Transurethral resection of bladder tumor: A systematic review of simulator-based training courses and curricula

Objective

Transurethral resection of bladder tumor is one of the most common everyday urological procedures. This kind of surgery demands a set of skills that need training and experience. In this review, we aimed to investigate the current literature to find out if simulators, phantoms, and other training models could be used as a tool for teaching urologists.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the recommendations of the European Association of Urology guidelines for conducting systematic reviews. Fifteen out of 932 studies met our inclusion criteria and are presented in the current review.

Results

The UroTrainer (Karl Storz GmbH, Tuttlingen, Germany), a virtual reality training simulator, achieved positive feedback and an excellent face and construct validity by the participants. The inspection of bladder mucosa, blood loss, tumor resection, and procedural time was improved after the training, especially for inexperienced urologists and medical students. The construct validity of UroSim® (VirtaMed, Zurich, Switzerland) was established. SIMBLA simulator (Samed GmbH, Dresden, Germany) was found to be a realistic and useful tool by experts and urologists with intermediate experience. The test objective competency model based on SIMBLA simulator could be used for evaluating urologists. The porcine model of the Asian Urological Surgery Training and Education Group also received positive feedback by the participants that tried it. The Simulation and Technology Enhanced Learning Initiative Project had an extraordinary face and content validity, and 60% of participants would like to use the simulators in the future. The 5-day multimodal training curriculum "Boot Camp" in the United Kingdom achieved an increase of the level of confidence of the participants that lasted months after the project.

Conclusion

Simulators and courses or curricula based on a simulator training could be a valuable learning tool for any surgeon, and there is no doubt that they should be a part of every urologist's technical education.

Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT

BACKGROUND

Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence.

OBJECTIVE

The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour.

DESIGN

This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex.

SETTING

The setting was 22 NHS hospitals.

PARTICIPANTS

Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible.

INTERVENTIONS

Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour.

MAIN OUTCOME MEASURES

The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years.

RESULTS

We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds.

LIMITATIONS

Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power.

CONCLUSIONS

Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer.

FUTURE WORK

Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers.

TRIAL REGISTRATION

This trial is registered as ISRCTN84013636.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.

[Impact of simulation-based training in endourology: A systematic review of the literature]

INTRODUCTION

The impact of simulation on the acquisition of surgical skills as well as their transfer to the operating room is still debated. The objective was to assess these two specific points, focusing on the field of endourology.

METHODS

A systematic review of the literature, following the PRIMA statement, was performed using Medline database through September 2021 without time limit. Studies focusing on the impact of simulators on the acquisition of surgical technical skills as well as their transfer to the operating room in the field of endourology were included. The endourological procedures were: cystoscopy, ureteroscopy, percutaneous nephrolithotomy, endoscopic treatment of benign prostatic hyperplasia, endoscopic bladder resection.

RESULTS

Among the 11,442 publications identified, fifty-two studies were included in the analysis. The majority reported an improvement in procedure time of the requested tasks and dexterity of participants, regardless of the type of simulator and procedure. The level of evidence of included studies was often low. Few studies evaluated the transfer of acquired skills from the simulator to the operating room.

CONCLUSION

This review showed the positive impact of simulation on the acquisition of technical skills in endourology. However, in order to include proficiency-based progression in the curriculum of trainees, some parameters such as the choice of reference simulators, choice of tasks, and method of validation of acquired skills must be validated in a consensual manner to offer a quality training.

Recurrence mechanisms of non-muscle-invasive bladder cancer - a clinical perspective

Non-muscle-invasive bladder cancer (NMIBC) is an early-stage cancer without invasion into the detrusor muscle layer. Transurethral resection of bladder tumour (TURBT) is a diagnostic and potentially curative procedure for NMIBC, but has some limitations, including difficulties in ascertaining complete tumour removal upon piecemeal resection and the possibility of tumour re-implantation after the procedure. The oncological control of NMIBC is far from satisfactory, with a 1-year recurrence rate of 15-61%, and a 5-year recurrence rate of 31-78%. Various recurrence mechanisms have been described for NMIBC, such as undetected tumours upon cystoscopy, incomplete resection during TURBT, tumour re-implantation after TURBT, drop metastasis from upper tract urothelial carcinoma and field change cancerization. Understanding the recurrence mechanisms from a clinical perspective has strong implications for the optimization of NMIBC oncological outcomes, as a cure for patients with NMIBC can only be achieved by tackling all possible recurrence mechanisms in a comprehensive manner.

