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BACKGROUND: EAU guidelines recommend a single instillation (SI) of intravesical chemotherapy (e.g. Mitomycin C) within 24 hours after transurethral resection of a bladder tumour (TURBT) in patients with low- to intermediate risk non-muscle invasive bladder cancer without (suspected) bladder perforation or bleeding requiring bladder irrigation. However, remarkable variation exists in the use of SI. The risk of severe complications is likely to contribute to this variation, but evidence is limited. OBJECTIVE: To investigate the absolute severe complication and mortality risk after SI in low- and intermediate risk bladder cancer. METHODS: In this observational, historic cohort study, data on 25,567 patients diagnosed with TaG1G2 urothelial bladder carcinoma (UBC) between 2009 and 2018 who underwent TURBT were collected from the Netherlands Cancer Registry. Data were supplemented with information on cause of death and severe complications after cancer treatment by re-examining the electronic health records and the 14-day complication risk and the 30-day mortality risk were evaluated. RESULTS: On average, 55% of patients had a SI after TURBT, varying from 0–>80% between hospitals. The 30-day mortality risk was 0.02% and the 14-day risk of severe complications was 1.6%. CONCLUSIONS: As the absolute risk of mortality and severe complications is very low, SI after TURBT can be considered a safe treatment in patients with low- to intermediate UBC without contraindications for SI. These results imply that a part of eligible patients is denied effective treatment.

Rationale: Resilience is a relatively new concept in medicine and, more specifically, it is new in geriatrics. It suits the new definition of health as introduced by Machteld Huber. However, resilience still needs a suitable, operationalizable definition for the field of geriatrics, given that it is still an emerging theme in medicine. Resilience in different disciplines: Investigation of the concept of resilience in mechanics, ecology, psychology and sociology shows that resilience is mostly considered as a dynamic, multidimensional and scalable concept. As such it may also apply to the field of medicine and potentially also to the field of geriatrics. However, the idea of resilience is still evolving. Therefore, time is needed to develop a common understanding of the concept. When this understanding is enhanced, operationalization is of great importance. Current operationalization in these disciplines varies from questionnaires to establish (static) characteristics defining a state that is prognostic for the resilience to be shown when perturbated to stress-tests, to mathematical indicators which evaluate the dynamic response or behavior of the system to (standardized) perturbations. Discussion: All measurements for operationalization are indicators of resilience and do therefore not directly measure resilience (if this is indeed possible). In addition, there is not only one concept of resilience. Resilience can be considered objectively as a systems characteristic, or subjectively, for example by gestalt . These different approaches cause a gap between the concepts and different operationalizations, which makes it difficult to operationalize the (general) concept of resilience. Implications and recommendations: Over time, resilience can potentially be measured by the use of new measurements, longitudinal data and wearables. For implementation in the clinic, validation of the measures is key. In addition, qualitative research on how the elderly experience, or would describe, resilience is recommended, in order to gain a better understanding about the concept. Then, there can be thought of intervening in resilience, especially in patients who face transition to another state of health.