Closed Loop Audit of Muscle Sampling in TransUrethral Resection of Bladder Tumour
BAUS ePoster online library. Varma R. 11/10/20; 304269; PCU-1
Raghav Varma
Raghav Varma
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Closed Loop Audit of Muscle Sampling in TransUrethral Resection of Bladder Tumour
Varma R 1, Roy D 1, Deb A 1, Ali A, 1 Brighton and Sussex University Hospitals NHS Trust United Kingdom, 2 Frimley Park Hospital, United Kingdom

Introduction

Trans-Urethral Resection of Bladder Tumour (TURBT) is the gold standard method for the diagnosis and treatment of bladder cancer. It was first introduced by Stern in 1926 (1). The initial TURBT should accurately determine the histological type, grade of the tumour, remove all tumour content from the bladder if possible and establish the presence of tumour invasion to the Detrusor muscle (DM) layer if suspected. (2).

It is well known that the presence of DM can be used as a surrogate marker of the quality of resection. (3) Herr et al. first described the need for re-resection in all patients with high risk NMIBC. This was based on her finding of higher risk of residual disease during the second look 83%, compared with 74% in those without DM at first resection (2). They also showed a 49% rate of upstaging on re-resection from T1 to T2 Muscle invasive cancer (MIBC) disease in those with DM absence at the initial resection (2).

There has been evidence recently to suggest that appropriate resection with DM in specimen might negate the need for re-resection. (3). Hence all the guidelines (EAU, AUA, NICE, and NCCN) recommend fully resecting all visible tissue and procuring muscle at the time of TURBT (4). Currently, re-TURBT is recommended due to high incidence of residual tumour and understaging of the disease (4).

Aims

Primary aim: To evaluate practice and perform a quality improvement exercise in the management of patients with bladder cancer in Frimley Park Hospital, UK.
Secondary aim: to assess if the level of surgeon can affect outcomes

Methods

Retrospective and prospective data collections for all patients undergoing TURBT for the period between January 2014 and May 2018 were analysed.

The first part of our three-part audit was a retrospective study conducted over five months from January 2014 to May 2014 where 92 cases were identified. The second part of the audit was a retrospective study conducted over eight months from July 2016 to February 2017 with 100 cases identified. The third part of the audit was a prospective study conducted over eight months from October 2017 to May 2018 with 109 cases identified.

Patient demographics, level of operating surgeon, indication, histology and procedure related data was collected. During the second audit the intervention used was to send specimens from different lesions in separate containers. In addition, sending separate biopsies from the base of the tumour to assess for muscle invasion as per the EAU guidelines (5). We ensured our pathologists and theatre team were aware of this change when implemented.

The third audit took place after adoption of En-Bloc Resection of bladder Tumour (EBRT) and having dedicated urologists who have an interest in bladder cancer to treat patients presenting with possible high risk disease. The tumours which were easily accessible and less than 3cm, we applied a circumferential incision using a bipolar resection loop, maintaining a distance of 5-10mm from the tumour edge. The tumour was then dissected down and centrally through submucosal and muscular layer and detached using biopsy forceps.

Results

A total of 301 cases were included of which 73.8% were men and 26.2% women. The age range was 35 - 97 years with a mean age of 76 years. 190 cases (63%) being the primary TURBT resection.

In the first audit DM was included in 36/92 (39%) of samples. DM was sampled in 17/34 (50%) cases of intermediate and high risk category. Of the 17 patients who required repeat TURBT 6 (35%) were upstaged, 3 died due to invasive disease (17%), 3 were lost to follow up (17%) and the remaining 5 were accurately staged (29%), at one year.

In the second audit DM was included in 65/100 (65%) of samples. DM was sampled in 28/41 (68%) cases of intermediate and high risk category.

In the third audit DM was included in 72/109 (66%) of samples. DM was sampled in 42/50 (84%) cases of intermediate and high risk category. Of the 8 patients only 1 was upstaged (12.5%) while the other 7 patients were accurately staged (87.5%), at one year. Muscle presence according to operators showed no statistical difference, with consultants sampling DM 65% (50/74) of cases and junior grades 62% of cases (22/35).





Discussion

Our study has shown a massive improvement in the quality of bladder tumour resection by implementing a structured approach to treating patients with bladder tumours and adopting new techniques. Correctly staging bladder cancer by obtaining samples for the DM to assess invasion and removing all visible tumour as possible is the most important factor in determining future management of bladder cancer patients and has a direct impact on patient outcomes. Many studies have showed that poor quality at initial resection will lead to worse outcomes in patients with NMIBC (6, 7). Patients with no DM in the first resection will have twice the risk of recurrence at 3 months (44.4% compared to 21.7%) (3). Furthermore, progression-free survival rates at 5 years after TURBT were 77.3 % vs 91.1% for patients who had no DM in their specimen compared to those with DM in histopathological samples respectively (7).

