The goal of our study, we retrospectively compared the results of patients undergoing transurethral resection of bladder tumor (TURBT) performed by supervised residents versus attendings. This study is a subanalysis of a prospective, randomized trial enrolling patients diagnosed with BC and undergoing endoscopic intervention. The trial (NCT04712201) was approved by the Institutional Review Board (2017/09c). Surgeons were either urology attendings or supervised residents of the 3rd-5th year.1
The analysis showed no difference in terms of intra (perforation, intraoperative complications) and post-operative (irrigation, catheterization, hospital stay, and post-operative complications) outcomes, as well as in the histopathological analysis of the specimen (presence of detrusor muscle and staging) between attending urologists and supervised residents.
Our results showed that, when adequately supervised, urology residents did not expose patients to an increased risk of complications nor perform a suboptimal procedure. These findings emphasize that residents are not dangerous, but a proper mentorship is essential to ensure optimal and comparable outcomes. However, conventional TURBT training programs, such as the one described in our study, present several limitations. The lack of a standardized teaching methodology and a certification of proficiency gives space to unreliability
To address these limitations, our group initiated the European Training in Urology (ENTRY) project, a collaborative effort between Humanitas University, ORSI Academy, and Fundació Puigvert, aimed at establishing a standardized training pathway for European urology residents in minimally invasive procedures. The ENTRY curriculum for TURBT aims to design a curriculum consisting of three structured and quality-assured phases: an e-learning, simulation, and intraoperative training. To further enhance the standardization of training, the ENTRY curriculum incorporated the Proficiency-Based Progression (PBP) methodology, as extensively proven to improve training quality.2
Paciotti et al. described the results from an international consensus panel to define and validate objective performance metrics for TURBT through a modified Delphi consensus of experts. The expert meeting reached consensus on the index patient (male patient undergoing an elective TURBT with less than 3 tumors, each under less than 3 cm) and defined the procedure in 6 phases, 63 steps, 47 errors, and 41 critical errors.3
Subsequently, during the 2025 EAU Congress, our group presented the construct and discriminative validity study of the TURBT performance metrics. Thirty anonymized procedures by novice and expert surgeons were assessed by trained evaluators employing the validated metrics. The videos were anonymized, and the assessors were blinded to the performing surgeon, hospital, and expertise. The study showed a statistically significant difference in TURBT performance between novices and experts in both step completion and errors/critical errors. This result was confirmed even comparing an expert urologist performing a high number of errors compared to novices performing a low number of errors. These results support the ability of these metrics to reliably discriminate experts from novices and differentiate performance levels within a group of surgeons with similar experience, denoting high sensitivity and specificity.4
In conclusion, our study highlights the optimal performance of residents if correctly trained and mentored and the importance of mentorship in surgical training. Furthermore, it underlines the importance of a standardized quality-assured training curriculum that is becoming fundamental in today’s clinical and surgical practice, even in what are considered trivial procedures such as TURBTs. Initiatives like the ENTRY project offer a more comprehensive and scientifically validated approach that hopefully will be implemented in the real-world training of urology residents.
Written by: Laura Mas Grilló, Pietro Diana, Andrea Gallioli, and Alberto Breda
- Department of Urology, Fundació Puigvert, Barcelona, Spain.
- Department of Surgery, Autonomous University of Barcelona, Bellaterra, Spain.
- Diana P, Gallioli A, Uleri A, Mas L, Pujol R, Territo A, et al. Attendings versus supervised residents: Educational results and future perspective in transurethral resection of bladder tumors. Actas Urológicas Españolas (English Edition). 2025 Aug;501830.
- Buffi N, Paciotti M, Gallagher AG, Diana P, De Groote R, Lughezzani G, et al. European training in urology (ENTRY): quality-assured training for European urology residents. Vol. 131, BJU International. 2023. p. 177–8.
- Paciotti M, Diana P, Gallioli A, De Groote R, Farinha R, Ficarra V, et al. International consensus panel for transurethral resection of bladder tumours metrics: assessment of face and content validity. BJU Int. 2024 Dec 1;134(6):932–8.
- Diana P, Paciotti M, Frego N, Gallioli A, Di Bello F, Arena P, et al. Intraoperative skills for transurethral resection of bladder tumor: objective assessment and construct validity of the ENTRY project [abstract]. Presented at: 40th Annual Congress of the European Association of Urology (EAU); 2025 Mar 21–24; Madrid, Spain.