Improving bladder tumor resection documentation using a closed-loop audit approach: a scalable quality improvement model from a resource-limited setting (Pakistan)

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Abstract Objective Transurethral resection of bladder tumor is the initiation of bladder cancer management, yet its quality often varies. Incomplete resections and inadequate documentation remain a challenge in making optimal treatment decisions. The European Association of Urology sets standards for high-quality procedures that can aid diagnosis and prognosis. This study reports a 4-year closed-loop audit that used a targeted approach to enhance TURBT practice and reporting in a developing world hospital. Methods We reviewed primary bladder tumor resection procedures during July–December 2020 (Cycle 1, n = 52) and July–December 2024 (Cycle 2, n = 55) that were done in one of the largest tertiary care hospitals of Pakistan. Following Cycle 1, interventions included structured operative templates and mandatory bladder diagrams. Compliance with the guidelines was compared across both the cycles. Results Documentation of tumor size improved from 44% to 76% (P = .001), and inclusion of bladder diagrams in operative notes increased from 92% to 98%. The presence of detrusor muscle in resected specimens rose from 83% to 95%. Histopathology reporting showed significant improvements in documenting Tumor stage, lamina propria status, and muscle presence. Areas requiring further quality improvement included the documentation of carcinoma in situ. Implications The use of structured operative templates and standardized reporting significantly enhances adherence to TURBT quality indicators. Closed-loop audit methodology provides a practical and low-cost strategy to improve surgical documentation and specimen quality in resource-limited settings. Conclusion This closed-loop audit with structured operative and histopathology templates improved adherence to TURBT quality indicators over a 4-year period in a tertiary care center.

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