Health-related quality of life prior to and 1 year after radical cystectomy evaluated with FACT-G and FACT-VCI questionnaires.

OBJECTIVE: The aim of this study was to investigate health-related quality of life (HRQoL) before and 1 year after radical cystectomy in relation to age and gender. METHODS: This prospective study involves 112 men and 40 women with bladder cancer treated with radical cystectomy between 2015 and 2018. HRQoL was assessed preoperatively and 1 year post-surgery through Functional Assessment of Cancer Therapy Scale - General (FACT-G) and Functional Assessment of Cancer Therapy Scale - Vanderbilt Cystectomy Index (FACT-VCI) questionnaires. The median age of the 152 patients was 71.5 years. RESULTS: Preoperatively, emotional and functional well-being were negatively affected. Physical, emotional and functional well-being presented higher values 1 year after surgery compared to before radical cystectomy, that is, better HRQoL. Social well-being showed a reduction, especially regarding closeness to partner and support from family. Men and women were equally satisfied with their sex life before radical cystectomy, but less so 1 year after, where men were less satisfied compared to women. Additionally, one out of five patients reported that they had to limit their physical activities, were afraid of being far from a toilet and were dissatisfied with their body appearance after surgery. CONCLUSIONS: Recovery regarding HRQoL was ongoing 1 year after radical cystectomy. Patients recovered in three out of four dimensions of HRQoL, but social well-being was still negatively affected 1 year after treatment. Sexual function after radical cystectomy was exceedingly limited for both men and women. An individual sexual rehabilitation plan involving the couple with special intention to encourage intimacy, might not only improve sexual life but also have a positive effect on social well-being as a consequence.

Women's experience of sexuality after radical cystectomy - a qualitative study.

PURPOSE: The aim of this study was to explore how women experienced sexuality after radical cystectomy due to bladder cancer. METHODS: We performed an interview study with qualitative design with content analysis. Inclusion criteria were age below 75 years. In total 10 women, with a median age of 64 years at surgery, were interviewed at median 24 months post radical cystectomy. RESULTS: The 10 women described sexual life as affected after surgery but they all tried to find ways to overcome the new situation together with their partner. The overall theme was 'A balance between emotional and physical closeness' emerged from 30 codes that were condensed into five subcategories and two categories: 'A sensual relationship' and 'A sexual relationship'. The first category constituted the subcategories 'Feeling of intimacy' and 'The importance of the relationship'. The category 'A sexual relationship' was revealed from the subcategories 'Reluctance to engage in sexual activity' and 'Partner inability to engage in sexual activity', and 'Acting for sexual rehabilitation'. CONCLUSIONS: The uncertainty that the women felt about their anatomical changes after radical cystectomy created a sexual anxiety and reluctance to resume intercourse. Even though the surgery had a major impact on their sexual life, the women tried to be sexually active. However, the meaning of sexual life was not just having sexual activity but also included closeness, affirmation, affection, and feeling attractive. Sexual counseling at an appropriate timepoint is essential to assure a balance between emotional and physical closeness, i.e. to regain sexual health.

Anorectal dysfunction after radical cystectomy for bladder cancer.

Objective: To prospectively assess anorectal dysfunction using patient-reported outcomes using validated questionnaires, manovolumetry and endoanal ultrasound before and 12 months after RC.Patients and methods: From 2014 to 2019, we prospectively included 44 patients scheduled for RC. Preoperatively and 12 months after surgery, 41 patients filled in a low anterior resection syndrome score (LARS-score) to assess fecal incontinence, increased frequency, urgency and emptying difficulties and a St Mark's score to assess fecal incontinence in conjunction with manovolumetry and endoanal ultrasound examinations. Pre- and postoperative patient-reported anorectal dysfunction were assessed by LARS-score and St Marks's score. At the same time-points, anorectal function was evaluated by measuring mean anal resting and maximal squeeze pressures, volumes and pressures at first desire, urgency to defecate and maximum toleration during manovolumetry. Wilcoxon's signed rank test was used to compare pre- and postoperative outcomes by questionnaires.Results: Postoperatively 6/41 (15%) patients reported flatus incontinence assessed by the LARS-questionnaire, and correspondingly the St Mark's score increased postoperatively. The median anal resting pressure decreased from 57 mmHg preoperatively to 46 mmHg after RC, but without any postoperative anatomic defects detected by endoanal ultrasound. Volumes and pressures at first desire, urgency to defecate and maximum toleration during manovolumetry all increased after RC, indicating decreased postoperative rectal sensation, as rectal compliance was unaltered.Conclusions: Postoperative flatus incontinence is reported by one out of seven patients after RC, which corresponds to decreased anal resting pressures. The finding of decreased rectal sensation might also contribute to patient-reported symptoms and anorectal dysfunction after RC.

