Voiding Dysfunction Following Transurethral Resection of the Prostate: Symptoms and Urodynamic Findings

Can we predict and manage persistent storage and voiding LUTS following bladder outflow resistance reduction surgery in men? ICI-RS 2023

AIMS

Lower urinary tract symptoms (LUTS) persist in up to 50% of patients after bladder outflow resistance reduction surgery (BORRS) in men. Our think tank aims to address the predictive factors for persistent LUTS after BORRS and to propose the recommendations for future research to enable improved better patient counseling and selection by more accurate prediction of treatment outcome.

METHODS

A think tank of ICI-RS gathered in 2023, Bristol, UK, to discuss the pre and postsurgical clinical and urodynamic evaluation of men undergoing BORRS and whether it is possible to predict which men will have persistent LUTS after BORRS.

RESULTS

Our think tank agrees that due to the multifactorial, and still not fully understood, etiology of male LUTS it is not possible to precisely predict in many men who will have persistent LUTS after BORRS. However, severe storage symptoms (overactive bladder, OAB) in association with low volume and high amplitude detrusor overactivity and low bladder capacity in preoperative urodynamics, increase the likelihood of persistent OAB/storage symptoms after BORRS. Furthermore, patients who are clearly obstructed and have good bladder contractility on preoperative pressure flow studies do better postoperatively compared to their counterparts. However, the benefit of pressure flow studies is decreased in patients who do not acceptably void during the study. Poor voiding after BORRS may occur due to persistent obstruction or detrusor underactivity.

CONCLUSION

Future research is needed to increase our understanding of why male LUTS persist after surgery, and to enable better patient selection and more precise patient counseling before BORRS.

Temporary implantable nitinol device for benign prostatic hyperplasia-related lower urinary tract symptoms: over 48-month results

BACKGROUND

This study (MT02) reports >48-month (50-79 months) results of a prospective, single-arm, multicenter study (NCT02145208) of temporary implantable nitinol device (iTind®) in men with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS).

METHODS

Men with symptomatic BPH (International Prostate Symptom Score [IPSS] ≥10, Maximum flow rate [Qmax] <12 mL/s, and prostate volume <75 mL) from 9 centers were enrolled from December 2014 to December 2016. Total 50/81 (62%) patients at 3/9 sites (Italy, Switzerland, and Belgium), pursued the study beyond 36 months following iTind® device, per study protocol. Due to COVID-19, follow-up was amended. Each patient was assessed once during 50-79 months postoperatively for IPSS and IPSS-quality of life (IPSS-QoL), change in medication, need for surgical re-treatment and adverse events telephonically.

RESULTS

Post 36 month-follow-up, 5 patients were lost to follow-up and 2 patients died unrelated to iTind® device placement. Two patients (36-48 months follow-up) required surgical re-treatments (1 transurethral resection of prostate, 1 Thulium laser enucleation of prostate). >48 months results were available for 41 patients wherein iTind® device treatment showed significant improvement in symptoms (IPSS: -45.3%, P<0.0001 and IPSS-QoL: -45.1%, P<0.0001) from baseline to 79 months post-procedure; mean±SD of 11.26±7.67 and 2.10±1.41 points, respectively. No complications were recorded between 36 up to 79 months; no patient required additional medication.

CONCLUSIONS

iTind® device provided significant and durable symptom reduction and improved IPSS-QoL for >48 months post treatment. No late postoperative complications were reported beyond 36 months of follow-up. Surgical re-treatment rate for >36 months was 4%.

Frailty as a risk marker of adverse lower urinary symptom outcomes in patients with benign prostatic hyperplasia undergoing transurethral resection of prostate

Purpose

Lower urinary symptoms (LUTS) may persist in a proportion of patients with benign prostatic hyperplasia (BPH) following transurethral resection of prostate (TURP), which is a major cause of reduced quality-of-life. We aimed to investigate the effect of frailty on LUTS in patients with BPH treated with TURP.

Methods

We longitudinally evaluated LUTS and health-related quality-of-life (HRQOL) in patients with BPH treated with TURP from February 2019 and January 2022 using International Prostate Symptom Score (IPSS) and Short Form-8 (SF-8), respectively. Patients were divided into frail and non-frail groups according to the Fried phenotype (FP). The primary purpose was comparing the outcomes of LUTS and HRQOL between two groups. Secondary purposes were investigating the frailty as a preoperative predictor of postoperative adverse LUTS outcomes following TURP using logistic regression analysis. A 1:2 propensity score matching (PSM) was performed to reduce the effects of selection bias and potential confounders.

Results

Of the 567 patients enrolled, 495 (87.3%) patients were non-frail (FP = 0-2), and the remaining 72 (12.7%) patients were classified into the frail group. There were no significant differences in body mass index (BMI), urine white blood cell (UWBC), creatinine, prostate-specific antigen (PSA) and prostate volume in both groups at baseline (all p > 0.05). However, patients with frailty were older, higher comorbidity rates, lower peak flow rates and lower HRQOL. In the frail group, although LUTS and HRQOL at 6 months following TURP improved significantly compared to those at baseline, it did not show a significant improvement compared with the non-frail group (both p < 0.001). Moreover, multivariable logistic regression analysis demonstrated that preoperative frailty was significantly associated with poor LUTS improvement in both the entire cohort and PSM subset (both p < 0.05), whereas age and comorbidities were not after PSM analysis.

