Evolution of the Bladder Cancer Pathway in a Secondary Care Unit Incorporating Transurethral Laser Ablation and ‘Bladder Cancer Surgery Planning Meetings’

Abstract

Background/Objectives: Transurethral Laser Ablation (TULA) is fast evolving as a surgical procedure, especially for small or recurrent bladder tumours. It offers a safe alternative for patients who are unsuitable for general anaesthetic (GA) or who cannot obtain timely pre-operative assessments for Transurethral Resection of Bladder Tumour (TURBT). Patients are identified for TULA in ‘Bladder Cancer Surgery Planning Meetings’ (BSPMs) and this significantly reduces their cancer waiting time (CWT). Its effectiveness as a diagnostic and therapeutic tool, including its complications and costs, has been assessed. Methods: All TULA procedures performed at the Trust were studied in two cycles. The first between August 2023 and November 2024, prior to initial audit, and then up to September 2025. Case notes, operation notes, and multidisciplinary team (MDT) outcomes were retrospectively reviewed. All procedures were performed with a flexible cystoscope and ‘cold cup’ biopsies with further ablation and haemostasis using a 1470 nm diode laser at 4 watts and 400 µm laser fibre. Patients were identified for TULA based on tumour size, location, and fitness for general anaesthetic. Results: During the study period, 95 TULA procedures were performed with a follow-up period between 4 weeks and 1 year. A total of 86 patients (90.5%) had local anaesthetic (LA) ± intravenous (IV) sedation, with 50% having LA alone in the second phase of the study; of the remaining patients, 8 had GA (8.4%) and 1 (1.1%) had spinal anaesthetic. None of the cases were considered to have missed a significant finding. One case (1.1%) was complicated, with ongoing bleeding requiring bladder washout under GA. BSPMs were introduced in July 2024 and audited in the first phase of this study. A total of 24 (39%) of patients were identified for TULA. Of those, 7 (29%) were originally scheduled for TURBT and were having difficulties obtaining pre-operative assessment (POA) clearance. Cost figures were provided by the hospital’s accountants. Conclusions: TULA has been implemented with a low complication rate and appropriate sampling. In the next phase, TULA will be rolled out to an outpatient setting, performed exclusively under LA. This will lead to a significant cost reduction.

1. Introduction

Bladder cancer is the eleventh most common cancer in the UK with non-muscle invasive bladder cancer (NMIBC) representing 75–80% of new bladder cancer diagnoses [1,2]. There is a wide variety of Urology practice across the National Health Service (NHS) making the bladder cancer pathway a recent target for national improvement [3]. Outlined recently in the UK Get It Right First Time (GIRFT) programme ‘Decarbonisation of the Bladder Cancer Pathway’ [4,5], Transurethral Laser Ablation (TULA) has emerged as both a diagnostic and a treatment tool with a reduced environmental impact. It is particularly useful for small or recurrent bladder cancer and is increasingly used for en bloc resections of appropriate tumours. TULA has already been implemented in many units in England and has shown promise in improving the delivery of bladder cancer services. However, many smaller units are still yet to adopt it with an unclear cost-effectiveness.

The current gold standard for evaluation and management of all NMIBC remains Transurethral Resection of a Bladder Tumour (TURBT) [6,7]. Limitations of this practice are evident, by subjecting even those with low-risk cancer to repeated general anaesthetic (GA) and a greater perioperative morbidity [8]. The complication rate is around 6% and can include bladder perforation, persistent haematuria, and incomplete sampling, which may necessitate further operations and inpatient admission [9]. Recurrence rates following TURBT for NMIBC vary widely depending on tumour risk stratification, with 5-year recurrence rates approaching 70–80% in selected high-risk cohorts [10]. High numbers of TURBTs and frequent, long-term monitoring contribute to bladder cancer having the highest lifetime cost of all cancers [11,12].

