nurse-led flexible cystoscopy: experience from one uk centre

C O M M E N T S

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2 5 6 J O U R N A L C O M P I L A T I O N copy 2 0 0 6 B J U I N T E R N A T I O N A L

NOVEL DISPLAY TECHNOLOGIES

Currently several new spatial display technologies are being developed One is the lsquosuspended image systemrsquo developed by Central Research Laboratories Ltd UK The spatial image produced lsquofloatsrsquo with no projection screen and is seen against a homogenous black background [13] The Human Interface Technology Laboratory (University of Washington Seattle WA USA) developed technology that allows the display of images directly onto the retina [14] This novel approach is called lsquovirtual retinal displayrsquo and creates images by scanning low-power laser light directly onto the retina Another manufacturer OKO Technology developed a prototype 3D display that allows viewers to shift accommodation bringing objects displayed at different viewing distances in and out of focus [15] These technological advances produce a stronger stereoscopic effect and allow a degree of horizontal motion parallax [13] The application of this technology is still experimental and trials on performing surgical tasks are eagerly awaited

CONCLUSION

In conclusion the use of 3D video endoscopy is not widespread mainly because of technological limitations of the early 3D video-imaging systems Recent advances in spatial image display technology have improved 3D image quality and reduced troublesome side-effects associated with prolonged use of the early 3D systems Although their superiority over 2D systems has yet to be proven the potential benefits of 3D displays are well documented

REFERENCES

1 Zobel J Basics of three-dimensional endoscopic vision Endosc Surg Allied Technol 1993 1 36ndash9

2 Wade NJ Swanston M An Introduction to Visual Perception London Routlage 1991

3 Hofmeister J Frank TG Cuschieri A Wade NJ Perceptual aspects of two-dimensional and stereoscopic display techniques in endoscopic surgery review and current problems Semin Laparosc Surg 2001 8 12ndash24

4 Mueller-Richter UD Limberger A

Weber P Ruprecht KW Spitzer W Schilling M Possibilities and limitations of current stereo-endoscopy Surg Endosc 2004 18 942ndash7

5 Herron DM Lantis JC 2nd Maykel J Basu C Schwaitzberg SD The 3-D monitor and head-mounted display A quantitative evaluation of advanced laparoscopic viewing technologies Surg Endosc 1999 13 751ndash5

6 Geis WP Head-mounted video monitor for global visual access in mini-invasive surgery An initial report Surg Endosc 1996 10 768ndash70

7 Tevaearai HT Mueller XM von Segesser LK 3-D vision improves performance in a pelvic trainer Endoscopy 2000 32 464ndash8

8 Taffinder N Smith SG Huber J Russell RC Darzi A The effect of a second-generation 3D endoscope on the laparoscopic precision of novices and experienced surgeons Surg Endosc 1999 13 1087ndash92

9 Wentink M Jakimowicz JJ Vos LM Meijer DW Wieringa PA Quantitative evaluation of three advanced laparoscopic viewing technologies a stereo endoscope an image projection display and a TFT display Surg Endosc 2002 16 1237ndash41

10 van Bergen P Kunert W Buess GF The effect of high-definition imaging on surgical task efficiency in minimally invasive surgery an experimental comparison between three-dimensional imaging and direct vision through a

stereoscopic TEM rectoscope Surg Endosc 2000 14 71ndash4

11 van Bergen P Kunert W Bessell J Buess GF Comparative study of two-dimensional and three-dimensional vision systems for minimally invasive surgery Surg Endosc 1998 12 948ndash54

12 Mueller-Richter UD Limberger A Weber P Spitzer W Schilling M Comparison between three-dimensional presentation of endoscopic procedures with polarization glasses and an autostereoscopic display Surg Endosc 2003 17 502ndash4

13 Holden J Frank TG Cuschieri A Developing technology for supended imaging for minimal access surgery Semin Laparosc Surg 1997 4 74ndash9

14 Viirre E Pryor H Nagata S Furness TA 3rd The virtual retinal display a new technology for virtual reality and augmented vision in medicine Stud Health Technol Inform 1998 50 252ndash7

15 Schowengerdt BT Seibel EJ True three-dimensional displays that allow viewers to dynamically shift accommodation bringing objects displayed at different viewing distances into and out of focus Cyberpsychol Behav 2004 7 610ndash20

Correspondence Hiten Patel Urology Institute of Urology University College London London UKe-mail hrhpatelhotmailcom

Abbreviations (3)(2)D (three)(two)-dimensional HMD head-mounted display

Blackwell Publishing LtdOxford UKBJUBJU International1464-4096BJU InternationalAugust 2006982bullbullbullbullComment Article

commentRADHAKRISHNAN

et al

NURSE-LED FLEXIBLE CYSTOSCOPY EXPERIENCE FROM ONE UK CENTRE SURESH RADHAKRISHNAN TREVOR J DORKIN PRAKASH JOHNSON PRAVEEN MENEZES and DAMIAN GREENE ndash St Bartholomews