Learning Curve of Botulinum Toxin Bladder Injection for the Treatment of Refractory Overactive Bladder

PURPOSE

Intradetrusor botulinum toxin injections is an established second-line treatment for patients with refractory overactive bladder syndrome (OAB). We aimed to evaluate the learning curve of intradetrusor injections with botulinum toxin for the treatment of refractory OAB.

PATIENTS AND METHODS

This retrospective study analyzed all women with idiopathic and refractory OAB who underwent botulinum toxin bladder injections performed by residents with no previous experience with operative cystoscopy under consultant supervision. Baseline International Consultation on Incontinence Questionnaire-Short Form questionnaire (ICIQ-SF) and Euroqol (EQ-5D) questionnaires were collected. Procedural data (operative time, number of valid injections, complications, subjective easiness, perceived tolerability) and patients' outcomes (Patients Global Impression of Improvement (PGI-I), ΔICIQ-SF, ΔEQ-5D, need for self intermittent catheterization, duration of efficacy) were considered as markers to evaluate learning curves for each resident.

RESULTS

Twenty-seven patients underwent intravesical injection of botulinum toxin performed by residents. Only a grade 1 Clavien-Dindo complication occurred, and none of the patients had urinary retention. PGI-I was very satisfactory, scoring 1.4 ± 0.9. Both ICIQ-SF and EQ-5D 2-2 were statistically improved (p < 0.00001 and p = 0.04, respectively). The mean duration of efficacy resulted to be 8.0±4.3 months. A positive effect of the learning curve was observed only for operative time, subjective easiness, and perceived tolerability.

CONCLUSION

Intradetrusor botulinum toxin injection for the treatment of refractory OAB is characterized by high efficacy and very low complications even at the very beginning of the learning curve when performed under proper mentorship.

Novel transurethral resection technologies and training modalities in the management of nonmuscle invasive bladder cancer: a comprehensive review

PURPOSE OF REVIEW

Conventional transurethral resection (TURBT) with tumor fragmentation is the primary step in the surgical treatment of nonmuscle invasive bladder cancer. Recently, new surgical techniques and training modalities have emerged with the aim to overcome short-comings of TURBT and improve oncologic outcomes. In this review, we provide a comprehensive update of recent techniques/techniques that aim to improve upon conventional TURBT and beyond.

RECENT FINDINGS

A systemic approach during conventional TURBT that features the use of a surgical checklist has been shown to improve recurrence-free survival. Several simulators have been developed and validated to provide additional training opportunities. However, transfer of improved simulator performance into real world surgery still requires validation. While there is no convincing data that demonstrate superior outcomes with bipolar TURBT, en-bloc resection already promises to offer lower rates of complications as well as potentially lower recurrence probabilities in select patients.

SUMMARY

TURBT remains the quintessential procedure for the diagnosis and treatment of bladder cancer. Urologists need to be aware of the importance and challenges of this procedure. Aside of embracing new resection techniques and a conceptual-systematic approach, training opportunities should be expanded upon to improve patient outcomes.

The Learning Curve for Transurethral Resection of Bladder Tumour: How Many is Enough to be Independent, Safe and Effective Surgeon?

OBJECTIVE

Transurethral resection of the bladder tumour (TURBT) is one the most common urological procedures. It is also one the fundamental surgeries performed by residents. The learning curve (LC) for TUR has never been analysed. The aim of the study was to analyse the learning curve of TURBT in a residency setting.

DESIGN, SETTING AND PARTICIPANTS

This retrospective multicentre analysis of prospectively maintained databases enrolled 993 consecutive TURBTs performed by 10 urology residents in 3 academic institutions. Study end-points were as follows: the absence of muscularis propria in a specimen, any intra- or postoperative surgical complication and 3-month recurrence-free survival.

RESULTS

With increasing experience, residents operated more complex cases defined by higher rate of large, multifocal or high-risk tumours. In the same time, surgery time, postoperative catheterization time and hospital stay became shorter. An improvement has been noticed regarding the muscularis propria sampling and 3-month recurrence-free survival, but not regarding the risk of surgical complications. Evident improvement in study end-points was noticed after 101 operations; surgeons achieved the best clinical outcomes after performing 170 procedures, whereas the poorest results for the first 45 operations.

