AUA 2019: Crowdsourcing: Transurethral Resection of Bladder Tumor
Dr. Khurshid Ghani, who moderated this session, began by introducing the tool being used by the Michigan Urological Surgery Improvement Collaborative (MUSIC) group for video review and feedback of surgical procedures. With this tool, anonymized 1-minute clips of surgical procedures are reviewed on a number of separate metrics on a 1-5 scale. For this session, the experts on the panel and the audience were invited to review 3 videos on 1) application of systematic and prioritized strategy in tumor approach 2) adequacy of depth and length of TUR strokes and 3) speed and progression of tumor resection.
Between each video, the experts gave a brief presentation on surgical technique of TURBT which was loosely based on the video. After the first video, clearly a more novice resectionist who earned mostly 2s and 3s, Dr. Martha Terris reviewed some basic surgical techniques of TURBT. Her review of positioning included the association of the various nerves with maneuvers that can cause their injury: calf pressure causing peroneal nerve damage and foot drop, hyperflexion of thighs causing femoral nerve strain, hyperabduction and flexion of the thighs causing sciatic nerve damage, and direct pressure causing injury to the nerves of the foot. She also reviewed techniques for avoiding obturator nerve stimulation: using bipolar or cold cup over monopolar resection, decreasing energy, minimizing hip abduction, using shorter swipes, and changing the placement of the grounding pad, to which I would add minimizing over-distension of the bladder.
Following the second video, a more experienced resectionist who earned mostly 4s and 5s, Dr. Cheryl Lee gave a more detailed breakdown focused more specifically on the particular video. She praised the surgeon’s choice of bipolar cautery, which is known to decrease cautery artifact in the pathology specimen, his maintenance of constant bladder volume using a moderate speed of irrigation, his care at testing the loop mechanics before beginning, and his assessment of the tumor characteristics with blunt probing prior to cautery activation. However, she stressed that even in small tumors, she prefers to send the base separately to increase the efficiency of assessment for muscle.
The third video was by far the most controversial. This video showed an en bloc resection of a moderately sized posterior wall tumor. The histogram of audience votes was essentially flat, showing nearly the same number of 1s, 2s, 3s, and 4s with slightly fewer 5s across all characteristics. Even Dr. Mark Solloway himself admitted that he dramatically changed his scores after realizing on his second viewing that he was seeing an en bloc resection and not a very strange standard TURBT. He briefly reviewed the data supporting the safety and efficacy of this approach, citing a meta-analyses of tumors <4cm showing 96% of en bloc specimens with muscle in the specimen, 4% overall complication rate, and 1% risk of significant bleeding or perforation as well as similar oncologic outcomes to standard TURBT. He then spoke more generally about the need to sample detrusor muscle: not in low grade disease or high grade Ta if there is adequate lamina propria, but yes otherwise. He also revisited the topic of office fulguration for low grade Ta, a favorite topic of his as he has demonstrated substantial decrease in cost to the patient, clinician, and health system with this technique.
This systematic, video-based approach to improving surgical technique is another exciting innovation to come out of MUSIC, and this session clearly demonstrated its value in generating discussion. The mixed ratings of the en bloc resection was an excellent illustration of the limitations of this technique, however, as it clearly demonstrated how the value of this review depends on the reviewers having an understanding of what the optimal surgical technique actually is.
Moderated by: Khurshid Ghani, MD, University of Michigan
Panelists: Cheryl Lee, MD. Dorothy M. Davis Professor of Urology, The Ohio State University, Martha Terris, MD. Chair and Residency Program Director, Medical College of Georgia, Mark Soloway, MD. Department Head, Memorial Hospital, Hollywood, FL
Written by: Marshall Strother, MD, Chief Resident, Division of Urology, University of Pennsylvania, Philadelphia PA at the 2019 AUA Annual Meeting - May 3-6, 2019 - Chicago, IL