Everyday life after a radical prostatectomy - A qualitative study of men under 65 years of age.

PURPOSE: The purpose of this study was to illuminate how men under 65 years of age experience their everyday Life one year or more after a radical prostatectomy for localised prostate cancer. METHOD: Interviews with 19 men aged under 65 were performed 12-18 months after their radical prostatectomy. The interviews were analysed using a thematic content analysis. RESULTS: The analysis of the interviews revealed three categories of experiences: 'Paying a price for survival', 'Feeling sidestepped' and 'Living with death lurking around the corner'. The side effects of the prostatectomy, such as sexual dysfunction, resulted in a changed self-image with a loss of manliness and reduced self-esteem. The men felt sidestepped and that they did not receive enough support. Prostate cancer was experienced as an embarrassing disease and the men felt their fundamental needs could not be openly discussed. Having cancer was associated with death. Thoughts about death faded away during recovery after the operation, but grew stronger in certain situations and reminded the men about their cancer. Returning to work and to previous activities helped them cope with the thoughts about death. CONCLUSIONS: Our study suggests a need for improved rehabilitation after a radical prostatectomy, including more structured sexual rehabilitation, and involving the partner. Sharing the experiences of other men who have undergone prostate cancer surgery may also be beneficial.

Toileting behavior and urinary tract symptoms among younger women.

INTRODUCTION AND HYPOTHESIS: Irregular or infrequent voiding due to avoiding school toilets can contribute to a number of urinary problems among school children. There is, however, a lack of studies on younger women. The aim of this study was to investigate toileting behavior and the correlation to lower urinary tract symptoms (LUTS) among young women (age 18-25 years). A further aim was to validate the Swedish version of the Toileting Behavior scale (TB scale). METHODS: Quantitative descriptive design was used with two questionnaires: the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and the TB scale, together with six background questions. The questionnaires were distributed in November 2014 to 550 women aged 18-25 years randomly selected from the population register in southern Sweden. RESULTS: A total of 173 (33%) women responded. Mean age was 21.6 years (range 18-25). The Swedish version of TB scale showed good construct validity and reliability, similar to the original. Most toileting behavior was significantly correlated with LUTS, which were common, as 34.2% reported urgency and 35.9% urine leakage at least sometimes or more often. CONCLUSIONS: LUTS were quite common in this group of young women. Toileting behaviors were also significantly related to urinary tract symptoms. Thus, TB scale was useful in this population, and the translated Swedish version showed good construct validity and reliability.

Patient-reported outcome after radical cystectomy: translation and psychometric validation of the Swedish version of the Functional Assessment of Cancer Therapy Scale Vanderbilt Cystectomy Index.

OBJECTIVE: The aim of this study was to translate and validate the Swedish version of the Functional Assessment of Cancer Therapy Scale - Vanderbilt Cystectomy Index (FACT-VCI). MATERIALS AND METHODS: For adaptation into Swedish, a multiprofessional team was used for translation including cultural adjustment, followed by back-translation. Test and retest in 10 individuals was followed by assessing metric properties in 75 consecutive patients with bladder cancer treated with radical cystectomy. Reliability and internal consistency were measured by Cronbach's alpha. Face validity was tested with two laypersons and construct validity was tested by correlation to the dimensions in the Functional Assessment of Cancer Therapy Scale - General (FACT-G). RESULTS: The translated Swedish instrument showed validity and reliability similar to the original, and the results were comparable to published studies using FACT-VCI. The correlation between the VCI sum score and FACT-G dimensions was significant in all dimensions and the item-total correlation was over 0.3; therefore, the construct validity was acceptable. In addition, it was possible to detect differences in separate items in the translated version of FACT-VCI between age groups, type of diversion and those treated with chemotherapy, even though the samples were small. CONCLUSIONS: The Swedish version of FACT-VCI is a valid and reliable instrument for use in the follow-up of patients with bladder cancer treated with urinary diversion. To measure changes after surgery, preoperative assessment with the related FACT-G instrument is advisable.

