Insights from the NHS: adoption of UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia at St Helens and Knowsley Teaching Hospital NHS Trust

Aims: Enhance the quality of care offered to men with BPH by making available an additional option for surgical management

Objectives:

• Offer men in whom it was clinically indicated, the option of the UroLift procedure, in addition to all other clinically appropriate options
• Increase capacity for surgical interventions for BPH by introducing UroLift
• Reduce the number if inpatient bed stays for patients undergoing surgical management of BPH
• Offer a management option for men who wish to preserve their sexual function

The urology department at St Helens and Knowsley Teaching Hospitals NHS 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:

• benefits to the trust (reduced admissions, reduced theatre time)
• potential future cost savings (despite there being a current shortfall between the cost of the procedure and payment)
• benefits for men (preserved sexual function, less post-operative pain, quicker return to work)
• NICE interventional procedure guidance on insertion of prostatic urethral lift implants to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia.

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.

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.

Table 1 BPH procedures done in St Helens and Knowsley Teaching Hospital NHS Trust

This case study has been adapted from the ‘NICE medical technology adoption support for UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia – insights from the NHS' which presents adoption experiences at 2 NHS sites. Overall key learning for both sites were:

• Before implementation, collect baseline data on current surgical interventions and develop data collection mechanisms to monitor how the technology affects quality and safety, patient experience, productivity and improved clinical outcomes.
• Ensure that care pathway mapping has been done to identify where the technology would fit into the proposed patient pathway. Clearly define the selection criteria and how many men will be expected to benefit from the introduction of the procedure.
• Providers and commissioners will need to agree a local tariff for the procedure that supports adoption.
• Oversee a trial period for training before doing the procedure independently to increase clinical confidence and efficiency.
• Develop robust protocols for procedure competence and ensure local governance arrangements are in place.