TULA is a less invasive procedure that has been well tolerated under local anaesthetic (LA) with a low complication risk. It uses a dual diode laser with wavelengths of 980 nm, which is highly absorbed in haemoglobin for coagulation, and 1470 nm, which is absorbed in water and is ideal for cutting tissue. It also offers a blend of these wavelengths according to surgeon preference. Long term follow-up of TULA cases has shown 5-year recurrence-free survival rates of 31.8% and 29% for intermediate- and high-risk NMIBC, respectively, equivocal to TURBT. However, it shows a high level of progression-free survival of 86.8% and 93.1%, respectively [13].

In this study, the stepwise introduction of TULA over a two-year period is assessed. The impact of introducing a dedicated TULA service in a secondary care unit is presented here, focusing on safe delivery of the service, with improved cancer waiting times (CWTs) and overall cost-effectiveness. This may demonstrate to Trusts who have not yet adopted it the practicality of establishing the service.

2. Materials and Methods

As per UK Health Research Authority guidelines, this study qualified as a service evaluation of a single-institution bladder cancer service. Informed consent for data analysis was waived by the local Ethics Committee. The study was conducted in accordance with the principles of the Helsinki Declaration.

A retrospective analysis of all bladder biopsies with TULA was performed in our secondary care bladder cancer unit. The study consisted of two audit cycles, with the first phase occurring from August 2023, when TULA was introduced to the unit, to November 2024. Following review of the service and presentation at the local governance meeting, the second cycle continued until September 2025. Patient records stored in the electronic hospital databases ‘Careflow’ and ‘Clinical Information Portal (CIP)’ were screened with a 4 week to 1 year follow-up.

The data on patients’ previous bladder cancer history, type of anaesthetic, intraoperative findings, histology results, and complications were collected. Accepted complications excluded social admissions, defined as overnight stays required for non-clinical reasons, such as lack of a responsible adult at home following GA/intravenous (IV) sedation, in accordance with the local discharge policy. Patients were identified for targeted bladder biopsy following a check flexible cystoscopy and a multidisciplinary team (MDT) discussion.

2.1. Bladder Cancer Surgery Planning Meetings

As introduced locally in July 2024, all patients on the bladder cancer pathway in our unit are discussed on a fortnightly basis with consultant support. Participants included the Consultant Urologist, the Cancer Patient Pathway Navigator, the Waiting List Coordinator, the Bladder Cancer Specialist Nurse, and the Specialty Doctor leading the haematuria pathway. The meeting identifies delays from various aspects of the bladder cancer pathway. This includes those who are awaiting high-risk anaesthetic clinic appointments and who, if suitable, could be re-allocated to TULA without the need for general anaesthetic. Cases appropriate for TULA were carefully selected. These included small, visually accessible lesions, that are typically recurrent and are low-grade in appearance on cystoscopic assessment. Large, multifocal, or suspicious tumours of high-risk diseases, including muscle invasive bladder cancer (MIBC), were usually managed with conventional TURBT. New bladder tumours, even if small, were also listed for TURBT unless the patient was unfit for GA. The Waiting List Coordinator can allocate dates for the appropriately selected bladder cancer surgical procedures in this meeting.

2.2. Setting for TULA Procedure

All the procedures included in this study were performed in a theatre setting with an anaesthetist present, regardless of whether the procedure was undertaken under LA, IV sedation, or GA. Transition to a fully outpatient TULA service represents a future phase of service development and was not implemented during the study period.

2.3. Biopsy

All bladder biopsies with TULA were gathered by expert Urologists using a reusable flexible cystoscope (Karl Storz^® Endoscopy UK Ltd., Slough, Berkshire, UK). The LEONARDO^® Mini Dual Laser System (Promed Ltd., Cambridgeshire, Cambridge, UK) was used for TULA alongside the following equipment from the same company: single-use Biopsy forceps for ‘cold cup’ biopsies and 400 µm flat tip laser fibre (3 m length) with a power output of 4 watts at 1470 nm for further ablation and haemostasis. All biopsies were graded by a uropathologist and reviewed in a weekly bladder cancer MDT setting.

