Insights from the UPSTREAM study, the best time for intervention, clinical efficacy for BPH and invalidating fake news were covered during “What is the optimal treatment for patients with male LUTS?”. Plenary Session 07 was chaired by Prof. Christopher Chapple (GB) and Prof. Arnulf Stenzl (DE).
The Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) is a trial that compares two assessment pathways for men who have difficulty passing urine and are seeking further treatment, which may include the possibility of surgery.
In his presentation, Prof. Marcus Drake (GB) shared that symptom outcomes are non-inferior when urodynamics (UDS) is included in the assessment of male lower urinary tract symptoms (LUTS). He said that most patients support the inclusion of UDS to facilitate understanding of their conditions.
According to Prof. Drake, presenting symptoms are categorised as storage LUTS since these affect patient quality of life. However, therapy is often shifted onto voiding LUTS by healthcare professionals which result to neglect in treating storage LUTS.
Key symptoms are best identified by the International Consultation on Incontinence Questionnaire – Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) due to inclusion of urgency urinary incontinence (UUI), post micturition dribble (PMD) and individual symptom bother.
Prof. Drake said that many men experience a deterioration in symptoms including post transurethral resection of the prostate (TURP).
Discussant Prof. Stavros Gravas (GR) asserted that the UPSTREAM trial reinforces that UDS is not for general use but for selected patients only. He stated that the trial also confirmed that the EAU diagnostic pathway is a good, realistic and practical approach for the evaluation of men with LUTS.
UPSTREAM provides additional information on the values and preferences of patients, and how to counsel them. The study also delivered insights on how centres perform UDS and how urologists interpret results from the diagnostic tests. “The UPSTREAM study has more to offer and we look forward to further analysis of the first results,” said Prof. Gravas.
Best time for intervention
“To determine the best time for surgery, clinical progression (i.e. complications and refractory symptoms) and deterioration of the progressive bladder function should be taken into account,” stated Dr. Ferdinando Fusco (IT)
He added that an accurate evaluation of bladder function in male patients with BPO would require invasive methods. New non-invasive methods such as near infrared spectroscopy may prove effective.
Aside from subjective measures (LUTS and symptom bother), more consideration should be given to objective common measures of BPO progression so that surgery can be performed before irreversible bladder damage occurs and affects surgical outcomes.
“We can choose the best therapeutic window for our surgical activity, not only after medical treatment has been exhausted, but even before some irreversible damage in the bladder has been established,” concluded Dr. Fusco.
Competing with pharmacotherapy
In his Société Internationale d’Urologie (SIU) lecture “What are we aiming at? Balancing costs or optimal clinical efficacy for intervention in BPH”, Assoc. Prof. Damien Bolton (AU) said, “While TURP has and probably will remain the benchmark in terms of metrics, voiding flow and International Prostate Symptom Score (IPSS) result, it does not tell the whole story.”
Pharmacotherapy has demonstrated substantial reduced costs upfront. Prof. Bolton stated that even though symptomatic improvement might be suboptimal, it is acceptable to most patients as they prioritise quality of life rather than flow rate.
According to Prof. Bolton, minimally invasive surgical techniques must compete against pharmacotherapy to demonstrate advantages and to become established. Such advantages could be the same as medical therapy’s such as reduced time off work, decreased side-effect profile, and deferment of cost of definitive treatment.
Beating fake news
“Guidelines do not correspond to unchangeable truth and depends on available evidence. However with available minimally-invasive therapies, there are different levels of maturation of the data. Therefore it is the task of the Guidelines Panel to define the sub-populations of patients who will benefit from this specific minimally-invasive therapy,” stated Prof. Stavros Gravas (GR) in his lecture “Introduction of new techniques for surgery in the treatment of BPH: Faith, truth or fake news?”.
According to Prof. Gravas, enthusiasm has often “outstripped clinical evidence”, and early and aggressive company marketing can also overpower clinical evidence. He urges national and international organisations to refuse sanctioning new treatments until minimum threshold of certainty of evidence is available. He encourages patients’ organizations, device manufacturers and other stakeholders to formulate the optimal guidance to provide the best care for patients.
Prof. Gravas concluded his lecture with a quote by American engineer and author, William Edwards Deming: “In God we trust, all others must bring data.” Prof. Gravas then altered it to “In God we trust, all others must bring the right data.”