Improving quality of care

Abstract

The management of BPH/PE/LUTS includes a gallimaufry of treatment options, from herbal compounds to several classes of drugs to many surgical options. It is a remarkable transition from only a generation ago, when BPH had one treatment: TURP. Most patients treated for symptoms of BPH improve and are satisfied with the outcome. The treatments are relatively innocuous, with few adverse quality of life effects. This may explain why so many treatments coexist. In fact, it is remarkable to me how moderate the debate is about which therapy is superior. The fact that, after 10 or more years of high quality clinical trials in BPH, there is still such a wide range of practice, emphasizes the difficulties in establishing clear superiority of one treatment over another when improved quality of life is the major goal. A corollary is that most of the large definitive trials in BPH have compared different drug therapies. Comparisons of surgical interventions have been smaller, with shorter follow-up, hence less conclusive observations. In this context, the BPH guideline from the CUA is a wonderfully clear and concise guide to the management of this important condition. It establishes the standard of care for BPH in Canada. It should be required reading for all those who treat BPH—in other words, all of Canada’s adult urologists. The point-counterpoint debate on laser prostatectomy versus TURP highlights the controversy. Laser prostatectomy delivers appealing results, with reduced blood loss and the possibility of outpatient management. However, there is a significant learning curve and some increased operating room costs (defrayed, potentially, by avoiding hospitalization). Should the laser replace the resectoscope for the management of BPH? You’ll have a more informed perspective on this after reading these articles. The vasectomy guideline is also terrific and useful. Recently, there was a successful “wrongful pregnancy” suit against a Canadian urologist by a patient with azoospermia on his post-vasectomy semen analysis, who had vasal recanalization resulting in recovery of fertility. While we consider vasectomy to be relatively trivial as a surgical procedure, there are significant pitfalls to consider. These are very well-summarized in this new guideline. Another theme in this issue is unnecessary tests. The article calling for selective use of free PSA, and another on reducing the burden of follow-up tests in kidney cancer, both point to simple ways by which we can all contribute to reducing health-care costs without affecting the quality of care.