Chapter 20: Diagnostic investigations
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Source: Adapted from BAUS ([19]).
Legal and professional issues
The nurse is required to have an intimate understanding of the anatomy and physiology of the male urinary system, factors that affect PSA measurement and other conditions of the urinary system and their management. In addition, the nurse must be competent in DRE and have a thorough understanding of the role of TRUS and possible ultrasound findings as well as familiarization with the possible complications of TRUS and their management (Greene et al. [58]).
For nurse specialists a minimum of 20 cases should be performed under supervision (Greene et al. [58], Turner et al. [164], Turner and Pati [163]). The nurse could be trained by any competent healthcare professional but ultimately competence should be assessed by an experienced practitioner, usually a urologist or radiologist. Each practitioner should regularly audit the outcome and management of complications. Examples and guidance for how this can be achieved exist within the published literature (Greene et al. [58], Turner and Pati [163]).
Consent
At the appointment at which the biopsy is requested, the patient should be counselled about the procedure and a transrectal prostate biopsy information sheet should be given, for example the British Association of Urology Surgeons’ Prostate Biopsy patient information leaflet’ (BAUS [19]). This information leaflet outlines the procedure in detail including benefits, risks, potential complications and emergency contacts. Patients should be warned of the possible side‐effects (Table 20.5) as part of the informed consent process.
Table 20.5 Possible side‐effects of transrectal ultrasound and prostate biopsy
| Frequency | Side‐effect |
|---|---|
| Common (greater than 1 in 10) | Blood in urine
Blood in semen for up to 6 weeks
Blood in stools
Urinary infection (up to a 10% risk)
Discomfort from the prostate due to bruising
Haemorrhage (bleeding) causing inability to pass urine (2% risk) |
| Occasional (between 1 in 10 and 1 in 50) | Blood infection (septicaemia) needing admission to hospital (2% risk)
Haemorrhage (bleeding) needing admission (1% risk)
Failure to detect a significant cancer of the prostate |
| Rare (less than 1 in 50) | Inability to pass urine (retention of urine) |
| Hospital‐acquired infection | Colonization with MRSA (0.9% – 1 in 110 patients)
MRSA bloodstream infection (0.02% – 1 in 5000 patients)
Clostridium difficile bowel infection (0.01% –1 in 10,000 patients) |
| MRSA, meticillin‐resistant Staphylococcus aureus. |
It is imperative that the procedure, potential complications, potential outcomes and discomfort to the patient are explained to the patient. Answer questions at a level and pace appropriate to the patient's understanding, culture and background, preferred way of communicating and needs. Both verbal and written consent must be obtained from the patient (DH [34]). The signed consent should be scanned to the patient's electronic records or kept in their clinical notes as a hard copy.
It is a legal requirement to seek written consent for transrectal biopsy. The healthcare professional responsible for carrying out the procedure is ultimately responsible for the patient consent for the examination (DH [34], Turner and Pati [163]).
Consent should be taken using a dedicated consent form in which the following should be discussed with the patient:
- how the biopsy is taken
- the risks and benefits of the procedure
- potential complications of the procedure and whether the risk is major or minor
- the number of cores that will be taken
- if any additional cores will be taken using MRI fusion.
It is also important that the patient is made aware of the potential outcome of the prostate biopsy, which may include:
- false negative result
- need for repeat biopsy
- cancer diagnosis.