Conclusion

In patients with frail or non-frail, TURP for BPH provides overall good results. However, frail individuals are at higher risk of postoperative adverse LUTS outcomes. Frailty has the potential to be a strong objective tool for risk stratification and should be considered during the perioperative evaluation.

Does Preoperative Bladder Compliance Affect Long-Term Functional Outcomes after Laser Prostatectomy?

PURPOSE

We assessed the effects of preoperative bladder compliance on the long-term functional outcomes, especially focused on postoperative storage symptom changes, after laser prostatectomy.

MATERIALS AND METHODS

From January 2008 to March 2014, 1,608 men who underwent laser prostatectomy, including holmium laser enucleation or photo-vaporization of the prostate, were included in the analysis. We divided patients into 3 groups according to bladder compliance on a baseline urodynamic study: <12.5, 12.5-25, ≥25 mL/cmH₂O. A multivariable analysis was performed to determine the impact of bladder compliance on changes in long-term functional outcomes after laser prostatectomy.

RESULTS

Bladder compliance was less than 12.5 mL/cmH₂O in 50 (3.1%), 12.5-25 mL/cmH₂O in 232 (14.4%) patients. As bladder compliance decreased, the baseline International Prostate Symptom (IPSS) total score and storage sub-score were increased; the voiding sub-score remain unchanged. At postoperative 12 and 36 months, absolute improvements in the IPSS total score and storage sub-score were higher in <12.5 mL/cmH₂O group compared to other groups, although those were equivalent at postoperative 1 months. On the multivariable analysis, decreased bladder compliance <12.5 mL/cmH₂O was significantly associated with superior improvement in storage sub-score at postoperative 36 months, although it was not associated with voiding sub-score.

CONCLUSIONS

In patients with preoperative bladder compliance <12.5 mL/cmH₂O, storage symptoms could be further improved at 36 months after laser prostatectomy compared to others. Thus, laser prostatectomy could be a considerable treatment option for patients with severely decreased bladder compliance.

The relation between the storage symptoms before and after transurethral resection of the prostate, analysis of the risk factors and the prevention of the symptoms with solifenacin

OBJECTIVE AND HYPOTHESIS

We aimed to investigate the reasons of storage symptoms ( SS) after transurethral resection of the prostate (TURP). The hypothesis was that a positive correlation would be identified between preoperative and postoperative SS in patients with undergoing TURP and starting early solifenacin treatment in patients with high preoperative SS would be reasonable. In addition, we aimed to analyze multiple other risk factors for post-TURP SS.

MATERIALS AND METHODS

A total of 160 patients undergoing TURP were prospectively evaluated and divided into two groups according to their OABS. Those with a score of ≥10 points were Group 1 (G1), and those with < 10 points Group 2 (G2). In addition, patients in each group were randomly further divided into two subgroups: those who were started on 5 mg solifenacin succinate in the early postoperative period (G1/G2 A) and those who were not (G1/G2 B). In additions to SS Preop, perop and at the 3rd-month of postoperatively 14 variable were evaluated. The effects of these factors, surgery and the efficacy of an early medical treatment on the postoperative SS were investigated. LUTS were assessed by International Prostate Symptom Score (IPSS) and SS were assessed by sum of IPSS 2, 4 and 7 questionnaires (Storage, S- IPSS).

RESULTS

Preoperative IPSS and S-IPSS were significantly higher in G1 (p< 0.001); there was a significant improvement at IPSS, S-IPSS, QoL score, Qmax, and PVR for all groups after surgery. Only preoperative S-IPSS was found to have significant effect on postoperative SS (p< 0.001). There was a significant difference between G1A and G1B but no significant difference between G2A and G2B in terms of SS at postoperatively. In addition to this, prostatic volume was found smaller than non-symptomatic patients in de novo SS patients.

CONCLUSION

TURP provides significant improvement in both storage and voiding symptoms. The predictive value of the preoperative S-IPSS on postop SS is significant. These results suggest that 5 mg solifenacin succinate treatment in the early postoperative period may be beneficial for patients with high preoperative SS and may not be beneficial in others. Small prostatic volume may bode ill for postoperative SS in the patients with de novo SS.

Urinary biomarkers of inflammation and tissue remodeling may predict bladder dysfunction in patients with benign prostatic hyperplasia

PURPOSE

To evaluate the expression of urinary biomarkers of inflammation and tissue remodeling in patients with BPH undergoing surgery and evaluate the association of biomarkers with postoperative urodynamic outcomes MATERIALS AND METHODS: We analyzed urine samples from 71 patients treated with TURP from 2011 to 2017. Urinary levels of epidermal growth factor (EGF), matrix-metalloproteinase-1 (MMP-1), interleukin-6 (IL-6), nerve growth factor (NGF) and monocyte-chemoattractant protein-1 (MCP-1) (by commercial ELISA kit) were measured, adjusted by urinary creatinine (Cr) and analyzed according to patients clinical and urodynamic characteristics (baseline and 12-month postoperative urodynamic) RESULTS: MMP-1/Cr levels were significantly higher among subjects with higher detrusor pressure on preoprative urodynamic. MCP-1/Cr levels were significantly higher amongs subjects with preoperative DO. Preoperative levels of NGF/Cr (0.13 vs 0.08, p = 0.005) and MMP-1/Cr (0.11 vs 0.04, p = 0.021) were predictors of persistent DO 12 months after surgery. The following factors were shown to be useful for predicting the persistence of DO in the postoperative period: NGF/Cr, with an AUC of 0.77 (95% CI 0.62-0.92) (p = 0.006), and MMP-1/Cr, with an AUC of 0.72 (95% CI 0.56-0.88) (p = 0.022).

