Abstract
BACKGROUND: Transurethral resection of bladder tumour (TURBT) is the gold standard for diagnosing and risk-stratifying bladder cancer. Accurate and comprehensive operative documentation is critical for ensuring effective patient management. The European Association of Urology (EAU) guidelines provide a framework for TURBT documentation, including tumour characteristics, procedural details, and complications. However, adherence to these guidelines varies, necessitating quality improvement initiatives. AIMS: This study aimed to assess the quality of TURBT operative notes at a single institution before and after implementing a standardised electronic TURBT template based on EAU guidelines. METHODS: A closed-loop audit was conducted at an academic teaching hospital. Operative notes for 40 consecutive TURBT cases from December 2021 to September 2022 were evaluated against EAU documentation criteria. Following the introduction of a standardised electronic TURBT template, a second audit cycle of 40 cases from September 2022 to March 2023 was conducted. Key documentation elements, including tumour location, appearance, size, multifocality, procedural steps, resection completeness, and complications, were compared. RESULTS: The introduction of the electronic template significantly improved documentation adherence, increasing overall compliance from 69 to 93%. Notable improvements were observed in tumour appearance (65 to 97.5%), tumour size (67.5 to 90%), completeness of resection (55 to 95%), and complication recording (2.5 to 75%). CONCLUSIONS: A structured electronic TURBT template enhances the quality and completeness of operative documentation, aligning with EAU guidelines. Standardised templates facilitate better communication, continuity of care, and quality improvement in TURBT procedures, ultimately contributing to improved patient management and outcomes.