The aim was to offer men a minimally-invasive treatment option, which would also improve the efficiency of the care pathway, while also offering benefits to patients in terms of reduced complication risk and preserved sexual function. Urolift has been recommended by NICE (MTG 26) as a day case alternative to standard treatments, such as TURP and laser.
Initially, we introduced the service as a day case procedure in the theatre setting, but quickly established that, with use of a local anaesthetic protocol and rapid discharge, the service could be moved to an outpatient setting, thereby freeing up theatre capacity for other more urgent cases. This case study describes how we established a local protocol for Urolift that enabled us to transform the pathway, improve efficiency and maintain quality of care for men in Fife with BPH. Performing Urolift in an outpatient setting in the Day Treatment Unit, with a local anaesthetic protocol is now part of NHS Fife’s SOP.
Aims and objectives
- Establish a pathway and anaesthetic protocol to transition Urolift treatment of men with BPO from theatre to an outpatient setting.
- Establish Urolift as a day case procedure, according to the recommendations in the NICE guidance.
- Free up inpatient bed capacity.
- Free up theatre capacity.
- Establish a local anaesthetic protocol for Urolift that could be carried out without the need for anaesthetist presence.
- Collect data to measure procedural and patient outcomes when using local anaesthetic to perform Urolift.
- Establish ambulatory pathway.
Reasons for implementing your project
Fife has the third largest population in Scotland, with around 372,000 people. It is an aging population with around 20% of the population aged over 65. NHS Fife currently performs around 200 procedures each year to treat benign prostatic obstruction (BPO), a condition that increases in prevalence and severity with advancing age.
The standard of care for BPO is currently a transurethral resection of the prostate (TURP), which is a resective procedure to remove part of the prostate and disobstruct the urethra. TURP is an inpatient procedure, performed under a general anaesthetic and taking up to 90 mins of main theatre time.
Patients stay in hospital for 2-3 days before being discharged with a community catheter care plan and returning to outpatients a few days later for a Trial without Catheter. TURP procedures place a considerable burden on theatre time and inpatient beds, and contribute to the waiting list. Also, as TURP involves a resection of the prostate, complications such as bleeding and infection can occur, contributing to unplanned readmissions. There is also a risk of permanent side effects such as sexual dysfunction and incontinence.
Our plan was to bring about change in the way BPO was managed, in line with Realistic Medicine, NHS Scotland’s vision for person-centred care, while managing risks and innovating to improve. NICE guidance recommends Urolift as a minimally-invasive alternative to TURP for the treatment of BPO. Urolift is a short day case procedure, taking only 20-25 mins. It can be performed under a local anaesthetic, with or without light sedation, and patients go home after a few hours, typically without a catheter.
We sought to introduce Urolift as a treatment option for men with BPO as an alternative to TURP. We expected to increase theatre and inpatient bed capacity, as well as reduce waiting lists and readmissions due to complications.
After auditing our results from the first cohort of patients treated in a theatre setting, we observed that patients could be discharged within a few hours, regardless of the type of anaesthesia used. We were also established a local anaesthetic protocol, enabling us to perform the procedure without the need to sedate the patient and without the need for anaesthetist presence.
To free up even more theatre time and 23-hour stay beds, we put in place a plan to move the Urolift service to the outpatient clinic in the Day Treatment Unit.
How did you implement the project
In order to transform our pathway for men with BPO, we first needed to establish Urolift as a treatment option. A local business case was submitted and approved and funding was provided by the Scottish Government. We set up dedicated BPH clinics and developed local eligibility criteria to guide patient selection.