2.4. Costs

Financial analysis was conducted locally, with a retrospective audit of the actual expenses of the procedures: TURBT with a Complete Case (CC) score of 2–4 (code M421), GBP 2481; TULA in theatre setting (accounting for additional staff) (M423), GBP 2043; and diagnostic flexible cystoscopy (M459), GBP 802. Unit costs of the equipment described in this study were provided by Promed Ltd.; the 400 µm flat tip laser fibre was GBP 160 per item and the TULA single-use biopsy forceps were GBP 30 per item.

3. Results

3.1. Study Population and Procedure Outcomes

Over the full 25-month study period, TULA was used for 95 patients in our secondary care unit. Of the procedures, 61 were performed during the first phase from August 2023 to November 2024. A further 34 procedures were performed up to September 2025. The median age was 71.2 years. A total of 57 (60%) patients were of an American Society of Anaesthesiologists (ASA) grade of III or higher and 48 (51%) had a previous history of biopsy/TURBT (

Table 1. Patient demographics and previous disease status by audit cycle. Data are presented as n (%) or median (interquartile range IQR), as indicated. ASA = American Society of Anaesthesiologists physical status classification. Biopsy-naïve refers to patients without prior bladder biopsy or Transurethral Resection of Bladder Tumour (TURBT). Tumour grade and stage are reported according to the International Society of Urological Pathology (ISUP) grading system and tumour, node, metastasis (TNM) staging where available. Percentages are calculated within each audit cycle.

Study Population and Previous Disease Status n, Median (IQR) or n (%)
		1st Cycle	2nd Cycle
Total Patients		61	34
Demographics
Age (years) Sex		71.5 (62.0–79.3) 51 (M) 10 (F)	74.0 (66.5–79) 24 (M) 10 (F)
ASA	(I + II)	31 (50.8%)	6 (17.6%)
	(III + IV)	30 (49.2%)	28 (82.4%)
History of Biopsy
Biopsy naïve		28 (45.9%)	17 (50%)
Unknown biopsy outcome		2 (3.3%)	0
Previous negative biopsy		2 (3.3%)	1 (2.9%)
Previous positive biopsy		29 (47.5%)	16 (47.1%)
Of which	G1pTa	6 (9.8%)	3 (8.8%)
	G1pT1	0	1 (2.9%)
	G2pTa	15 (24.6%)	8 (23.5%)
	G2pT1	4 (6.6%)	1 (2.9%)
	G3pTa	2 (3.3%)	1 (2.9%)
	G3pT1	2 (3.3%)	1 (2.9%)
	G3pT2	0	1 (2.9%)
	Other grade or stage	0	0

).

Of the initial 61 patients, 47 (77.1%) had LA + IV sedation administered by an anaesthetist; 8 (13.1%) had GA; 5 (8.2%) had LA alone and 1 (1.6%) had spinal anaesthetic (SA). In this cohort, 16 (26.2%) cases were found to have incomplete sampling, defined as absence of detrusor muscle within the biopsy specimen. Of these, following MDT discussion, 5 (8.2%) were rebooked for TURBT; 1 (1.6%) was rebooked for repeat TULA; 9 (14.8%) continued with check cystoscopies and 1 (1.6%) was discharged. Tumours on the anterior bladder wall and those seen only on J-manouvre proved the most difficult to sample, all with incomplete sampling (four tumours total).

In the second phase of the study, out of 34 patients, 17 (50%) had LA + IV sedation and 17 (50%) had LA alone. A total of 16 (47%) were found to have incomplete sampling and of these, 3 (8.8%) were rebooked for TURBT; 10 (29.4%) continued with check cystoscopy and 3 (8.8%) were discharged.

