Transurethral resection of bladder tumor (TURBT) is considered a trivial procedure, and it is usually performed by residents and young urologists. However, TURBT is a crucial step in the diagnosis and management of bladder cancer. A recent study comparing TURBT performances between residents and attendings showed that urology residents do not expose patients to an increased risk of complications nor perform a suboptimal procedure, if correctly supervised. This study emphasized that proper mentorship is essential to ensure optimal and comparable outcomes, but it does not provide any information about a specific, standardized, and reproducible TURBT training.
The ENTRY project is 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 enhance the standardization of training.
After validating objective TURBT performance metrics following a modified-Delphi international consensus, the next step is to evaluate whether these metrics can reliably discriminate between different levels of surgical expertise during real-world intraoperative performance. This study aimed to assess the reliability and construct validity (via known-group and convergent validity) of objective metrics for characterizing the intraoperative performance of TURBT as optimal versus suboptimal.
Thirty videos of TURBT performed by experts (n = 15) and novices (n = 15) were evaluated by three experienced urologists trained to reliably and independently score TURBT performance using the metrics previously developed. TURBT videos were included if they respected the index patient characteristics of the validation process: male patients presenting with a single lesion between 0.5 and 1.5cm in dimension located anywhere in the bladder. All patients had to undergo a full diagnostic work-up, including cystoscopy, cytology, and a CT scan. The videos were anonymized, and the assessors were blinded to the surgeon, hospital, and expertise. The inter-rater reliability score was assessed, and surgical errors were reported using a dummy dichotomous variable.
The median number of overall errors was 1 (interquartile range [IQR] 0-2) in the expert group versus 5 (IQR 4-7) in the novice group, with a median difference of -4 errors (95% confidence interval [CI] -5 to -3; p = 0.001). The median number of noncritical errors per TURBT procedure was 1 (IQR 0-2) in the expert group versus 3 (IQR 2-4) in the novice group, with a median difference of -2 errors (95% CI -3 to -1; p = 0.001). The median number of critical errors was 0 (IQR 0-1) for the expert group versus 2 (IQR 2-3) for the novice group, with a median difference of -2 errors (95% CI -3 to -1; p = 0.001).
These metrics could reliably distinguish Novice and Experienced surgeon performances, highlighting a substantial performance gap between non-critical and critical error rates. This finding was further supported by the C-index (0.66 for overall errors, 95% CI: 0.58–0.74), confirming that in two-thirds of novice–expert pairs the expert committed fewer errors. Notably, the discriminative capacity was even stronger for critical errors (C-index 0.73 [95% CI: 0.63–0.81]). Specifically, this gap might potentially suggest the starting point to establish performance benchmarks (i.e., proficiency levels). This study now proved the known-group and convergent validity of our metrics, which now set a cornerstone for a quality-assured, structured, and standardized TURBT program following a PBP methodology for urology residents.
Although these metrics were developed for straightforward cases and despite the novice surgeons being required to complete the TURBT independently, a supervisor was present, this study reflects a real-training scenario where, initially, the resident would face forthright cases and a mentor should always be present.
To the best of our knowledge, this is the first report applying metrics that effectively objectively characterize intraoperative TURBT performance, reporting quantitative evidence to support construct validity.
Written by: 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, et al. Intraoperative Skills for Transurethral Resection of Bladder Tumor: Objective Assessment and Construct Validity of the ENTRY Metrics. Eur Urol Focus. 2025 Dec 17:S2405-4569(25)00357-8. doi: 10.1016/j.euf.2025.12.004.