5 Insights from the NHS

Frimley Health NHS Foundation Trust

Frimley Park Hospital, part of Frimley Health NHS Foundation Trust, is a district general hospital located in Surrey which serves a population of more than 400,000 across north‑east Hampshire, west Surrey and east Berkshire. It has 750 beds and 4200 staff.

The urology department at Frimley Park Hospital comprises 4 consultant urological surgeons. The team offers TURis, the GreenLight laser and the UroLift procedure as options for men with BPH. The hospital does 250–300 surgical interventions per year for BPH.

Having taken part in the BPH6 trial[1], which compared the UroLift system with TURP, the team championed UroLift as an intervention that should be routinely offered to NHS patients. A lead project team was established, which consisted of a consultant urological surgeon, a nurse specialising in lower urinary tract symptoms and a deputy directorate manager.

At the end of the trial the team developed a business case to approve the use of the UroLift system on a routine basis. Although the national tariff is likely to change in the future, the 2015/16 national tariff system (2015/16) does not cover the full cost of the UroLift system so the business case needed to emphasise the clinical and financial benefits for the trust and men before final approval was given. The business case focused on the following:

  • that the procedure can be done as a day case

  • UroLift is associated with low readmission rates

  • careful patient selection (suitable for day case, prostate size).

The surgeon who was trained for participation in the trial started to offer the UroLift procedure to NHS patients in October 2014.

The UroLift procedure is done in the operating theatre by the consultant urological surgeon with the support of the theatre staff, meaning that training is needed for everyone involved. The manufacturer organised and funded the surgeon's training at the start of the trial, which involved:

  • watching at least 2 cases

  • practising on a simulator and model

  • undertaking cases in theatre at Frimley Park under the mentorship of a manufacturer representative.

The manufacturer also trained theatre staff in ordering and handling the single‑use delivery device and implants.

As the surgeon became more confident the team moved from using general anaesthesia and urinary catheterisation to doing the procedure under sedation and without urinary catheters. All UroLift procedures at Frimley Park are done by 1 trained surgeon, so there are enough cases to allow the development of expertise in this procedure. On average, the surgeon uses 3 implants per procedure. At Frimley Park Hospital the procedure is generally only done on prostate sizes 60 ml or less. The surgeon noted that as their experience has increased, they have needed to use slightly fewer implants per procedure.

Men are selected (that is, they are suitable for a day‑case procedure) and identified for the procedure using the existing care pathway for BPH, although the team have made some changes to the pathway to better incorporate the UroLift system (see below). This involves a nurse specialist and a GP with special interest or a consultant urological surgeon assessing all men referred to secondary care. Men at the surgical stage of the pathway (that is, where symptoms are severe and conservative management has failed or is inappropriate) for whom surgery is an option are given information about all appropriate surgical options, including the UroLift procedure. They are then seen by a consultant urological surgeon to discuss these options in more detail. Men who choose the UroLift procedure are generally those who wish to preserve their sexual function or do not want TURP. There is currently demand for the procedure from men outside the hospital's usual catchment area. This is provided for those who have funding agreed from their local clinical commissioning group.

The team has made a number of changes to the care pathway for BPH to incorporate the UroLift system, including:

  • Assessing the size of the prostate and the presence of a middle lobe by cystoscopy (or in some cases ultrasound). This often means an additional outpatient appointment and is not part of the routine pathway for BPH.

  • After confirmation that the UroLift procedure is appropriate, the patient follows the same day‑case pathway as all other urological day‑case procedures, including the GreenLight laser.

  • Following patient discharge, the nurse follows up by phone at 3 weeks and again at 3 months.

The surgeon aims to carry out a number of UroLift procedures in the same theatre session in order to maximise capacity. The number of UroLift procedures that can be done in a single session is limited by the number of tailored scopes available in the hospital (each of which needs to be sterilised between use).

The nurse specialist collects post‑procedure data including symptom scores and patient satisfaction, in line with the BPH 6 trial.

Table 1 BPH procedures done in Frimley Park Hospital

Procedure

Number of procedures: September 2014 to September 2015

Admission status

Estimated theatre time (minutes)

UroLift

75

Day case

25

TURis

190

Inpatient

60

GreenLight

80–90

Day case

60

The team concluded that compared with TURP, using the UroLift system:

  • reduces the number of formal follow‑up appointments (of the 75 procedures done, only one needed a subsequent clinic appointment)

  • may increase the number of interventions done in 1 theatre session because of a faster procedure time

  • improves post‑procedure symptoms and patient satisfaction with respect to quality of recovery and preservation of sexual function

  • reduces readmission rates particularly for urosepsis and bleeding.

