Anaesthesia in PROstate Biopsy Pain Obstruction Study: A Study Protocol for a Multicentre Randomised Controlled Study Evaluating the Efficacy of Perineal Nerve Block in Controlling Pain in Patients Undergoing Transperineal Prostate Biopsy

Introduction: Transperineal prostate biopsy is as effective as the transrectal biopsy in detecting prostate cancer and has a lower risk of infection. However, concerning the procedural pain of the transperineal route, a higher level of anaesthesia is needed, which prevents this approach from being widely used. Although several methods of local anaesthesia to relieve pain during transperineal biopsy have been described, few well-designed trials have been conducted to assess the efficacy of local anaesthesia.Methods: This is a prospective, multicentre, randomised controlled study in men suspected of having prostate cancer and planning to undergo transperineal prostate biopsy. The aim of this trial is to determine whether the perineal nerve block and periprostatic block relieve pain to different extents in men undergoing transperineal biopsy. The main inclusion criteria are men aged between 18 and 80 years old, a prostate-specific antigen (PSA) level of 4–20 ng/ml, or/and suspicious rectal examination findings. A sample size of 190 participants, accounting for a 10% loss, is required. All participants will be randomly allocated at a ratio of 1:1 to the perineal nerve block (n = 95) and periprostatic block groups (n = 95). The primary outcome will be the level of the worst pain experienced during the transperineal prostate biopsy procedure, which will be measured by a numerical rating scale (NRS). The key secondary outcomes will include the pain severity score at 1, 6, and 24 h after prostate biopsy.Results: The primary outcome is the level of the worst pain experienced during the prostate biopsy procedure. The main secondary outcomes are as follows: (1) Post-biopsy pain severity score at 1, 6, and 24 h after the prostate biopsy; (2) Changes in blood pressure, heart rate and breathing rate during the biopsy procedure; (3) External manifestations of pain during biopsy; (4) Anaesthesia satisfaction; (5) The detection rate for clinically significant prostate cancer and any prostate cancer.Conclusion: Anaesthesia in PROstate biopsy Pain Obstruction Study (APROPOS) is randomised controlled trial aiming to determine the efficacy of the perineal nerve block in controlling pain in patients undergoing prostate biopsy via the transperineal approach.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04501055.

Determinants of urologists’ adherence to active surveillance follow-up protocol for low-risk prostate cancer.

12 Background: The National Comprehensive Cancer Network (NCCN) guideline offers a guideline for follow-up care for patients with low-risk prostate cancer on active surveillance (AS). However, in practice, 70% of patients receive follow-up care that is not guideline-adherent, characterized by insufficient or excessive surveillance testing, potentially diminishing AS effectiveness and contributing to poor patient outcomes. The objective of this study is to identify provider- and organization-level determinants of guideline-adherent AS follow-up care. Methods: We used in-depth semi-structured qualitative interviews with 13 United States urologists to examine determinants of urologists’ adherence to the active surveillance follow-up guideline. Guided by the combined use of the Consolidated Framework for Implementation Research, which focuses on organization-level determinants, and the Theoretical Domains Framework, which focuses on provider-level determinants, we used template analysis to identify multilevel determinants of urologists’ adherence to guideline-recommended AS follow-up care. Results: Relevant determinants were comfort with varied utilization behaviors of the guideline, perspectives on the prostate biopsy procedure, and the degree of structure within the practice setting. At the provider level, there was variation in how urologists provided AS follow-up care. All urologists referred to the NCCN guideline; however, most urologists adapted the guidelines to their needs and/or comfort level (e.g., following a subset of recommendations; adapting the interval/frequency of serial tests). Most providers felt that strictly adhering to the repeated biopsy aspect of the guideline was difficult because of concerns about fitting everybody to one type of frequency that does not stratify patients by risk. Others reflected on patients expressing physical discomfort and concerns of infection stemming from the biopsy procedure. At the organization level, urologists in a structured practice environment had the tendency towards providing NCCN guideline-adherent care whereas urologists practicing in settings with less organization relied more on individual discretion, which created room for flexibility with the care that they provide. Conclusions: Both provider- and organization-level determinants affected urologists’ provision of NCCN guideline-adherent follow-up care which may partially explain why patients eventually fail to receive guideline-adherent AS follow-up care. Findings call on the need for multilevel strategies to increase adherence or to modify existing guidelines to reflect the need at multiple levels.

609 Referral for Temporal Artery Biopsy: A Closed-Loop Audit to Improve Quality of Referrals with A Standardised Proforma

Aim Temporal artery biopsies are performed by the ENT department within our hospital, with referrals generally coming from the Rheumatology team. The motivation to audit practice came from concerns that patients were perhaps not fully aware when a referral had been made, that they may not have understood the logistical implications of this and that key pieces of information were frequently missing. We aimed to audit current practice to assess overall quality of referrals in line with GMC guidance. Method We retrospectively audited all referrals for a temporal artery biopsy procedure between July 2018 – March 2020. Assessed the quality of referrals by presence of information relating 15 data points taken from GMC guidelines, covering patient demographics, investigation results and operative factors. In collaboration with the Rheumatology team, we designed and introduced a standardised referral proforma. We re-audited the quality of referrals between June – November 2020. Results In the baseline audit of 34 referrals, 2 of the 15 data points were present in 100% of referrals, 5 were present in 50-90%, and 8 were present in < 50%. Two patients were found to be unaware a referral had been made for a biopsy. Upon re-audit after introduction of the standardised proforma; out of 9 referrals, 14 out of the 15 data points were included in 100% of referrals. Conclusions Following introduction of a standardised referral proforma we saw significant improvements in the overall quality of referrals for temporal artery biopsy. We plan to continue to prospectively audit the pathway to ensure these improvements are sustained.

Preliminary Evaluation of Hydraulic Needle Delivery System for MRI Guided Prostate Biopsy Procedures

In clinical routine, the prostate biopsy procedure is performed with the guidance of transrectal ultrasound (TRUS) imaging to diagnose prostate cancer. However, the TRUS-guided prostate biopsy brings reliability concerns due to the lack of contrast difference between prostate tissue and lesions. In this study, a novel hydraulic needle delivery system that is designed for performing MRI-guided prostate biopsy procedure with transperineal approach is introduced. The feasibility of the overall system was evaluated through in-vitro phantom experiments under an MRI guidance. The in vitro experiments performed using a certified prostate phantom (incorporating MRI visible lesions). MRI experiments showed that overall hydraulic biopsy needle delivery system has excellent MRI compatibility (SNR Loss < 3%), provides acceptable targeting accuracy (average 2.05±0.46 mm) and procedure time (average 40 minutes).

Teaching bone marrow procedures at pelvic and sternal sites: a high fidelity anatomy simulation

Implication Statement: The bone marrow aspirate and biopsy procedure are fundamental to the diagnosis of many hematologic pathologies. We describe a hands-on, anatomy-based workshop that allows learners to practice bone marrow procedures on cadavers. Notably, participants learned how to perform sternal aspirates: a procedure rarely performed in real-life practice. Learners valued the experience and described increased comfort with the procedure after the workshop. This workshop provides a valuable opportunity for trainees to learn a procedural skill in a safe, high fidelity environment. Given its hands-on nature, residency training programs could also adapt it for direct observation and trainee assessment.