Chief Investigator, Mr Marcus Drake, recently had a chat with a centre and talked through possible reasons why recruitment might be slow and one emerged which might be relevant to others. So, we wanted to share this information. Mr Drake is happy to discuss if it would be of help - please just call/email. Basically, it’s the issue of making a treatment decision based on already having some results (which is a mistake even we made when we were first getting going). 

Scenario 1;

1. Patient referred by GP with LUTS
2. Sent for flow test
3. Flow result returned and reviewed; turns out to be good, so don’t think surgery would be suitable, hence UPSTREAM not even considered.

This is wrong, as it effectively means you’ve leaped straight to the treatment decision, and the point of the study is to capture what information you need to make a treatment decision. 

Here’s what actually should happen;

1. Patient referred by GP with LUTS
2. Ask research nurse (RN)/assistant to see them and invite them to join UPSTREAM

Please do not mention treatment to the patient (“I think you probably need surgery, but I’ll ask you to see 'RN' anyway”). Simply say “we’d better look into your symptoms a bit further, so please see 'RN'…”

Alternative scenario 2;

1. Patient referred by GP with LUTS
2. Sent for flow test
3. Ask 'RN' to see them BEFORE THE RESULT IS REVIEWED

Another alternative scenario 3;

1. The first time you meet the patient is when they come to you in clinic from a flows test
2. Ignore the flows result for now, ask 'RN' to see the patient. (Even if you see Qmax is good, they’re still eligible for the study)
3. 'RN' invites them to UPSTREAM, completes the data collection according to randomised allocation
4. Review all results together once available (including the flow rate). That’s when you would decide they don’t need surgery.

Just to remind you, the exclusion criteria are lower urinary tract cancer, current indwelling catheter, previous prostate surgery, relevant neurological disease. Other stuff is not a problem- e.g. bladder diverticulum.