title: Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience.
abstract: BACKGROUND
  An European Organisation for Research and Treatment of Cancer analysis of multicentre trials found significant interinstitutional variability in recurrence rates at first follow-up cystoscopy (RR-FFC) and attributed this to variable transurethral resection of bladder tumour (TURBT) quality.
  
  
  OBJECTIVE
  To determine whether resection of detrusor muscle (DM) in the first, apparently complete TURBT is a surrogate marker of quality and whether the presence of DM is dependent on a surgeon's experience.
  
  
  METHODS
  Over a 2-yr period, patients with new bladder tumours that were judged to have been completely resected were recruited from our prospectively maintained bladder tumour database. Strict exclusion criteria were applied.
  
  
  METHODS
  Prospectively recorded tumour size, tumour multiplicity, surgeon category, DM status, grade and stage of tumour, and findings at first follow-up cystoscopy (at 3 mo) and at early re-TURBT were evaluated. Surgeons were stratified into seniors (consultants and year 5 or year 6 trainees) and juniors (trainees lower than year 5). Early recurrence (for calculating RR-FFC) was defined as pathologically confirmed tumour on early re-TURBT or recurrence at the first follow-up cystoscopy. Logistic regression multivariate analyses were carried out to determine associations between variables.
  
  
  CONCLUSIONS
  In a total of 356 patients, DM was present in 241 patients (67.7%). Multivariate analyses revealed that large tumours, high-grade tumours, and surgery by senior surgeons was independently associated with the presence of DM in the resected specimens. The RR-FFCs when DM was absent and present were 44.4% and 21.7%, respectively (odds ratio: 2.9; 95% confidence interval: 1.6-5.4; p=0.0002). The absence of DM and resection by less experienced surgeons independently predicted a higher RR-FFC. This association was also seen in small and low-grade tumours. The number of patients in this study appears modest, and further validation may be required.
  
  
  CONCLUSIONS
  DM absence or presence in the first, apparently complete TURBT specimen appears to be a surrogate marker of resection quality by independently predicting the RR-FFC, which is also dependent on surgeon experience.
authors.affiliation: Department of Urology, Western General Hospital, Edinburgh, United Kingdom.
authors.forename: Paramananthan
authors.initials: P
authors.lastname: Mariappan
authors.forename: Alexandra
authors.initials: A
authors.lastname: Zachou
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Grigor
mesh_terms: D000368:Aged; D015415:Biomarkers; D002983:Clinical Competence; D015653:Cystectomy / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D009130:Muscle, Smooth / Q000601:surgery; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011786:Quality Control; D018570:Risk Assessment; D013997:Time Factors; D014521:Urethra; D001749:Urinary Bladder Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*
chemical_list: D015415:Biomarkers