None of the cases were considered to have missed a significant finding. Three (3.2%) cases later required repeat biopsies following check flexible cystoscopy, These findings may represent tumour recurrence rather than missed lesions, although formal oncological outcome analysis was not the aim of this study. One (1.1%) case had a complication with ongoing bleeding, requiring catheterisation and subsequent washout under GA. This patient had not stopped their anticoagulation medication. There were no other cases reporting complications. Post-MDT outcomes are shown in Figure 1, with the additional cases rebooked for TURBT for completion of resection. There were two deaths in the follow-up period, both were inpatients under the medical team and died of non-bladder cancer-related causes.

Between July and November 2024, with the addition of the bladder cancer surgery planning meetings (BSPMs), 24 patients were identified for TULA, out of the total of 108 patients discussed in BSPMs. Of these, 7 (29%) were originally booked for TURBT and were waiting for a long period for pre-operative assessment clearance.

3.2. Costing Analysis

Following the local average procedure pricing methodology, considering the total number of TULA procedures in the study period and assuming they were all performed in an outpatient setting, the cost estimates represent an average cost per patient of GBP 992 and an approximate saving of GBP 99,845 for the Trust (

Table 2. Cost estimates of the diagnostic methods using the average unit local cost. The estimated cost difference is shown assuming that all of the TULA cases were performed in an outpatient setting.

Cost Estimates of the Studied Population
	Cost per Unit (£)	Cost over Study Period (n = 95) (£)
TURBT day case	2481	Not Available (N/A)
TULA in theatre	2043	194,085
Outpatient flexible cystoscopy	802
400 µm TULA laser fibre	160	94,240
Grasper for flexible cystoscopy	30
	Δ (£)	−99,845

TURBT: Transurethral Resection of Bladder Tumour; TULA: Transurethral Laser Ablation.

).

4. Discussion

This study demonstrates the clinical and cost-effective integration of TULA into a bladder cancer service. Coupled with bladder cancer surgery planning meetings, TULA enabled a significant reduction in cancer waiting time, especially for those awaiting high-risk general anaesthetic pre-operative assessment (POA) clearance. It also reduced unnecessary TURBT procedures, which supports a reduction in local Trust spending. The study was designed as a service evaluation assessing the feasibility, safety, and cost-effectiveness of TULA within an established bladder cancer pathway, rather than an assessment of long-term oncological outcomes.

Bladder cancer is a common cancer in Europe, including in the UK, with around 10,500 new cases every year. Incidence rates are highest in the elderly population with 56% of bladder cancer cases in the UK occurring in those aged 75 and over [14,15]. This has a significant financial impact, with 3-year estimates of bladder cancer costs in the UK at GBP 66.14 million [16]. TULA represents a diagnostic and treatment pathway that reduces morbidity, obtains biopsies effectively and is cost-effective. As a result, over 100 TULA services have now been established in the UK with around 10,000 procedures estimated to be performed annually [17]. A great deal of research has supported this implementation and international urological associations including the European Association of Urology (EAU) have endorsed the use of TULA. TULA has additional uses for ureteric or renal pelvi-calyceal tumour biopsy, but these have been excluded from this study as they would not be used in an outpatient setting. TULA remains an adjunct to the bladder cancer pathway with TURBT still remaining the gold standard. However, in scenarios such as suspected metastatic or muscle-invasive bladder cancer, where obtaining histopathological evidence to determine appropriate radical/oncological treatment with standard TURBT is delayed, TULA may also be sufficient to progress the bladder cancer pathway. Future uses of TULA may develop, for example, the newly available 200 µm laser fibre will allow better access to difficult areas in the bladder and upper tract. It may also become feasible to treat high-risk NMIBC with TULA when blue-light flexible cystoscopy becomes available.

This study demonstrates a clear cost saving that could be achieved by moving the TULA service to an outpatient setting, with an approximate 60% cost reduction compared to a day-case TURBT. The local costs of major and intermediate endoscopic bladder procedures and flexible cystoscopy differ from the national averages suggested by NHS England (GBP 2002, GBP 841, and GBP 257, respectively). This may be attributed to differences in medical staffing and the use of consumables. Additional equipment costs associated with the service include the base pricing of the LEONARDO^® Mini dual laser system at around GBP 11,500 with the stand and a cost of GBP 1100 for laser eye protection at GBP 245 per unit. Any facility offering TULA as an outpatient procedure needs to ensure laser safety protocols are followed.

