When a ‘routine’ TURBT is not routine: Lessons from SEER-medicare

TURBT is one of the most common operations performed by urologists, with over 100,000 procedures carried out annually in the United States, most in the ambulatory setting.^1,2 It is often described to patients as a “well-tolerated” and “incision-free” procedure, yet this perception masks a harsher truth. Bladder cancer is a disease of the elderly, with a median age at diagnosis of 73 - the highest among all cancers. ³ This simple demographic fact has enormous clinical implications. A significant share of these patients are frail, with multimorbidity, polypharmacy, and diminished physiologic reserve; estimates suggest that one in three to four TURBT patients meets criteria for frailty.^4,5 Frailty, more than age alone, drives complications even after procedures we call “minor.” This matters because most patients undergo more than one TURBT in their lifetime, and each repeat occurs in someone who is not getting younger but rather older, frailer, and more vulnerable, making complications not just possible but expected. And complications are not just inconveniences. They carry real consequences: unplanned hospital admissions, emergency visits, prolonged antibiotic use, rehabilitation, and caregiver burden. Bladder cancer is already among the most expensive malignancies to treat, and TURBT complications are an underappreciated driver of that cost.

Against this backdrop, Zhang and colleagues, in the August issue of Urologic Oncology: Seminars and Original Investigations, analyzed 72,284 patients in the SEER-Medicare database (2004–2015) who underwent TURBT, focusing on both complications and costs. ⁶

The results are eyebrow-raising. Overall, 43.6% of patients experienced at least one complication within 30 days of TURBT. Nearly one in two patients - after a procedure we so often reassure patients is “routine.” Most complications were Clavien–Dindo grade I–II, particularly lower urinary tract symptoms, urinary tract infections, and catheter reinsertion for retention. These are not trivial; they are disruptive, burdensome, and undermine trust, but they were the least costly. What stands out is the other end of the spectrum: a 1.9% risk of death within 30 days and nearly 1% risk of Clavien IV events. To put this in perspective, the 30-day mortality after radical cystectomy - one of the most complex operations we perform - is 2–3% in high-volume centers. ⁷ That TURBT approaches this level is concerning. And complications were not contained: 60.1% of those who had one required an Emergency Room (ER) visit, and nearly half needed hospital admission within 30 days.

The picture broadens further when we step outside urology-specific datasets. In a study of more than 36,000 nursing home residents undergoing so-called ‘minor’ urologic surgery, including TURBT, the outcomes were striking: 11% died within 30 days, nearly half within a year, and many survivors never regained baseline function. ⁸ On average, residents lost 1.9 points in ADL, and those starting in the best quartile declined by 4.7 points. For frail older adults, the real ‘complication’ is not bleeding or infection but a fall, delirium, pneumonia, or the permanent loss of independence that leads to institutionalization. The lesson is simple but important: the complications we rarely measure are the ones that define a patient's trajectory. Whether the decline is triggered by the TURBT itself or by the patient's underlying vulnerability doesn’t change the conclusion - in these settings, the benefit might have not outweighed the risk.

The financial consequences mirror the clinical ones. Patients with complications incurred nearly double the 30-day Medicare costs compared with those without ($7393 vs. $3934). At the population level, 30-day Medicare spending for TURBT exceeded $207 million, with 53% of this total attributable to patients who suffered complications. A complication translated into a 47% increase in per-patient cost, and the divergence persisted out to one year. For a procedure we often consider “minor,” this is a staggering economic footprint.

All this points toward refining how we apply TURBT in practice. It is not a benign intervention - especially in an elderly, frail population. With nearly half of patients experiencing complication and almost 2% dying within 30 days, TURBT has consistently proven to be less trivial than we often assume or communicate. The obvious question then becomes: are we overusing it? For small, papillary, low-grade recurrences, alternatives such as in-office fulguration, laser ablation, or even surveillance are guideline-endorsed and have been shown to be more cost-effective, ⁹ yet they remain underutilized. Barriers such as reimbursement structures, ¹⁰ training variability, and inertia of practice have slowed their adoption, but the evidence suggests they are safe and could spare frail patients the risks of anesthesia and hospitalization. ¹¹

Innovation is also beginning to reshape the landscape. The recent FDA approval of UGN-102 (mitomycin reverse thermal gel) for low-grade, intermediate-risk Non–Muscle-Invasive Bladder Cancer (NMIBC) represents a true “surgery-free” alternative.^12,13 Phase III data show 3-month complete response rates in four out of five patients, with durability beyond one year in a substantial proportion. From a cost standpoint, UGN-102 is unlikely to reduce overall expenditure, as novel intravesical agents are costly. But such alternatives change the risk equation, hopefully sparing frail patients’ exposure to anesthesia and the possibility of catastrophic complications. In selected populations, that trade-off may justify the cost of the drug.

Of course, registry-based analyses have limitations. SEER-Medicare reflects an elderly, fee-for-service population and may overrepresent frailty, inflating complication rates compared with younger or privately insured patients. ¹⁴ Coding errors and tumor location, surgeon volume, anesthesia type, or perioperative pathways may further limit interpretation, and the database cannot fully separate complications caused by TURBT itself from those due to comorbidity. These factors may overestimate both complication rates and costs. For example, Doshi et al. (2025) reported that the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) offers prospectively collected, rigorously audited 30-day outcomes. ¹⁵ In its 2022 analysis of 9448 TURBTs, it reported an overall complication rate of 8%, most commonly UTIs (4.5%), reoperations (1.6%), and transfusions (1.3%). Serious adverse events such as stroke (0.2%) or pneumonia (0.3%) were rare. The truth is likely somewhere in between: complication rates are higher than suggested by surgical registries, yet not as extreme as seen in the frailest SEER-Medicare or nursing home populations. Together, these datasets paint a more complete and sobering picture of TURBT risk across the spectrum of patients we treat.

Taken together, the message is that TURBT, the gold standard and most effective endoscopic surgical resection of bladder lesions, is not as safe or benign as often assumed. It should not be considered trivial, particularly in older or frail populations. These findings raise important questions about overuse of TURBT and highlight opportunities for change - from incorporating frailty assessment into everyday practice, to expanding use of office-based or “surgery-free” alternatives, to opening a broader discussion about the implementation challenges of recurrence-reducing treatments,^16,17 structured surveillance, and improved patient communication. Helping patients understand the implications of TURBT and anticipating common postoperative symptoms may help reduce avoidable readmissions.