The Scalpel's Blog

Urology nurses are leading the way in adoption of prostate cancer biopsy technique

Jonah Rusere, Advanced Nurse Practitioner for South East London Accountable Cancer Network, outlines an opportunity for urology nurses to make a difference to prostate cancer pathways.

What is TRexit and why is it great news for prostate cancer patients all over the country?

Let me explain.

TRexit is the name given to a national initiative for hospitals to phase out TRUS biopsies and replace them with transperineal biopsies under local anaesthetic (LA TP).

The roots of the initiative are in the South East London Accountable Cancer Network, where hospitals set a date of 29 March to eliminate TRUS procedures.

It’s a deadline that, unlike our politicians, we’ve met: TRUS biopsies have left the building, and in their place, LA TP biopsies are being safely carried out by nurses and clinicians in outpatient settings.

It’s a great story – and it’s one that once again underlines the important role that urology nurses play along the prostate cancer pathway. Ultimately, greater adoption of LA TP paves the way for Advanced Nurse Practitioners to provide even greater value in the delivery of safe, timely and efficient care, fuelling a better patient experience and better patient outcomes. For urology nurses, ever passionate about patient care, this is our opportunity to drive positive change and make a difference. These are exciting times for the profession.

The urology pathway story at South East London (SEL) Accountable Cancer Network is a great example of collaborative, multi-disciplinary change management. I’m proud to be playing my part.

Last November, having been a urology Clinical Nurse Specialist (CNS) in London for many years, I took on a new role as an Advanced Nurse Practitioner (ANP) for the network on a one-year secondment to establish fully operational LA TP clinics across all our hospitals; Guy’s & St. Thomas’, King’s College, Queen Elizabeth Lewisham & Greenwich, Beckenham Beacon and the Princess Royal University. The appointment, championed by consultant urologist and NHS Innovation Accelerator Mr Rick Popert, made me the first ANP to work for the whole Network, rather than a single trust. Mr Popert is a leading advocate of LA TP biopsies and has done much to raise awareness of their clinical and operational benefits.

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It’s increasingly recognised that there are risks in traditional TRUS biopsies compared to LA TP; there’s evidence that TRUS biopsies can yield inaccuracies in identifying potential cancer cells, while the nature of the procedure brings an increased likelihood of infection. Uptake of the alternative, transperineal (TP) approach - while providing a more thorough sampling of the prostate with less risk of infection - has historically been hampered by its need to be conducted under a general anaesthetic, leading to increased costs, longer waiting lists and subsequent delays in diagnosis. Patients whose biopsies are delayed are more likely to breach. 

However, advances in transperineal biopsy techniques means the procedure can now be performed under local anaesthetic through a freehand approach with certainty for targeted and systematic biopsies. It represents a safer and more accurate method to detect potential cancer cells at an earlier stage of progression, with lower costs and fewer side effects including sepsis. The technique has been operational at St. Guy’s & St. Thomas’ Hospital for over a year and has transformed clinical practice. The opportunity to spread this innovation – and all its inherent gains – across the NHS is something we cannot afford to squander. 

A major advantage of the technique is that it does not need to be carried out by doctors or surgeons – it can also be conducted by nurses in outpatient settings. As such, the emergence of LA TP biopsy presents a fantastic opportunity to put clinical nurse specialists at the forefront of clinical practice to add huge value to a cancer pathway that – at the national level – is under increasing demand. To make the most of it, urology nurses – particularly those already well-versed in TRUS guided biopsies – require specialist training in LA TP techniques. This training is at the heart of my role as ANP for the network.

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My work to date has been varied, challenging but highly rewarding. At the SEL network level, all trusts had agreed to make the move away from TRUS, so my first priority was to establish the infrastructure and processes for LA TP in each Trust.

This required conducting comprehensive needs assessments that looked at everything from equipment, staffing, clinical workflows, diagnostic pathways and training requirements – and addressing those needs in line with the 29 March deadline.

The bulk of my work, however, has looked beyond ‘set-up’, focusing on training staff and, in particular, giving nurses the confidence to carry out the procedure. This manifests itself in a daily experience that sees me journey from hospital to hospital across the network, working – quite literally – hand-in-hand with urology nurses to demonstrate, train and guide them in performing LA TP on real-world patients. 

LA TP training is not a one-off activity where clinical staff – encompassing nurses, registrars and doctors – are upskilled overnight. Urology nurses – even those well-skilled in traditional TRUS biopsies – are understandably nervous when introduced to the new technique. On average, it takes around six weeks, or between 18 and 25 biopsies, to train a nurse. However, by the third or fourth biopsy, many are controlling the procedure by themselves and require only verbal guidance and support. It’s hugely rewarding for both parties.

At the local level, my goal is to ensure that all SEL hospitals (and teams) are self-sufficient when my secondment concludes in November 2019.  But the move away from TRUS biopsies is not limited to South East London – it’s a national initiative, designed to support and drive adoption of LA TP across the NHS. As such, we’ve also developed a BAUN accredited national training programme to increase the number of NHS nurses skilled in LA TP. I know from personal experience that nurses’ training needs differ from those of other HCPs.

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We’ve therefore worked hard to tailor a learning experience that’s personalised for nurses and flexes to suit varied levels of experience and knowledge. It’s a testament to the effectiveness of that training – and the determination, passion and talent of the nurses that have undertaken it – that we’ve managed to achieve rapid change across our hospitals in South East London.

The challenge now is to push that innovation out to all corners of the NHS. Fortunately, with the consensus and support of leading urologists, clinical nurse specialists and thought leaders in prostate cancer diagnosis, the move to adopt LA TP is building a national momentum that will hopefully help other hospitals replicate that SEL success.

Fundamentally, my work as ANP has only reinforced my belief that nurses can play a significant role in prostate cancer care. The emergence of LA TP is a big opportunity for nurses to cement their place at the heart of that pathway. The LA TP technique is a skill that can be learned – and up and down the country, we’re showing that nurses can do it at a very, very high level. 

For the nursing profession, it’s a platform for career progression. For the NHS and – most important of all – its patients, it’s an opportunity for quicker, safer and more cost-effective prostate cancer care, and better patient outcomes. 

Best of all, it’s urology nurses leading the way.