Can a trained non-physician provider perform transrectal ultrasound-guided prostatic biopsies as effectively as an experienced urologist?


Correspondence: Satoshi Hori, Department of Uro-oncology, University of Cambridge, Hutchison / MRC Research Centre, Cambridge, CB2 0XZ, UK.



What's known on the subject? and What does the study add?

  • PSA testing has resulted in a large number of patients being referred to urologists for investigation of potential prostate cancer. Despite limited evidence, non-physician providers now perform a number of routine urological procedures such as transrectal ultrasound-guided prostatic biopsies (TRUSP) in a bid to help relieve this increasing workload.
  • In the largest series to date, we provide evidence that an adequately trained non-physician provider is able to perform TRUSP as effectively as an experienced urologist after an initial learning curve.


  • To evaluate differences in cancer detection rates between a trained non-physician provider (NPP) and an experienced urologist performing transrectal ultrasound-guided prostatic biopsies (TRUSP) at a single UK institution.

Patients and Methods

  • We retrospectively analysed a prospectively accrued database of patients (n = 440) referred for investigation of an abnormal digital rectal examination and/or a raised age-specific prostate-specific antigen (PSA) value undergoing first-time outpatient prostatic biopsies who were sequentially allocated to either an NPP or a physician-led TRUSP clinic.
  • Differences in overall and risk-stratified prostate cancer detection rates were evaluated according to TRUSP operator.
  • Continuous variables were analysed using Mann–Whitney U test whereas categorical variables were analysed using Pearson's chi-squared test. A multivariate binary logistic regression model was fitted for predictors of a positive biopsy.


  • In all, 57.3% (126/220) of patients who underwent physician-led TRUSP were diagnosed with prostate cancer compared with 52.7% (116/220) in the NPP-led clinic (P = 0.338).
  • Sub-group analysis revealed a lower cancer detection rate in men presenting with a low PSA level (<9.9 ng/mL) during the first 50 independent TRUSP procedures performed by the NPP (P = 0.014). This initial difference was lost with increasing case volume, suggesting the presence of a learning curve.
  • Multivariate logistic regression analysis revealed age (odds ratio (OR) 1.054, 95% confidence interval (95% CI) 1.025–1.084, P ≤ 0.001), presenting PSA level (OR 1.05, 95% CI 1.02–1.081, P = 0.001), prostatic volume (OR 0.969, 95% CI 0.958–0.981, P ≤ 0.001) and clinical stage (OR 1.538, 95% CI 1.046–2.261, P = 0.029) to be predictors of a positive prostatic biopsy outcome.
  • The choice of TRUSP operator was not predictive of a positive prostatic biopsy (OR 0.729, 95% CI 0.464–1.146, P = 0.171).


  • An adequately trained NPP is able to perform TRUSP as effectively as an experienced urologist after an initial learning curve of 50 cases.