Spontaneous voiding is surprisingly recoverable via outlet procedure in men with underactive bladder and documented detrusor underactivity on urodynamics

Surgical Outcomes and Predictive Factors in Patients With Detrusor Underactivity Undergoing Bladder Outlet Obstruction Surgery

PURPOSE

This study was conducted to evaluate the efficacy of bladder outlet surgery in patients with detrusor underactivity (DU) and to identify factors associated with successful outcomes.

METHODS

We conducted a retrospective review of men diagnosed with DU in urodynamic studies who underwent bladder outlet surgery for lower urinary tract symptoms between May 2018 and April 2023. The International Prostate Symptom Score (IPSS) questionnaire, uroflowmetry (UFM), and multichannel urodynamic studies were administered. Successful treatment outcomes were defined as either an IPSS improvement of at least 50% or the regaining of spontaneous voiding in patients urethral catheterization prior to surgery.

RESULTS

The study included 93 male patients. Men diagnosed with significant or equivocal bladder outlet obstruction (BOO) experienced significant postoperative improvements in IPSS (from 20.6 to 6.0 and from 17.4 to 6.5, respectively), maximum urine flow rate (from 5.0 mL/sec to 14.4 mL/sec and from 8.8 mL/sec to 12.2 mL/sec, respectively) and voiding efficiency (from 48.8% to 86.0% and from 61.2% to 85.1%, respectively). However, in the group without obstruction, the improvements in IPSS and UFM results were not significant. The presence of detrusor overactivity (odds ratio [OR], 3.152; P=0.025) and preoperative urinary catheterization (OR, 2.756; P=0.040) were associated with favorable treatment outcomes. Conversely, an unobstructed bladder outlet was identified as a negative prognostic factor.

CONCLUSION

In men with DU accompanied by equivocal or significant BOO, surgical intervention to alleviate the obstruction may enhance the IPSS, quality of life, and UFM results. However, those with DU and an unobstructed bladder outlet face a comparatively high risk of treatment failure. Preoperative detrusor overactivity and urinary catheterization are associated with more favorable surgical outcomes. Consequently, active deobstructive surgery should be considered for patients with DU who are experiencing urinary retention.

Two-Staged Sacral Neuromodulation for the Treatment of Nonobstructive Urinary Retention: A Multicenter Study Assessing Predictors of Success

OBJECTIVES

The aims of this study were to 1) determine the success rate of the tined lead test phase in patients with nonobstructive urinary retention (NOUR), 2) determine predictive factors of a successful test phase in patients with NOUR, and 3) determine long-term treatment efficacy and satisfaction in patients with NOUR.

MATERIALS AND METHODS

The first part was a multicenter retrospective study at two centers in The Netherlands. Patients with NOUR received a four-week tined lead test phase. Success was defined as a ≥50% reduction of clean intermittent catheterization frequency or postvoid residual. We analyzed possible predictors of success with multivariable logistic regression. Second, all patients received a questionnaire to assess efficacy, perceived health (Patient Global Impression of Improvement), and treatment satisfaction.

RESULTS

This study included 215 consecutive patients (82 men and 133 women) who underwent a tined lead test phase for the treatment of NOUR. The success rate in women was significantly higher than in men, respectively 62% (83/133) and 22% (18/82, p < 0.001). In women, age per ten years (odds ratio [OR] 0.74, 95% CI: 0.59-0.93) and a history of psychiatric illness (OR 3.92, 95% CI: 1.51-10.2), including posttraumatic stress disorder (PTSD), significantly predicted first stage sacral neuromodulation (SNM) success. In men, age per ten years (OR 0.43, 95% CI: 0.25-0.72) and previous transurethral resection of the prostate and/or bladder neck incision (OR 7.71, 95% CI: 1.43-41.5) were significant predictors of success. Conversely, inability to void during a urodynamic study (for women, OR 0.79, 95% CI: 0.35-1.78; for men, OR 3.06, 95% CI: 0.83-11.3) was not predictive of success. Of the patients with a successful first stage, 75% (76/101) responded to the questionnaire at a median follow-up of three years. Of these patients, 87% (66/76) continued to use their SNM system, and 92% (70/76) would recommend SNM to other patients.

