Audit of Detrusor Muscle Sampling in Trans-Urethral Resection of Bladder Tumour
BAUS ePoster online library. English L. Jun 26, 2018; 217791
Louise English
Louise English
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Abstract
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Introduction
Transurethral resection for bladder tumour (TURBT) is the commonest urological cancer operation. TURBT is both a diagnostic and therapeutic operation, vital in the diagnosis, staging and treatment of primary and recurrent non-muscle invasive bladder tumours (NMIBC)(Mostafid and Brausi, 2012). The principle aims of TURBT are:
- To identify all papillary tumours within the bladder
- To remove all tumours completely
- To ensure that each tumour has been correctly staged
- To identify areas of dysplasia or carcinoma in situ (CIS) in the bladder
Unfortunately, these aims may not always be achieved. Reasons for this include poor cystoscopic views, tumour size and multiplicity, difficult location, surgeon's level of experience or complications such as bleeding or perforation. With this in mind, the overall rate of recurrence following TURBT in patients with NMIBC can be as high as 70%, with the greatest risk being at the first follow-up cystoscopy (Mariappan, Zachou and Grigor, 2010).
In a review of seven randomised controlled trials, the European Organisation for Research and Treatment of Cancer (EORTC) detected significant interinstitutional variation in the RR-FFC despite controlling for established predictors of recurrence (i.e. tumour size, multiplicity, stage and grade). The authors hypothesised that this discrepancy was a result of the variability in the quality of the resections(Mariappan et al., 2012).

Until the first follow up cystoscopy, however, objectifying the quality of TURBT is not without difficulty. Although in an ideal setting one would measure the above aims, this is not always achievable due to the unique way in which the specimen is obtained at TURBT compared to other cancer operations (Mostafid and Brausi, 2012).
Instead, surrogate markers are utilised to measure the quality of TURBT. The two most common markers are the presence of detrusor muscle (DM) in the resected specimen, and the recurrence rate at first follow-up cystoscopy (RR-FFC). Grigor et al demonstrated DM presence in the first, apparently complete TURBT specimen, is a surrogate marker of resection quality by independently predicting the RR-FFC. European Association of Urology (EAU) guidelines state that presence of DM in the specimen is required in all cases except for TaG1/LG tumours. Despite this, it is widely reported that DM may not be sampled in up to 50% of first resections(Mostafid and Brausi, 2012).
Currently at our institution, TURBT is performed by both consultants and non-consultant grade doctors (ST3 registrar, three associate specialist doctors, CT2 trainee) under consultant supervision. This is the first audit focussed specifically on evaluating and enhancing the quality of TURBT locally.
Aim
The objectives of this audit were therefore to assess:
- the quality of our TURBT with respect to the rate of DM sampling and recurrence rate at first check cystoscopy
- whether tumour grade or stage is associated with presence or absence of DM
- the correlation between the rate of DM sampling and the surgeon's experience level
Methods
We conducted a single loop audit of the last 100 TURBTs performed at or institution between the 1st May 2017 and 1st December 2017, including all TURBTs for newly diagnosed bladder tumours determined to have been completely resected by the operating surgeon. All patients underwent standard TURBT, with Mitomycin C given in theatre for all non-muscle invasive appearing lesions, unless contraindicated.
Data was collected retrospectively, using Evolve electronic operative notes, patient letters and histopathology report as sources, and scrutinised against a set of standards adapted from the EAU guidelines on NMIBC(Babjuk et al., 2017)
Results
Of the total of 100 TURBTs evaluated in this audit, 13 were excluded from the analysis: in 7 cases there was no evidence of bladder cancer on cystoscopy (no TURBT performed), in 3 the resection was documented as incomplete. In all cases this was due concerns of perforation due to a very thin bladder. Notes were unavailable for 3 patients.
87 patients thus underwent analysis. 58 males and 29 females, at the average age of 75, were included. Surgeons were stratified into 2 groups: consultants and non-consultants. 60 operations were performed by consultants, with 27 cases performed by non-consultants. Table 1 shows the distribution of the grade and stage of tumours.
66 patients had DM present in the histological specimen, allowing for accurate staging (75.9%). DM was not sampled in 21 patients (24.1%). The most frequently noted histological staging in cases where DM was not sampled was pTa - this was the case in 16 of the 21 patients (76.2%). This represented 37.2% of all pTa tumours. 22 patients were found to have muscle invasive bladder cancer (25.3%). High grade G3 tumours had an 85.4% DM sampling rate (see table 2).
60 cases were carried out by Consultants, with 27 cases performed by non-consultants. DM was present in the 76.7% of cases performed by a Consultant, compared with 74.1% when performed by a non-consultant.
Of those where DM was not sampled, 2 were pTaG1/LG disease. These patients had a check flexible cystoscopy at 3 months and did not require a re-resection. 10 were pTaG2 disease - 5 of these patients went on to have a re-resection, however only 1 was upstaged. 4 were pTaG3 - none of these patients were upstaged during their follow up.
Looking at the pT1 tumours, in 4 cases DM was absent. Of these 4 patients, all underwent early re-resection. 3 cases had no evidence of recurrence. In one case the stage was upgraded to pT2 disease. In line with EAU guidelines, an early re-look was performed on the 13 pT1 tumours which did have DM sampled. No patients had their disease upstaged if a further resection was carried out (see table 3).
Discussion
NMIBC has a high cumulative risk of recurrence throughout the period of surveillance, despite the established use of intravesical chemotherapy after resection. It is well established that the presence of DM in the specimen is an important determinant of the recurrence rate at follow up cystoscopy (RR-FFC)(Mariappan, Zachou and Grigor, 2010).

