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Development and validation of the TOCO–TURBT tool: a summative assessment tool that measures surgical competency in transurethral resection of bladder tumour

Surgical Endoscopy
Anna H. de Vries, Arno. M. M. Muijtjens, Hilde G. J. van Genugten, Ad. J. M. Hendrikx, Evert L. Koldewijn, Barbara M. A. Schout, Cees P. M. van der Vleuten, Cordula Wagner, Irene M. Tjiam, Jeroen J. G. van Merriënboer
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Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s00464-018-6251-8) contains supplementary material, which is available to authorized users.



The current shift towards competency-based residency training has increased the need for objective assessment of skills. In this study, we developed and validated an assessment tool that measures technical and non-technical competency in transurethral resection of bladder tumour (TURBT).


The ‘Test Objective Competency’ (TOCO)–TURBT tool was designed by means of cognitive task analysis (CTA), which included expert consensus. The tool consists of 51 items, divided into 3 phases: preparatory (n = 15), procedural (n = 21), and completion (n = 15). For validation of the TOCO–TURBT tool, 2 TURBT procedures were performed and videotaped by 25 urologists and 51 residents in a simulated setting. The participants’ degree of competence was assessed by a panel of eight independent expert urologists using the TOCO–TURBT tool. Each procedure was assessed by two raters. Feasibility, acceptability and content validity were evaluated by means of a quantitative cross-sectional survey. Regression analyses were performed to assess the strength of the relation between experience and test scores (construct validity). Reliability was analysed by generalizability theory.


The majority of assessors and urologists indicated the TOCO–TURBT tool to be a valid assessment of competency and would support the implementation of the TOCO–TURBT assessment as a certification method for residents. Construct validity was clearly established for all outcome measures of the procedural phase (all r > 0.5, p < 0.01). Generalizability-theory analysis showed high reliability (coefficient Phi ≥ 0.8) when using the format of two assessors and two cases.


This study provides first evidence that the TOCO–TURBT tool is a feasible, valid and reliable assessment tool for measuring competency in TURBT. The tool has the potential to be used for future certification of competencies for residents and urologists. The methodology of CTA might be valuable in the development of assessment tools in other areas of clinical practice.

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Online Appendix 1a (TIFF 1521 KB)
Online Appendix 1b (TIFF 1521 KB)
Online Appendix 1c (TIFF 1521 KB)
Online Appendix 2 (DOCX 3228 KB)
Online Appendix 3 (DOCX 19 KB)
Online Appendix 4 (DOCX 53 KB)
Online Appendix 5 (DOCX 17 KB)
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