During the appointment, patients are assessed and available treatment options (including medical management) and patient expectations are discussed. For the first 4 patients, Urolift was performed in theatre, under a general anaesthetic. This was to ensure that the patient experience was not compromised during the early mentored period. Since this first list, all patients now receive only a local anaesthetic, using a protocol developed with the anaesthetist. The patient is cannulated prior to the procedure in a preparation room, and intravenous Gentamycin is administered. Optilube sterile gel is kept at 5°C in the clinical area. Two syringes of the gel are administered intra-urethrally by a trained member of the nursing staff, 15-20 minutes prior to the procedure. A penile/urethral clamp is applied to prevent leakage of the gel and maximise the effect of the anaesthetic. The clamp is removed immediately before the operation and two more syringes of anaesthetic gel are administered. If additional local anaesthetic is required during the procedure, additional Optilube gel is added. This protocol is now our SOP. During the consenting process, a very small number of men request a general anaesthetic, in which case they are wait-listed for a main theatre slot.
At the start of the procedure, if a patient does not tolerate the endoscopy under a local anaesthetic, the procedure is stopped and the patient is listed for a Urolift under a general anaesthetic at a later date. In our experience to date, this happens very rarely. We collected procedural and outcome data to compare local and general anaesthetic protocols.
Once a workable local anaesthetic protocol was established, and we were confident we could maintain quality of care and not compromise patient outcomes or experience, we looked for a suitable place within hospital to transition the procedure to an outpatient setting. With NHS Fife senior management and local theatre nurse support, we moved the Urolift service to the Day Treatment Unit (DTU), an outpatient clinic in Queen Margaret Hospital.
We performed our first ambulatory list in the DTU in December 2019. Audit data that informed our decision to move Urolift to outpatient setting are described below. Prior to transitioning the Urolift procedure to the outpatient clinic in the Day Treatment Unit, we collected data on 42 consecutive patients who underwent Urolift. Patients were assessed before and 3–4 months after surgery with the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) and quality of life questionnaires. Pain was measured on a visual analogue scale (VAS) in the recovery bay within 1 hour following the procedure. Of the 42 men assessed, 32 were treated under the local anaesthetic (LA) protocol described above and 10 under general anaesthetic (GA).
Our findings are described in the attached table.
- IPSS and Quality of Life scores were significantly improved in both groups, with no significant difference between the LA and GA groups.
- The 36 (85%) men who were sexually active had mean IIEF-5 score of 18 before and 18 after Urolift (range 16–18).
- The mean pain VAS score was 2, and not significantly different between the LA and GA groups.
- 2 patients had urinary retention after, 2 patients had a mild UTI, 6 reported temporary urinary urgency and 2 patients required irrigation postoperatively due to haematuria but did not require an overnight stay. Our positive findings gave us the confidence and the information we needed to transition the pathway to the outpatient setting. Our new pathway is described below.
- Patients attend a BPH clinic, where they are assessed.
- Treatment options are discussed with the patient. If the patient opts for Urolift, he is referred to the Day Treatment Unit
- On the day of the procedure, current medications, drug allergies and observations are recorded by a urology nurse. All patients who are on anticoagulation medication are requested to stop them 5 days pre-operatively in their appointment letter.
- The patient is consented by the Urology Consultant.
- The Urolift procedure is performed in an outpatient treatment room under a local anaesthetic. No anaesthetist is present
- After the patient voids twice, is comfortable and he has been reviewed by the operating surgeon, they are discharged. Post-op observations and pain score (1-10 scale) are recorded prior to discharge.
- A follow up appointment in the nurse lead BPH clinic is made for 3-4 months post-operatively.
Key learning points
To date, we have treated 61 men with Urolift instead of TURP, saving 61 theatre hours and 122 inpatient bed days. On one occasion, a patient had to be treated with Urolift at our main site under an elective general anaesthetic due to other co-morbidities.
- We have demonstrated that Urolift is easily performed in an outpatient setting, under a local anaesthetic and without an anaesthetist, while maintaining good clinical outcomes and patient experience.
- Eligible patients can be recruited from the BPH clinic or the urology waiting list.
- Average procedure time is 17 mins. Around 6-8 patients can be treated in a session.
- By treating patients with Urolift in an outpatient setting, the patient pathway for treating BPO can be dramatically simplified, without compromising patient outcomes or experience, with significant efficiency savings in terms of staff time, theatre time and inpatient bed days.
- The key to success is patient selection and establishing practical expectations.
- Urolift can be offered as a primary treatment.