A Systematic Review of Nurse-Led Cystoscopy as a Safe and Effective Alternative to Consultant-Led Services

 

INTRODUCTION

• The growing awareness of lower urinary tract symptoms (LUTS) among women where

prevalence is estimated at 76% (Coyne et al., 2009), has led to an increased demand for

cystoscopy.

• Unfortunately, this led to longer wait times , particularly in the post-pandemic era.

• To address the mismatch between demand and workforce capacity, nurses trained to

perform cystoscopy under the supervision of urologists (Richardson and Cunliffe, 2003).

• Nurse-led cystoscopy clinics have been established in urology (Gidlow et al., 2000),

although this approach is relatively new in urogynaecology.

 

OBJECTIVE

To evaluate the safety, efficacy, acceptability, and training requirements for cystoscopy

performed by nurses.

 

METHODS

• Review protocol: The protocol, established a priori, was registered with the

PROSPERO database (CRD42021270171).

•Literature search: Relevant studies were identified through electronic searches of

databases including PubMed and Embase up to February 4, 2021. Conference

abstracts from international organizations such as the International Continence

Society (ICS) and the International Urogynaecology Association (IUGA) etc.

•Inclusion and exclusion criteria: Studies reporting on nurse-led cystoscopy and the

relevant outcome measures (listed below) in adult patients were included.

•Study selection and data extraction: Two reviewers independently screened titles

and abstracts, and full-text articles were assessed for eligibility. A standardized data

extraction form was used to extract data,.

•Quality assessment: The Critical Appraisal of Skills Programme (CASP) checklist was

used

•Data synthesis: A thematic analysis and narrative synthesis were performed to

analyse and summarise the results.

•Outcome measures: Both quantitative and qualitative outcome measures were

considered: patient acceptability, diagnostic yield, user learning curve, costs, impact

on wait lists, process, training required, implementation issues, user impressions,

acceptability, staff impressions, and service impact.

 

RESULTS:

SAFETY:

• Comparable cancer detection rates- Madaan 2021, Kavanagh

2016

• Proven diagnostic accuracy – Krieg 2020, McConkey 2019,

Quallich 2019, Gidlow 2000 (sensitivity 96% for both nurses and

doctors), Forsyth 2005, Taylor 2002

• Equal reporting and over-reporting rate- Smith 2016

• No difference in referral to GA cystoscopy - Kavanagh 2016, Sapre

2012, Radhakrishnan 2006 (equivalence after 1 year), Fagerberg

and Nostell 2005, Lewin and Lupton 2005, Gidlow 2000 (specificity

100% for accurate referral for GA cystoscopy in both groups)

• No difference in discharge rate - Radhakrishnan 2006

Complications

• 1 case of urosepsis - Krieg 2020

• 2 major complications (managed conservatively)- Sapre

2012

 

EFFICACY:

2 week wait targets met 100% - Madaan 2021

• Same time taken to complete procedure (nurse

and doctors)- McConkey 2019, Osborne 2007

• Waiting time reduced- Quallich 2019,

Radhakrishnan 2006, A.M 2014

• Less patients per list for nurses- Smith 2016

• Helped ease the pressure on the day unit- Booth

2005

 

STAFF ACCEPTABILITY:

Good to outstanding multisource feedback - R

2020

• Resident training days maintained alongside nurse

training- Quallich 2019

 

TRAINING:

Supervised procedures before independent practice- Krieg,

2020, Osborne 2007

• Theory learning followed by supervised practice- Quallich

2019, Bsc and MNrs 2011

• Training using structured competency framework (BAUN

and BAUS guideline)- McConkey and Hahessy 2018, Sapre

2012, Forsyth 2005

 

PATIENT ACCEPTBILITY:

92-100% positive patient experience reported

with a nurse-led service- Madaan 2021, Sapre

2012

• Statistically significant lower post-operative pain

with nurses- Arndal 2015

• Better approach to counselling after cancer

diagnosis which patients preferred- Taylor 2003

 

DISCUSSION:

DISCUSSION

• All studies in this review were from urology departments that

predominantly focused on bladder cancer surveillance as the indication

for cystoscopy. In contrast, the indication for cystoscopy in

urogynaecology is largely focused on LUTS. It is important to interpret the

results considering these differences.

• The review provides evidence that nurse-led cystoscopy is a safe and

viable alternative to a consultant-led service. While the evidence was

derived from non-randomized controlled trials, most studies included

were of acceptable quality.

• The review found no significant difference in diagnostic yield, cancer

detection rates, and accuracy of findings between nurses and doctors. In

fact, one study reported a high sensitivity of 96% for nurse-led cystoscopy,

which was supported by other studies that examined safety.

• All seven studies that reported on patient acceptability demonstrated

positive responses ranging from 92% to 100%. The evidence also indicates

that multidisciplinary team support and training were important factors in

the successful implementation of this service, suggesting that staff found

the service acceptable.

• Nurse-led cystoscopy had a positive impact on the waitlist and resulted in

improved continuity of care.

 

CONCLUSION:

CONCLUSION

Though the indication for cystoscopy differed between urology and urogynaecology,

nurse-led cystoscopy was shown to be a safe and acceptable alternative to a

consultant-led service. The results of this review suggest that nurse-led cystoscopy

has a positive impact on waitlists and continuity of care.

Note: This work formed part of the author's MSc dissertation to demonstrate feasibility of setting up a nurse led cystoscopy service in

urogynaecology in Thames Valley. 

 

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