Transurethral resection of bladder tumour: is day-case surgery appropriate?

Authors


Roger Kockelbergh, Department of Urology, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK.
e-mail: roger.kockelbergh@uhl-tr.nhs.uk

Abbreviations
TURBT

transurethral resection of bladder tumour.

INTRODUCTION

Transurethral resection of bladder tumour (TURBT) for bladder cancer is usually the first treatment in a disease requiring long-term endoscopic follow-up. The rate of recurrence determines the intensity and perhaps length of follow-up [1,2], and these factors determine the cost and morbidity of the follow-up. Surgery performed as a day case is preferred by patients and is cost-effective. Moving treatment to the day-case setting is one of the NHS Modernization Agency's 10 ‘top tips’. The NHS report [3] lists 25 procedures identified by the Audit Commission which should be administered more often as day-case surgery. One of these procedures is described as TURBT but in fact the report refers to the whole Office of Population and Census Survey procedure code of M42. TURBT is M42.1 and hence M42 includes cystodiathermy, with a rigid or flexible endoscope, and laser destruction of a bladder tumour. It has been suggested that 40% of such procedures may be delivered as a day case [4]. However, few would argue that this is appropriate for follow-up treatment, and delivery of the diagnostic TURBT as a day case requires further examination.

There are two aims of the diagnostic TURBT, to provide accurate staging of what may be unsuspected invasive disease, and to provide a low long-term recurrence rate. Adequate staging relies on the presence of muscle in the biopsy [5]; this is not always obtained, even at inpatient TURBT. In cases of pT1 disease where there is no muscle present, multidisciplinary teams often recommend a further resection. Day-case TURBT may be more conservative in both depth and extent, to try to get the patient home, and hence fewer biopsies may contain muscle. If this were required regularly then the total cost of treating such patients may be greater than for inpatient TURBT. There are no data available to show that day-case TURBT is an equivalent staging procedure or to show that it is cost-effective.

There are no adequate studies showing that day-case TURBT can be performed with a comparable recurrence rate to that of inpatient TURBT. Many studies have shown a substantial risk of residual tumour [5,6] at the first inpatient TURBT. The early recurrence rate for similar types of patients varies by 7-fold among hospitals [7], probably because of the residual tumour in many patients. That study suggests that the quality of surgery is very variable. Recurrence at the first cystoscopy is a strong predictor of the long-term recurrence rate [2]. These facts imply that the quality of surgery is an important factor influencing the long-term recurrence rate. If day-case TURBT is less extensive to facilitate patient discharge, then the early recurrence rate may increase. The cost of the first TURBT will be small compared to the cost of long-term follow-up and hence total cost may be greater for day-case TURBT. No studies have addressed this issue.

The diagnostic or primary TURBT is becoming an increasingly complex procedure, as there is mounting evidence that several interventions at the time of the first TURBT will reduce the long-term recurrence rate. These include the instillation of a single dose of chemotherapy [8], postoperative irrigation [9] and photodynamic diagnosis [10], which has also been shown to decrease the rate of residual tumour. To provide all of these in a day-case setting is difficult logistically, although it may be achieved in a 23-h stay. Omitting these treatments is likely to result in a higher recurrence rate and hence lower cost-effectiveness and patient acceptability.

Patients undergoing TURBT are often elderly, live alone or are unfit. In addition, many index tumours are large or multiple, while others may be surgically challenging due to difficult anatomy. These patients (a substantial proportion) are never likely to be suitable for day-case surgery. Day-case surgery is widely practised for procedures encompassed by the M42 code and both the NHS and private sector (Health Episode Statistics data from the National Cancer Services Analysis Team, and supplied by BUPA UK Membership from claims database) perform 19% and 15.5%, respectively, of TURBT (M42.1) as a day case. It is not clear whether these represent diagnostic TURBT or surgery for recurrence.

The widespread use of day-case TURBT is probably not justified until it has been shown to be equivalent to inpatient TURBT in terms of recurrence and staging accuracy. Inevitably there will be selection bias; larger and more multifocal tumours will not be offered day surgery, and hence either a carefully controlled audit or a randomized trial are required to confirm safety. This issue warrants debate amongst the urological community.

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