The Association between Diabetes Medication Use and Tumour Characteristics at Diagnosis in Patients with Urothelial Carcinoma: A Retrospective Registry-Based Study.

BACKGROUND: Observational studies indicate a potential association between diabetes medication use and aggressiveness of bladder cancer. OBJECTIVE: The objective is to exploratively study the association between diabetes medication use, as proxy for diabetes, and cancer characteristics of urothelial carcinoma at diagnosis. Furthermore, differences in associations between specific types of diabetes medication are studied. METHODS: The association between use of diabetes medication and urothelial carcinoma (UC) characteristics at diagnosis is studied. A retrospective registry-based study among UC patients in the Netherlands was performed for which two large linked registries from PHARMO and IKNL were used. Patients diagnosed with UC between 2000 and 2016 and no previous cancer were included in this study. In this study, 1,168 UC patients who were diabetes medication users were included as well as 3,609 non-users. Conditional logistic regression analysis was performed to determine odds ratios comparing cancer characteristics between different types of diabetes medication users to non-users. RESULTS: Noninsulin antidiabetic drugs (NIAD) use was associated with a muscle-invasive type of UC compared to non-users (OR = 1.31, 95% CI: 1.10-1.55 for T2+ versus Ta) as well as a poorly differentiated tumour (OR = 1.31, 95% CI: 1.07-1.59 for poorly versus well differentiated tumours). CONCLUSION: Users of diabetes medication are potentially more likely to be diagnosed with a more aggressive tumour than non-users; however, lifestyle factors could not be adjusted for.

Treatment Preferences of Patients With Benign Prostatic Hyperplasia Before and After Using a Web-based Decision Aid.

OBJECTIVE: To evaluate treatment preferences of patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) before and after using a web-based decision aid (DA). PATIENTS AND METHODS: Between July 2016 and January 2017 patients were invited to use a web-based LUTS/BPH DA. Treatment preferences (for lifestyle advices, medication or surgery) before and after DA use and responses on values clarification exercises were extracted from the DA. RESULTS: In total, 126 patients were included in the analysis. Thirty-four percent (43/126) had not received any previous treatment and were eligible for (continuation of) lifestyle advices or to start medication, as initial treatment. The other 66% (83/126) did use medication and were eligible, either for continuing medication or to undergo surgery. Before being exposed to the DA, 67 patients (53%) were undecided and 59 patients (47%) indicated an initial treatment preference. Half of the patients who were initially undecided were able to indicate a preference after DA use (34/67, 51%). Of those with an initial preference, 80% (47/59) confirmed their initial preference after DA use. Five out of 7 values clarification exercises used in the DA were discriminative between final treatment preferences. In 79%, the treatment preferred after DA use matched the received treatment. Overall, healthcare providers were positive about DA feasibility. CONCLUSION: Our findings suggest that a LUTS/BPH DA may help patients to confirm their initial treatment preference and support them in forming a treatment preference if they did not have an initial preference.

Effectiveness of a web-based treatment decision aid for men with lower urinary tract symptoms due to benign prostatic hyperplasia.

OBJECTIVES: To evaluate the effectiveness of a web-based decision aid (DA), with values clarification exercises compared with usual care, for men with lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH). PATIENTS AND METHODS: Between July 2016 and January 2017, all new patients with LUTS/BPH who consulted the urologist were invited to use the DA and participate in this prospective questionnaire study. Patients who consulted the urologist between December 2015 and February 2016 served as controls. The DA was designed to support patients in making a well-informed treatment decision, corresponding with their personal preferences and values. Well-informed decision was measured by using a knowledge questionnaire. Value congruent decision was measured by the correspondence between responses on nine value statements and chosen treatment. The primary outcome, decision quality, was defined as the combination of well-informed decision and value congruent decision. Secondary outcomes were decisional conflict, involvement and received role in shared decision-making, decisional regret, and treatment choice. RESULTS: A total of 109 DA-users and 108 controls were included. DA-users were younger (68.4 vs 71.5 years; P = 0.003) and their education level was higher (P = 0.047) compared with the controls. Patients who used the DA made a well-informed and value congruent decision more often than the control group (43% vs 21%; P = 0.028). DA-users had less decisional conflict (score 33.2 vs 46.6; P = 0.003), experienced a less passive role in decision-making (22% vs 41%; P = 0.038), and reported less process regret (score 2.4 vs 2.8; P = 0.034). Furthermore, DA-users who had not used prior medication chose lifestyle advices more often than the control group (43% vs 11%; P = 0.002). Outcomes were adjusted for significantly different baseline characteristics. CONCLUSION: The LUTS/BPH DA seems to improve the decision quality by supporting patients in making more well-informed and value congruent treatment decisions. Therefore, further implementation of this DA into routine care is suggested.

