Staging TURBT - Are we doing it right?
BAUS ePoster online library. Sibartie T. Jun 26, 2018; 217792
Ms. Tara Sibartie
Ms. Tara Sibartie
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Abstract
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INTRODUCTION
Transurethral resection of bladder tumour (TURBT) is one of the most commonly performed operations for cancer in the United Kingdom and is performed by both consultants and trainees. The presence of muscle on histology is required for accurate staging. Careful documentation at the time of TURBT allows accurate risk stratification and planning for further treatment in accordance with NICE guideline Bladder cancer: diagnosis and management (2015) and EAU guideline Non-muscle-invasive bladder cancer (2017).

AIMS
The aims of this audit were to retrospectively review the case notes of patients who had undergone primary TURBT for a newly diagnosed bladder tumour. Primary outcomes were the proportion of patients with muscle on histology and documentation in the TURBT operation note of the number of tumours, size of the largest tumour, whether resection was complete, whether the prostatic urethra was biopsied, findings of examination under anaesthetic.

METHODS
A database of patients diagnosed with bladder cancer (M.421) from 1st January 2015 to 31st December 2016 was retrieved from the urology multidisciplinary co-ordinators at a large teaching hospital. Clinical notes, electronic case notes and histology reports were reviewed retrospectively and analysed. Inclusion criteria: Patients over 18 years of age who had undergone primary TURBT with a new diagnosis of bladder cancer. Exclusion criteria: No available operation note for primary TURBT; No TURBT performed; TURBT performed outside the auditing hospital.

RESULTS
Nineteen patients were excluded from analysis following review of case notes: 9 patients had not undergone primary TURBT; there was no available operation note for 4 patients; 4 patients had their TURBT performed in an outside hospital; 1 patient's histology did not show any malignancy but significant diathermy artefact leading to an MDT decision to treat as a low risk transitional cell carcinoma and one patient's TURBT had been performed before the audit period.

One hundred consecutive patients were included in analyses, all having met the inclusion criteria. The period audited spanned 13 months from 7th December 2015 to 5th February 2016 to allow a year of follow-up. Sixty-eight patients were male and 32 female (M:F = 2:1).

Overall, 51% of patients had muscle present on their histology. A sub-analysis was performed of patients fit for radical treatment (n=85). This excluded patients with an ASA grade of 4 or with a poor performance status (n=6) and patients with metastatic disease or another primary tumour with poor prognosis (n=9). In this sub-analysis, 53% of patients had muscle in their TURBT specimen. The base of the tumour was sampled separately in 34% (n=29/85). In cases where the base was sent separately, the presence of muscle on histology was 72%. Table 1 demonstrates the muscle pick-up rate by level of operating surgeon and Table 2 by risk stratification group.

DISCUSSION
Absence of detrusor muscle is associated with a significantly increased risk of residual disease, early recurrence and tumour understaging. As such, the presence of detrusor muscle on tumour histology is considered as a surrogate criterion of resection quality (Babjuk et al, 2017). Our muscle pick-up rate of 53% in those suitable for radical treatment is lower than described in the literature (67.7%) by Mariappan et al (2010). Our data suggests that sampling the base of the tumour separately may increase the presence of muscle on histology by as much as 41%.

The muscle pick-up rate is higher with increasing risk group. Reasons for this may include a heightened awareness of the need for muscle in more severe disease or operative factors such as the technical difficulty of the operation.

The documentation of the TURBT operation in our department is inadequate. This may affect the ability to accurately risk stratify and follow-up patients.

RECOMMENDATIONS
Following presentation of this audit at our local departmental audit meeting, the following recommendations were made:
1. Introduction of a specialised TURBT operation note proforma (Figure 1).
2. Separate sampling of the base of all new bladder tumours. This may be with a cold-cup forcep or loop biopsy
3. Posters in and around urology theatres to act as visual reminders.
4. Involvement of urology theatre staff in encouraging urologists to sample base separately and use specialised operation note.
5. Surgeon education regarding the importance of accurate staging and use of new operation note proforma.

RE-AUDIT RESULTS and CONCLUSIONS
A re-audit is currently in progress using the same methodology as the initial audit. Thus far, this has demonstrated an increase in the presence of muscle on histology from 53% to 71% (n=17/24). Of these 24 patients, 13 had the base of their tumour sampled separately. In these 13 patients, 87% had muscle on histology.

Use of a specialised TURBT operation note has increased the documentation of number of tumours, the diameter of the largest tumour, whether the base was sampled separately and whether resection was complete. Where the previous audit showed no single operation note with these findings documented, the re-audit has demonstrated compliance in 92%.
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