The adoption of the UroLift system at Frimley Park Hospital has been driven by the urology surgeons' view that patient satisfaction and quality of life for men at the surgical stage of the pathway will be enhanced if they are offered more choice about management of their symptoms. The team plan to explore how a specific UroLift procedure pathway can be developed, including how it could be offered in an ambulatory setting alongside other simple urological procedures.

St Helens and Knowsley Teaching Hospitals NHS Trust

St Helens and Knowsley Teaching Hospitals NHS Trust provides a range of acute healthcare services including inpatient, outpatient, maternity and emergency services across Whiston and St Helens hospitals. The urology department at the trust comprises 5 consultant urological surgeons. The team offers the following surgical interventions for men with BPH: bipolar and monopolar TURP, HoLEP, TUIP and the UroLift procedure. Four surgeons are trained in using the UroLift system. The team does over 200 surgical interventions for BPH per year.

The consultant urological surgeons actively seek new technologies and developments to improve their clinical practice. Aware of the problems around sexual function that can happen as a result of treatment for BPH, they were interested in the UroLift system when it became available on the UK market. They considered that the device's FDA approval, supportive NICE guidance and available data all supported the case for adoption.

The trust formed a project team that comprises the clinical director of urology (clinical champion), the directorate manager, the directorate accountant and the directorate business manager. A pilot project was planned and sanctioned through the trust's 'new technology' process, with final approval from the chief executive. Information provided included:

The UroLift system pilot started in autumn 2014. A pilot approach has allowed the department to control numbers, monitor results and ensure they are properly equipped to offer the procedure to all eligible men once an appropriate national tariff is agreed.

Before implementing the device, 4 of the consultant urological surgeons undertook the manufacturer's training programme. The manufacturer also trained theatre staff in equipment handling and the ordering process for consumables.

Men are referred to the consultant urological surgeons using the existing care pathway for BPH, through a number of routes:

  • referral from the prostate assessment clinic (which receives referrals from GPs)

  • direct referrals from GPs and other urologists

  • identification of hospital in‑patients (men with retention).

Most men who choose the UroLift procedure do so in order to preserve their sexual function or to specifically avoid TURP. Before the procedure, men have a flexible cystoscopy (or in some cases ultrasound) to assess their suitability for the UroLift procedure.

In the pilot, the UroLift procedure is offered to men with BPH who have a small to moderate prostate with no middle lobe and low anaesthetic risk. Any men having the procedure are added to the day‑case list. The care pathway for a urological day case is well established in the trust because of the many other urological procedures it offers. The pre‑operative process for a UroLift procedure is relatively simple (unlike, for example, TURP, which requires blood group and cross matching). The procedure itself is done under general anaesthetic. Four implants are needed per procedure, although a smaller prostate may only require 3. If a urine catheter is used, it is removed 4 hours after the procedure. If there are no complications the patient is discharged in line with the existing urology criteria‑led discharge policy.

After the procedure, follow‑up involves an outpatient appointment at 4 weeks followed by another at 12 weeks. The department plans to review this follow‑up schedule when more men have had the procedure.

All men who have had the UroLift procedure are entered onto a specifically designed in-house database. Pre‑ and post‑operative International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) scores are recorded and entered onto the database by a clinical fellow.

Table 2 BPH procedures done in St Helens and Knowsley Teaching Hospital NHS Trust

Procedure

Number of procedures: January 2015 to June 2015

Average length of stay

Estimated theatre time (minutes)*

UroLift

7

N/A (day case)

10–30

Bipolar TURP

75

1–2 days

30–75

Monopolar TURP

17

1–2 days

30–60

HoLEP

6

1–2 days

60–120

Bladder neck incision/TUIP

5

1–2 days

10–30

*Excluding 35 minutes induction and recovery time in all cases.

As the surgeons become more confident in their skills they anticipate that the UroLift procedure will be done without catheterisation and more quickly under sedation or local anaesthetic, with recovery in a comfortable chair and discharge the same day. The urology team is also considering whether the UroLift system could be used to address incontinence and the need for long‑term catheterisation in older men with multiple comorbidities for whom TURP is not suitable. The team is currently in discussions with the trust's continence service to explore this further.



[1] Sønksen J, Barber NJ, Speakman MJ, et al. (2015) Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12‑month results from the BPH6 study. European Urology.


This page was last updated: 27 April 2017