Hospital London and Sunderland Royal Hospital Sunderland UK

Accepted for publication 28 March 2006

INTRODUCTION

Following reports that nurse practitioners in urology are currently involved in clinics for erectile dysfunction [1] prostate assessment [23] prostate cancer follow-up [4] and

preoperative assessment the urology nurse specialist has also been increasingly important in the running of flexible cystoscopy (FC) lists This has the perceived dual advantage of reducing the urologists workload and increasing the stimulus and

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challenge of the nurse-specialist role Reports suggested that adequately trained urology nurse practitioners can undertake FC as accurately as can a consultant urologist [56] The role of the nurse cystoscopist has been developed now to include diagnostic cystoscopy with telephone follow-up and counselling [7] Direct access to the service has reduced waiting times from presentation to diagnosis The telephone follow-up has improved patients experience of a diagnostic urology service [7]

The bladder cancer workload of urologists is increasing [8] leading to a greater demand for FC One way to improve the provision of this service is to share this skill with appropriately trained and supervised nurses However if a nurse is to perform such procedures the issues of training competence and accountability must be considered Legal questions also arise about negligence and liability In our institution there are two trained senior nurses with substantial urological experience who are performing unsupervised FC sessions after a formal training period under supervision in accordance with the nationally agreed guidelines (BAUS 2000) [910] However there was a high incidence of referrals for general anaesthetic (GA) procedures after FC as a consequence of this Hence an audit was done to assess the effect of nurse-led FC sessions on the referrals for a GA cystoscopy and the difficulties faced by them

The two urology nurse specialists in our centre have been performing FC independently since January 2003 with an average of asymp10 patients per session By a retrospective case-notes review data were

collected on all patients who had a check FC (patients with known bladder tumours) independently by specialized urology nurses during a 4-month period from January to April 2003 and who were subsequently referred for a GA procedure Patients with incomplete examinations eg due to urethral stricture poor vision caused by ongoing haematuria or debris in bladder which could not be cleared by bladder irrigation at FC and patients who had had intravesical mitomycin within 6 months before check FC were excluded from the study Findings at FC were cross referenced to findings at GA cystoscopy in terms of the nature of lesion detected (papillary tumours suspicious lesions) or a normal cystoscopy

A similar audit was done for check FCs by the medical staff which consisted of consultants and registrars during the preceding 5-month period (August 2003 to December 2003) the results were the compared This period was selected as the services of nurse-led FC were not available at that time A repeat audit was done during the period January to April 2004 for the nurse-led group to quantify the increase in experience By this time the nurse cystoscopists would have done ge200 FCs each The results were analysed statistically using the chi-square test with two-tailed P values for analysing the significance of the difference with P lt 005 considered to indicate statistical significance

In the nurse-led group there was a total of 202 check FCs over the period of these 54 patients were referred for GA cystoscopy for either papillary tumours or suspicious areas on FC In all 27 papillary tumours were found

under GA and 14 patients had a normal cystoscopy Twelve suspicious areas were found and biopsy of these areas showed nonspecific cystitis or a normal biopsy in seven patients and low-grade TCC in five One patient had diathermy with no biopsy

In the doctor-led group there were 332 check FCs during the period of these 31 patients were referred for GA cystoscopy for either papillary tumours or suspicious areas on FC In all 19 papillary tumours were found under GA and five patients had a normal cystoscopy In seven patients suspicious areas were found and biopsy of these areas showed nonspecific cystitis or a normal biopsy These findings are summarized in Table 1 with the results of the repeat audit The referral for GA procedures was analysed between the groups Nurses referred 54 of 202 (267) patients for GA cystoscopy whereas the doctors referred 31 of 332 (93) the difference was statistically significant (P lt 0001) The referral for GA procedures for the nurse-led list in the re-audit was 159 (P = 0063 not statistically significant vs doctor-led list) Considering the number of patients who had a normal cystoscopy (ie no abnormal areas to biopsy) then the statistical significance vs the doctors was P = 0002 for the first audit and 0032 for the re-audit both statistically significant

FINANCIAL IMPLICATIONS

The extra cost incurred for additional GA procedures required due to the introduction of nurse-led FC sessions was UK pound48 000 during the initial 4-month period and 1 year later it was pound30 000 during the 4-month re-audit period For financial calculations we used information from the cost and accounts department of our institution on the following basis Assuming the costs incurred for a transurethral resection of bladder tumour as pound1506patient episode for a normal cystoscopy as pound580patient and for a cystoscopy and biopsy as pound888patient the total cost incurred for all GA procedures after referral from doctors was pound12 016 and that incurred for all GA procedures after referral from nurses was pound60 018 On this basis the additional cost due to the nurse-led service during the first audit period was pound48 002 and similar calculations during the re-audit period for nurse-led FC was pound29 122 Additional cost due to the nurse-led service during the re-audit period was pound17 106