CONCLUSIONS

MMP-1/Cr was associated with higher detrusor pressure and MCP-1/CR with DO. NGF/Cr and MMP-1/Cr were shown to be predictors of persistent postoperative DO.

De novo OAB After ATOMS: An Underestimated Problem or a Rare Side Effect?

Background: The urinary incontinence system ATOMS (A.M.I., Austria) generates suburethral compression through its sphincter cushion. To what extent the ATOMS may lead to overactive bladder (OAB) symptoms or which risk factors for these symptoms exist remain unknown to date. We report on our multicentre evaluation on the prevalence, status, and therapy of OAB after ATOMS.

Methods: Between 10/09 and 01/17, a total of 361 patients received an ATOMS device in Vienna and Halle. A prerequisite for surgery was persistent male stress urinary incontinence lasting at least 6 months after the primary intervention, as well as the failure of conservative treatment. Patients with a preoperative untreated anastomotic stricture or detrusor overactivity were excluded. In addition to continence and voiding parameters, patient's age, BMI, comorbidities, and pre-treatment strategies of the underlying disease and urinary incontinence were examined. If de novo OAB was present, urodynamics were used for further clarification. Statistical analysis was performed with GraphPad Prism 7® (GraphPad Software, Inc., La Jolla, USA), p < 0.05 considered significant.

Results: OAB presented 18 patients (4.9%). Regarding the degree of urinary incontinence as well as uroflowmetry, residual volume and comorbidities, patients with an OAB showed no differences compared to patients without an OAB (p < 0.05). Only previous radiotherapy or urinary incontinence surgery and urethral stricture interventions resulted in statistically significant differences based on the bivariate analysis (p = 0.030, p = 0.006, p = 0.007). The consecutive postoperative urodynamics revealed a sensory OAB in 17 patients and a low-compliance bladder in a patient with newly diagnosed insulin-dependent type II diabetes mellitus. OAB was treated with a standard dose of antimuscarinic drugs and for the low-compliance bladder with botulinum toxin type A.

Conclusion: OAB symptoms can occur after ATOMS implantation, but are rare and have no clear correlation to the incontinence device but rather are due to urinary incontinence-related underlying diseases and previous treatments.

Influence of solifenacin on the improvement of storage symptoms in the early period after photoselective vaporization of the prostate

Purpose

We studied the effect of solifenacin on reducing storage symptoms after photoselective vaporization of the prostate (PVP).

Materials and Methods

This study included patients with persistent storage symptoms of urgency and frequency in a 3-day voiding diary, International Prostate Symptom Score (IPSS) storage subscore (IPSS-s) ≥5, overactive bladder symptom score (OABSS) ≥5, and OABSS for question 3 ≥4 at 5 days after urethral catheter removal. The patients were randomly assigned to receive once-daily solifenacin 5 mg or placebo for 4 weeks. Evaluation of the 3-day voiding diary, IPSS, and OABSS was performed at 2 and 4 weeks after treatment.

Results

At 2 and 4 weeks after treatment, the urgency and frequency in the 3-day voiding diary, IPSS, IPSS-s, and OABSS were decreased in the solifenacin group. Although the OABSS of the solifenacin group was not significantly different from that of the placebo group, the OABSS of the placebo group increased at 4 weeks compared with that at 2 weeks after treatment. The Benefit, Satisfaction, and Willingness to continue questionnaire showed no significant difference in patient satisfaction between the groups. Although the solifenacin group showed increased post-void residual volume compared with the placebo group, there was no statistically significant difference.

Conclusions

Storage symptoms measured using OABSS tended to decrease after medication with solifenacin in the early period after PVP. Therefore, we suggest that anticholinergics have a potential role in improving storage symptoms after PVP.

The effects of bladder training on bladder functions after transurethral resection of prostate

AIM AND OBJECTIVES

The aim of this was to examine the effect of bladder training on bladder functions.

BACKGROUND

Urinary catheterization is frequently performed in order to evaluate the outcomes of the surgical procedures and to monitor the urine output after urology operations.

DESIGN AND METHODS

This quasi-experimental study was conducted in the urology clinic in Istanbul, Turkey in which 50 males were nonrandomly assigned to either a bladder training (n = 28) or a control group (n =22). In the bladder training groups, the urinary catheters of the patients were clamped at 4-hr intervals and then were left open for 5 min on the second postoperative day. This study was created in accordance with TREND Statement Checklist.

RESULTS

The first urgency time and the first voiding time were longer, and the prevoiding and the voiding volumes were higher following the removal of the catheter in the training group (p = 0.001). In addition, the evaluation of the patient bladder diaries in the first three days after the discharge period revealed that the daily frequencies of micturition and nocturia were lower (p = 0.04), the mean duration of intervals between the micturition was longer (p = 0.006), and the mean voided urinary volume was higher (p = 0.024) in the training group.

CONCLUSION

At the end of the study, it is observed that bladder training performed by clamping the catheter on postoperative day 2 after Transurethral Resection of Prostate (TUR-P) operation is a significant positive effect on the storage symptoms of the patients.

RELEVANCE TO CLINICAL PRACTICE

Before removing the urinary catheter, bladder training programme affects positively to patients, especially prevoiding and the voiding volumes, the daily frequencies of micturition and nocturia on postoperative periods.

