Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM).

BACKGROUND: Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies). OBJECTIVE: To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included. DESIGN, SETTING, AND PARTICIPANTS: A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments. INTERVENTION: Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient. RESULTS AND LIMITATIONS: Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure. CONCLUSIONS: Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function. PATIENT SUMMARY: We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.

Surgical treatment of varicose veins: effect of rationing.

INTRODUCTION: A substantial part of vascular surgical workload is devoted to the treatment of varicose veins. To control demand for cosmetic venous surgery, primary care trusts in Somerset introduced clinical criteria in 2000 for the referral and treatment of varicose veins based on the presence of skin change or ulceration, a history of bleeding, or two or more episodes of thrombophlebitis. PATIENTS AND METHODS: A comparison of workload and case mix for the referral and treatment of new patients presenting with varicose veins to the Taunton and Somerset Hospital was carried out over two 6-month periods, before and after the introduction of clinically based assessment criteria. RESULTS: A total of 134 operations for varicose veins were carried out in 2000 and 85 such operations in 2002/03 after the introduction of new referral criteria (P = 0.001). Of these, 69% (92/134) were day-case procedures in 2000 compared to only 48% (41/85) in 2002/03 (P = 0.004). There was no significant difference in the type of cases (e.g. single, bilateral or recurrent surgery) performed as a day-case (P = 0.34) or as an in-patient (P = 0.43) over the two periods. There was, however, a significant difference (P = 0.007) in the mean ages of patients in the two periods (48.5 years in period 1; 57.8 years in period 2) and in the average ASA grade (1.15 in period 1; 1.42 in period 2; P = 0.0002). CONCLUSION: The introduction of clinical criteria for the referral and treatment of varicose veins reduced workload by 37%.