Transrectal Ultrasound Guided Biopsy of the Prostate (2019)

1. INTRODUCTION

Topic

Transrectal ultrasound (TRUS)-guided prostate biopsy remains the gold standard for diagnosing prostate cancer, by which tissue samples of the prostate are obtained for histological analysis (http://www.erspc.org/prostate-cancer/erspc-background/). Ultrasound-guided biopsy is now sometimes combined with MRI to characterise suspicious lesions in the prostate. An increasing number of nurses now undertake this procedure independently. The role of nursing continues to progress and to cross professional boundaries.

Aim

The aim of these guidelines is to assist in the professional development of nurses carrying out TRUS biopsy, while ensuring patient safety, dignity and comfort, and the delivery of the highest quality patient care. [1] These guidelines provide a benchmark against which the individual can be measured and their competence assessed. It may also inform those practitioners not directly involved in the procedure as they support patients.

Intended users

These guidelines are intended to complement and support clinical practice of new practitioners and those seeking updates on best practice. The intended readership is specialist urology nurses and other health care professionals working in urology or prostate cancer diagnostics. It is acknowledged that there is wide variation in nursing titles: for the purpose of this document, the term specialist nurse is used to mean nurses undertaking this advanced practice role. It is acknowledged that throughout Europe nurses have different levels of involvement with the biopsy procedure.

Inclusions

These guidelines include anatomy and physiology of the prostate, aetiology of prostate cancer, steps to undertake the biopsy procedure, pre-biopsy considerations, post-biopsy complications, and knowledge and understanding required by health care professionals to carry out the procedure.

Limitations

These guidelines are limited to transrectal ultrasound-guided biopsy and do not include ultrasound-guided transperineal biopsy and other imaging technologies (e.g. magnetic resonance imaging; MRI) used for prostate cancer diagnosis, although the working group recognises that these approaches are becoming more widely used.

These guidelines should be used within the context of local policies and existing protocols.

Rationale

In the European Union prostate cancer is currently the most frequently diagnosed cancer among men. [2] This has led to an increased demand for TRUS-guided prostate biopsy for prostate cancer diagnosis.

Workforce

An ongoing workforce problem continues in Europe where the medical profession remains under constant pressure to deliver high-quality clinical services in a timely and cost-effective manner. This requires nurse specialists to perform routine diagnostic services as a solution. To accelerate the prostate cancer patient journey, an increasing number of nurses working within the specialty are now performing prostate biopsies independently. Nurse-led prostate biopsy has highlighted improved access, reduced patient waiting time, and an enhanced patient journey with continuity of care. [3]

Skills and development

The ability to undertake prostate biopsy competently and safely is a developmental process and is only expected of specialist health care professionals, such as specialist nurses, physician assistants, or urologists, who are technically skilled as well as rational decision makers. The practitioner should:

• hold an expert understanding of the prostate cancer patient journey, including the risks, benefits, complications and disadvantages of undertaking prostate biopsy;
• have a comprehensive understanding of the anatomy and physiology of the male urinary system, factors that affect prostate-specific antigen (PSA) measurement, and other conditions of the urinary system and their management;
• have an understanding of the role of TRUS and possible ultrasound findings; and
• be familiar with the possible complications of TRUS and their management, and always ensure that senior staff are available should an emergency situation arise.

Supervision from an expert practitioner is necessary during the training period and auditing the procedure performed by nurses to measure clinical outcomes is important to support future accreditation. [3,4] Ultimately, competence for independent practice should be assessed by the senior urologist.

Specialist-nurse-led prostate biopsy allows professional development, as expansion of the role suggests that nurses in this position should be proficient with history taking and physical examination, alongside performing the procedure itself. [5]

All independent practitioners are responsible for their continuing professional development in relation to prostate cancer and prostate biopsy and must work within their own professional code of conduct.

Non-physician versus physician performance (PICO 4)

The Hori (2013) study and several audits have contributed to the evidence that an adequately trained non-physician provider is able to perform TRUS-guided prostate biopsy as effectively as an experienced urologist after an initial learning curve. To reach a level of competence, at least 50 biopsy procedures are needed. [5–9]