Catheter-associated urinary tract infections and other infections in patients hospitalized for acute stroke: A prospective cohort study of two different silicone catheters.

OBJECTIVE: Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection. The primary aim of this study was to investigate whether the use of a silicone catheter coated with an ultrathin layer of a combination of the noble metals gold, palladium and silver (BIP™-silicone catheter) could reduce the incidence of CAUTI and antibiotic prescription compared with a standard silicone catheter in a cohort of acute neurological patients suffering primarily from stroke. At the same time, all infectious events requiring prescription of an antimicrobial agent were registered and are reported. MATERIALS AND METHODS: The study was designed as a crossover cohort study enrolling men and women aged over 18 years, requiring emergency management for stroke including the insertion of an indwelling catheter. Data on patient characteristics, urinary tract infections (UTIs), other infectious events and all antibiotic prescriptions were recorded prospectively. RESULTS: The patients' characteristics differed in the two centres in terms of age but not in diagnosis distribution. UTIs were recorded in 78 (24.2%) of the patients, ahead of pulmonary tract infections (n = 65; 20.2%). There was no difference in terms of CAUTI in the two catheter groups, even in subgroups with catheter treatment for 1 week or less. The patients with a diagnosed UTI required 3.5 more days of hospitalization than those without a UTI. CONCLUSION: CAUTIs were the most frequent healthcare-associated infections, slightly ahead of pulmonary tract infections. No advantages of the coated catheter could be found in this cohort of critically ill patients.

High School Students' Experiences in School Toilets or Restrooms.

Previous research about school toilets is based on studies of children in elementary school. Thus, the aim of this study was to explore the experiences when using the school toilets reported by students aged 16-18 years. Qualitative interviews with 21 students were conducted and analyzed using content analysis. The data revealed that the toilets were considered insecure, dirty, and unpleasant. Additionally, students refrained from drinking during school hours and remained in constant movement or jumped up and down to withhold urine and stool. This was illustrated in the following categories: assessing the toilet environment, coping with the situation, and feeling exposed Hence, there is an urgent need to improve the school toilet environment in order to respect the rights of all students to void or defecate when necessary, a process which will require involvement of students, teachers, and other school staff as well as the School Health Service.

The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review.

BACKGROUND: urinary incontinence (UI) is a common symptom among older people, with a higher prevalence among frail older persons living in nursing homes. Despite consequences such as reduced health and quality of life, many older people do not seek help for their symptoms, resulting in missed opportunity for treatment. OBJECTIVE: the aim of this study was to investigate the evidence and the effect of conservative treatment of UI and the quality of life among older and frail older persons. METHODS: a systematic review of randomised controlled studies and prospective, non-randomised studies was conducted, evaluating interventions of conservative treatment of UI in an older population (65 years or older). A total of 23 studies fulfilled the inclusion criteria and 9 were of high or moderate quality. Fourteen studies were of low quality and were therefore excluded from the analysis. RESULTS: documented and effective conservative treatments are available even for older persons with UI. Pelvic muscle exercise, physical training in combination with ADL, prompted voiding and attention training, and help to toilet are important treatments. In some studies, however, the evidence of effectiveness is limited. CONCLUSIONS: this systematic review concludes that there are conservative treatments for UI for older and frail older persons that reduce leakage and increase quality of life. There is however a need for further high-quality studies.

Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review.