Long-lasting bladder overactivity and bladder afferent hyperexcitability in rats with chemically-induced prostatic inflammation

BACKGROUND

Benign prostatic hyperplasia (BPH) is one of the major causes of lower urinary tract symptoms (LUTS), including storage LUTS such as urinary frequency and urgency. Recently, a growing number of clinical studies indicate that prostatic inflammation could be an important pathophysiological mechanism inducing storage LUTS in patients with BPH. Here we aimed to investigate whether nonbacterial prostatic inflammation in a rat model induced by intraprostatic formalin injection can lead to long-lasting bladder overactivity and changes in bladder afferent neuron excitability.

METHODS

Male Sprague-Dawley rats were divided into four groups (n = 12 each): normal control group, 1-week prostatic inflammation group, 4-week inflammation group, and 8-week inflammation group. Prostatic inflammation was induced by formalin (10%; 50 µL per lobe) injection into bilateral ventral lobes of the prostate. Voiding behavior was evaluated in metabolic cages for each group. Ventral lobes of the prostate and the bladder were then removed for hematoxylin and eosin (HE) staining to evaluate inflammation levels. Continuous cystometrograms (CMG) were recorded to measure intercontraction intervals (ICI) and voided volume per micturition. Whole-cell patch clamp recordings were performed on dissociated bladder afferent neurons labeled by fluorogold injected into the bladder wall, to examine the electrophysiological properties.

RESULTS

Results of metabolic cage measurements showed that formalin-treated rats exhibited significantly (P < 0.05) increases in micturition episodes/12 hours and decrease in voided volume per micturition at every time point post injection. Continuous CMG illustrated the significant ( P < 0.05) higher number of nonvoiding contractions per void and shorter ICI in formalin-treated rats compared with control rats. HE staining showed significant prostatic inflammation, which declined gradually, in prostate tissues of formalin-induced rats. In patch clamp recordings, capsaicin-sensitive bladder afferent neurons from rats with prostatic inflammation had significantly ( P < 0.05) lower thresholds for spike activation and a "multiple" firing pattern compared with control rats at every time point post injection.

CONCLUSIONS

Formalin-induced prostatic inflammation can lead to long-lasting bladder overactivity in association with bladder afferent neuron hyperexcitability. This long-lasting model could be a useful tool for the study of inflammation-related aspects of male LUTS pathophysiology.

The Use of Urodynamics Assessment Before the Surgical Treatment of BPH

Lower urinary tract symptoms (LUTS) are a common problem in men especially with aging. The International Continence Society (ICS) revealed an overall prevalence of LUTS of about two-thirds of men age 40 years and above. The treatment approach depends on accurate determination of the underlying etiology. LUTS is not unique to benign prostate enlargement (BPE) and can be secondary to other causes. In the era where quality of care is important, accurate diagnosis and counseling to meet patients' expectations is of extreme paramount. Thus, proper assessment of patients who present with BPE and LUTS should be an important part of the work up process. Accurate diagnosis and identification of the cause will help to improve quality of treatment, optimize counseling, and improve treatment outcomes. Pressure flow urodynamic studies (PFUDs) are not only important tools that help to identify the underlying causes of LUTS; it is considered the "gold standard" for diagnosis of bladder outlet obstruction (BOO) in patients with enlarged prostate [1, 2]. However, there is a continuous debate on the value of using PFUDs and its association with improved outcomes.

Evaluation and Management of Lower Urinary Tract Symptoms After Outlet Surgery for Benign Prostatic Hyperplasia

There are many options available in the surgical treatment of outlet obstruction secondary to benign prostatic hyperplasia (BPH). While most patients exhibit improvement in their lower urinary tract symptoms (LUTS) following intervention, up to 35 % of patients may exhibit persistent or recurrent LUTS. In the present review, we discuss the patho-physiology of LUTS after bladder outlet surgery and discuss considerations in evaluating and managing such patients. We highlight the crucial role of thorough evaluation with complete urodynamics testing, as pure obstruction only accounts for a minority of post-operative LUTS. Hence, detrusor contractility, detrusor overactivity, urethral sphincter function, and urinary incontinence must be assessed to appropriately guide subsequent therapy and improve patients' quality of life.

Treatment of benign prostatic hyperplasia using transurethral split of the prostate with a columnar balloon catheter

Transurethral dilation of the prostate (TUDP) with a spherical balloon catheter is a traditional treatment for patients with benign prostatic hyperplasia (BPH). TUDP, however, has been abandoned in clinical application because of its unsatisfying treatment benefit and severe complications. In this study, we redesigned an improved TUDP surgical procedure-transurethral split of the prostate (TUSP)-by replacing the spherical balloon with a columnar balloon. To evaluate the clinical therapeutic effect, we compared the lower urinary tract symptoms (LUTS) of patients with BPH after TUSP treatment and analyzed the urethra through CT films. Animal experiments were performed on aged dogs to investigate the urine function and electromyography (EMG) changes. Histopathology was used to evaluate the inflammation and injury. In addition, collagen content was detected by Trichrome Masson. TUSP attenuated LUTS and reconstructed the urethra in patients with BPH. The attenuation of LUTS was reflected in terms of LUTS parameters such as peak urine flow rate, postvoid residual urine volume, quality of life score, and International Prostate Symptom Score. TUSP expanded the urethra in experimental dogs by splitting the prostate tissues and decreasing the collagen content, with maintenance of normal urinary function and EMG characteristics. The successful clinical application of TUSP with significant therapeutic effect and limited complications made TUSP an ideal choice for the patients with BPH.