Is on-demand sacral neuromodulation in patients with OAB syndrome a feasible therapy regime?

INTRODUCTION: Sacral neuromodulation (SNM) of the lower urinary tract has proven to be safe and effective in patients with complaints of OAB syndrome who are not responding to conservative therapy. After 5 years of treatment the implanted system is still effective in 56-71% of patients. The loss of effect could be caused by adaptation of the nerve system to prolonged stimulation of the sacral nerves. MATERIALS AND METHODS: We set up a pilot intervention study. After a run-in period of 2 weeks patients were randomized into two groups: one group with on-demand neuromodulation (intervention group) and one group with continuous neuromodulation (control group). Patients in the intervention group were instructed to switch their INS off by default and to switch it on again when they felt recurrent symptoms, patients in the control group were asked to use their system as normally. RESULTS: After 2 weeks 10 out of 16 subjects reported a comparable symptom score during on-demand use of their neuromodulation system. Patients appreciated the comfort of being self-determent in the need for therapy. CONCLUSIONS: Possible benefits for patients could be: more autonomy, longer battery life of the implanted INS, decreasing the chance of adaptation by the nervous system.

Sacral nerve stimulation for neuromodulation of the lower urinary tract.

Patients with symptoms of overactive bladder syndrome or non-obstructive urinary retention, refractory to conservative therapy, can nowadays be treated minimally invasively with sacral nerve stimulation (SNS). The use of electric currents to treat urological pathology has a long history but SNS therapy only received FDA approval in 1997. The mechanisms of action are still not known so there are different theories explaining the modulation effect. Recent studies have shown a central modulation effect. Predictive factors which can help to identify the perfect candidates are not known. Over the years the technique of SNS has become less invasive and because of two stage implantation test results have proven to be more reliable. The clinical results for this therapy have proven to be safe and effective and with the technical improvements over the years the re-operation and complication rates have decreased significantly. The clinical results have led to expanding indications because of positive effects in other symptoms. In the field of urology this has resulted in the use of SNS therapy for interstitial cystitis, neurogenic lower urinary dysfunction, and pediatric voiding dysfunction. In the field of gastro-intestinal pathology, SNS therapy is used to treat faecal incontinence and constipation.

Medium-term experience of sacral neuromodulation by tined lead implantation.

OBJECTIVE: To describe patient selection for sacral neuromodulation, also known as Interstim therapy, and the results of tined-lead implantation in the medium term. PATIENTS AND METHODS: In all, 49 patients, 39 with refractory overactive bladder symptoms and 10 with urinary retention, were implanted with the tined lead under local anaesthesia. The mean (sd) test period was 12.4 (5.8) days. Patients were implanted when they had a > or = 50% improvement in voiding diary variables during the test period. The mean follow-up for implanted patients was 15.5 (7.9) months. Changes in voiding variables were compared using a t-test. RESULTS: Ten patients had a one-stage and 39 a two-stage implant; of the latter group, 31 (80%) had a positive response and eight (21%) did not. In all, 31 patients were included in the follow-up. At the last follow-up, 28 (90%) patients had a >50% improvement in diary variables and three (10%) did not. In 21 patients with urgency symptoms the mean (sd) number of voids decreased from 11.7 (8.9)/day at baseline to 7.3 (3.4)/day (P = 0.1); the voided volume increased from 160.2 (70.7) mL to 231.1 (119.5) mL (P = 0.001); and the number of leakages decreased from 9.5 (8.7) to 3.3 (2.2)/day (P = 0.17). In the 10 patients with retention, the number of catheterizations decreased from 5.44 (1.6)/day with a volume of 297.6 (76.8) mL, to 1.2 (1.7)/day and 111.6 (158.1) mL; the mean number of voids increased from 3.7 (3.8)/day with a volume of 123.3 (141.7) mL, to 4.2 (2.4)/day and 248.3 (146.0)mL. There were no significant differences in the variables in the patients with retention. Seven patients had an adverse event. There was one incomplete electrode migration that was treated conservatively. CONCLUSION: This new minimally invasive approach gives positive results in the medium term. Two-stage testing with the tined lead seems more reliable than the classic percutaneous nerve evaluation. The lead anchoring method seems sufficient for fixing the electrode in the medium term.