BACKGROUND/OBJECTIVES: Transurethral resection of bladder tumor (TURBT) is commonly performed in elderly patients and often requires repeated procedures. A high proportion of non-procedural time in TURBT affects operating room utilization, highlighting the need for a safe and efficient anesthesia method. This study aimed to compare remimazolam-based monitored anesthesia care (MAC) guided by analgesia nociception index (ANI) monitoring to inhalation-based general anesthesia (GA) for TURBT, focusing on induction and emergence time (IAET). METHODS: Forty-six patients who underwent TURBT were randomly assigned into either the MAC group or GA group. The primary outcome was the IAET. The secondary outcomes included hospital and anesthesia charges, safety (intraoperative hypotension and desaturation), and feasibility (surgeon and patient satisfaction) of both anesthetic methods. RESULTS: The MAC group demonstrated a significantly shorter IAET (14 vs. 25 min, CONCLUSIONS: Remimazolam-based MAC, guided by ANI monitoring, offers significant advantages including shorter IAET, reduced costs, and improved safety for TURBT, particularly in patients with small tumors. These findings support MAC as a promising alternative to GA for TURBT, as it enhances perioperative outcomes and operating room efficiency.