Clinical outcome in male patients with detrusor overactivity with impaired contractility

PURPOSE

To review the clinical outcomes of patients with voiding dysfunction who have detrusor overactivity with impaired contractility (DOIC) diagnosed with urodynamic studies.

METHODS

Urodynamic reports from 2005 to 2009 were reviewed, and 54 male patients had findings consistent with DOIC. Patients with acontractile or neuropathic bladders were excluded. Clinical outcomes were obtained from patient records.

RESULTS

Of 54 men, 8 presented with voiding symptoms, 17 had storage symptoms, and 29 had mixed symptoms. Twenty-two had a previous transurethral resection of the prostate. The median follow-up was 12 months. Four patients received no intervention. Two patients were taught intermittent self-catheterization. Five patients underwent surgery to reduce outlet resistance and all reported improvement. Forty-three patients were started on pharmacotherapy; symptomatic improvement was reported by 9 of 16 patients commenced on anticholinergics alone, 6 of 16 on alpha-blockers alone, and 4 of 5 treated with a combination of alpha-blockers and anticholinergics. Eleven patients experienced no difference on pharmacotherapy and 2 reported deterioration. One patient developed acute urinary retention (18 months after commencing treatment with alpha-blockers). No patient had urosepsis.

CONCLUSIONS

Anticholinergics and alpha-blockers appear to be safe in patients with DOIC. The risk of urinary retention and sepsis is low. The majority of patients report symptomatic benefit from either drugs or surgical treatment.

Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction

OBJECTIVES

To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate.

METHODS

A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate. All patients had preoperative urgency symptoms. The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity, degree of obstruction, bladder contractility). The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups.

RESULTS

Overall, there was a statistically significant improvement in mean overactive bladder symptoms score from 9.6 to 2.7 (P < 0.001). However, patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (P < 0.05). Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (P < 0.05), and were more likely to have persistent urge incontinence. Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement.

CONCLUSIONS

Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate. The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement. The preoperative severity of overactive bladder symptoms, detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect.

Adipose-derived stem cells (ADSCs) and muscle precursor cells (MPCs) for the treatment of bladder voiding dysfunction

PURPOSE

Bladder outflow obstruction (BOO) is common in the elderly and can result in bladder voiding dysfunction (BVD) due to severe bladder muscle damage. The goal of this research was to evaluate the use of adult stem cells for the treatment of BVD due to decreased muscle contractility in a rat model.

MATERIALS AND METHODS

Adipose-derived stem cells (ADSCs) and muscle precursor cells (MPCs) were harvested from male Lewis rats and expanded in culture. BOO was induced by tying a suture around the urethra. Six weeks after obstruction, the development of BVD was confirmed by cystometric analysis in conscious rats, histology and molecular investigations. Injection of ADSCs or MPCs into the bladder wall and synchronous deligation was performed 6 weeks after the obstruction. After stem-cell treatment, morphological and functional changes were assessed. Age-matched rats and animals without cellular therapy but deligation-only served as controls.

RESULTS

Voiding pressures decreased progressively 6 weeks after obstruction with increased bladder capacities. Structural changes of the detrusor muscle occurred during the time of obstruction with an increased connective tissue-to-smooth muscle ratio and decreased SMA/smoothelin expression. After stem-cell injection, improved voiding pressures and voiding volumes were observed together with recovered tissue architecture. RT-PCR and Western blotting showed an up-regulation of important contractile proteins.

CONCLUSIONS

We established a reliable model for BVD and demonstrated that ADSCs and MPCs can prevent pathophysiological remodelling and provide regenerated bladder tissue and function.

Comparative Analysis of Outcomes after Transurethral Resection of the Prostate according to Prostate Shape Shown by Transrectal Ultrasonography

PURPOSE

Transrectal ultrasonography (TRUS) is a non-invasive modality widely used in urology on an outpatient basis to measure the volume and anatomical structure of the prostate. However, the prostate volume measured by TRUS often varies from test to test. The aim of this study was to determine the clinical significance of the different shapes of the prostate, as shown by TRUS before and after transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

We evaluated 103 patients who underwent TURP. TRUS was performed preoperatively, and the International Prostatic Symptom Score (IPSS) and quality of life (QoL) were assessed preoperatively and at 6 months postoperatively. Patients were classified into two groups: patients with a bilaterally enlarged transitional zone were assigned to group A, and those with a protruding retrourethral zone were assigned to group B.

RESULTS

There were no statistically significant differences between the two groups in preoperative variables. However, postoperative IPSS scores were lower in group A than group B (9.87+/-6.15 vs. 13.18+/-8.07, p=0.02). With regard to postoperative IPSS scores relative to preoperative IPSS scores, both groups showed a significant decrease, but group A experienced a significantly greater decrease than group B (13.43+/-7.47 vs. 8.67+/-8.33, p=0.005).

CONCLUSIONS

Patients with a prostate protruding into the bladder have less of a decrease in their IPSS scores after TURP, compared to patients that do not have prostate protrusion, meaning that patients with protrusion experience less symptomatic relief.

Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction

AIMS

To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO).

