Early recurrence after primary TURBT for non-muscle-invasive bladder cancer in Iceland: the critical role of surgical quality

INTRODUCTION: Transurethral resection of bladder tumor (TURBT) is the standard treatment for non-muscle-invasive bladder cancer (NMIBC), but early recurrences remain frequent. The objective of this study was to standardize TURBT management at our institution through the implementation of a treatment protocol designed to reduce early recurrence after primary TURBT. MATERIAL AND METHODS: All patients with newly diagnosed NMIBC who underwent primary TURBT at Landspítali University Hospital between 2013-2015 (control) and 2017-2019 (intervention) were included. The treatment protocol restricted procedures to four surgeons, mandated blue-light cystoscopy, routine postoperative bladder irrigation, and guideline-based instillation therapy. The primary endpoint was recurrence rate at first follow-up cystoscopy; secondary endpoints included adherence to protocol measures and recurrence-free survival. RESULTS: A total of 133 control and 138 intervention patients were included. Baseline characteristics were comparable. After implementation, bladder irrigation increased from 46 to 90%, blue-light cystoscopy was used in 59% of intervention cases, and instillation therapy rates rose (Mitomycin-C: 0-49% in intermediate-risk; Bacillus Calmette-Guérin (BCG):35-63% in high-risk patients). Early recurrence rates remained comparable (15% vs. 16%). Early recurrence varied markedly between surgeons (11-40%) and correlated strongly with detrusor muscle presence. No significant difference in recurrence-free survival was observed, though a trend toward lower recurrence was seen in the intervention group after adjusting for risk factors. CONCLUSION: Implementation of a standardized TURBT protocol improved adherence to recommended measures but did not reduce early recurrence. Marked inter-surgeon variability highlights surgical quality as the key determinant of early recurrence in non-muscle-invasive bladder cancer.