Furthermore, in a survey of 2410 patients from European Organisation for Research and Treatment of Cancer (EORTC) trials found a 7% to 45% variance in tumour recurrence rates at the first follow-up cystoscopy among different institutions. They concluded, having controlled for established predictors of recurrence such as tumour grade and size, quality of TURBT resection most likely responsible for the variance (9).

Based on the above data, the current practice is to arrange re-resection or second TURBT within 4 - 6 weeks from the initial resection as recommended by both European and American guidelines. However, to date there has been no improvement in bladder cancer recurrence and mortality rates for the past 50 years.

We felt that change in practice is required and during first audit cycle we found 50% (17/34) cases of intermediate and high risk category lacked DM in their resections. Of those that required repeat TURBT, approximately 1/3rd were upstaged.

After the first cycle, we put in place a standard protocol to ensure all surgeons send two specimens to include deep biopsies from the base of the tumor and also different biopsies to be placed in separately labelled containers for the pathologist, following the EAU recommendation (5).

The second audit showed an improvement of 36% in the presence of DM in specimen, with 68% (28/41) cases of intermediate and high risk category with DM in specimen. When we sub analyzed the data we found that outcomes could be improved further by limiting the cases to fewer surgeons. The benefit of self-reflection and continuity of care, we hoped would improve outcome and follow up of patients.

Furthermore, we introduced the principle of en-bloc resection to help reduce the risk of tumour spillage and also increase the level of DM in specimen. This has helped the pathologist interpreting the specimen by having a clear orientation to the tumour. This was similar to the reported data in literature (10 - 12).

The last audit revealed a further 24% improvement from the previous audit and 68% improvement from the first audit. This represents an overall of 84% of DM in intermediate and high risk category cases.

As a second major finding, we found surgeon experience did not impact resection quality in our last audit, with consultants sampling DM in 68% of cases and Middle/Junior Grade 63% of cases. This goes against published evidence showing a two-fold increase in DM sampling with senior rather than junior surgeons (6). One explanation would be that all cases are currently performed in bladder cancer theatre lists which are fully supervised by a consultant urologist with interest in bladder cancer.

Conclusion

Through our study, we have demonstrated the value of closed loop audits in achieving improved quality of resections without affecting training junior urologists. The main interventions we put in place were: increasing awareness, sending separate biopsies form base of tumour to sample invasion to DM, dedicated bladder cancer lists and conducting en-bloc resection where appropriate. Further research is required to analyse the need for re-resection in patients with good quality resection at initial TURBT.


References:
1. Herr HW. Early history of endoscopic treatment of bladder tumors from Grunfeld's polypenkneipe to the Stern-McCarthy resectoscope. J Endourol. 2006;20:85-91.
2. Herr HW, Donat SM. Quality control in transurethral resection of bladder tumours. BJU Int. 2008;102:1242-1246.
3. 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 2001:166:490-493
4. Woldu SL, Bagrodia A, Lotan Y. Guideline of guidelines: non-muscle-invasive bladder cancer. BJU Int 2017;119:371-80.
5. Leiblich, A, Bryant RJ, McCormick R, et al. 'The management of non-muscle-invasive bladder cancer: A comparison of European and UK guidelines', Journal of Clinical Urology, 2018:11(2), pp. 144-148.
6. 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;57:843-849.
7. Shindo T, Masumori N, Kitamura H, et al. Clinical significance of definite muscle layer in TUR specimen for evaluating progression rate in T1G3 bladder cancer: multicenter retrospective study by the Sapporo Medical University Urologic Oncology Consortium (SUOC). World J Urol. 2014;32:1281-1285.
8. Babjuk M, Böhle A, Burger M, et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol. 2017 Mar;71(3):447-461. doi: 10.1016/j.eururo.2016.05.041. Epub 2016 Jun 17.
9. 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.
10. Gakis G, Karl A, Bertz S, et al. Transurethral en-bloc hydrodissection for non-muscle invasive bladder cancer: Results of a randomized controlled trial. Eur Urol Supplements 2017;16:e1143-4
11. Wu YP, Lin TT, Chen SH, et al. Comparison of the efficacy and feasibility of en bloc transurethral resection of bladder tumor versus conventional transurethral resection of bladder tumor. Medicine (Baltimore) 2016;95:e5372.
12. Yang H, Wang N, Han S, et al. Comparison of the efficacy and feasibility of laser enucleation of bladder tumor versus transurethral resection of bladder tumor: a meta-analysis. Lasers Med Sci 2017;32:2005-12.
Closed Loop Audit of Muscle Sampling in TransUrethral Resection of Bladder Tumour
Varma R 1, Roy D 1, Deb A 1, Ali A, 1 Brighton and Sussex University Hospitals NHS Trust United Kingdom, 2 Frimley Park Hospital, United Kingdom

