We aimed to determine whether audit, feedback, and education improves surgical performance after transurethral resection of bladder tumour surgery for non–muscle-invasive bladder cancer and as a secondary aim if it reduced recurrence rates.
This cluster randomised controlled trial compared audit and feedback plus peer comparison and education, with audit alone for four coprimary outcomes: (1) Single-instillation chemotherapy, (2) detrusor muscle sampling, (3) documentation of tumour features, and (4) resection completeness. Early recurrence was a secondary outcome.
A total of 100 sites were randomised to intervention and 101 to control. In total, 14 915 patients were included. Intervention sites significantly improved documentation of tumour features (adjusted mean difference [95% confidence interval {CI}]: 6.0 [1.8, 10], p = 0.005) and of resection completeness (adjusted mean difference [95% CI]: 5.5 [1.5, 9.5], p = 0.007). There was no statistically significant difference in chemotherapy use (adjusted mean difference [95% CI]: 0.3 [–4.7, 5.3], p = 0.9) or detrusor muscle sampling (adjusted mean difference [95% CI]: 2.6 [–1.3, 6.4], p = 0.2). There was no statistically significant difference in early recurrence rate between arms (adjusted odds ratio [95% CI]: 1.02 [0.8, 1.4], p = 0.9); however, in the control arm, the early recurrence rate reduced compared with baseline (adjusted odds ratio [95% CI]: 0.7 [0.6, 0.9]).
Audit and feedback with education improved the documentation of important surgical findings that influence clinical management, but not the performance of detrusor muscle sampling, adjuvant chemotherapy use, or early recurrence rates. Improvements observed in the control arm may explain a lack of effect of the intervention in some outcomes.
Raising the bar for TURBT quality: Insights from the RESECT trial
Commentary by Dr. Elisabeth Grobet-Jeandin
Although it has been referred to as “the neglected procedure” [1], transurethral resection of bladder tumour (TURBT) remains the cornerstone of diagnosis and initial management in non-muscle-invasive bladder cancer (NMIBC). Current European Association of Urology (EAU) Guidelines strongly recommend adherence to multiple quality determinants for TURBT [2], however real-world practice remains highly heterogeneous, both in the technical execution and in its documentation. While the positive impact of high-quality TURBT on oncological outcomes is beyond dispute, the most effective strategies to improve the quality of TURBT remain unclear. The RESECT trial [3] aimed to address this gap by evaluating whether structured audit, feedback and education could reduce variation and enhance adherence to guidelines, potentially improving TURBT quality at scale.
Conducted between 2021 and 2023, the RESECT trial is a large international cluster-randomised trial, which enrolled nearly 15,000 patients treated across 200 centres, predominantly academic (68%). Investigators compared audit alone with audit combined with feedback, peer comparison, and educational support. Four co-primary outcomes were assessed: administration of single-instillation intravesical chemotherapy, detrusor muscle sampling, documentation of tumour features and resection completeness. Early recurrence was a secondary outcome.
Re-establishing education as a central component of high-quality surgical care, this study generated considerable enthusiasm within the urology community and yielded nuanced findings. The intervention significantly improved documentation of tumour characteristics and resection completeness, two key factors in therapeutic decision-making. In contrast, neither detrusor muscle sampling nor the use of adjuvant chemotherapy was improved. This discrepancy underscores a limitation of audit-and-feedback strategies: while they may effectively influence reporting behaviour, changes in technical performance and perioperative management seem harder to achieve and may require more intensive or multimodal approaches.
Interestingly, the control group also improved over baseline in all co-primary outcomes, except for detrusor muscle sampling. Furthermore, a reduction in early recurrence rate was detected in the audit-only group. Surgeons appear to perform better when aware that their practice is being watched and monitored. This highlights the powerful effect of audit itself, showing that systematic outcome measurement can drive behavioural changes even in the absence of additional interventions.
In conclusion, widely regarded as the most powerful tool for change, education is once again shown by the RESECT trial to be contributory to higher-quality surgical practice. At the same time, audit alone appears to contribute to improved outcomes. The key question remains: can the educational benefits highlighted in this study be implemented in clinical routine practice without the ever-watchful “Eye of Sauron”, or is universal audit necessary to ensure high-quality TURBT?
References
[1] Mostafid H, Babjuk M, Bochner B, Lerner SP, Witjes F, Palou J, et al. Transurethral Resection of Bladder Tumour: The Neglected Procedure in the Technology Race in Bladder Cancer. Eur Urol 2020;77:669–70. https://doi.org/10.1016/j.eururo.2020.03.005.
[2] Gontero P, Birtle A, Capoun O, Compérat E, Dominguez-Escrig JL, Liedberg F, et al. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ)-A Summary of the 2024 Guidelines Update. Eur Urol 2024;86:531–49. https://doi.org/10.1016/j.eururo.2024.07.027.
[3] Gallagher K, MacLennan S, Bhatt N, Clement K, Zimmermann E, Khadhouri S, et al. RESECT: A Randomised Controlled Trial of Audit and Feedback in Non-muscle-invasive Bladder Cancer Surgery. Eur Urol 2025:S0302-2838(25)04736-0. https://doi.org/10.1016/j.eururo.2025.09.4174.