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NICE Guidance – Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia

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1 Recommendations

  • 1.1 Current evidence on the safety and efficacy of prostate artery embolisation for benign prostatic hyperplasia is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit.
  • 1.2 Patient selection should be done by a urologist and an interventional radiologist.
  • 1.3 This technically demanding procedure should only be done by an interventional radiologist with specific training and expertise in prostatic artery embolisation.

2 The Condition, Current Treatments and Procedure

The Condition

  • 2.1 Benign prostatic hyperplasia is common in older men. Stromal and epithelial cells increase in number, causing the prostate to increase in size. It often occurs in the periurethral region of the prostate, with large discrete nodules compressing the urethra. Symptoms include hesitancy during micturition, interrupted or decreased urine stream (volume and flow rate), nocturia, incomplete voiding and urinary retention.

Current Treatments

  • 2.2 Mild symptoms are usually managed conservatively. Drugs may also be used, such as alpha blockers and 5‐alpha‐reductase inhibitors. If other treatments have not worked, then surgical options include transurethral resection of the prostate, transurethral vaporisation of the prostate, holmium laser enucleation of the prostate or prostatectomy (see the NICE guideline on lower urinary tract symptoms in men https://www.nice.org.uk/guidance/cg97). Insertion of prostatic urethral lift implants has been introduced more recently as an alternative treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. Potential complications of surgical procedures include bleeding, infection, strictures, incontinence and sexual dysfunction.

The Procedure

  • 2.3 Prostate artery embolisation for benign prostate hyperplasia is usually done using local anaesthesia. Under X‐ray guidance, the prostate is approached through the left or right femoral artery. Super‐selective catheterisation of the small prostatic arteries is done using fine microcatheters through the pelvic arteries. Embolisation involves the introduction of microparticles to completely block the prostatic vessels. Embolisation agents include polyvinyl alcohol (PVA) and other newer synthetic biocompatible materials.
  • 2.4 The aim of prostate artery embolisation is to reduce the prostate’s blood supply, causing some of it to undergo necrosis and shrink. It is common for patients to experience pelvic pain during and after the procedure. This does not usually last more than 1 to 3 days. The potential benefits of prostate artery embolisation compared with surgery include fewer complications, avoiding a general anaesthetic and it may be done as a day case procedure.

3 Committee Considerations

The Evidence

  • 3.1 To inform the committee, NICE did a rapid review of the published literature on the efficacy and safety of this procedure. This comprised a comprehensive literature search and detailed review of the evidence from 10 sources, which was discussed by the committee. The evidence included 1 systematic review, 2 randomised controlled trials (also included in the systematic review), 1 non‐randomised comparative study (also included in the systematic review), 2 case series, 3 case reports, and data provided by the UK‐ROPE register and is presented in table 2 of the interventional procedures overview (https://www.nice.org.uk/guidance/IPG611/evidence). Other relevant literature is in the appendix of the overview.
  • 3.2 The specialist advisers and the committee considered the key efficacy outcomes to be: quality of life, urinary symptoms as measured by the International Prostate Symptom Score, and improvement in urodynamics.
  • 3.3 The specialist advisers and the committee considered the key safety outcomes to be: inadvertent embolisation of other sites, urinary retention, prostatic bleeding (haematuria and haematospermia), groin haematoma, pain, retrograde ejaculation, and no loss of sexual function.
  • 3.4 Four commentaries from patients who had experience of this procedure were received, which were discussed by the committee.

Committee Comments

  • 3.5 The evidence showed a relatively high incidence of urinary retention after the procedure.
  • 3.6 The committee was informed that this procedure involves extensive imaging, which may result in significant radiation exposure.
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Article of the Week: NICE Guidance ‐ Complicated UTIs: ceftolozane/tazobactam

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Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

NICE Guidance ‐ Complicated urinary tract infections: ceftolozane/tazobactam

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Introduction and Current Guidance

Urinary tract infection is a non‐specific term that refers to infection anywhere in the urinary tract, from the urethra to the bladder and the ureters to the kidneys. According to the European Association of Urology Guidelines on urological infections (https://uroweb.org/guideline/urological-infections/?type=archive), complicated urinary tract infections are associated with certain conditions, such as structural or functional abnormalities of the genitourinary tract, or the presence of underlying disease in the lower or upper urinary tract, which increases the risk of persistent or relapsing infection. Factors associated with complicated urinary tract infections include:

  • indwelling urinary catheters
  • urinary obstruction (such as stones or tumour)
  • anatomical abnormalities
  • peri‐ and post‐operative urinary tract infection, including renal transplantation.