CONCLUSIONS

TURBT has a flat LC with 100 cases being the absolute minimum for a resident in training to achieve acceptable oncological and surgical outcomes.

Current Educational Interventions for Improving Technical Skills of Urology Trainees in Endourological Procedures: A Systematic Review

Objective: Endourology continues to grow with the introduction of new technologies into clinical practice. Simulators and training models have been developed to improve comfort and proficiency in endoscopic procedures. The purpose of this systematic review was to examine the current educational interventions utilized to improve the performance of endourology trainees and to critically appraise the strengths and limitations of each. Methods: A search of the Ovid MEDLINE, EMBASE, PsycINFO, and the Cochrane Library databases was performed to identify literature focused on current educational interventions for improving technical skills of trainees in endourologic procedures. The Medical Education Research Study Quality Instrument (MERSQI) was used to evaluate the methodological quality of the abstracted articles. Results: Of the 2236 articles identified, 22 met the inclusion criteria. The types of educational interventions included: bench/wet lab models, virtual reality simulators, and instructional courses. Metrics used to quantify the impact of these interventions include global rating scales, Objective Structured Assessment of Technical Skills (OSATS) scores, and task-specific checklists. The setting of these evaluations comprises both virtual reality simulators and live surgery. Conclusions: In the surgical education literature, simulation-based training and assessment continues to play a prominent role in urologic training. The educational interventions highlighted in this review address various aspects of endourology, from stone management to transurethral resection. Additional work is needed to correlate technical performance in clinical and nonclinical settings with patient outcomes and develop a focused approach to nontechnical skill training.

Clinical evaluation of a device providing simultaneous white-light and fluorescence video streams as well as panoramic imaging during fluorescence assisted-transurethral resection of bladder cancer

The current clinical study is aimed at evaluating the clinical relevance of an innovative device (called CyPaM2 device) that for the first time provides urologists with (i) a panoramic image of the bladder inner wall within the surgery time, and with (ii) a simultaneous (bimodal) display of fluorescence and white-light video streams during the fluorescence assisted-transurethral resection of bladder cancers procedure. The clinical relevance of this CyPaM2 device was evaluated on 10 patients according to three criteria (image quality, fluorescent lesions detection relevance, and ergonomics) compared with a reference medical device. Innovative features displayed by the CyPaM2 device were evaluated without any possible comparison: (i) simultaneous bimodal display of white-light and fluorescence video streams, (ii) remote light control, and (iii) time delay for the panoramic image building. The results highlight the progress to achieve in order to obtain a fully mature device ready for commercialization and the relevance of the innovative features proposed by the CyPaM2 device confirming their interest.

Transurethral resection of bladder tumours: established and new methods of tumour visualisation

Transurethral resection (TUR) of bladder tumours does not only serve diagnostic purposes by securing histological proof of the disease but might also resemble the final therapy. During recent years, technical innovations improved the intraoperative detection and visibility of tumourous lesions during TUR. The most important techniques, which have individually found their way into international guidelines, are photodynamic imaging (PDI) and narrowband imaging (NBI). Furthermore, there are more or less experimental approaches such as optical coherence tomography (OCT), confocal laser endomicroscopy (CLE), red/green/blue analysis (RGB) of WLC. Moreover, the combination of two or more techniques in a multiparametric setting is another development in improving intraoperative imaging. The aim of this review is to describe today’s knowledge of the more established methods and to depict the most recent developments in intraoperative imaging.

Validation of a High-End Virtual Reality Simulator for Training Transurethral Resection of Bladder Tumors

OBJECTIVE

The oncological outcome in patients with bladder cancer (BC) significantly correlates with the quality of transurethral resection of bladder tumors (TUR-BT). Virtual reality (VR) training simulators have been developed to improve surgical skills. We evaluated the advantages and limitations of the novel Uro Trainer (UT) (Karl Storz GmbH, Germany) with respect to training for TUR-BT.

DESIGN

Participants underwent VR training based on 4 different TUR-BT cases accompanied by self-assessment and evaluation questionnaires. Results were compared between experienced endourologists and novices, and furthermore, correlated with self-rated capabilities for content and construct validity. Student's t tests, Pearson's correlation, and chi-squared tests were performed for statistical evaluation.

SETTING

The study was performed at the tertiary care urological department of the Ludwig-Maximilians-University, Munich, Germany.

