Improving practice patterns in patients with newly diagnosed bladder masses treated with transurethral resection

Abstract

Transurethral resection (TUR) is the mainstay for diagnosis, staging, and treatment of both high-grade and low-grade nonmuscle invasive bladder cancer (NMIBC). It is reported that 51% of initial transurethral resection of bladder tumors (iTURBT) does not contain muscle, which results in higher rates of clinical upstaging on repeat transurethral resection (reTUR) and worse oncologic outcomes. Presence of muscle on iTURBT specimen and performing reTUR within 6weeks in high-risk NMIBC aids in accurate staging and, therefore, guides proper treatment. This study aimed to assess and improve TURBT quality by making surgeons aware of their practice patterns and setting improvement goals. Patients who received TURBT for a newly diagnosed bladder mass were analyzed by retrospective chart review for 9months prior to quality improvement (QI) intervention. Data were collected pertaining to muscle presence/absence on biopsy, pathology of the tumor, risk stratification, whether reTUR was indicated, and time to reTUR. The primary endpoints were the presence of muscle on initial TURBT, whether a reTUR was performed when clinically indicated, and time to reTUR. Tumors requiring reTUR were defined as being HGT1 or HGTa >3cm. The QI intervention, physician education, was then implemented by presenting initial performance results to the physicians, and a second dataset was then collected by prospective analysis for another 9months to assess for changes in practice patterns. A total of 101 patients receiving TURBT were reviewed, including 52 patients prior to and 49 patients following QI intervention. Patients with a history of, or treatment for, bladder cancer were excluded, along withthose without assessment of muscle on pathological analysis. Fisher's exact test was utilized to determine differences in categorical data by comparing each of the following groups prior to and following QI intervention: percent of muscle presence on iTURBT, percent reTUR performed when indicated, and mean time to reTUR in days. A p<0.05 was considered statistically significant. After comparing the TURBT results before and after our QI intervention, we found a significant improvement in the number of patients receiving a reTUR when indicated, with 5/13 (38.5%) before compared to 15/19 (78.9%) after, p=0.03. The number of specimens on iTURBT with muscle present were not significantly different, with 38/52 (73.1%) before and 33/49 (67.3%) after, p=0.66. The average time to reTUR before (32.4days; n=5; range, 21-50days) and after (42.4days; n=15; range, 11-77days) QI intervention was also not significantly different, p=0.28. Our data suggest that critical analysis of physician practice patterns followed by education and setting improvement goals can significantly impact clinical practices and improve quality of care. Future studies will be performed to determine the impact that these changes have on oncologic outcomes.