TULA procedures are generally well tolerated with better patient-reported outcomes compared to TURBT [18]. This includes a lower perception of pain, shorter duration of haematuria, and fewer instances of acute urinary retention. This study demonstrates this with the majority of procedures (90.5%) being performed under LA with or without IV sedation, provided by an anaesthetist. There was a significant improvement between the two phases of the study with more patients in the second phase having LA alone. This represents the learning curve of a new procedure with improved confidence over time and the progression towards forming an outpatient service.

The low complication rate in this study is in-line with similar published standards [13,19,20]. This supports its role as a less invasive treatment option. The overall rates of detrusor muscle sampling with TULA in this study was 66.3%, even though the flexible cold-cup biopsy forceps used through the flexible cystoscope are relatively small when compared to the rigid cold-cup biopsy forceps used through a rigid cystoscope. The TULA muscle sampling rate approaches the British Association of Urological Surgeons’ set standard for TURBT at 70% and suggests TULA can achieve similar resection depths with room for improvement. Lack of muscle in the specimen did not mandate a significant number of repeat procedures, with the majority of patients continuing with check flexible cystoscopy. Variation in sampling may further demonstrate differences of surgeon experience, as more surgeons began learning the procedure in the second phase. Patients were appropriately selected for the procedure with the majority being of an older age cohort and an ASA III or above. Furthermore, no cases were converted intra-operatively to TURBT, for example, for large tumours. Rarely were tumours treated with an en bloc resection, but as this is being increasingly used nationally; further assessment of its safety in the TULA setting is necessary.

Although there was one patient (1.1%) with a bleeding complication that required re-admission and bladder washout, generally TULA procedures can be performed safely in patients on anticoagulants and antiplatelet agents without stopping them or requiring a peri-operative bridging plan, based on evidence from multiple UK NHS trusts and the UK’s GIRFT programme (4).

Following the introduction of the bladder cancer surgery planning meetings in July 2024, a total of 108 patients were discussed during the initial implementation period up to November 2024. Within this cohort, 24 patients were directed to TULA rather than TURBT after a multidisciplinary review. However, this snapshot analysis reflects an early implementation phase of the pathway and does not span the full duration of either audit cycle in the present study. As such, these data are presented for contextual service insight only and were not included in the primary analysis.

This retrospective analysis of clinical outcomes over 2 years is not without limitations. The results describe economic benefits in a single secondary care unit. It is acknowledged that these results might not exactly replicate the exact procedure costs in different healthcare Trusts or systems. Furthermore, cost estimates assume that all the TULA procedures could be performed in an outpatient setting. However, as with flexible cystoscopy procedures, there is variability of patient tolerance to the procedure and IV sedation may still be needed in some cases. The follow-up period ranged from 4 weeks to 1 year. As a result, not all patients had undergone a flexible check cystoscopy at the time of analysis, and so we cannot yet comment on long-term oncological outcomes. The proportion of all bladder cancer cases directed to TULA over time was not specifically analysed and this represents an area for future service evaluation.

5. Conclusions

Our results further support the role of TULA as a safe and cost-effective adjunct within a secondary care bladder cancer pathway with low complication rates and appropriate sampling. The next step will involve using TULA in a fully outpatient setting under LA. This will help further reduce the cancer waiting times, create additional GA theatre slots for other more deserving surgical procedures, and represent a significant cost saving. We believe the pathway described is reproducible in similar healthcare settings. Our experience may guide other units, especially those facing long surgical wait times or servicing elderly, comorbid populations, in developing their own outpatient bladder cancer laser treatment services. However, longer term follow-up will be required to assess oncological outcomes as outpatient TULA services continue to evolve.