Studies have shown the rate of absence of DM to be as high as 51%. Failing to obtain DM can lead to under-staging of tumours, which can significantly affect further treatment. Herr and Donat have shown that in pT1 tumours, when no DM was submitted in the first TURBT, at early re-TURBT residual tumour was found in 49% compared with only 14% when DM was present. Furthermore, Mariappan et al have shown that the RR-FFC was 21.7% when DM was present compared with 44.4% when DM was absent(Mariappan, Zachou and Grigor, 2010). Overall, our department showed good levels of DM sampling with our TURBT, with an overall figure of 75.9%. Naturally, improvements can be made but this is a promising figure.

The literature suggests that experienced surgeons are more likely to resect DM with a lower risk of early recurrence. Jesuraj et al found significant surgeon-related differences in the ability to resect DM which were more pronounced in the higher grade tumours. DM was seen in 45.5% of resections by juniors, compared with 67.3% of resections by seniors. Our results show that the non-consultant level Surgeons are resecting DM in 74.1% of cases, compared with 76.7% of consultants. This is likely due to the focus on good training and close supervision at our institution, along with the widespread understanding of the importance of sampling DM. Studies have shown that a dedicated teaching programme including supervised TURBT training improves the quality of TURBT - over a 5 year period with this programme the presence of DM in the TURBT specimen increased from 50 to 79%(Mostafid and Brausi, 2012).
Interestingly, our data showed that those with high grade (G3) and T1 disease were more likely to have DM sampled. DM was present in 85.4% of those with G3 disease and 76.5% of T1 disease. Again, this is perhaps due to the fact the consultants are performing a greater proportion of these cases. Interestingly, the most frequently noted histological staging in cases where DM was not sampled was pTa - this was the case in 16 of the 21 patients (76.2%). This may represent the fact that juniors are more likely to non-consultants are more likely to perform these operations. Nevertheless, this distribution of results suggests that extra care should be taken in the resection of superficial looking lesions to ensure that DM is sampled.
Conclusions
DM sampling has been shown to be an important measure of the quality of TURBT, given its correlation with the risk of recurrence of non-muscle invasive bladder cancer. This audit aimed to look at the rate of DM sampling at our local institution and the results are promising. Our results support previous studies that surgical experience is a factor in the quality of TURBT. Good training is of utmost importance and the DM sampling rate in non-consultant staff suggests that the current training model is successful. Improvements can always be made, and our results suggest that additional care should be taken in the resection of superficial looking tumours to ensure that muscle is sampled.
Recommendations
To continue the close supervision of non-consultant Surgeons when performing TURBT.
Recommend that all surgeons continue to make a conscious effort at removing DM at the time of TURBT.
To perform regular audit and re-audit of our TURBT performance so that high standards of care are maintained.
To look in particular at the recurrence rate at first flexible cystoscopy (RR-FFC) and identify any factors which may be contributing to recurrent disease.
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