Introduction

Trans-Urethral Resection of Bladder Tumour (TURBT) is the gold standard method for the diagnosis and treatment of bladder cancer. It was first introduced by Stern in 1926 (1). The initial TURBT should accurately determine the histological type, grade of the tumour, remove all tumour content from the bladder if possible and establish the presence of tumour invasion to the Detrusor muscle (DM) layer if suspected. (2).

It is well known that the presence of DM can be used as a surrogate marker of the quality of resection. (3) Herr et al. first described the need for re-resection in all patients with high risk NMIBC. This was based on her finding of higher risk of residual disease during the second look 83%, compared with 74% in those without DM at first resection (2). They also showed a 49% rate of upstaging on re-resection from T1 to T2 Muscle invasive cancer (MIBC) disease in those with DM absence at the initial resection (2).

There has been evidence recently to suggest that appropriate resection with DM in specimen might negate the need for re-resection. (3). Hence all the guidelines (EAU, AUA, NICE, and NCCN) recommend fully resecting all visible tissue and procuring muscle at the time of TURBT (4). Currently, re-TURBT is recommended due to high incidence of residual tumour and understaging of the disease (4).

Aims

Primary aim: To evaluate practice and perform a quality improvement exercise in the management of patients with bladder cancer in Frimley Park Hospital, UK.
Secondary aim: to assess if the level of surgeon can affect outcomes

Methods

Retrospective and prospective data collections for all patients undergoing TURBT for the period between January 2014 and May 2018 were analysed.

The first part of our three-part audit was a retrospective study conducted over five months from January 2014 to May 2014 where 92 cases were identified. The second part of the audit was a retrospective study conducted over eight months from July 2016 to February 2017 with 100 cases identified. The third part of the audit was a prospective study conducted over eight months from October 2017 to May 2018 with 109 cases identified.

Patient demographics, level of operating surgeon, indication, histology and procedure related data was collected. During the second audit the intervention used was to send specimens from different lesions in separate containers. In addition, sending separate biopsies from the base of the tumour to assess for muscle invasion as per the EAU guidelines (5). We ensured our pathologists and theatre team were aware of this change when implemented.

The third audit took place after adoption of En-Bloc Resection of bladder Tumour (EBRT) and having dedicated urologists who have an interest in bladder cancer to treat patients presenting with possible high risk disease. The tumours which were easily accessible and less than 3cm, we applied a circumferential incision using a bipolar resection loop, maintaining a distance of 5-10mm from the tumour edge. The tumour was then dissected down and centrally through submucosal and muscular layer and detached using biopsy forceps.

Results

A total of 301 cases were included of which 73.8% were men and 26.2% women. The age range was 35 - 97 years with a mean age of 76 years. 190 cases (63%) being the primary TURBT resection.

In the first audit DM was included in 36/92 (39%) of samples. DM was sampled in 17/34 (50%) cases of intermediate and high risk category. Of the 17 patients who required repeat TURBT 6 (35%) were upstaged, 3 died due to invasive disease (17%), 3 were lost to follow up (17%) and the remaining 5 were accurately staged (29%), at one year.

In the second audit DM was included in 65/100 (65%) of samples. DM was sampled in 28/41 (68%) cases of intermediate and high risk category.

In the third audit DM was included in 72/109 (66%) of samples. DM was sampled in 42/50 (84%) cases of intermediate and high risk category. Of the 8 patients only 1 was upstaged (12.5%) while the other 7 patients were accurately staged (87.5%), at one year. Muscle presence according to operators showed no statistical difference, with consultants sampling DM 65% (50/74) of cases and junior grades 62% of cases (22/35).





Discussion

Our study has shown a massive improvement in the quality of bladder tumour resection by implementing a structured approach to treating patients with bladder tumours and adopting new techniques. Correctly staging bladder cancer by obtaining samples for the DM to assess invasion and removing all visible tumour as possible is the most important factor in determining future management of bladder cancer patients and has a direct impact on patient outcomes. Many studies have showed that poor quality at initial resection will lead to worse outcomes in patients with NMIBC (6, 7). Patients with no DM in the first resection will have twice the risk of recurrence at 3 months (44.4% compared to 21.7%) (3). Furthermore, progression-free survival rates at 5 years after TURBT were 77.3 % vs 91.1% for patients who had no DM in their specimen compared to those with DM in histopathological samples respectively (7).

