The introduction of a surgical checklist for the transurethral resection of the bladder improves recurrence-free survival in non-muscle invasive bladder cancer patients
More than half of patients with non-muscle invasive bladder cancer (NMIBC) will experience an intravesical recurrence, requiring additional treatment and its resulting morbidity, decreasing quality of life and increasing healthcare costs. The quality of surgical resection is essential in the management of bladder cancer (BC) patients and may have a significant impact on the risk of intravesical recurrence. To standardize the procedure and to improve surgical outcomes, the introduction of a surgical checklist (SC) has been proposed. Moreover, the SC improves operative reporting, which can be considered a proxy of surgical quality. However, studies reporting the impact of a SC on oncological outcomes are lacking. The aim of our study was to evaluate the impact of the introduction of a SC on recurrence-free survival (RFS) of NMIBC patients undergoing TURBT.
An eight-item SC was progressively implemented into clinical practice at two tertiary referral centers. We reviewed the reports of TURBTs performed before and during the SC’s implementation. Patients undergoing TURBTs between January 2012 and January 2017 were enrolled in this retrospective study. The number of reported items was collected from surgical reports. A multivariable logistic regression was performed to assess the impact of operative report on the presence of detrusor muscle in pathologic specimen. A multivariable Cox regression model was built to assess the impact of operative reports on RFS rate.
Overall, 547 patients were included in the study and 266 of them (49%) underwent TURBT after the SCs’ implementation. Median follow-up for patients alive at last follow-up was 20 months (IQR 10-31). Median age at TURBT was 72 years (IQR 63-78) and 459 (84%) patients were male. Most of the patients had NMIBC (91%) and high-grade disease (58%). Detrusor muscle in TURBT specimen was detected in 60% of the cases. The implementation of the SC increased the number of reported items from 5 to 6 (median values). On logistic multivariable regression analysis, the number of reported items was not significantly associated with the presence of detrusor muscle in the surgical specimen (HR 1.01, 95% CI 0.75-1.35, p=0.9). On multivariable Cox regression analysis, the number of reported items was independently associated with a significative improvement of RFS (OR 0.78, 95% CI 0.61-0.99, p=0.04).
TURBT is essential in the management of BC patients. We demonstrated that the implementation of a SC into clinical practice increases the quality of operative report thereby potentially improving individualized risk-stratification and care resulting in lower disease recurrence-rate. Therefore, the introduction of a SC should be recommended in order to enhance oncological outcomes by improving surgical standardization and operative reporting.