Pyelonephritis is infection of the upper urinary tract and can occur in 1 or both kidneys. Acute pyelonephritis may be caused by bacteria ascending from the lower urinary tract or spreading via the bloodstream to the kidney. It is considered to be uncomplicated if it is caused by a typical pathogen in an immunocompetent person with a normal urinary tract anatomy and kidney function. As for urinary tract infections generally, acute pyelonephritis is considered to be complicated in people with increased susceptibility, for example: children or older people; people with functional or structural abnormalities of the genitourinary tract or people who are immunocompromised, such that the infection is more likely to be severe. However, most episodes are uncomplicated and are cured with no residual renal damage. Complicated urinary tract infections are a frequent cause of hospital admissions and a common healthcare associated complication. The pathogens most commonly encountered in complicated urinary tract infections are the gram‐negative bacteria Escherichia coli, other common Enterobacteriaceae (for example, Proteus spp., Klebsiella spp. or Citrobacter spp.) and Pseudomonas spp. Successful treatment has become increasingly more challenging because the majority of pathogens responsible for healthcare associated complicated urinary tract infections, including catheter‐related infections, are now commonly resistant to multiple antimicrobial agents (European public assessment report [https://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/003772/human_med_001917.jsp&mid=WC0b01ac058001d124]).

The English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report (2015) (https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report) found that, overall, antibiotic resistant infections continue to increase. Notably, the rate of E. coli and Klebsiella pneumoniae bloodstream infections increased by 15.6% and 20.8% respectively from 2010 to 2014. Urinary tract infections are most commonly caused by E. coli (recorded in more than half of all the mandatory surveillance reports for E. coli bacteraemia when foci of infection are reported). The data indicate that 97% of E. coli isolates for urinary tract infection from GP practices, other community sources (such as care homes and outpatient clinics) and acute trusts were susceptible to nitrofurantoin. Resistance to trimethoprim was seen in over a third (35–37%) of isolates and resistance to amoxicillin was seen in over 50% of isolates, in all 3 settings. It is unclear if these data include cases of complicated urinary tract infections. Also, specialists involved in the production of this evidence summary noted that the results could be prone to bias because samples may have been be submitted from a population with a higher likelihood of antimicrobial resistance caused by, for example, failed treatments, recurrent infection or repeated courses of antibiotics.

Risk factors for resistance should be taken into consideration before prescribing antibiotics for urinary tract infection according to Public Health England guidance for primary care on managing common infections (https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care).

As well as some other groups, Public Health England advises performing culture and sensitivity testing in people with a higher risk of recurrent urinary tract infection (such as those aged over 65 years or with urinary catheters), and people with abnormalities of the genitourinary tract or suspected pyelonephritis.

The management of suspected community‐acquired bacterial urinary tract infection in adults aged 16 years and over is covered in the NICE quality standard on urinary tract infection in adults (https://www.nice.org.uk/guidance/qs90). This includes women who are pregnant, people with indwelling catheters and people with other diseases or medical conditions such as diabetes. The guidance was developed to contribute to a reduction in emergency admissions for acute conditions that should not usually require hospital admission, and improvements in health‐related quality of life. It does not make any recommendations around antibiotic treatment of complicated urinary tract infection, but includes 7 statements that describe high‐quality care for adults with urinary tract infection.

This evidence summary outlines the best available evidence for a new antimicrobial that is licensed for complicated urinary tract infections and acute pyelonephritis, ceftolozane/tazobactam. Ceftolozane/tazobactam was developed to address antimicrobial resistance in serious infections caused by gram‐negative pathogens.

 

Article of the Week: NICE Guidance. Sepsis – recognition, diagnosis and early management

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Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this month, it should be this one.

Sepsis: recognition, diagnosis and early management

 

Overview
This guideline covers the recognition, diagnosis and early management of sepsis for all populations. The guideline
committee identified that the key issues to be included were: recognition and early assessment, diagnostic and prognostic value of blood markers for sepsis, initial treatment, escalating care, iden tifying the source of infection, early monitoring, information and support for patients and carers, and training and education.
Who is it For?
•People with sepsis, their families and carers.
•Healthcare professionals working in primary, secondary and tertiary care. Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in
your care [https://www.nice.org.uk/about/nice-communities/public-involvement/your-care].Making decisions  using NICE guidelines [https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/using-NICE-guidelines-to-make-decisions] explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

 

More Information
You can also see this guideline in the NICE pathway on sepsis [https://pathways.nice.org.uk/pathways/sepsis].
To find out what NICE has said on topics related to this guideline, see our web page on infections [https://www.nice.org.uk/guidance/conditions-and-diseases/infections]. See also the guideline committee’s discussion and the evidence reviews (in the full guideline [https://www.nice.org.uk/Guidance/NG51/evidence]), and information about how the guideline was developed [https://www.nice.org.uk/Guidance/NG51/documents], including details of the committee. Recommendations for Research The guideline committee has made the following recommendations for research.