AIM: The prevalence and severity of urinary incontinence (UI) increase with age and comorbidity. The benefits of pharmacotherapy for UI in the elderly are questionable. The aim of the present study was to systematically review the efficacy of pharmacological treatment for UI in the elderly and frail elderly. METHODS: We searched PubMed, EMBASE, Cochrane library and Cinahl databases through October 2013 to identify prospective controlled trials that evaluated pharmacological treatment for UI in persons aged ≥65 years. Elderly persons living in nursing homes were regarded as frail elderly. Outcomes were urinary leakage, quality of life and adverse events. RESULTS: We screened 1038 abstracts and assessed 309 full-text articles. We identified 13 trials of high or moderate quality; 11 evaluated anticholinergic drugs and two evaluated duloxetine. Oxybutynin, the only drug studied in the frail elderly population, had no effect on urinary leakage or quality of life in elderly with urgency UI (UUI). Seven trials evaluated the effects of darifenacin, fesoterodine, solifenacin, tolterodine or trospium. Urinary leakage decreased (standard mean difference: -0.24, 95% confidence interval -0.32-0.15), corresponding to a reduction of half a leakage per 24 h. Common side-effects of treatment were dry mouth and constipation. Data were insufficient for evaluation of the effect on quality of life or cognition. The evidence was insufficient to evaluate the effects of duloxetine. No eligible studies on mirabegron and estrogen were found. CONCLUSIONS: Anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI. Treatment with drugs for UUI in the frail elderly is not evidence based.

Surgery for urinary incontinence in women 65 years and older: a systematic review.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common among the elderly, but the literature is sparse on the surgical treatment of UI among the elderly. This systematic review aims to assess the effectiveness of surgical interventions as treatment for urinary incontinence in the elderly population ≥65 years of age. METHODS: Randomized controlled trials (RCT) and prospective nonrandomized studies (NRS) were included. The databases PubMed (NLM), EMBASE (Elsevier), Cochrane Library (Wiley), and Cinahl (EBSCO) were searched for the period 1966 up to October 2013. The population had to be ≥65 years of age and had to have undergone urethral sling procedures, periurethral injection of bulking agents, artificial urinary sphincter surgery, bladder injection treatment with onabotulinumtoxin A or sacral neuromodulation treatment. Eligible outcomes were episodes of incontinence/urine leakage, adverse events, and quality of life. The studies included had to be at a moderate or low risk of bias. Mean difference (MD) or standard mean difference (SMD)as well as risk difference (RD) and the 95% CI were calculated. RESULTS: Five studies--all on the suburethral sling procedure in women-- that fulfilled the inclusion criteria were identified. The proportion of patients reporting persistent SUI after surgery ranged from 5.2 to 17.6%. One study evaluating quality of life (QoL) showed a significant improvement after surgery. The complication rates varied between 1 and 26%, mainly bladder perforation, bladder emptying disturbances, and de novo urge. CONCLUSION: The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited.

Noble metal alloy-coated latex versus silicone Foley catheter in short-term catheterization: a randomized controlled study.

OBJECTIVE: The primary aim of this study was to compare the incidence of catheter-associated bacteriuria with a noble metal alloy-coated latex catheter or a non-coated silicone catheter in patients undergoing elective orthopaedic surgery with short-term catheterization. Secondary objectives included identifying risk factors for bacteriuria and catheter-associated urinary tract symptoms. MATERIAL AND METHODS: The study compared 217 patients randomized to and receiving a silicone catheter with 222 patients treated with a coated latex catheter. Before removal of the catheter a sample for urinary culture was obtained. Bacteriuria was defined as the growth of ≥100 000 cfu/ml. A logistic regression model was used to identify risk groups for bacteriuria. Patients were interviewed about urinary tract symptoms during and after catheterization. RESULTS: The incidence of bacteriuria was 1.5% with the coated latex catheter and 5.5% with the silicone catheter (p = 0.027) after a mean period of 2 days' catheterization time. Female gender (odds ratio 6.02) and obesity (odds ratio 5.08) were significant risk factors for bacteriuria. A quarter of the patients reported at least one symptom from the urinary tract during and after catheterization. Most patients defined the symptoms as "yes, a little" and a few consulted a healthcare professional because of the symptoms. CONCLUSION: This study confirmed previous results that the noble metal alloy coating significantly reduces the risk of catheter-associated bacteriuria in short-term catheterization (1-3 days). Female gender and obesity were significant risk factors for developing bacteriuria, while the use of an open drainage system and insertion of the catheter on the ward were not.

