Getting answers in minutes, not weeks: A new approach to first bladder cancer surgery

The challenge

For most people diagnosed with bladder cancer, diagnosis and treatment begin with an operation called a transurethral resection of bladder tumour (TURBT). During this procedure, surgeons remove the tumour and surrounding tissue so that pathologists can determine how deeply the cancer has grown. To be able to accurately stage the cancer, the specimen removed in surgery needs to contain detrusor muscle, the deep muscle layer of the bladder wall. If this deep muscle is missing from the sample, it can be difficult to determine the true stage of the cancer, increasing the risk of under-staging and leading some patients to require a second operation.

The problem is that surgeons typically do not know whether detrusor muscle is present until the pathology report is returned, often one to two weeks after the operation. This delay can cause anxiety for patients, increase pressure on healthcare services, and mean that patients need to undergo another operation to remove more tissue.

The research

The IB1-LaserCOMPLETE study investigated whether a technology called fluorescence confocal microscopy could analyse freshly removed bladder tissue during surgery and provide immediate information about the presence of detrusor muscle.

Researchers recruited patients undergoing their first bladder tumour resection and used the technology to scan tissue samples in the operating theatre. The images were reviewed independently by both a specialist uro-pathologist and a urologist, and the results were compared with standard laboratory pathology, the current gold standard

The study found that:

• High-quality images suitable for assessment were obtained in 100% of patients.
• Results could be generated in around five minutes, compared with a median wait of 11 days for standard pathology reporting.
• There was 83% agreement between specialist pathologists and urologists when interpreting the images, indicating that urologists may be able to report at the bedside without the need for a specialist pathologist
• When detrusor muscle was identified by the technology, it was highly reliable, with 100% specificity.

This research shows that rapid, real-time assessment during surgery is achievable and worthy of further investigation.

Our role

The Urology Foundation funded this innovative feasibility study, enabling researchers to test a promising technology in bladder cancer surgery for the first time. Our funding helped deliver a robust prospective clinical trial that has already resulted in publication in a leading international urology journal and presentations at major scientific meetings.

By supporting early-stage research, The Urology Foundation helps researchers generate the evidence needed to explore new ways of improving diagnosis, treatment and patient care. Studies like this provide the critical first step towards larger trials with the potential to change clinical practice.

Impact of the study

This research has shown that real-time digital pathology during bladder cancer surgery is not only possible but can be delivered quickly and consistently in the operating theatre. While additional validation is needed before the technology can be used routinely, the findings suggest a future in which surgeons could receive immediate feedback during an operation rather than waiting days for laboratory results.

In future, a larger study will confirm the technology’s diagnostic accuracy results, it could help reduce the number of patients requiring repeat surgery, improve the patient experience and reduce pressure on NHS resources. Researchers estimate that reducing unnecessary repeat procedures could ultimately generate substantial savings for the healthcare system while improving quality of life for patients.

The project has also helped develop the next generation of clinical researchers, supporting early-career investigators and generating award-winning presentations at national and international meetings.

The study’s Principal Investigator Mr Martin Connor, Clinical Lecturer & Honorary Consultant Urologist at Imperial College London, stated “For the first time, urological surgeons can access digital pathology information while they are still in the operating room. Instead of waiting up to 11 days for laboratory results, they can immediately determine whether they have obtained the deep muscle needed at first bladder cancer resection. At present, one in three patients with bladder cancer undergo unnecessary repeat surgery. We know these second operations cause delays to vital cancer treatment, increase patient anxiety and add significant NHS costs.“

Next steps

The study established that fluorescence confocal microscopy can produce high-quality images rapidly enough to be used during bladder cancer surgery. The next step is to determine whether the technology can reliably guide clinical decision-making to undertake additional bladder sampling in routine practice. Researchers are now planning further research to validate these findings across a wider range of hospitals and patients. This future research will focus on reporting the technologies accuracy to identify detrusor muscle on a larger scale across different hospitals, this will lead to guidance on how surgeons can use to the technology to reduce the need for repeat operations.

This is exactly how donor-funded research creates lasting impact: by enabling innovative ideas to be tested, generating vital evidence, and laying the foundations for advances that could improve the lives of patients for years to come.