CONCLUSIONS

A history of psychiatric illness, including PTSD, in women with NOUR increased the odds of first stage SNM success 3.92 times. A previous transurethral resection of the prostate and/or bladder neck incision in men increased the odds of success 7.71 times. In addition, a ten-year age increase was associated with an OR of 0.43 in men and 0.74 in women, indicating a 2.3- and 1.3-times decreased odds of success, respectively.

Outcomes of Aquablation in Men With Acute and Chronic Urinary Retention

OBJECTIVE

To compare outcomes of Aquablation in men with acute and chronic urinary retention.

METHODS

We conducted a retrospective review of all men undergoing Aquablation resection of the prostate between May 2021 and August 2022. Men were classified as having acute urinary retention if they required either intermittent or indwelling catheter and chronic urinary retention if they had a postvoid residual >300 mL prior to surgery. We compared success rates and time to passage of trial without catheter as well as complication rates to those with no retention.

RESULTS

A total of 113 men underwent Aquablation including 28 with acute retention and 16 with chronic retention. Failure of initial void trial was significantly higher in patients with preoperative urinary retention (40%) and chronic retention with postvoid residual >300 mL (12.5%) compared to those with no retention (7.2%, P < .001). Among men with acute and chronic retention 98% were voiding spontaneously at a mean 5months follow-up. There was no difference in utilization of postoperative prostate medications, complications, International Prostate Symptom Score or uroflowmetry among men with acute, chronic, or no retention.

CONCLUSION

Aquablation is an effective method for treatment of men with urinary retention, with 98% achieving spontaneous voiding regardless of preoperative urodynamic findings. Men in acute retention prior to surgery were more likely to fail their initial void trial, which may support the recommendation for a delayed trial without catheter.

The bladder contractility and bladder outlet obstruction indices in adult men: Results of a global Delphi consensus study

AIMS

This Delphi study was planned to examine global expert consensus with regard to utility, accuracy, and categorization of Bladder Contractility Index (BCI) and Bladder Outlet Obstruction Index (BOOI) and the related evidence.

METHODS

Twenty-eight experts were invited to answer the two-round survey including three foundation questions and 15 survey questions. Consensus was defined as ≥75% agreement. The ordinal scale (0-10) in round 1 was classified into "strongly agree," "agree," "neutral," "disagree," and "strongly disagree" for the final round. A systematic search for evidence was conducted for therapeutic studies that have examined outcome stratified by the indices in men.

RESULTS

Nineteen experts participated in the survey with 100% completion. Consensus was noted with regard to 6 of 19 questions. Experts strongly agreed with utility of quantifying bladder contractility and bladder outflow obstruction with near unanimity regarding the latter. There was consensus that BCI and BOOI were accurate, that BCI was clinically useful, and for defining severe bladder outflow obstruction as BOOI > 80. Systematic search yielded 69 publications (BCI 45; BOOI 50). Most studies examined the indices as a continuous variable or by standard cutoffs (BCI 100, 150; BOOI 20, 40).

CONCLUSION

There is general agreement among experts on need for indices to quantify bladder contractility and bladder outflow obstruction as well as with regard to accuracy and utility of BCI and BOOI indices. Few studies have examined the discriminant power of existing cutoffs or explored new ones. This is an extraordinary knowledge gap in the field of urology.

Detrusor Underactivity in Men with Bladder Outlet Obstruction

Detrusor underactivity (DU) and bladder outlet obstruction (BOO) are both common troublesome causes of lower urinary tract symptoms (LUTS) and often impact on quality of life simultaneously in men. This article aims to focus on DU with BOO in male patients.

METHODS

Original articles concerning DU with BOO were identified through literature research from PubMed and EMBASE database. We selected 38 articles in our review, including those concerning pathophysiology, evaluation, treatment and predictors for a successful BOO surgery for DU.