PARTICIPANTS

A total of 22 urological physicians, including residents and consultants, were included in the study.

RESULTS

There is a need to improve TUR-BT training as 27.3% of the participants had already experienced overtaxing situations during TUR-BT and only a few reported of high satisfaction with the classical "see one-do one" teaching mode. Construct validity was demonstrated, as consultants achieved significantly higher overall scores (p < 0.001) and safety (p = 0.004) and visualization (p = 0.001) subscores. Interestingly, the self-assessed capability to perform a TUR-BT correlated significantly (p = 0.01) with overall UT scores. Significant progress of self-rated abilities was shown for several parameters, including inspection (p = 0.046) and resection (p = 0.026). Although participants indicated improvements in several procedural skills and overall benefit of the VR training with the UT was rated 4.6 on a 5-point scale by consultants, limitations of the UT were demonstrated predominantly for tissue feedback and authenticity of different tissue layers.

CONCLUSIONS

The novel VR simulator showed a high face and construct validity, and therefore has a great potential to complement endourological training.

Transurethral Resection of Bladder Tumors: Next-generation Virtual Reality Training for Surgeons

BACKGROUND

The number of virtual reality (VR) simulators is increasing. The aim of this prospective trial was to determine the benefit of VR cystoscopy (UC) and transurethral bladder tumor resection (TURBT) training in students.

DESIGN, SETTING, AND PARTICIPANTS

Medical students without endoscopic experience (n=51, median age=25 yr, median 4th academic year) were prospectively randomized into groups A and B. After an initial VR-UC and VR-TURBT task, group A (n=25) underwent a video-based tutorial by a skilled expert. Group B (n=26) was trained using a VR training program (Uro-Trainer). Following the training, every participant performed a final VR-UC and VR-TURBT task. Performance indicators were recorded via the simulator. Data was analyzed by Mann-Whitney U test.

INTERVENTION

VR cystoscopy and TURBT.

RESULTS AND LIMITATIONS

No baseline and post-training differences were found for VR-UC between groups. During baseline, VR-TURBT group A showed higher inspected bladder surface than group B (56% vs 73%, p=0.03). Subgroup analysis detected differences related to sex before training (male: 31.2% decreased procedure time; 38.1% decreased resectoscope movement; p=0.02). After training, significant differences in procedure time (3.9min vs 2.7min, p=0.007), resectoscope movement (857mm vs 529mm, p=0.005), and accidental bladder injury (n=3.0 vs n=0.88, p=0.003) were found. Male participants showed reduced blood loss (males: 3.92ml vs females: 10.12ml; p=0.03) after training.

CONCLUSIONS

Measuring endoscopic skills within a virtual environment can be done easily. Short training improved efficacy and safety of VR-TURBT. Nevertheless, transfer of improved VR performance into real world surgery needs further clarification.

PATIENT SUMMARY

We investigated how students without endoscopic experience profit from simulation-based training. The safe environment and repeated simulations can improve the surgical training. It may be possible to enhance patient's safety and the training of surgeons in long term.

Transurethral Resection of Bladder Tumors: Improving Quality Through New Techniques and Technologies

PURPOSE OF REVIEW

Cystoscopy with transurethral resection of bladder tumors (TURBT) is essential in the diagnosis of bladder cancer as well as the management of non-muscle-invasive disease yet remains a comparatively imprecise procedure secondary to variability among patients, tumors, and surgeons alike. We will review evolving technologies and techniques used to enhance safety and efficacy of TURBT performance and education in the management of bladder cancer.

RECENT FINDINGS

Though a generally safe procedure, efficacy of TURBT in terms of complete tumor excision, appropriate pathologic diagnosis, and absence of complications can vary significantly with direct impact on patient outcomes. Application of new techniques including bipolar electrocautery and photodynamic enhancement continues to shape endoscopic management of bladder cancer and improve safety, tumor excision rates, and downstream outcomes. High-quality bladder tumor resection is essential for effective bladder cancer management. Technologies such as bipolar electrocautery and photodynamic visualization improve safety and tumor eradication. Improved education and surgical technique will further standardize high-level outcomes for patients undergoing TURBT.

