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Objective: Currently the National Institute for Health and Care Excellence (NICE) recommends an abnormal digital rectal examination (DRE) as a standalone referral criterion for suspected prostate cancer. Unlike referrals for a raised prostate-specific antigen (PSA) which are triaged directly to magnetic resonance imaging (MRI), an abnormal DRE requires re-examination in a secondary clinic first. Here, we investigated the ongoing value of the abnormal DRE as a referral criterion. Methods: This study is a retrospective review of patients referred to secondary care for suspected prostate cancer based on an abnormal DRE over a 15-month period at a single UK hospital ( n = 158). Age, PSA, primary and repeat DRE findings and eventual diagnosis were collated. Results: A concurrent raised PSA was present in 65/158 (41%). Concordance between primary and secondary care DRE was only 72/158 (46%). The overall and significant cancer detection rate was 26/158 (16%) and 22/158 (14%), respectively. Among men with a concurrent raised PSA, 19/65 (29%) had significant cancer found, whereas with an abnormal primary care DRE and normal PSA ( n = 93), only 3/93 (3%) had a significant cancer. Mandating a PSA before referral for an abnormal DRE would have redirected 65/158 (41%) of men to MRI first, negating the need for a repeat DRE ( p < 0.0001). This finding was recapitulated in a second prospective validation cohort ( n = 30) with 9/30 (30%) redirected to MRI first. Conclusions: This is one of the first studies to investigate the value of the DRE in contemporary practice. We propose that PSA is used to triage men with an abnormal DRE to MRI without needing a repeat DRE. If the PSA is normal, the diagnostic yield is low but may still warrant a repeat DRE to assess the need for further investigations. Additional multi-centre studies are required to further validate our findings. Level of evidence: 4

Introduction: Holmium Laser enucleation of the prostate (HoLEP) is an effective treatment, yet the learning curve is considered difficult. We propose the trimodal approach of Holmium Laser ablation (HoLAP), then ablation with resection (HoLARP) and finally enucleation (HoLEP) during the development of surgical competence. Methods: A centre experienced in Holmium Laser (HoL) prostatectomy evaluated ablation techniques in prostates less than 50cc as a training modality. Prospective data were collected and outcomes compared with controls who had HoLEP. Subsequently a HoL prostatectomy service was introduced to a new centre and evaluated prospectively during the initial experience of two surgeons mentored by another trained in the trimodal staged approach. Results: Outcomes following HoLAP were comparable to HoLEP in prostate volumes under 50 cm3. The new HoL service was evaluated over 6 months. 70 cases were carried out, 42 HoLAP and 28 HoLEP. Outcomes were compared prospectively with 30 TURPs by another surgeon. A decrease in catheterisation time and hospital stay was noted in the laser group. Conclusion: The staged progression from HoLAP, then HOLARP and finally to HOLEP with morcellation appears a safe and reproducible way to introduce HoL prostatectomy into standard urological practice.