 

Read the full article

© NICE (2017) Sepsis: recognition, diagnosis and early management

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Article of the Month: NICE Guidance – Routine preoperative tests for elective surgery

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Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

NICE Guidance – Routine preoperative tests for elective surgery

 

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Overview

This guideline covers routine preoperative tests for people aged over 16 who are having elective surgery. It aims to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery, taking into account specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and obesity). It does not cover pregnant women or people having cardiothoracic procedures or neurosurgery.

Who is it for?

  • Healthcare professionals
  • People having elective surgery, their families and carers

This guideline updates and replaces NICE guideline CG3 (published June 2003).

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care [https://www.nice.org.uk/about/nice-communities/public-involvement/your-care].

We expect you to take our guidance into account. But you should always base decisions on the person you are working with.

Making decisions using NICE guidelines [https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/using-NICE-guidelines-to-make-decisions] explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Guidance on consent for young people aged 16–17 is available from the reference guide to consent for examination or treatment [https://www.gov.uk/government/publications/reference-guide-to-consent-for-examination-or-treatment-second-edition] (Department of Health).

The tests covered by this guideline are:

  • chest X-ray
  • echocardiography (resting)
  • electrocardiography (ECG; resting)
  • full blood count (haemoglobin, white blood cell count and platelet count)
  • glycated haemoglobin (HbA1c) testing
  • haemostasis tests
  • kidney function (estimated glomerular filtration rate, electrolytes, creatinine and sometimes urea levels)
  • lung function tests (spirometry, including peak expiratory flow rate, forced vital capacity and forced expiratory volume) and arterial blood gas analysis
  • polysomnography
  • pregnancy testing
  • sickle cell disease/trait tests
  • urine tests.

The recommendations were developed in relation to the following comorbidities:

  • cardiovascular
  • diabetes
  • obesity
  • renal
  • respiratory.

 

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Editorial: Viewpoint – Rationing and Surgical Care

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Limitation in the provision of surgical care has many causes. In a nationalised healthcare system, this often reflects lack of funds, leading to rationing of clinical services. Rationing itself takes a number of forms. Deliberate exclusion of specific operations (usually elective) or specific patient groups (smokers, obese) are the most common examples, but strategic extension of waiting times by the removal of ‘target’ times can also be used as a rationing tool.

Many surgeons are dismayed by these decisions. They feel that the surgical patient is unfairly targeted as the clinical and cost-effectiveness of many planned surgical interventions have been well characterised. Surgeon and institutional outcomes are freely available – unlike the situation in many non-surgical specialties, so how can it be fair to pick on the surgical patient?

The idea that non-urgent elective surgery falls into neat categories where delay has no adverse consequences for the patient mystifies many surgeons. Whilst all would advocate a healthy diet, exercise, weight loss and smoking cessation, decisions to withhold surgery from the obese or those who smoke is rarely evidence-based. Rationing based on such prejudice soon becomes illogical. Why should the obese cancer patient receive an operation when the obese incontinent patient cannot?

In the long term, the absence of a substantial volume of ‘routine’ surgery damages training as exposure to such procedures is limited. Surgery has become the soft target for rationing clinical services. Surgeons should make their patients aware of how this process will affect them. Healthcare planners need to hear a public voice as well as that of the clinicians.

Just occasionally, an apparent limitation can be beneficial. In this issue of the BJUI, the National Institute for Health and Care Excellence (NICE) provides clear guidance on preoperative testing. This is based on sensible recommendations such as: avoiding routine urine dipstick testing, routine chest X-rays, and glycated haemoglobin (HbA1c) in non-diabetic patients. All surgeons irrespective of their specialty would benefit from paying close attention to these important guidelines [1].

Derek Alderson

President of the Royal College of Surgeons of England; Emeritus Professor of Surgery, University of Birmingham; Editor-in-chief of BJS Open.

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Reference

1 National Institute of Health and Care Excellence (NICE). Routine preoperative tests for elective surgery: © NICE (2016) Routine preoperative tests for elective surgery. BJU Int 2018; 121: 12–6

 

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