Validation of the Swedish short forms of the Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

OBJECTIVE: To psychometrically evaluate the Swedish translations of the short forms of the Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). DESIGN AND SETTING: Cross-sectional design, University hospital. SAMPLE: Forty-four patients awaiting prolapse surgery. METHODS: The dual-panel translation method followed by an evaluation of validity and reliability in prolapse patients. MAIN OUTCOME MEASURES: Construct, convergent and discriminant validity, reliability via test-retest and internal consistency. RESULTS: Item response rates were high (range 95.5-100%) for PFIQ-7 and PFDI-20. The corrected item-total correlations showed acceptable construct validity for PFIQ-7 (r=0.338-0.826) but low for PFDI-20 (r=0.116-0.581) and PISQ-12 (r=0.024-0.735). Acceptable convergent validity was found in all three instruments, with a negative correlation with the SF-12. There were no floor or ceiling effects in the three instruments. In the test-retest analysis, intraclass correlation coefficients were significant (r=0.888-0.943). Cronbach's α varied between 0.57 and 0.94. CONCLUSION: This is the first validated translation of the PFIQ-7, PFDI-20 and PISQ-12 in Swedish. All three instruments indicated acceptable psychometric properties.

Bowel function among people 75+ reporting faecal incontinence in relation to help seeking, dependency and quality of life.

AIMS AND OBJECTIVES: The aim was to compare faecal incontinence and related bowel symptoms among men and women and being dependent or not (aged >or=75 years) and furthermore to identify which bowel symptoms predicted help seeking, dependency and low quality of life (QoL). BACKGROUND: Faecal incontinence (FI) in old age is a common condition and influences daily life to a great extent, although few actually seek medical help. METHODS: A total of 248 people with reported difficulties controlling faeces answered a postal questionnaire or were interviewed with questions about FI-related bowel symptoms. A factor analysis resulted in four areas of bowel symptoms and was used in logistic regression with help seeking, dependency and low QoL as dependent variables. RESULTS: Of all the subjects, 56.4% had leakage, 54.7% did not reach the toilet in time, 55.6% had incomplete emptying, 27.9% had hard stool, 36.8% bother from moisture from the anus, 32.2% could not withstand urgency for five minutes and 17% had red skin or wounds in the genital region. Women and those dependent were most affected. Totally 40.8% had sought help and 30.1% used protective aids. Leakage, discomfort, consistency and contractibility symptoms were the categories of bowel symptoms related to FI. Discomfort predicted help seeking (OR 3.0), dependency (OR 1.5) and physical QoL (OR 1.7). Leakage predicted help seeking (OR 1.9) but not dependency and QoL. CONCLUSIONS: Overall bowel function was disturbed among those with FI and unmet needs seem problematic especially for women and those needing help in Activities of Daily Living (ADL). Encouragement to seek and get medical help and to use protective aids may improve the very low quality of life in this group. RELEVANCE TO CLINICAL PRACTICE: Older people with FI should be asked about, assessed for and examined for overall bowel function to get adequate treatment and be encouraged to use protection.

Older women and men with urinary symptoms.

The aim was to compare urinary symptoms and their influence on daily life among elderly (75+) women and men in a sample that previously had reported difficulties controlling urine (urine incontinence (UI)) and/or other urinary symptoms (OU). A further aim was to find underlying structures of urinary symptoms and to identify symptoms that had an impact on seeking medical help and need of help in daily activities (dependency). In total, 771 persons (352 men and 419 women) over 75 years answered a questionnaire, addressed to those (n=1881) who in a previous population-based study had reported having symptoms of UI and/or OU using the Bristol Female Lower Urinary Tract Symptoms (BF-LUTS) questionnaire and International Continence Society male (ICSmale) questionnaire. The groups with UI, OU, women and men reported similar symptoms of frequency, day and night, as well as influence on social life, and avoidance of places and situations due to the urinary symptoms although they differed in storage and voiding symptoms. Feeling incomplete emptying of bladder differed between the UI, OU, and mixed symptoms (MS) groups but not between genders. Of the whole sample, 43.3% had sought medical help. Factor analysis of similar questions in BF-LUTS and ICSmale questionnaire resulted in the factors labeled voiding, storage, pain, frequency, and daily life. Predictors of the urinary symptoms for needing help in daily activities were frequent micturition day and night (OR 3.2) when aged was controlled for. Influence on daily life (OR 2.5), storage symptoms (OR 2.2), and pain symptoms (OR 2.1) predicted seeking medical help. The results show that urinary symptoms are equally bothersome among men and women. There is a need to encourage elderly to seek medical help and to obtain treatment or alleviations for symptoms that give most bother and indicate dependency, such as frequent micturition day and night and difficulties to reach the toilet in time without leakage.

