Urology - USC (2WW)

Service Overview

Service provided by NBT at Southmead Hospital. The service is for patients who meet the local Urology Cancer Urgent Suspected Cancer criteria (see section below).

The service offers consultation with diagnostics and onward referral for treatment as required.

At time of referral please issue the BNSSG Understanding Your Urgent Fast Track Referral patient information leaflet.

Contact details ADULT USC:

NBT - Tel on 0117 414 0522 / 0536 / 0537 / 0538 or email to  fasttrackoffice2ww@nbt.nhs.uk

Testicular Cancer Updates

Suspected testicular cancer pathway now live on NBT ICE

Update 16/5/23

The Testicular Cancer fast track pathway launched on NBT ICE in September 2022 for patients with suspected testicular cancer. This has worked well with excellent feedback from patients.

In order to successfully track these referrals in secondary care the way to refer on ICE is changing from Monday the 22^nd May.

The pathway is now accessed through a general Testicular US request on NBT ICE. Please select Yes when asked if this is a suspected testicular malignancy to ensure patients are tracked on the correct pathway.

UHBW do not provide a USC urology service so please refer patient with possible testicular cancer to NBT.

Please safetynet your patients as with all other cancer referral pathways.

Please only refer patients on the fast track urology pathway if they have clinical signs suggestive of testicular cancer; ie unexplained non-painful swelling, mass, or change in the shape or body of the testis.

For testicular/scrotal changes that are not concerning but where there is diagnostic uncertainty then consider referral for ultrasound  outside of the fast track service which is available at both UHBW and NBT.

If a patient is found to have testicular cancer outside of the NBT fast track ICE pathway then they will need to be referred using the USC (2WW) form via eRS, unless the radiographers report confirms that a fast track referral has already been made to urology (this pathway is in development at UHBW).

Patients with other suspected urological cancers should continue to be referred as before using the USC (2WW) pathway outlined below.

Referral Guidance

Patients must meet the referral criteria as indicated on the Suspected Urological Cancer Referral Form (word doc) (also on EMIS).  Patients must be referred using this form. Please also take note of section below on 'Guidelines on making a USC referral'.

Please note: This service is moving to a RAS from 21/11/22. Therefore, you need to select 'send for triage' in eRS rather than selecting a date and time for dummy appointment.

If advised to refer into MDT, then please submit a USC (2WW) referral to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion.

Please also see the Prostate - PSA page for advice on PSA testing.

Prostate

• Prostate feels malignant on digital rectal examination - features include asymmetry, irregularity, nodules and differences in texture e.g firm or hard. Please request PSA prior to referral

• Elevated age specific PSA in men with 10 year life expectancy. PSA test should be postponed for at least 1 month after treatment of UTI.

• Age specific PSA ranges (updated in line with NICE guidance NG12 - Dec 2021):

• Below 40	Use clinical judgement
  40 to 49	More than 2.5
  50 to 59	More than 3.5
  60 to 69	More than 4.5
  70 to 79	More than 6.5
  Above 79	Use clinical judgement - see advice below

   

• Raised PSA in men 80 years or older should be referred according to criteria below:

  • asymptomatic and abnormal PSA <20 , please discuss with urologist or use urology A and G service as referral may not be necessary
  • asymptomatic and PSA 20-50, urgent rather than USC referral
  • asymptomatic and PSA> 50 for USC referral
  • symptomatic (e.g bone pain and weight loss) and PSA 20 or over, for USC referral

• Finasteride and PSA testing - Finasteride reduces the PSA level (1) but the effect of finasteride is hugely variable from patient to patient. However, local urologists suggest that generally speaking, it seems a safe option to double the PSA value if a patient is taking finasteride in order to obtain a more reliable reading.