TABLE 1 A summary of the outcome of the audit

VariableSession

Re-audit nurse-ledNurse-led Doctor-ledPeriod 012003ndash042003 082002ndash122002 012004ndash042004Number of check FCs 202 332 188N () referred for GA procedures 54 (267) 31 (93) 30 (159)Pathology of biopsy in patients with suspicious findings on FC

TCCcarcinoma in situ 12 0 4Normal biopsy 2 5 1Cystitis 5 2 6

Number of normal cystoscopies 15 5 10Number of papillary tumours

requiring resection27 19 9

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DISCUSSION

BAUS has recognized the importance of nurse-led FC and issued guidelines [10] Apart from the theoretical knowledge and observational skills required the nurses must have passed a FC in a patient under GA in the theatre in 10 patients within a predetermined time and must have performed ge50 consecutive surveillance FCs with the accuracy of findings confirmed by the supervising urologist BAUS also recognized the importance of regular audit and the availability of a designated and experienced urologist to be available on-site and be able to attend the intervention at the request of the nurse practitioner Our audit showed the shortcomings of the service despite these guidelines

We cannot refute that the nurses conducted most (76) of the check FCs during this period and the perceived advantage might be that doctors can concentrate on difficult check FCs and on diagnostic FCs However at the same time the effect on the waiting list for the GA procedures due to the increased referrals for GA cystoscopy needs to be considered From our audit we know that the two main reasons for referral for GA cystoscopy are red areas the nature of which cannot be ascertained by nurses and follicular cystitis which can mimic a small papillary tumour

It can be argued that doctors might not be referring an adequate number of patients for GA cystoscopy One shortcoming of this audit

is that we did not quantify the chance of missing a tumour by doctors and nurses We did not assess this aspect as we need a longer follow-up for the data to be meaningful and many patients were having annual FC Although there are additional costs involved in running a nurse-led service it is also important to recognize the benefits gained in terms of decreased waiting lists due to additional availability of experienced staff who are able to conduct FCs independently

In conclusion the introduction of nurse-led FC sessions has led to more referrals for GA cystoscopy This has implications both in terms of the risks of GA procedures and cost of and constraint on inpatient treatment facilities Specialist nurses seem to require a long training period and hence the current recommendations after which the nurses are allowed to do FC independently should be revised The additional cost involved in running the nurse-led clinics during training needs to be considered by NHS Trusts seeking to implement such a service

REFERENCES

1 Malloy L Nigam A Nurse directed impotence therapy improved compliance and understanding Br J Urol 1996 77 (Suppl 1) 36

2 Booth CM Chaudry AA Smith K Griffiths K The benefits of a shared-care prostate clinic Br J Urol 1996 77 830ndash5

3 Joyce J Pope A The nurse led

prostate clinic Br J Urol 1996 77 (Suppl 1) 36

4 Gurun M McGuire I Mulholland R Conn G A nurse-led prostate cancer follow up clinic initial experience and patient perceptions Br J Urol 1998 81 (Suppl 4) 2

5 Fagerberg M Nostell PO [Follow up of urinary bladder cancer ndash a task for the urology nurse] Lakartidningen 2005 102 2149ndash50

6 Gidlow AB Laniado ME Ellis BW The nurse cystoscopist a feasible option BJU Int 2000 85 651ndash4

7 Forsyth I Shaikh S Gunn I The nurse cystoscopist Extending the role Br J Perioper Nurs 2005 15 342ndash5

8 Parkin DM Muir CS Cancer Incidence in Five Continents Comparability and quality of data IARC Sci Publ 1992 120 45ndash173

9 Ellis BW Fawcett DP Fowler CG Gidlow A Sounes P Nurse cystoscopy Report of a working party of the British Association of Urological Surgeons March 2000 Available at httpwwwbausorgukDisplayaspxitem=185 Accessed March 2006

10 Gidlow A National guidelines for nurse cystoscopy Prof Nurse 2000 16 992ndash3

Correspondence Suresh Radhakrishnan 100 Brentwood Road Romford Essex RM1 2RX UKe-mail sureshradhakrishyahoocom

Abbreviations FC flexible cystoscopy GA general anaesthetic

C O M M E N T S


J O U R N A L C O M P I L A T I O N copy 2 0 0 6 B J U I N T E R N A T I O N A L 2 5 7

challenge of the nurse-specialist role Reports suggested that adequately trained urology nurse practitioners can undertake FC as accurately as can a consultant urologist [56] The role of the nurse cystoscopist has been developed now to include diagnostic cystoscopy with telephone follow-up and counselling [7] Direct access to the service has reduced waiting times from presentation to diagnosis The telephone follow-up has improved patients experience of a diagnostic urology service [7]

