Guerero Daniel N, Bruce Angus, Vayalapra Sushanth, Menon Vishnu, El Hadi Mohammed, Khashaba Shehab
Trauma and Orthopaedics, Russells Hall Hospital, Dudley, GBR.
Urology, Sandwell and West Birmingham NHS Trust, Birmingham, GBR.
Cureus. 2022 Oct 10;14(10):e30131. doi: 10.7759/cureus.30131. eCollection 2022 Oct.
Background The European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration. Aim To assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines. Methods Operative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements. Results TURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42). Conclusion The operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation.
背景 欧洲泌尿外科学会（EAU）建议，膀胱癌成功且恰当管理所需的手术步骤及记录包括确定疾病风险分层、临床分期、切除充分性、并发症情况以及即刻膀胱内化疗给药等必要因素。目的 根据EAU 2022指南，评估并提高英国一家地区综合医院目前膀胱肿瘤经尿道切除术（TURBT）记录的充分性。方法 对为期一年的手术记录进行评估，看是否包含EAU指南所概述的实现全面TURBT的关键步骤。结果包括手术发现和干预细节以及围手术期评估的记录。创建了TURBT程序的标准化模板，并对手术人员进行了使用培训。六个月后重复进行审核以评估改进情况。结果 将第一个周期的78例TURBT记录与第二个周期的37例记录进行比较。结果显示，肿瘤大小记录（从46%提高到89%；p<0.05）、肿瘤描述（从59%提高到89%；p<0.05）、切除深度（从36%提高到89%；p<0.05）、化疗给药（从21%提高到46%；p<0.05）以及穿孔评估（从22%提高到68%；p=0.001）均有显著改善。麻醉下术前和术后检查率的提高也具有统计学意义（分别从47%和14%提高到89%；p<0.05）。切除完整性的记录有所增加，但未达到统计学意义（从59%提高到68%；p=0.42）。结论 手术记录模板使记录得到改善，提高了接受TURBT患者膀胱癌的风险分层。所有常见手术均应采用特定手术的手术记录模板，以提高记录的完整性。