RESULTS

DU from BOO can result from several pathophysiological mechanisms. Although urodynamic study (UDS) is considered as a precise method to diagnose DU and BOO, there are some previous studies which proposed a non-invasive method to identify DU related to BOO. The treatment goal of DU is restoring bladder contractility using medication or surgery. Releasing outlet obstruction and resistance is the main strategy to restore bladder contractility when medication to directly increase bladder contractility has had limited efficacy.

CONCLUSIONS

DU from BOO is poorly understood and is largely under-researched. The etiology and pathophysiology still need to be evaluated. Effective and safe medication to restore bladder contractility is also lacking. It remains valuable to perform further research to reveal the unknown aspects of DU.

Men with Chronic Urinary Retention: Treatments, Complications, and Consequences

OBJECTIVES

To explore the treatment options for chronic urinary retention (CUR) in men, including treatment-related complications and consequences.

METHODS

This retrospective cohort study included male patients diagnosed with a non-neurogenic, symptomatic and/or high-risk, CUR >150 mL in a large Dutch non-academic teaching hospital. Data for treatments, complications, and consequences (e.g., diagnostics, additional treatments, and hospital contact) were recorded and incidence rate ratios (IRRs) were calculated.

RESULTS

We enrolled 177 patients (median age, 77 years; range, 44-94) with a median follow-up of 68 months (range, 1-319) during which they had a median of 8 events (range, 1-51). Most patients initially received a urethral catheter (74%) and some form of catheterization as their final treatment (87%). Compared with non-surgical cases, catheterization was more likely to be stopped after de-obstructive prostate surgery (IRR, 4.18; p < 0.001). Urinary tract infection (IRR, 3.68; p < 0.001) and macroscopic hematuria (IRR, 5.35; p < 0.001) were more common with catheterization, but post-renal problems were more likely in patients with no catheterization (IRR, 25.36; p < 0.001). The lowest chance of complication was with clean intermittent catheterization, and complications were usually managed in outpatient (77%) or emergency (6%) departments, rather than by admission (17%).

CONCLUSIONS

Most patients require catheterization for CUR, with clean intermittent catheterization preferred due to its comparatively lower complication risk. De-obstructive prostate surgery increases the chance of stopping catheterization and may be considered in suitable cases.

DU Is Induced by Low Levels of Urinary ATP in a Rat Model of Partial Bladder Outlet Obstruction: The Incidence of Both Events Decreases after Deobstruction

Objectives. To investigate, in initial phases of bladder outlet obstruction (BOO), the urinary ATP levels, the incidence of detrusor underactivity (DU), and if they change after deobstruction. Methods. Adult female Wistar rats submitted to partial BOO (pBOO) and sham-obstruction were used. Cystometry was performed 3 or 15 days after pBOO and fluid was collected from the urethra for ATP determination. Bladders were harvested for morphological evaluation of the urothelium. DU was defined as the average of voiding contractions (VC) of sham-operated animals, with 3 SD at 15 days after the sham surgery. In another group of animals in which pBOO was relieved at 15 days and bladders were let to recover for 15 days, the incidence of DU and ATP levels were also accessed. The Kruskal–Wallis test was followed by Dunn’s multiple comparisons test, and Spearman’s correlation test was used. Results. DU was present in 13% and 67% of the bladders at 3 and 15 days after pBOO, respectively, and in 20% of the bladders at 15 days after deobstruction. ATP levels were significantly lower in DU/pBOO versus sham and non-DU/pBOO rats. A strong positive correlation between ATP levels and VC/min was obtained (r = 0.63). DU bladders had extensive areas in which umbrella cells appeared stretched, the width exceeding that presented by sham animals. Conclusions. Low urothelial ATP parallels with a high incidence of DU early after pBOO.

Persistent Lower Urinary Tract Symptoms After Prostatic Urethral Lift Successfully Treated with Water Jet Ablation of the Prostate: A Case Report and Review of the Literature

Background: We describe a patient who underwent waterjet ablation of the prostate after an unsuccessful prostatic urethral lift (PUL) procedure. Case Presentation: After PUL, our patient had incomplete bladder emptying with a postvoid residual of 600 mL. Urodynamic study of the bladder suggested detrusor underactivity. Our patient was motivated to undergo a salvage bladder outlet surgery. At 3 months after Aquablation, he reported complete resolution of bothersome lower urinary tract symptoms (LUTS). Conclusion: This case report illustrates return of volitional voiding and significant improvement in LUTS after salvage bladder outlet treatment with waterjet ablation of the prostate.

