Résumé
Introduction & Objective: Prostate Biopsy remains the gold standard for histological confirmation of prostate cancer. The near exponential increase in the need for biopsies, in selected men, has ushered an evolving need for improving detection rates while reducing side effects. Diagnostic accuracy and infection complication rates remain obstacles in transrectal prostate biopsy. PrecisionPoint is a disposable, low cost device which enables transperineal biopsy in the outpatient setting under local anaesthetic. We present data from a predominantly nurse-performed LATP service using PrecisionPoint, which was newly started in July 2019. Initial indications were;repeat biopsy, anterior lesions, and active surveillance patients. Service was expanded in March 2020 to all prostate pathway patients following national COVID guidance. Methods: All patients underwent prebiopsy MRI and dedicated image-review meetings. Biopsies were performed in PIRADS 3-5, or PSAD >0.15. PIRADS 3-5 lesions were targeted with ≥3 cores (sent separately). Systematic Ginsburg protocol biopsies were also performed (each zone sent separately). Tamsulosin was started for BOO patients. No antibiotics were used unless immunocompromised or previous sepsis. A prospective database at point of care was created detailing patient information, MRI and biopsy characteristics. Patient Reported Outcome Measures (PROMs) are collected. Histology and complications are also reported. Results: 750 consecutive patients analysed. Detection of significant cancer (Gl ≥3 + 4) in PIRAD1-2, 3, 4, 5 groups was 25%, 40%, 59%, 92% respectively. Systematic biopsy alone detected significant cancer in 36%, systematic plus targeted achieved 63%. Of AS patients;40% with Gl3 + 3 were upgraded, and 49% with Gl3 + 4 were upgraded to Gl ≥4 + 3. 5 experienced vasovagal episodes. Only 5 patients were readmitted (0.6%): 2 UTI, 2 AUR, 1 urosepsis. PROMs demonstrated majority favourable results regarding pain (98%), discomfort (97%), embarrassment (96%) and further biopsies (89%). Conclusions: Adoption of this new technology into an integrated prostate cancer diagnostic pathway has enabled us to set up a safe, effective, antibiotic free LATP biopsy service in the outpatient setting. Data shows high cancer detection rates and low complication rates. PROMs data suggests this iswell tolerated by patients.
Résumé
Introduction & Objective: The management of patients with ureteric stones can be logistically challenging in large volume centres with long waits for outpatient clinics and definitive interventions. Many units in publicly funded health systems resort to temporising obstructed kidneys with stent insertion and a subsequent plan for elective ureteroscopy at a later date. This can result in unnecessary stent insertions, repeated attendances to the emergency department and an overall poor experience for patients. We aimed to reorganise resources to improve waiting times for definitive intervention, reduce the need for pre-stenting, reduce emergency department re-attendance and improve the overall patient experience. Methods: All patients diagnosed with ureteric stones between March-September 2017 were collected as baseline data. Time to clinic review and definitive treatment were measured. By collaborating with the emergency department, radiology and operation schedulers, our intervention for improvement where a consultant led acute stone clinic (ASC) with a pathway for primary ureteroscopy was implemented and a second cycle was performed June 2018-January 2019. Further data was collected January-October 2020 to assess performance during the COVID-19 pandemic. Results: After implementing the ASC model, median time from diagnosis to clinic consultation reduced from 77 to 9 days. Median time to definitive procedure reduced from 56 to 25 days. Emergency ureteric stent insertion reduced from 69.1% to 27.9%. Reattendance to the emergency department reduced from 3.0 to 1.6 episodes/month. Primary definitive treatment increased from 31.0% to 72.1%. Patients receiving definitive treatment within 4 weeks improved from 26.2% to 51.2% post intervention and sustained at 54.5% during the pandemic period. Conclusions: Implementation of the ASC model has led to a reduced time from diagnosis to clinic review and from diagnosis to definitive treatment. Further improvement is limited by the lack of extra operating lists to reduce the waiting times for ureteroscopy. The ASC model can provide a blueprint for other hospitals to improve outcomes and care of patients with acute ureteric stones.
