Infrastructure

Before commencing the delivery of an outpatient service for minimally invasive BOO procedures, the appropriate supporting staff and resources are required. This includes an admission bay where the patient can be consented and changed into a theatre gown. Staff should include at least a trained nurse, preferably a clinical nurse specialist (CNS) in BPE, and a supporting healthcare assistant (HCA). The same admission bay can be used for post procedure observations and recovery before discharge. A dedicated Consultant-led weekly clinic has been set up to deliver this service in our unit.

Room setup

The ultrasound machine (BK3000) is placed on the right side of the patient couch, and the cystoscopy stack and Rezūm™ machine on the left side at the head of the couch (Fig. 1). The scrub trolley is situated on the left of the surgeon’s chair at the foot of the couch.

Fig. 1

Room setup with ultrasound machine to the right of the couch, and cystoscopy stack, IV drip stand, Rezūm™ machine and scrub trolley to the left

Fig. 2

Scrub trolley equipment setup

Equipment setup

The scrub trolley includes (Fig. 2):

Chloraprep 3 ml applicator.

Antiseptic cleaning solution (0.015% chlorhexidine gluconate + 0.15% Centrimide).

Rampleys and gauze.

Under buttock drape, leg drapes and abdominal drape.

Two 11 ml syringes of local anaesthetic gel.

10 ml 1% lidocaine with adrenaline 1:200,000 attached to a blue hypodermic needle.

20 ml 1% lidocaine without adrenaline attached to a spinal needle (20G).

PrecisionPoint™ Transperineal access system with 15G access needle.

Marker pen.

Rezūm™ device.

30-degree cystoscope and camera and light lead in sterile cover.

Ultrasound setup

A biplane linear ultrasound probe 7 Hz is used. 3 M™ Coban™ 2 layer compression system is wrapped around the proximal end of the ultrasound probe to increase the diameter and improve the grip for mounting the PrecisionPoint™ Transperineal access system. The transducer cover (Civco) tip is inverted. A 50 ml bladder syringe filled ultrasound gel is used to inject 5-10 ml of gel in the inverted tip being careful to evacuate any air bubbles that may be present in the gel surrounding the tip of the transducer probe. The cover is then fitted over the shaft of the probe and secured with two rubber bands at the base after wiping any excess gel from proximal end of the probe. (Fig. 3)

Fig. 3

Biplane linear ultrasound probe 7 Hz with 3 M™ Coban™ wrapped around proximal shaft and a transducer cover with ultrasound gel secured with rubber bands at the base. PrecisionPoint access system over proximal shaft

Patient setup

2 × 11 ml local anaesthetic refrigerated gel syringes (we use gel that contains 2% Lidocaine) are inserted into the patient’s urethra. A penile clamp is applied over gauze around the distal shaft of the penis for 2 to 5 min. The patient is placed in the lithotomy position on the couch with a nurse or HCA at the head end to converse with the patient throughout the procedure.

Procedure

The ultrasound probe with PrecisionPoint access system mounted is inserted into the lubricated rectum. The prostate is visualised, and the lateral aspect identified. The perineal skin is marked where the access needle is pointing. The perineal skin is sterilised with Chloraprep applicator. Ethyl chloride spray is applied to the perineal skin followed by subcutaneous infiltration of 5 ml 1% lidocaine with 1:200,000 adrenaline on each marked side. The access needle punctures the skin at the marked site and advanced into the perineal tissue. The spinal needle is advanced through the access needle. The neurovascular bundle at the most lateral aspect of the prostate lobe is identified between the prostate and the seminal vesicle, and infiltrated with 10 ml 1% lidocaine on each side, ensuring the injectate is in the correct plane. The ultrasound probe is removed from the rectum.

The penile clamp is removed, and patient is prepared with antiseptic solution, then draped. Two further 11 ml syringes of local anaesthetic and antiseptic gel are instilled into the urethra. The Rezūm™ device is primed to ensure irrigation is running appropriately and steam comes through the needle. The Rezūm™ device with cystoscope is advanced into the urethra and a urethrocystoscopy is performed. The configuration of the prostate is inspected, and a decision is made on the number of treatments to each lobe according to the length of the gland. The needle is deployed at each point of treatment within the prostate gland on either side.

Whilst rotating the delivery device 90 degrees laterally, the needle is deployed and fully inserted into the prostatic tissue up to the black depth marker ensuring that the emitter holes are within the prostatic tissue. The vapour activation button is pulled and held until the treatment cycle is complete. The vapour activation button is released, and the needle retraction button is pressed to retract the needle. Further treatments in the same manner are given as appropriate. The patient is monitored for pain throughout the procedure. The device is removed and a two way 14-16Fr urethral catheter is inserted urethrally with 10 ml water in the balloon. The drapes are removed, the patient taken to the recovery area for monitoring, and a Visual Analogue Pain score filled in, by the patient, to reflect the pain during the procedure itself (0 being no pain and 10 is maximum pain). We do not routinely give any further post operative analgesia either immediately or at discharge. The patient may take simple analgesia at home if they require it.

Post-operative follow-up

The urethral catheter is removed in 5–7 days at the Urology out-patient clinic with post-void residual to ensure a successful removal. Patients are instructed to stop any alpha blockers at 6 weeks. Patients may contact the specialist nurse at any time postoperatively if there is a problem, however all patients are routinely followed-up at a dictated BPE clinic at approximately three months by the CNS with uroflowmetry study and residual volume. An IPSS [7] and IIEF-5 [8] qualitative questionnaire are also recorded at the time as this is considered as an ejaculatory-sparing procedure. The patients are also asked about any change to the quality of their ejaculate post-operatively.

Data collection

We collect anonymised data retrospectively into a dedicated data collection tool to audit practice and ensure good quality patient care. As this was an audit, ethical approval was not required as per NHS Health research authority. We registered the audit with our local research and development department, NHS Fife. Data included patient demographics, size of prostate, PSA, comorbidities and medication history, pre-operative work up data in clinic, number of treatments on each lobe, post operative outcomes and complications. The intraoperative pain score is recorded immediately post operatively. The other parameters are recorded at the 3-month follow-up clinic appointment.