METHODS

A retrospective review was conducted in 298 patients with BPO who had undergone TURP. All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics, as well as symptomatic assessment postoperatively. OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2, 4 and 7 stand for frequency, urgency and nocturia). They were divided into three categories based on an individual score >or=3 for on urgency, frequency and nocturia in the preoperative state. The association between the baseline variables and the improvement in each symptom score was analyzed.

RESULTS

A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normal/weak detrusor: 9.5, 3.4, 3.0 for score on urgency, frequency and nocturia, respectively). Both the patient's age (Odds ratio: 0.93) and the maximum flow rate (Odds ratio: 0.20) influenced the improvement in the score on nocturia.

CONCLUSION

The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms, suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction. Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP.

Urodynamics: what to do and when is it clinically necessary?

The role of urodynamics in the evaluation and treatment of men with lower urinary tract symptoms is not well defined. Symptoms do not correlate very well with urodynamic findings, but patients with prostatic obstruction fare better after ablative prostatic surgery than those with impaired detrusor contractility. The only proven method for distinguishing between the two is urodynamics, ie, the detrusor pressure/uroflow study. This article reviews urodynamic techniques and the literature pertaining to urodynamics, along with their clinical utility in benign prostatic hyperplasia. The role of urodynamics in clinical practice is discussed as well.

Overactive bladder in the male patient: epidemiology, etiology, evaluation, and treatment

The urologist's approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with "prostatism," an all-encompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.

The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic followup of transurethral resection of prostate for bladder outlet obstruction

PURPOSE

Despite long-term symptomatic and uroflowmetry studies following transurethral prostate resection (TURP) there are sparse pressure flow data. Consequently there is minimal information to account for the long-term symptomatic failure and flow rate decrease seen with time following early improvements after surgery.

MATERIALS AND METHODS

Men older than 45 years who were investigated at our department between 1972 and 1986, diagnosed with bladder outlet obstruction and elected surgical intervention were invited for repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of results.

RESULTS

A total of 1,068 men were initially diagnosed with bladder outlet obstruction, of whom 428 (40%) died in the interim. Of the men who were followed 217 underwent TURP with a mean followup since surgery of 13.0 years. A significant, sustained decrease in the majority of symptoms and improvements of urodynamic parameters was seen. Long-term symptomatic failure and decreased flow rate were principally associated with detrusor under activity (DUA) rather than obstruction. Presentation predictive factors for the future development of DUA were decreased detrusor contractility and a lesser degree of obstruction.

CONCLUSIONS

This unique long-term study provides valuable information on surgically treated bladder outlet obstruction. The association of long-term failure following surgery with DUA emphasizes the importance of pressure flow studies before repeat surgery. However, our faith in the long-term efficacy of TURP is justified.

Correlation of abdominal leak point pressure with objective incontinence severity in men with post-radical prostatectomy stress incontinence

AIMS

To determine if the abdominal leak point pressure (ALPP) correlates with objective incontinence severity in patients suffering from post-prostatectomy stress incontinence.

METHODS

Twenty-nine men were evaluated for urinary incontinence after radical prostatectomy with videourodynamics and a 24-hr pad test. ALPP was determined with and without a 7-French urodynamics catheter and the lowest value was accepted. Six patients with urgency incontinence associated with detrusor overactivity or decreased bladder compliance were excluded leaving 23 patients for analysis. The relationship between the variables of ALPP, 24-hr pad weight, age and time from prostatectomy were examined with Pearson correlation.

RESULTS

The mean age was 66.4 years (SD +/- 7.9, range: 45-81) and the median time from radical prostatectomy was 23 months (IQR = 14-64, range: 9-204). The mean ALPP was 92.8 cm H(2)O (SD +/- 42.4 cm H(2)O) and the mean pad weight was 279.1 g (SD +/- 238.3 g). There was only a weak inverse correlation between ALPP and 24-hr pad weight which was not statistically significant (r = - 0.191, P = 0.38). Age and time from prostatectomy did not significantly correlate with ALPP (r = - 0.122, P = 0.58 and r = - 0.23, P = 0.29, respectively).

CONCLUSIONS

ALPP did not correlate significantly with the 24-hr pad test in patients with post-prostatectomy stress incontinence. This suggests that in this patient subset, the ALPP is a relatively poor predictor of incontinence severity and, therefore, has limited clinical value in the urodynamic evaluation of post-prostatectomy incontinence. The urodynamic assessment of these patients should focus on the presence or absence of stress incontinence and on the presence of associated bladder dysfunction.

A urodynamics protocol to optimally assess men with post-prostatectomy incontinence

AIMS

To propose a urodynamic protocol to comprehensively assess all parameters of post prostatectomy incontinence (PPI).

METHODS

Sixty men with a history of PPI after radical prostatectomy prospectively underwent a standardized video urodynamics protocol. A 7F urethral catheter was used for standard cystometry, abdominal leak point pressure (ALPP), and pressure flow measurements. The International Continence Society nomogram classified obstruction and further classification of obstruction was based on fluoro voiding cystourethrography and non-invasive flow rates (free Qmax).

RESULTS

Twenty-four (40%) men had detrusor overactivity with 8 (13%) also having detrusor overactivity incontinence. Only one patient had impaired compliance. All men had urodynamic stress incontinence, but 21 (35%) men demonstrated it only after removal of the urethral catheter. For men leaking with and without the urethral catheter, the respective ALPP was significantly different, 86.3 and 67 cmH2O, respectively (P = 0.002). The men who leaked only in the absence of the urethral catheter had significantly higher ALPP measurements, P < 0.001. After reclassification using the fluoroscopic images of the bladder outlet and free Qmax, only 13.3% patients were obstructed.