Résumé
INTRODUCTION AND OBJECTIVE: A LATP service using PrecisionPoint™ was newly started in July 2019, with procedures performed by both surgeon and nurse practitioners. Initial indications were: repeat biopsy, anterior prostate lesions, and Active Surveillance patients. Service was expanded in March 2020 to all prostate pathway patients according to British Association of Urology COVID guidance. METHODS: All patients underwent prebiopsy MRI and dedicated image-review meetings. Biopsies were performed in PIRADS 3-5, or PSAD>0.15. Systematic Ginsburg protocol biopsies were performed for all patients (each zone sent separately), and PIRADS 3-5 lesions were targeted with ≥3 cores (also sent separately). Alpha-blockers were started for patients with Bladder Outlet Obstruction. No antibiotics were used unless patients were immunocompromised or had a previous history of urinary sepsis. A prospective database at point of care was created detailing patient demographics, MRI and biopsy characteristics. Patient Reported Outcome Measures (PROMs) are collected. Histology and complications are also reported. RESULTS: 750 consecutive patients are analysed. Detection of clinically significant prostate cancer (Gl≥3+4) in PIRADS 1-2, 3, 4, 5 groups was 25%, 40%, 59%, 92% respectively. Systematic biopsy alone detected clinically significant cancer in 36%, whereas systematic plus targeted biopsy achieved 63%. Of Active Surveillance patients;40% with Gl 3+3 were upgraded, and 49% with Gl3+4 were upgraded to Gl≥4+3. n=5 (0.6%) experienced vasovagal episodes causing delayed discharge. Only n=5 patients were readmitted (0.6%): 2 urinary tract infection, 2 acute urinary retention, 1 urinary sepsis. PROMs demonstrated majority favourable results regarding pain (98%), discomfort (97%), embarrassment (96%) and further repeat biopsies (89%). CONCLUSIONS: We have set up a safe, effective, antibiotic free LATP biopsy service, with high cancer detection rates and low complication rates. PROMs data suggests this is well tolerated by patients.
Résumé
Introduction: A predominantly nurse-performed LATP service using PrecisionPoint was newly started in July 2019. Initial indications were repeat biopsy, anterior lesions, and AS patients. Service was expanded in March 2020 to all prostate pathway patients according to BAUS COVID guidance. Methods: All patients underwent prebiopsy MRI and dedicated image-review meetings. Biopsies were performed in PIRADS 3-5, or PSAD >0.15. PIRADS 3-5 lesions were targeted with 3 cores (sent separately). Systematic Ginsburg protocol biopsies were also performed (each zone sent separately). Tamsulosin was started for BOO patients. No antibiotics were used unless immunocompromised or previous sepsis. A prospective database at point of care was created detailing patient information, MRI and biopsy characteristics. Patient Reported Outcome Measures (PROMs) are collected. Histology and complications are also reported. Results: 750 consecutive patients analysed. Detection of significant cancer (Gl3+4) in PIRAD1-2, 3, 4, 5 groups was 25%, 40%, 59%, 92% respectively. Systematic biopsy alone detected significant cancer in 36%, systematic plus targeted achieved 63%. Of AS patients;40% with Gl3+3 were upgraded, and 49% with Gl3+4 were upgraded to Gl4+3. 5 experienced vasovagal episodes. Only 5 patients were readmitted (0.6%): 2 UTI, 2 AUR, 1 urosepsis. PROMs demonstrated majority favourable results regarding pain (98%), discomfort (97%), embarrassment (96%) and further repeat biopsies (89%). Conclusion: We have set up a safe, effective, antibiotic free LATP biopsy service, with high cancer detection rates and low complication rates. PROMs data suggests this is well tolerated by patients.