Patterns of health complaints among people 75+ in relation to quality of life and need of help.

This cross-sectional study aimed to investigate patterns, type and degree of health complaints and their relations to need of help and health-related quality of life (QoL) across gender among people aged 75-105 (n = 4277, mean age 83.6, S.D. 5.7) who answered a postal questionnaire covering health complaints, self-reported diseases socio-economy, QoL and need of help with personal and instrumental activities of daily living (PADL, IADL). A principal component analysis gave six categories of health complaints, of which communication (80.9%), mobility problems (66.6%), and psychosocial problems (61%) were most prevalent followed by elimination (42.5%), respiratory-circulatory (38.2%) and digestion-related problems (36.4%). Women reported significantly lower QoL than men. Those needing help with PADL and IADL had significantly lower QoL than those not requiring help. Mobility problems were the strongest predictor besides age, socio-economic factors and female gender for need of help with PADL, IADL and low physical QoL (OR 3.97, 3.67 and 7.47 respectively). Psychosocial problems (OR 3.60) were the strongest predictor besides age, socio-economic factors and female gender for low mental QoL. The findings indicate the importance of focusing on health complaints in coexistence patterns described as dysfunctions, and also the need for primary and secondary preventive actions related especially to mobility and psychosocial problems in geriatric care.

Symptoms of urinary and faecal incontinence among men and women 75+ in relations to health complaints and quality of life.

AIMS: The aim was to investigate the prevalence of self-reported symptom of urinary, faecal, and double incontinence (UI, FI, and DI) in men and women 75+ and to identify how other health complaints and Quality of Life (QoL) relate to incontinence symptoms. METHODS: A randomised sample, stratified for age, of eligible men and women from the population were included in the study and 4,277 out of 8,500 completed a postal questionnaire (61.6% women). The questions focused on difficulties in controlling urine and faeces, other health complaints, socio-economic background, and social relations. RESULTS: Among all respondents 39% reported symptom of UI (more so among women P < 0.001), symptom of FI in 16.9% (ns between sexes), DI, i.e., a combination of UI and FI, was reported among 14.5% (ns between sexes). Incontinence increased with age, and persons reporting incontinence also had significantly more of all other health complaints compared with persons without incontinence. Those reporting DI comprised an especially vulnerable group. Health complaints associated with UI were communicative and mobility problems, other urinary complaints, dizziness, cough, and fatigue. FI was associated with diarrhoea, stomach pain, fatigue, and other pain. Risk factors for DI were diarrhoea, communication, and mobility problems. CONCLUSIONS: UI and FI were common among elderly men and women and increased with age. Furthermore, incontinence was associated with many other co-existing health complaints, and the most frail were those with DI.

[Palliative cancer care is an important part of urology. A study of the last year of life of patients who died because of urologic cancer]. / Palliativ cancervård är en betydande del av urologin. Studie av det sista levnadsåret för patienter som dog av urologisk cancer.

A total of 330 in-patient episodes at the urology ward, with a mean duration of 9.8 days, were registered in a study of 100 patients who died from urological cancer. Twelve patients spent more than two months of their last year of life at the urology ward. As many as 82% of the admittances were on an emergency basis. A total of 101 operations were performed on 84 patients; 47 patients received palliative radiotherapy. This patient category needs a great deal of palliative care--at short notice--in order to get an optimal quality of life. Although many symptoms could have been alleviated outside hospital, the majority of patients needed specialised urological hospital care during their last year of life.