CONCLUSIONS

The proposed urodynamic protocol allows for an optimal assessment of bladder and sphincter dysfunction and outlet obstruction in men with PPI.

Changing aspects in the evaluation and treatment of patients with benign prostatic hyperplasia

Lower urinary tract symptoms are a common clinical symptom among men and a frequent reason for referring to a urologist. The most important information comes from the patient history because evaluation of symptoms is fundamental in the diagnosis and treatment planning for LUTS. Other aspects of the initial evaluation, such as the physical examination and initial laboratory values, can provide valuable additional information about the severity of the disease and the need for treatment. If treatment is warranted based on this information, additional diagnostic tests may be appropriate to set a pretreatment baseline, rule out other conditions, and plan treatment approach. Fortunately, a variety of effective medical and surgical treatments are available to treat this common disease.

Overactive bladder and men: Indications for anticholinergics

Similar to bladder outlet obstruction (BOO), overactive bladder (OAB) symptoms are very common and increase in prevalence as men age. Whether or not OAB symptoms are thought to be secondary to BOO, the goal of treatment of symptoms should result in an improved quality of life and ultimately prevent clinical deterioration. A common dilemma when treating men with obstruction and OAB is the risk of acute urinary retention or morbidities related to increasing postvoid residuals. In this article, the relationship of OAB to BOO is examined and the role of urodynamics and data on the use of anticholinergics in men with OAB and obstruction are reviewed. An algorithm for managing men with OAB also is proposed. In men with OAB without evidence of obstruction (including OAB after treatment for BOO), first-line medical therapy with anticholinergics is indicated. However, in men with OAB and concomitant BOO, nomogram has been developed to assist in the management of patients at risk for urinary retention. Men with significant obstruction should be appropriately treated to decrease bladder outlet resistance before adding anticholinergics for the treatment of OAB.

Urodynamic studies in the surgical treatment of benign prostatic hyperplasia

OBJECTIVE

We compared the clinical and urodynamic outcome of men with lower urinary tract symptoms with and without previous urodynamic evaluation submitted to transurethral resection of the prostate.

MATERIALS AND METHODS

A prospective and randomized study was performed in 315 patients who underwent transurethral resection of the prostate. In 151 patients (group A) with a mean age of 63 years, transurethral resection of the prostate was performed without a prior urodynamic study, and group B, 164 patients with a mean age of 61 years, underwent a urodynamic study prior to surgical procedure. In group B, only obstructed patients were selected for surgery. All patients had I-PSS higher than 15 and underwent at least 2 uroflowmetry and flow was lower than 10 ml/sec. At 6-month follow up, patients in both groups underwent the I-PSS questionnaire and pressure / flow study.

RESULTS

The symptomatology and uroflowmetry did not display different behavior between the groups. The mean postoperative score for group A was 8.87 + 3.27 and for group B was 9.32 + 3.14 (p = 0.22). The mean postoperative uroflow for group A was 17.0 + 2.1 mL/s and for group B was 16.6 + 2.2 mL/s (p = 0.15).Postoperative, in group A, 27 patients (17.8%) were obstructed and in group B, 16 patients (9.75%) were obstructed (p = 0.03).

CONCLUSION

The study suggests that the previous urodynamic study is not the only factor related to the success of surgical outcome; and therefore, the symptomatology and uroflowmetry associated would be enough during the preoperative routine studies for BPH patients.

Correlation among maximal urethral closure pressure, retrograde leak point pressure, and abdominal leak point pressure in men with postprostatectomy stress incontinence

OBJECTIVES

To assess the correlation among abdominal leak point pressure (ALPP), maximal urethral closure pressure (MUCP), and retrograde leak point pressure (RLPP) in the evaluation of men with stress urinary incontinence (SUI) after radical prostatectomy.

METHODS

Patients were evaluated with a self-administered questionnaire regarding pad use and with multichannel videourodynamics. The ALPP, MUCP, and RLPP were compared with each other and with the severity of SUI.

RESULTS

The mean ALPP was 49.4 +/- 24.4 cm H(2)O. The mean MUCP was 52.0 +/- 21.1 cm H(2)O. The mean RLPP was 48.0 +/- 13.5 cm H(2)O. No statistically significant difference in the mean values of the three parameters was found. Regression analysis revealed a statistically significant correlation among the three parameters: RLPP versus MUCP, r = 0.59, P <0.005; MUCP versus ALPP, r = 0.75, P <0.0001; and RLPP versus ALPP, r = 0.79, P <0.0001. ALPP, MUCP, and RLPP were each significantly related to pad use.

CONCLUSIONS

Intrinsic sphincter deficiency is the primary cause of SUI after radical prostatectomy. Therefore, evaluation of intrinsic sphincter function is important in the treatment of postprostatectomy SUI. In incontinent men after radical prostatectomy, with a dysfunctional bladder neck and proximal sphincter unit, the intrinsic function of this distal sphincter may be assessed equally well by evaluating the resistance to antegrade leakage, retrograde leakage, or profilometric measurement of the urethral closure pressure. RLPP and MUCP offer reliable alternatives to ALPP for the evaluation of postprostatectomy SUI.

