Bladder Cancer

Enhanced Quality and Effectiveness of Transurethral Resection of Bladder Tumour in Non–muscle-invasive Bladder Cancer: A Multicentre Real-world Experience from Scotland’s Quality Performance Indicators Programme

Background: Clinical outcomes from non–muscle-invasive bladder cancer (NMIBC) are partly determined by the quality of initial interventions. To improve and standardise treatment for cancer, Scotland implemented a national Quality Performance Indicator (QPI) programme for bladder cancer (BC).

Objective: To evaluate compliance with specific quality indicators (QIs) related to transurethral resection of bladder tumour (TURBT) and to understand clinical outcomes from NMIBC following the introduction of the QPI programme.

Design, setting, and participants: Within a robust governance framework, 12 mandatory evidence-based QPIs were implemented nationally in April 2014. We report prospectively collected data for all new BC patients (between April 2014 and March 2017). We include follow-up data for 2689 (63%) patients.

Intervention: The TURBT-related QPIs were (1) using a bladder diagram, (2) single post-TURBT instillation of mitomycin C (SPI-MMC), (3) detrusor muscle (DM) in the specimen, and (4) early re-TURBT in high-risk NMIBC.

Outcome measurements and statistical analysis: We measured compliance with these QPIs and (1) recurrence rate at first follow-up cystoscopy (RRFFC), (2) rates of residual cancer, and (3) pT2 cancer at re-TURBT. Associations between QPI compliance, tumour features, and outcomes were assessed with multivariable logistic regression models.

Results and limitations: Among 4246 new BC patients, SPI-MMC was used in 67% (2029/3023) NMIBC patients. In 1860 NMIBC patients undergoing TURBT, RRFFC, rate of residual cancer, and rate of pT2 at re-TURBT were 13% (116/888), 33% (212/653), and 2.9% (19/653), respectively. SPI-MMC was associated with lower RRFFC, independent of all variables including hospital volume and surgeon. Presence of DM in the specimen halved the likelihood of residual disease in pT1 cancers. The main limitation is the lack of a pre-QPI introduction cohort for comparison.

Conclusions: The implementation of a QI programme in Scotland appears to facilitate high-quality TURBT, which in a real-world setting is associated with low early recurrence/residual cancer and accurate pathological staging.

Patient summary: Following the first 3 yr of implementing a novel Quality Performance Indicator (QPI) programme in Scotland, we assessed compliance and outcomes in non–muscle-invasive bladder cancer. Evaluating over 4000 new bladder cancer patients, we found that the QPI programme was associated with low recurrence and accurate staging following the initial transurethral resection of bladder tumour.

Authors: Paramananthan Mariappan, Allan Johnston, Luisa Padovani, Eilidh Clark, Matthew Trail, Sami Hamid, Graham Hollins, Helen Simpson, Benjamin G. Thomas, Rami Hasan, Jaimin Bhatt, Imran Ahmad, Ghulam M. Nandwani. Ian D.C. Mitchell, David Hendry, for members of the Scottish Bladder Cancer QPI Research Collaborative

Author Affiliations: Department of Urology, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh; Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK; Edinburgh Bladder Cancer Surgery, Department of Urology, Western General Hospital, Edinburgh, UK; University of Edinburgh, Edinburgh, UK; Department of Urology, Ninewells Hospital, Dundee, UK; Department of Urology, Ninewells Hospital, Dundee, UK; Department of Urology, Victoria Hospital, Kirkcaldy, UK; Edinburgh Bladder Cancer Surgery, Department of Urology, Western General Hospital, Edinburgh, UK, Department of Urology, Borders General Hospital, Melrose, UK; Department of Urology, University Hospital Ayr, Ayr, UK; Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK; Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK; Department of Urology, Ninewells Hospital, Dundee, UK; Department of Urology, Victoria Hospital, Kirkcaldy, UK; Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK

Source: Mariappan P, Johnston A, Padovani L, et al. "Enhanced Quality and Effectiveness of Transurethral Resection of Bladder Tumour in Non-muscle-invasive Bladder Cancer: A Multicentre Real-world Experience from Scotland's Quality Performance Indicators Programme." Eur Urol. July 17 2020. doi: https://doi.org/10.1016/j.eururo.2020.06.051

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