Everyone knows that Brexit didn't happen on 29 March 2019, but ‘TRexit’ did—and it is great news for prostate cancer patients.
Confused? 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 (LATP). The roots of the initiative are in the South East London (SEL) Accountable Cancer Network, where hospitals set a deadline of 29 March (original ‘Brexit day’) to eliminate TRUS procedures. Unlike politicians, we have delivered: in place of TRUS biopsies, LATP are being safely carried out by nurses and clinicians in outpatient settings.
It is a great story—and one that, once again, underlines the important role that urology nurses play along the prostate cancer pathway. Ultimately, greater adoption of LATP paves the way for advanced nurse practitioners (ANPs) to provide even greater value in the delivery of safe, timely and efficient care. For urology nurses this is an opportunity to drive positive change.
The urology pathway story at the SEL network is a great example of collaborative, multidisciplinary change management and I am proud to be playing my part. Having been a urology clinical nurse specialist (CNS) for many years, in 2018, I took on a new role as ANP for the network to establish fully operational LATP clinics across all our hospitals: Guy's and St Thomas', King's College, Queen Elizabeth, Lewisham and Greenwich, Beckenham Beacon, and the Princess Royal University. The appointment, championed by consultant urologist and NHS innovation accelerator Rick Popert, made me the first ANP to work for the entire network, rather than a single trust.
It is increasingly recognised that there are risks in traditional TRUS biopsies, with evidence that they can yield inaccuracies in identifying potential cancer cells, while the nature of the procedure brings an increased risk of infection. Uptake of the alternative, transperineal (TP) approach 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. However, the latest advances in transperineal biopsy, such as the PrecisionPoint Transperineal Access System, have made the technique available under local anaesthetic through a freehand approach that allows the practitioner to manoeuvre the ultrasound probe to align the access needle to target the location for biopsy. It is a safer, more accurate method to detect potential cancer cells at an earlier stage, with lower costs and fewer side-effects.
A major advantage of the PrecisionPoint technique is that it can be conducted by nurses in outpatient settings. As such, LATP biopsy presents a fantastic opportunity to put CNSs at the forefront of clinical practice to add huge value to a cancer pathway. To make the most of it, urology nurses, particularly those already well versed in TRUS-guided biopsies, require specialist training in LATP techniques. This training is at the heart of my role.
In view of the coronavirus outbreak, the SEL Cancer Alliance has worked hard to arrange a COVID-19 secure outpatient environment, with appropriate PPE to reduce risk of transmission between clinician, staff and patients. On arrival, patients have a temperature check, routine observations and complete a COVID-19 health questionnaire, having been asked to self-isolate for 2 weeks beforehand. These processes have allowed us to perform LATP prostate biopsies for patients stratified as high risk in a safe outpatients setting.
My work to date has been challenging, but rewarding. At 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 LATP in each trust. This required conducting comprehensive needs assessments and addressing these in line with the 29 March deadline. The bulk of my work, however, has looked beyond ‘set-up’, focusing on training and, in particular, giving urology nurses the confidence to carry out the procedure. This sees me journey daily from hospital to hospital, to demonstrate, train and guide nurses in performing LATP.
LATP training is not a one-off activity where clinical staff are upskilled overnight. It takes around 6 weeks, or 18–25 biopsies, to train a nurse. However, by the third or fourth biopsy, many are controlling the procedure themselves and require only verbal guidance and support.
At local level, my goal is to ensure all SEL hospitals (and teams) are self-sufficient when my secondment ends in March 2021. However, TRexit is not limited to South East London, it is a national initiative. As such, we have also developed a BAUN-accredited national training programme to increase the number of NHS nurses skilled in LATP. I know from personal experience that nurses' training needs differ from those of other practitioners. We have therefore developed a learning experience that can be tailored to suit varied levels of experience and knowledge. It is a testament to the effectiveness of that training—and the determination and talent of the nurses involved—that we have managed to achieve rapid change across our hospitals. The challenge now is to push that innovation out across the NHS. Fortunately, with the consensus and support of leading urologists, CNSs and policymakers in prostate cancer diagnosis, TRexit is building a national momentum that should help other hospitals replicate our success.
My work as ANP has reinforced my conviction that nurses can play a significant role in prostate cancer care. The emergence of LATP is a big opportunity for nurses to cement their place at the heart of that pathway. The LATP technique is a skill that can be learnt, and up and down the country we are showing that nurses can do it at a very high level.
For nurses it is a offers career progression. For the NHS and, most importantly, patients, it is an opportunity to offer faster, safer and more cost-effective prostate cancer care and better outcomes. Forget Brexit—it's all about TRexit, with urology nurses leading the way.