• Transgender Patients

  • Trans women who have had bottom surgery (gender affirming surgery), usually retain their prostate. For these individuals it will be easiest to examine the prostate via the anterior wall of the neovagina.
  • Trans women taking feminising hormone therapy (including testosterone suppression with GnRH analogues) will have a smaller prostate on examination and clinicians should have a lower threshold for referral to urology of PSA >1ng/ml see here 

Please also see Gender Identity (Remedy BNSSG ICB)

Testicular

• Non-painful swelling or mass or change in shape of the body of the testis
• Please refer straight to test on NBT ICE for direct access to a ultrasound scan and select suspected malignancy when given this option which will mark this patient as a fast track ?cancer referral.
• Patients should also be directed to the NBT PIL webpage for this service

For testicular/scrotal changes that are not concerning but where there is diagnostic uncertainty then refer for routine ultrasound at UHBW or NBT.

If a patient is found to have testicular cancer outside of the NBT fast track ICE pathway then they will need to be referred using the USC (2WW) form via eRS unless the radiographers report confirms that a referral has already been made to urology (this pathway is in development at UHBW).

Bladder & Renal

• Unexplained visible haematuria  in adults without UTI - refers to patients where UTI and urinary  stone disease have been excluded.

• Visible haematuria that persists or recurs after successful treatment of a UTI.

(Patients < 45 with unexplained visible haematuria may be referred urgently but outside USC system. Patients aged 45 years or over should be referred as USC.)

• Non- visible haematuria in patients aged 60 or over with either dysuria or raised white cell count on a blood test.

(Patients with NVH outside of this group should be managed according to local haematuria guidelines.)

• Abdominal mass identified clinically or on imaging thought to arise from urinary tract. Includes solid renal masses, complex renal cysts (i.e cysts containing septa, calcification or soft tissue elements) and soft tissue bladder masses.

Penis

• Any suspected Penile cancer. Includes a penile mass or ulcerated lesion, where a sexually transmitted infection has been excluded as a cause. For lumps in the corpora cavernosa that do not involve the penile skin, please use the routine referral process  or see local Peyronies disease guidelines .
• Unexplained or persistent symptoms affecting foreskin or glans. This excludes simple phimosis. Underlying fungal infection or balanoposthitis should be excluded or treated before USC referral

Guidelines on making a referral

Please refer USC patients using the above Proforma through eReferral. The clinical information you enter on this form will directly affect the booking of slots for these patients. Please try and avoid ticking more than one box on the referral forms. 

Suspected bladder or renal cancer

Patients who are referred with haematuria will be booked into direct slots with flexible cystoscopy and upper tract imaging on the day for the majority of cases. There may be instances when demand is greater than capacity and patients will need to return for diagnostic investigations. 

Please ensure that the clinical details are accurate so we can ensure the appropriate use of diagnostic slots:

If a patient is referred with non visible haematuria they will have a slot with a flexible cystoscopy and ultrasound on the day. 

If a patient is referred with visible haematuria they will have a slot with a flexible cystoscopy and a CT urogram on the day. 

Please document the patients EGFR on the USC (2WW) referral form so we can book directly and safely into a CTU slot.

Suspected prostate cancer

Patients who are referred with suspected prostate cancer will be seen on our new prostate pathway. For some patients this will include a same day MRI and consideration for prostate biopsy based on the results. 

Suspected testicular cancer

Patients with suspected testicular cancer should be referred straight to test using NBT ICE on the fast track testicular cancer pathway.

Patients will be seen for an ultrasound and if there is a suspicion of testicular cancer they will be booked into a Urology fast track appointment the same day. If the ultrasound does not show cancer the results will be explained to the patient and they will be discharged back to primary care.

Patient information is available on the NBT website: The rapid access testicular ultrasound clinic | North Bristol NHS Trust (nbt.nhs.uk)

Suspected penile cancer

Will be seen and assessed clinically and a decision made about on-going diagnostics.

Patients will be sent a leaflet about the one stop clinic and there is also information on the BUI website.

Resources

(1) PSA and finasteride - General Practice notebook (gpnotebook.com)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.