Integration of TULA and BSPMs in a Secondary Care Bladder Cancer Pathway

The authors describe a stepwise service implementation of transurethral laser ablation (TULA) alongside a new planning-meeting process within a secondary care bladder cancer pathway, presented as a single-institution service evaluation spanning an initial audit cycle and a subsequent re-audit.

The report focuses on how the procedure was delivered in routine workflow (including anesthesia), what was observed in the near term after treatment and biopsy, and what was documented about service pressures and local cost estimates.

TULA was introduced in phases, starting when the unit began offering flexible-cystoscope biopsy with cold-cup sampling followed by laser ablation and haemostasis using a 1470 nm diode laser system. Across the reported study period (August 2023 to September 2025), the authors report 95 TULA procedures, with early experience reviewed before November 2024 and subsequent cases extending to September 2025. In their description, cases were selected in relation to tumor size and location and to patient suitability for general anesthesia, and patients were typically identified after a check flexible cystoscopy and multidisciplinary discussion. The authors position TULA in this setting as an adjunctive pathway option for selected bladder lesions within their local service model.

Delivery was described as theatre-based throughout the evaluation, with an anesthetist present regardless of technique, while a fully outpatient service was discussed as a future phase. Anesthesia in this series was predominantly local anesthetic (LA) with or without intravenous sedation (90.5%), with smaller proportions undergoing general anesthesia (8.4%) or spinal anesthesia (1.1%); the authors also report that, in the later phase, half of procedures used LA alone rather than LA plus sedation.

For near-term outcomes, the report notes one case with ongoing bleeding requiring catheterisation and subsequent washout under general anaesthesia, with no other complications reported. The authors reported an overall detrusor muscle sampling rate of 66.3%, and a subset of cases with absent muscle were managed through post-procedure multidisciplinary review pathways that sometimes included booking further endoscopic management. Overall, the authors describe delivery under local anaesthetic in many patients with limited immediate adverse events in this service experience.

The authors describe bladder cancer surgery planning meetings (BSPMs) as a fortnightly, consultant-supported forum introduced in July 2024 to review patients on the pathway, identify delays, and identify individuals who might be suitable for TULA (including those waiting for high-risk anaesthetic assessment). In an early implementation snapshot covering July to November 2024, 108 patients were discussed and 24 were identified for TULA; among those identified, 7 had originally been scheduled for TURBT and were awaiting pre-operative assessment clearance. The authors reported that identifying patients for TULA via this meeting structure significantly reduced cancer waiting time, and present the BSPM as a mechanism for reallocating selected cases within the local waiting-list workflow.

Under the authors’ costing scenario assuming outpatient delivery, they estimated an average cost of GBP 992 per patient and an approximate saving of GBP 99,845 across the cohort if all cases had been performed as outpatient procedures. They also described a planned next phase of service development to roll TULA out to a fully outpatient pathway performed exclusively under local anaesthetic (not implemented during the study period). Governance was described in terms of selection and oversight processes embedded in existing structures, including BSPM-based triage and subsequent review of histology and management in routine bladder cancer multidisciplinary team meetings.

Key Takeaways:

• In this single-unit evaluation, most TULA procedures were reported as performed with local anaesthetic approaches, with one bleeding event requiring washout and sampling adequacy assessed by detrusor muscle presence.
• BSPMs were described as a structured, fortnightly pathway review that identified a subset of discussed patients for TULA, including some who had been listed for TURBT and were delayed awaiting pre-operative assessment.
• The authors reported local outpatient cost estimates and outlined plans to expand toward an outpatient, local-anaesthetic-only TULA service model in a subsequent phase.