Detrusor overactivity and underactivity: implication for lower urinary tract symptoms related to benign prostate hyperplasia diagnosis and treatment

INTRODUCTION

Detrusor underactivity (DUA) and detrusor overactivity (DO) have potential impact on the outcomes of surgery for lower urinary tract symptoms related to benign prostate hyperplasia (LUTS/BPH).

EVIDENCE ACQUISITION

We performed a literature search including studies on humans enrolling patients with preoperative urodynamic evidence of DO and/or DUA undergoing LUTS/BPH surgery. Factors that may influence the outcomes of surgery in these patients were evaluated.

EVIDENCE SYNTHESIS

In patients with DUA mean bladder contractility index improved from +4 to +44.6, mean total International Prostate Symptom Score (IPSS) improved from -3 to -19.5 points, mean maximum urinary flow (Q<inf>max</inf>) improved from +1.4 to +11.7 mL/s, and mean postvoid residual volume (PVR) improved from -16.5 to -736 mL. Older age, lack of obstruction, concomitant DO, lower detrusor contractility and use of transurethral resection of the prostate (TURP) or photovaporization (PV) instead of Holmium laser enucleation of the prostate (HoLEP) were associated with worse outcomes. In patients with DO, the percentage of DO resolution ranged from 57.1% to 83.3%. Mean total IPSS, Q<inf>max</inf>, and PVR variations ranged from +0.9 to -15.7 points, from -0.2 mL/s to +14 mL/s, and from -19.6 to -202.5 mL, respectively. Older age, lack of obstruction, terminal DO, low maximum cystometric capacity, early and high amplitude DO, and use of transurethral prostate incision instead of TURP or open adenomectomy were associated with worse outcomes.

CONCLUSIONS

In patients with DUA or DO, surgery for LUTS/BPH provides overall good results. However, a number of factors can affect these outcomes.

The mechanical stop test and isovolumetric detrusor contractile reserve are associated with immediate spontaneous voiding after transurethral resection of prostate

PURPOSE

To identify urodynamic factors associated with the mechanical stop test and immediate spontaneous voiding following transurethral resection of prostate (TURP).

METHODS

We identified 90 men who underwent TURP over a 12-month period. Forty-three (mean age 68 years) underwent urodynamic evaluation prior to TURP. Isovolumetric detrusor contractile pressure (P_iso) was obtained using the mechanical stop test during the voiding phase, and used to calculate detrusor contractile reserve (P_res = P_iso - P_det@Q_max). Primary outcome was spontaneous voiding after TURP.

RESULTS

Preoperative catheter-free spontaneous voiding was present in 63% of men (27/43) with a urodynamic (mean ± SD): Q_max 6.2 ± 2.7 mL/s, P_det@Q_max 102 ± 47 cmH₂O, P_iso 124 ± 49 cmH₂O, P_res 22 ± 16 cmH₂O, bladder outlet obstruction index (BOOI) 90 ± 49, and bladder contractility index (BCI) 132 ± 44. The remaining 16 catheter-dependent men demonstrated a urodynamic (mean ± SD): Q_max 3.6 ± 3.3 mL/s, P_det@Q_max 87 ± 38 cmH₂O, P_iso 99 ± 51 cmH₂O, P_res 10 ± 18 cmH₂O, BOOI 82 ± 36, and BCI 106 ± 48. Following TURP, 67% of men voided spontaneously with their first void trial, and in receiver operator analysis of urodynamic measures (P_det@Q_max, P_iso, P_res, BOOI and BCI), only P_res was significantly associated with immediate spontaneous voiding after TURP (threshold P_res ≥ 9 cmH₂O, AUC = 0.681, p = 0.035).

CONCLUSIONS

In men who underwent TURP, a P_res ≥ 9 cmH₂O was associated with immediate spontaneous voiding and may be easily incorporated into the postoperative pathway.