The bladder cancer workload of urologists is increasing [8] leading to a greater demand for FC One way to improve the provision of this service is to share this skill with appropriately trained and supervised nurses However if a nurse is to perform such procedures the issues of training competence and accountability must be considered Legal questions also arise about negligence and liability In our institution there are two trained senior nurses with substantial urological experience who are performing unsupervised FC sessions after a formal training period under supervision in accordance with the nationally agreed guidelines (BAUS 2000) [910] However there was a high incidence of referrals for general anaesthetic (GA) procedures after FC as a consequence of this Hence an audit was done to assess the effect of nurse-led FC sessions on the referrals for a GA cystoscopy and the difficulties faced by them

The two urology nurse specialists in our centre have been performing FC independently since January 2003 with an average of asymp10 patients per session By a retrospective case-notes review data were

collected on all patients who had a check FC (patients with known bladder tumours) independently by specialized urology nurses during a 4-month period from January to April 2003 and who were subsequently referred for a GA procedure Patients with incomplete examinations eg due to urethral stricture poor vision caused by ongoing haematuria or debris in bladder which could not be cleared by bladder irrigation at FC and patients who had had intravesical mitomycin within 6 months before check FC were excluded from the study Findings at FC were cross referenced to findings at GA cystoscopy in terms of the nature of lesion detected (papillary tumours suspicious lesions) or a normal cystoscopy

A similar audit was done for check FCs by the medical staff which consisted of consultants and registrars during the preceding 5-month period (August 2003 to December 2003) the results were the compared This period was selected as the services of nurse-led FC were not available at that time A repeat audit was done during the period January to April 2004 for the nurse-led group to quantify the increase in experience By this time the nurse cystoscopists would have done ge200 FCs each The results were analysed statistically using the chi-square test with two-tailed P values for analysing the significance of the difference with P lt 005 considered to indicate statistical significance

In the nurse-led group there was a total of 202 check FCs over the period of these 54 patients were referred for GA cystoscopy for either papillary tumours or suspicious areas on FC In all 27 papillary tumours were found

under GA and 14 patients had a normal cystoscopy Twelve suspicious areas were found and biopsy of these areas showed nonspecific cystitis or a normal biopsy in seven patients and low-grade TCC in five One patient had diathermy with no biopsy

In the doctor-led group there were 332 check FCs during the period of these 31 patients were referred for GA cystoscopy for either papillary tumours or suspicious areas on FC In all 19 papillary tumours were found under GA and five patients had a normal cystoscopy In seven patients suspicious areas were found and biopsy of these areas showed nonspecific cystitis or a normal biopsy These findings are summarized in Table 1 with the results of the repeat audit The referral for GA procedures was analysed between the groups Nurses referred 54 of 202 (267) patients for GA cystoscopy whereas the doctors referred 31 of 332 (93) the difference was statistically significant (P lt 0001) The referral for GA procedures for the nurse-led list in the re-audit was 159 (P = 0063 not statistically significant vs doctor-led list) Considering the number of patients who had a normal cystoscopy (ie no abnormal areas to biopsy) then the statistical significance vs the doctors was P = 0002 for the first audit and 0032 for the re-audit both statistically significant

FINANCIAL IMPLICATIONS

The extra cost incurred for additional GA procedures required due to the introduction of nurse-led FC sessions was UK pound48 000 during the initial 4-month period and 1 year later it was pound30 000 during the 4-month re-audit period For financial calculations we used information from the cost and accounts department of our institution on the following basis Assuming the costs incurred for a transurethral resection of bladder tumour as pound1506patient episode for a normal cystoscopy as pound580patient and for a cystoscopy and biopsy as pound888patient the total cost incurred for all GA procedures after referral from doctors was pound12 016 and that incurred for all GA procedures after referral from nurses was pound60 018 On this basis the additional cost due to the nurse-led service during the first audit period was pound48 002 and similar calculations during the re-audit period for nurse-led FC was pound29 122 Additional cost due to the nurse-led service during the re-audit period was pound17 106

TABLE 1 A summary of the outcome of the audit

VariableSession

Re-audit nurse-ledNurse-led Doctor-ledPeriod 012003ndash042003 082002ndash122002 012004ndash042004Number of check FCs 202 332 188N () referred for GA procedures 54 (267) 31 (93) 30 (159)Pathology of biopsy in patients with suspicious findings on FC

TCCcarcinoma in situ 12 0 4Normal biopsy 2 5 1Cystitis 5 2 6

Number of normal cystoscopies 15 5 10Number of papillary tumours

requiring resection27 19 9

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DISCUSSION






REFERENCES














C O M M E N T S



DISCUSSION






REFERENCES














nurse-led flexible cystoscopy: experience from one uk centre

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