Development of a patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Abstract

There are several surgical options to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). These treatment options vary in their treatment intensity, need for anaesthesia, risk of morbidity, functional outcomes, durability, effects on patient’s health-related quality of life (HRQoL), and accessibility [1]. Given the growing number of options available to treat BPH, patients and urologists are exposed to a tremendous amount of information when deciding on the best surgical management option for an individual patient. It may be challenging for urologists to ensure patients are aware of the options, and have the ability to incorporate their values and preferences to help inform a high-quality decision [2]. Patient decision aids (PtDAs) can be used to overcome this challenge by providing evidence-based and standardised education. A PtDA is a clinical tool that is used to facilitate shared decision-making between a patient and their healthcare provider using a structured development process [2-4]. PtDAs have been shown to increase patients’ knowledge of their health condition, decrease indecisiveness, and improve patients’ satisfaction with the choice made [2, 3]. With the help of patient advocates, a PtDA was developed to facilitate shared decision-making for patients considering surgical options for the management of BPH. We planned to include all guideline-approved surgical treatments for BPH in the PtDA. This article aims to present a detailed description of the development process of this BPH decision aid, provide insight into patient’s perception of this development process, and review the literature on this topic. The International Patient Decision Aids Standards (IPDAS) and the Ottawa Decision Support Framework were used to guide the systematic development of the PtDA [4]. A steering committee consisting of two patient advocates who had previously undergone surgery for BPH (J.S. and H.G.), two methodological experts (K.M. and L.T.L.), and six clinical experts that were either community (P.M.) or academic-based urologists (N.B., H.R., D.S.E., K.C.Z. and R.P.) was formed (Fig. 1). Two medical students (D.B. and D.D.N.) supported the activities of the steering committee. Using an iterative feedback process, each step in the development of the PtDA was planned and reviewed by the steering committee. First, a literature review was performed to identify similar PtDAs. Then, the American Urological Association (AUA), European Association of Urology (EAU), and Canadian Urological Association (CUA) BPH guidelines were reviewed to identify the recommended surgical modalities (Fig. 1). Society guidelines and the literature were reviewed for the best method to stratify patients based on risk factors. Based on the review of society guidelines, the PtDA was divided according to patient’s prostate volumes, as many studies and society guidelines follow volume cut-offs when selecting a treatment modality for patient’s LUTS secondary to BPH. Therefore, stratifying this PtDA according to prostate volume cut-offs determined by these guidelines will enable patients and urologists to follow these evidence-based recommendations and make the appropriate decision when selecting a treatment option. Then, a literature review was performed across a number of areas identified by the steering committee as important to patients and providers when selecting a surgical modality to characterise the outcomes of each treatment (Fig. 1). Notably, these areas included clinical and quality of life outcomes as well as treatment-related costs. The Medical Literature Analysis and Retrieval System Online (MEDLINE) was searched for the surgical management of LUTS secondary to BPH. This was done using pre-defined search terms that included all treatment modalities in combination with BPH, benign prostatic enlargement (BPE), benign prostatic obstruction (BPO), and bladder outlet obstruction (BOO). Additionally, the AUA, EAU, and CUA guid