Urodynamics tests for the diagnosis and management of male bladder outlet obstruction: long-term follow-up of the UPSTREAM non-inferiority RCT

Background
Lower urinary tract symptoms are common in older men and can be bothersome, leading to treatment. The UPSTREAM randomised controlled trial (Phase I) investigated whether assessment of these symptoms with invasive urodynamic testing could improve symptoms when guiding treatment options.

Objective
To assess the long-term lower urinary tract symptoms and the rates of surgery for bladder outlet obstruction in men participating in the UPSTREAM study (Phase I).

Design
Pragmatic, multicentre, parallel-group, two-group open randomised controlled study, with outcome assessors blinded to aggregate data.

Setting
Urology departments of 26 National Health Service hospitals in England.

Participants
Men ≥ 18 years, seeking further treatment for their bothersome lower urinary tract symptoms, which may include surgery, who were existing participants of the UPSTREAM study (Phase I). Men were excluded if they were unable to pass urine without a catheter, had a relevant neurological disease, were currently undergoing treatment for prostate or bladder cancer, had previous prostate surgery or were unfit for surgery.

Interventions
Routine care plus invasive urodynamics (intervention) or non-invasive routine care.

Main outcome measures
The primary outcome was a patient-reported International Prostate Symptom Score 5 years post randomisation. Rates of surgery was the key secondary outcome. Patient-reported outcomes included measures of lower urinary tract symptoms, sexual function, overall quality of life and cost-effectiveness from a secondary care perspective.

Data sources
Questionnaires to participants for patient-reported outcome measures, and National Health Service England Hospital Episode Statistics and mortality data.

Results
Of 820 men randomised in UPSTREAM (Phase I) between October 2014 and December 2016, 211/427 men randomised to the intervention group completed Phase II questionnaires (49.4%) and 205/363 in the routine care group (56.5%). There was no difference found between International Prostate Symptom Scores in the two groups at 5 years (adjusted difference 0.41, 95% confidence interval −1.10 to 1.93). There was also no difference in other lower urinary tract symptoms, sexual function or quality of life. Routine data were received for 98% of men. Three hundred and forty-seven (43.3%) men with routine data available had received at least one related surgical procedure for the treatment of lower urinary tract symptoms. Over the 5-year time horizon, incremental mean costs were slightly higher (£176.63, 95% confidence interval −£464.06 to £817.32) in the intervention group and incremental mean QALYs were slightly lower (−0.039, 95% confidence interval −0.152 to 0.073) in the intervention group. This suggests that routine care is the cost-effective option.

Limitations
Around half of the men from Phase I study completed questionnaires at 5 years, although their characteristics were similar to those of non-responders, withdrawn participants or those who had died. The majority of men were of white ethnicity, so results may be less applicable to other ethnicities.

Conclusions
Five-year follow-up does not support the introduction of invasive urodynamics in reducing lower urinary tract symptoms or rates of prostate surgery, from a clinical or cost-effectiveness perspective.

Future work
This should identify if there are subgroups of patients who might benefit from the addition of urodynamics to routine care for bothersome lower urinary tract symptoms.

Trial registration
This trial is registered as ISRCTN56164274.