The importance of transurethral resection of bladder tumor in the management of nonmuscle invasive bladder cancer: a systematic review of novel technologies

PURPOSE

Transurethral bladder tumor resection is one of the most commonly performed procedures by practicing urologists for the diagnosis, staging and treatment of nonmuscle invasive bladder cancer. There is wide variation in the technique and quality of transurethral bladder tumor resection among urologists. This is the first and critically important diagnostic and staging tool in the management of bladder cancer, which is a potentially lethal malignancy and the most costly urological malignancy to manage. In this review we provide an evidence-based rationale for the incorporation of novel technologies for transurethral resection of bladder tumor in the setting of previously set standards.

MATERIALS AND METHODS

A systematic MEDLINE®/PubMed®, Cochrane Library and Ovid MEDLINE® search was performed using 2 separate search queries. The MEDLINE/PubMed search was performed using the key words "transurethral resection bladder tumor," filtering the search to include studies published within the last 5 years, English language and human species. A second search without filters was performed with the same key words in the Cochrane Library and Ovid MEDLINE. Study eligibility was defined based on patients with nonmuscle invasive bladder cancer, treatment with transurethral bladder tumor resection and with variable comparators based on novel technology used. All study designs were accepted except case reports, animal studies, editorials and review articles with various outcome measures reported including tumor detection, residual tumor detection, disease recurrence/progression and adverse events.

RESULTS

The literature search ultimately yielded 971 manuscripts for review with 42 meeting inclusion criteria for systematic review. Refinements in technique and surgeon experience are critical for the performance of a thorough, complete, high quality transurethral bladder tumor resection. Recent technological advances including bipolar electrocautery and regional anesthetic techniques may help reduce the complications associated with transurethral bladder tumor resection. Photodynamic diagnosis may help increase the diagnostic accuracy, reduce the recurrence rate and decrease the cost of treating patients with nonmuscle invasive bladder cancer. Repeat transurethral bladder tumor resection and perioperative intravesical chemotherapy remain standard components in select patients with nonmuscle invasive bladder cancer. Appropriate clinical staging and treatment of patients with nonmuscle invasive bladder cancer remain a challenge.

CONCLUSIONS

Recent advances in transurethral bladder tumor resection should aid its diagnostic accuracy, reduce recurrences, decrease complications and reduce the cost of management of nonmuscle invasive bladder cancer. Urologists should incorporate these evidence-based strategies into current guideline recommendations to improve patient outcomes following transurethral resection of bladder tumor in everyday practice.

The economics of bladder cancer: costs and considerations of caring for this disease

CONTEXT

Due to high recurrence rates, intensive surveillance strategies, and expensive treatment costs, the management of bladder cancer contributes significantly to medical costs.

OBJECTIVE

To provide a concise evaluation of contemporary cost-related challenges in the care of patients with bladder cancer. An emphasis is placed on the initial diagnosis of bladder cancer and therapy considerations for both non-muscle-invasive bladder cancer (NMIBC) and more advanced disease.

EVIDENCE ACQUISITION

A systematic review of the literature was performed using Medline (1966 to February 2011). Medical Subject Headings (MeSH) terms for search criteria included "bladder cancer, neoplasms" OR "carcinoma, transitional cell" AND all cost-related MeSH search terms. Studies evaluating the costs associated with of various diagnostic or treatment approaches were reviewed.

EVIDENCE SYNTHESIS

Routine use of perioperative chemotherapy following complete transurethral resection of bladder tumor has been estimated to provide a cost savings. Routine office-based fulguration of small low-grade recurrences could decrease costs. Another potential important target for decreasing variation and cost lies in risk-modified surveillance strategies after initial bladder tumor removal to reduce the cost associated with frequent cystoscopic and radiographic procedures. Optimizing postoperative care after radical cystectomy has the potential to decrease length of stay and perioperative morbidity with substantial decreases in perioperative care expenses. The gemcitabine-cisplatin regimen has been estimated to result in a modest increase in cost effectiveness over methotrexate, vinblastine, doxorubicin, and cisplatin. Additional costs of therapies need to be balanced with effectiveness, and there are significant gaps in knowledge regarding optimal surveillance and treatment of both early and advanced bladder cancer.

CONCLUSIONS

Regardless of disease severity, improvements in the efficiency of bladder cancer care to limit unnecessary interventions and optimize effective cancer treatment can reduce overall health care costs. Two scenarios where economic and comparative-effectiveness research is limited but would be most beneficial are (1) the management of NMIBC patients where excessive costs are due to vigilant surveillance strategies and (2) in patients with metastatic disease due to the enormous cost associated with late-stage and end-of-life care.