifying small tumor that can be easily neglectable and associated with intra-vesical recurrence of non-muscle invasive bladder cancer.

Suarez-Ibarrola et al. (25) have described that the surgical checklist is more user friendly and easily applicable than the 10-item checklist previously reported by Anderson et al. (13). They have successfully demonstrated the impact of careful cystoscopic inspection before TURBT on recurrence free survival. However, the clinical goal of TURBT in NMIBC is not only reducing recurrence free survival, but also reducing progression to MIBC. The detrusor muscle containment of TURBT specimen is one of the most important markers to justify the quality of TURBT. Thus, this surgical checklist needs more improvement.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86. [Crossref] [PubMed]
2. Burger M, Catto JW, Dalbagni G, et al. Epidemiology and risk factors of urothelial bladder cancer. Eur Urol 2013;63:234-41. [Crossref] [PubMed]
3. Antoni S, Ferlay J, Soerjomataram I, et al. Bladder Cancer Incidence and Mortality: A Global Overview and Recent Trends. Eur Urol 2017;71:96-108. [Crossref] [PubMed]
4. van Rhijn BW, Burger M, Lotan Y, et al. Recurrence and progression of disease in non-muscle-invasive bladder cancer: from epidemiology to treatment strategy. Eur Urol 2009;56:430-42. [Crossref] [PubMed]
5. Sylvester RJ, van der Meijden AP, Oosterlinck W, et al. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol 2006;49:466-5; discussion 475-7.
6. Power NE, Izawa J. Comparison of Guidelines on Non-Muscle Invasive Bladder Cancer (EAU, CUA, AUA, NCCN, NICE). Bladder Cancer 2016;2:27-36. [Crossref] [PubMed]
7. abjuk M, Böhle A, Burger M, et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017;71:447-61.
8. Chang SS, Boorjian SA, Chou R, et al. Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol 2016;196:1021-9. [Crossref] [PubMed]
9. Grayson M. Bladder cancer. Nature 2017;551:S33. [Crossref] [PubMed]
10. Al Hussein Al Awamlh B, Lee R, Chughtai B, et al. A cost-effectiveness analysis of management of low-risk non-muscle-invasive bladder cancer using office-based fulguration. Urology 2015;85:381-6. [Crossref] [PubMed]
11. Yeung C, Dinh T, Lee J. The health economics of bladder cancer: an updated review of the published literature. Pharmacoeconomics 2014;32:1093-104. [Crossref] [PubMed]
12. Fung C, Pandya C, Guancial E, et al. Impact of bladder cancer on health related quality of life in 1,476 older Americans: a cross-sectional study. J Urol 2014;192:690-5. [Crossref] [PubMed]
13. Anderson C, Weber R, Patel D, et al. A 10-Item Checklist Improves Reporting of Critical Procedural Elements during Transurethral Resection of Bladder Tumor. J Urol 2016;196:1014-20. [Crossref] [PubMed]
14. Brausi M, Collette L, Kurth K, et al. Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur Urol 2002;41:523-31. [Crossref] [PubMed]
15. Mariappan P, Zachou A, Grigor KM, et al. Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience. Eur Urol 2010;57:843-9. [Crossref] [PubMed]
16. Rolevich A, Minich A, Nabebina T, et al. Surgeon has a major impact on long-term recurrence risk in patients with non-muscle invasive bladder cancer. Cent European J Urol 2016;69:170-7. [PubMed]
17. Dutta SC, Smith JA Jr, Shappell SB, et al. Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy. J Urol 2001;166:490-3. [Crossref] [PubMed]
18. Badalato G, Patel T, Hruby G, McKiernan J. Does the presence of muscularis propria on transurethral resection of bladder tumour specimens affect the rate of upstaging in cT1 bladder cancer? BJU Int 2011;108:1292-6. [Crossref] [PubMed]
19. Gontero P, Sylvester R, Pisano F, et al. The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette-Guérin. BJU Int 2016;118:44-52. [Crossref] [PubMed]
20. Zapała P, Dybowski B, Poletajew S, et al. Clinical rationale and safety of restaging transurethral resection in indication-stratified patients with high-risk non-muscle-invasive bladder cancer. World J Surg Oncol 2018;16:6. [Crossref] [PubMed]
21. World Health Organization. WHO Guidelines for Safe Surgery 2009. Available online: https://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/
22. Pugel AE, Simianu VV, Flum DR, et al. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health 2015;8:219-25. [Crossref] [PubMed]
23. Gitelis ME, Kaczynski A, Shear T, et al. Increasing compliance with the World Health Organization Surgical Safety Checklist-A regional health system's experience. Am J Surg 2017;214:7-13. [Crossref] [PubMed]
24. Anwer M, Manzoor S, Muneer N, et al. Compliance and Effectiveness of WHO Surgical Safety Check list: A JPMC Audit. Pak J Med Sci 2016;32:831-5. [PubMed]
25. Suarez-Ibarrola R, Soria F, Abufaraj M, et al. Surgical checklist impact on recurrence-free survival of patients with non-muscle-invasive bladder cancer undergoing transurethral resection of bladder tumour. BJU Int 2019;123:646-50. [Crossref] [PubMed]