Furthermore, in a survey of 2410 patients from European Organisation for Research and Treatment of Cancer (EORTC) trials found a 7% to 45% variance in tumour recurrence rates at the first follow-up cystoscopy among different institutions. They concluded, having controlled for established predictors of recurrence such as tumour grade and size, quality of TURBT resection most likely responsible for the variance (9).

Based on the above data, the current practice is to arrange re-resection or second TURBT within 4 - 6 weeks from the initial resection as recommended by both European and American guidelines. However, to date there has been no improvement in bladder cancer recurrence and mortality rates for the past 50 years.

We felt that change in practice is required and during first audit cycle we found 50% (17/34) cases of intermediate and high risk category lacked DM in their resections. Of those that required repeat TURBT, approximately 1/3rd were upstaged.

After the first cycle, we put in place a standard protocol to ensure all surgeons send two specimens to include deep biopsies from the base of the tumor and also different biopsies to be placed in separately labelled containers for the pathologist, following the EAU recommendation (5).

The second audit showed an improvement of 36% in the presence of DM in specimen, with 68% (28/41) cases of intermediate and high risk category with DM in specimen. When we sub analyzed the data we found that outcomes could be improved further by limiting the cases to fewer surgeons. The benefit of self-reflection and continuity of care, we hoped would improve outcome and follow up of patients.

Furthermore, we introduced the principle of en-bloc resection to help reduce the risk of tumour spillage and also increase the level of DM in specimen. This has helped the pathologist interpreting the specimen by having a clear orientation to the tumour. This was similar to the reported data in literature (10 - 12).

The last audit revealed a further 24% improvement from the previous audit and 68% improvement from the first audit. This represents an overall of 84% of DM in intermediate and high risk category cases.

As a second major finding, we found surgeon experience did not impact resection quality in our last audit, with consultants sampling DM in 68% of cases and Middle/Junior Grade 63% of cases. This goes against published evidence showing a two-fold increase in DM sampling with senior rather than junior surgeons (6). One explanation would be that all cases are currently performed in bladder cancer theatre lists which are fully supervised by a consultant urologist with interest in bladder cancer.

Conclusion

Through our study, we have demonstrated the value of closed loop audits in achieving improved quality of resections without affecting training junior urologists. The main interventions we put in place were: increasing awareness, sending separate biopsies form base of tumour to sample invasion to DM, dedicated bladder cancer lists and conducting en-bloc resection where appropriate. Further research is required to analyse the need for re-resection in patients with good quality resection at initial TURBT.


References:
1. Herr HW. Early history of endoscopic treatment of bladder tumors from Grunfeld's polypenkneipe to the Stern-McCarthy resectoscope. J Endourol. 2006;20:85-91.
2. Herr HW, Donat SM. Quality control in transurethral resection of bladder tumours. BJU Int. 2008;102:1242-1246.
3. 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 2001:166:490-493
4. Woldu SL, Bagrodia A, Lotan Y. Guideline of guidelines: non-muscle-invasive bladder cancer. BJU Int 2017;119:371-80.
5. Leiblich, A, Bryant RJ, McCormick R, et al. 'The management of non-muscle-invasive bladder cancer: A comparison of European and UK guidelines', Journal of Clinical Urology, 2018:11(2), pp. 144-148.
6. 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;57:843-849.
7. Shindo T, Masumori N, Kitamura H, et al. Clinical significance of definite muscle layer in TUR specimen for evaluating progression rate in T1G3 bladder cancer: multicenter retrospective study by the Sapporo Medical University Urologic Oncology Consortium (SUOC). World J Urol. 2014;32:1281-1285.
8. Babjuk M, Böhle A, Burger M, et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol. 2017 Mar;71(3):447-461. doi: 10.1016/j.eururo.2016.05.041. Epub 2016 Jun 17.
9. 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.
10. Gakis G, Karl A, Bertz S, et al. Transurethral en-bloc hydrodissection for non-muscle invasive bladder cancer: Results of a randomized controlled trial. Eur Urol Supplements 2017;16:e1143-4
11. Wu YP, Lin TT, Chen SH, et al. Comparison of the efficacy and feasibility of en bloc transurethral resection of bladder tumor versus conventional transurethral resection of bladder tumor. Medicine (Baltimore) 2016;95:e5372.
12. Yang H, Wang N, Han S, et al. Comparison of the efficacy and feasibility of laser enucleation of bladder tumor versus transurethral resection of bladder tumor: a meta-analysis. Lasers Med Sci 2017;32:2005-12.
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