The Urodynamics for Prostate Surgery Trial

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?”.

The Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) compared two assessment pathways for men who are seeking further treatment for difficulty passing urine, including the possibility of surgery. In his presentation, Prof. Marcus Drake (North Bristol Hospital, United Kingdom) shared that symptom outcomes are non-inferior when urodynamics (UDS) is included in the assessment of male lower urinary tract symptoms (LUTS). However, in a patient preference analysis, most patients supported the inclusion of UDS to facilitate understanding of their condition.

One problem that must be addressed, according to Prof. Drake, is that presenting symptoms are often categorised as storage LUTS, directly affecting patient quality of life. However, therapy is often focussed on treating these patients for voiding LUTS by healthcare professionals. Obviously, this approach is misinformed and negligent to the patients’ actual symptoms. Prof. Drake underscored that key symptoms are best identified by the International Consultation on Incontinence Questionnaire – Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) [1] due to inclusion of urgency urinary incontinence, post micturition dribble, and individual symptom bother.

Discussant Prof. Stavros Gravas (University of Thessaly, Greece) asserted that the UPSTREAM trial reinforces that UDS use is best applied for selected patients only, and is not for general implementation. He also pointed out that UPSTREAM independently confirmed the EAU diagnostic pathway as a realistic and practical approach for the evaluation of men with LUTS.

Critically, UPSTREAM provides additional information on the values and preferences of patients, and how to counsel them. Data was also gathered on how centres perform UDS, how their standard operating procedures are adhered to, and how urologists interpret diagnostic results.

Timing of surgery was also considered: “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 Prof. Ferdinando Fusco (University of Naples, Italy). One concern he raised was that accurate evaluation of bladder function in male patients with BPO currently requires invasive methods. New non-invasive methods such as near infrared spectroscopy may prove effective in the near future.

He also stressed that 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 Prof. Fusco.

1. https://iciq.net/iciq-mluts

Posted on 21 May 201929 February 2024