Highlights
The RESECT trial represents the largest global effort to date to standardize and improve the quality of transurethral resection of bladder tumour (TURBT) through implementation science. Key highlights include:
- Audit, feedback, and education significantly improved the documentation of tumour features and resection completeness.
- The intervention did not yield statistically significant improvements in technical surgical performance, specifically detrusor muscle sampling.
- Adherence to guidelines regarding single-instillation chemotherapy (SI) remained unchanged despite the intervention.
- Early recurrence rates were not reduced by the intervention, highlighting a persistent gap between administrative documentation and clinical efficacy.
Background: The Challenge of Quality in TURBT
Non-muscle-invasive bladder cancer (NMIBC) is a heterogeneous disease with a high propensity for recurrence and progression. The cornerstone of management is the transurethral resection of bladder tumour (TURBT). However, the quality of TURBT is notoriously variable across different surgeons and institutions. Suboptimal resection leads to incomplete staging, missed tumours, and higher recurrence rates, necessitating more frequent surveillance and increasing the economic burden on healthcare systems.
Clinical guidelines emphasize several quality indicators for TURBT: the presence of detrusor muscle in the specimen (to ensure adequate depth), the use of single-instillation postoperative chemotherapy (to reduce cell seeding), and meticulous documentation of tumour characteristics. Despite these clear benchmarks, real-world adherence remains inconsistent. The RESECT trial was designed to test whether a structured program of audit and feedback (A&F)—a strategy often successful in other medical fields—could bridge the gap between guideline recommendations and surgical practice in urology.
Study Design and Methodology
The RESECT trial was a pragmatic, cluster randomized controlled trial conducted across 201 sites globally. Sites were randomized to either the intervention arm (100 sites) or the control arm (101 sites). The study included a staggering 14,915 patients, making it one of the largest surgical quality improvement trials in the field of urology.
The intervention consisted of a multifaceted approach: audit and feedback (providing surgeons with data on their own performance), peer comparison (showing how they rank against colleagues), and targeted education. The control arm received audit alone, where data was collected but no active feedback or educational intervention was provided during the study period.
The investigators established four coprimary outcomes to measure surgical quality:
1. Single-instillation chemotherapy (SI)
The administration of intravesical chemotherapy within 24 hours of resection for low- or intermediate-risk tumours.
2. Detrusor muscle sampling
The presence of muscle in the histological specimen, which serves as a surrogate for the depth and adequacy of the resection.
3. Documentation of tumour features
The recording of essential parameters such as tumour size, number, and morphology in the operative note.
4. Resection completeness
Clear documentation of whether all visible tumours were successfully removed.
The secondary outcome was the rate of early recurrence, defined as the presence of tumour at the first follow-up cystoscopy.
Key Findings: Documentation vs. Performance
The results of the RESECT trial present a nuanced picture of how surgeons respond to feedback. The most significant impact was observed in the administrative aspects of surgical care.
Significant Gains in Documentation
Intervention sites showed a statistically significant improvement in the documentation of tumour features. The adjusted mean difference was 6.0 (95% CI: 1.8, 10, p = 0.005). Similarly, the documentation of resection completeness improved by 5.5 (95% CI: 1.5, 9.5, p = 0.007). These findings suggest that when surgeons are made aware that their notes are being audited and compared to peers, they become more diligent in recording the details of the procedure.
The Performance Gap: Muscle Sampling and Chemotherapy
In contrast to the documentation gains, the intervention failed to move the needle on technical or procedural outcomes. There was no statistically significant difference in the performance of detrusor muscle sampling (adjusted mean difference: 2.6, 95% CI: -1.3, 6.4, p = 0.2). This is a critical finding, as the presence of detrusor muscle is a primary indicator of a high-quality, staging-competent resection.
Furthermore, the use of single-instillation chemotherapy remained stagnant (adjusted mean difference: 0.3, 95% CI: -4.7, 5.3, p = 0.9). This lack of change may reflect systemic or logistical barriers—such as pharmacy availability or nursing protocols—that are not easily overcome by surgeon-directed feedback alone.
Recurrence Rates and the Control Arm Phenomenon
Perhaps the most disappointing result was the lack of impact on early recurrence rates. The adjusted odds ratio was 1.02 (95% CI: 0.8, 1.4, p = 0.9), indicating no difference between the intervention and control arms. Interestingly, the early recurrence rate in the control arm actually reduced compared with the baseline period (adjusted odds ratio: 0.7, 95% CI: 0.6, 0.9). This suggests a secular trend or a ‘Hawthorne effect,’ where the mere act of participating in a study and knowing that outcomes are being recorded leads to improvement across all participants, regardless of the intervention.
Expert Commentary: Why Did the Intervention Fall Short?
The RESECT trial provides a masterclass in the complexities of implementation science. Experts suggest several reasons for the discrepancy between documentation and clinical performance. First, documentation is a cognitive task that requires minimal physical change. Improving the quality of an operative note is relatively simple compared to changing the physical maneuvers of a TURBT to ensure muscle sampling without increasing perforation risk.
Second, the “feedback” provided might not have been frequent or granular enough to drive technical skill acquisition. While surgeons may have been told their muscle sampling rates were low, they were not necessarily given intraoperative coaching or simulation training to improve that specific skill.
Third, the improvement in the control group is a significant finding. It suggests that the urological community is already moving toward better standards, or that the simple awareness of being monitored is as powerful as a structured feedback program. This raises questions about the cost-effectiveness of complex A&F programs if simple data collection achieves similar results.
Study limitations include the pragmatic nature of the trial, which allowed for variation in how feedback was delivered across different sites. Additionally, the follow-up period for recurrence was relatively short, and longer-term data might be needed to see the full impact of improved surgical diligence.
Conclusion and Clinical Implications
The RESECT trial demonstrates that while audit, feedback, and education are effective tools for improving the quality of clinical documentation, they are insufficient on their own to change complex surgical behaviors or improve oncological outcomes like recurrence rates. For clinicians and hospital administrators, the takeaway is clear: documentation is the first step, but not the final goal.
To truly improve NMIBC outcomes, future interventions may need to focus on intraoperative technologies (such as blue-light cystoscopy or en-bloc resection techniques) and systemic changes that facilitate guideline-adherent care, such as automated chemotherapy ordering systems. The RESECT study sets a new benchmark for global collaborative research in urology, proving that large-scale surgical trials are feasible and essential for evaluating the real-world impact of our quality improvement efforts.
References
- Gallagher K, et al. RESECT: A Randomised Controlled Trial of Audit and Feedback in Non-muscle-invasive Bladder Cancer Surgery. Eur Urol. 2025. doi: 10.1016/j.eururo.2025.09.4174.
- Babjuk M, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS). European Association of Urology Guidelines. 2024.
- Ivers N, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012.