Overactive bladder in men: special considerations for evaluation and management

Lower urinary tract symptoms (LUTS) in men may arise from a variety of underlying causes, including benign prostatic hyperplasia. LUTS may have a significant component of storage symptoms (urgency, frequency, urge incontinence) at presentation; however, the absence of overactive bladder (OAB) symptoms does not necessarily imply pure outlet obstruction nor does their presence indicate the lack thereof. Symptomatic correlates to urodynamic findings are high when considering isolated OAB symptoms. However, mixed presentations or more overtly obstructive scenarios have less correlation with baseline symptom appraisal instruments. The ideal approach for diagnosis and management is predicated on a graded approach, with more invasive evaluation withheld for those men in whom presumptive therapy fails or who present with associated complex symptoms and in whom a higher level of intervention is being considered. The increasing incidence of LUTS with age implies a partial detrusor contribution, which must be considered in the overall management schema.

Nocturnal polyuria in type 2 diabetes: a symptom of obstructive sleep apnea

PURPOSE

Polyuria and nocturia in individuals with type 2 diabetes may be due to obstructive sleep apnea (OSA), a recently recognized etiology of excess nighttime urine production. This exploratory study examined the relationships among glucose control, OSA, and nocturnal urine production.

METHODS

A sample of community-dwelling older adults (20 nondiabetic subjects and 10 poorly controlled type 2 diabetes subjects) was recruited based on self-report of nocturia more than twice per night. Participants were monitored on a metabolic research unit for 24 hours to track intake/output, collect blood and urine samples, and conduct an overnight polysomnography sleep study.

RESULTS

None of the subjects had fasting serum glucose levels above the renal threshold. OSA was found in 65% of subjects. Those with moderate/severe OSA had significantly greater overnight urine production than subjects without OSA. Subjects with type 2 diabetes and moderate/severe OSA had the highest nocturnal urine production.

CONCLUSIONS

The high incidence of undetected OSA in subjects with type 2 diabetes with nocturia suggests that nocturia, OSA, and type 2 diabetes frequently coexist and may be interrelated.

Benign prostatic hyperplasia: challenges for the new millennium

The understanding and therapy of benign prostatic hyperplasia (BPH) has become more complex recently. The molecular mechanisms and growth factors involved in BPH need to be elucidated in the new millennium. The current classification of disease reflects the varied pathophysiologic mechanisms causing lower urinary tract symptoms (LUTS). In addition, symptom scores have improved evaluation of men with BPH, yet 'bother' and 'health-related quality of life' should be better recognized as significant outcome parameters. Clinical evaluation with laboratory markers specific for BPH or LUTS is currently inadequate. Yet, urodynamic evaluation should remain an important aspect of evaluation to guide selection of therapy. Recently medical therapy has expanded to include uroselective alpha blockade and phytotherapy, yet more research is needed. The most significant growth in the field, however, is in minimally invasive therapies of the prostate. Long-term comparative prospective multicenter studies are needed to properly evaluate the outcomes of new technologies compared to traditional procedures that are considered standard of care.

Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder

Lower urinary tract symptoms (LUTS), benign prostatic obstruction (BPO), and the overactive bladder have increasing prevalence with age in both men and women (with the obvious exception). The question is, are they interrelated or independently related to age? The specific issue is whether BPO causes the overactive bladder. There are two pieces of evidence that might appear to suggest such a cause and effect. First, the overactive bladder is more common in men than in women of the same age, although physiologically, men are 5-10 years older at the same biological age. Second, the overactive bladder resolves in two-thirds of individuals after surgical interventions such as transurethral prostatectomy. The symptoms suggestive of an overactive bladder are the most troublesome, even though they may not be the most prevalent. Long-term follow-up studies with repeated urodynamic investigations have shown that the incidence of the overactive bladder and its attendant symptoms increases despite there being no deterioration in outlet obstruction over follow-up periods of 10 and 20 years. These data, and others, indicate that the situation is not as straightforward as some believe. The statement that 'the overactive bladder is secondary to BPO' cannot be made, as there are too many unanswered questions and pieces of the puzzle that do not fit. The overactive bladder is undoubtedly associated with BPO, and it leads to the most troublesome LUTS in older men. Epidemiological research, coupled with urodynamic evaluation, may provide further evidence. We also need better and more relevant models (e.g. ageing animals), together with further histological and other biological data before the waters become crystal clear.

Clinical prostate score for diagnosis of bladder outlet obstruction by prostate measurements and uroflowmetry

OBJECTIVES

To establish a clinical prostate score based on the parameters of uroflowmetry and prostate measurements to provide a better prediction of benign prostatic obstruction (BPO) in men with lower urinary tract symptoms (LUTS) and small prostate volume.

METHODS

From October 1997 to September 1998, a prospective study of 324 consecutive men with LUTS was conducted in a community hospital in Taiwan. All patients were first evaluated by uroflowmetry and transrectal sonography of the prostate, and a videourodynamic study (VUDS) was performed before any medication was given. Patients were grouped as obstructed or unobstructed according to the results of the VUDS. Parameters from uroflowmetry and prostate measurements were evaluated for their sensitivity in predicting BPO. A clinical prostate score was established by summing scores on seven prostatic and uroflowmetric items: maximal flow rate (Qmax), flow pattern, voided volume, residual urine amount, total prostate volume (TPV), transition zone index (TZI), and prostatic configuration. Each of these items had a score representing the grade of sensitivity of BPO.

RESULTS

Among the 324 men examined, only 65.4% were found to have obstruction by VUDS. A value of Qmax 10 mL/s or less had a sensitivity of only 75.4% and specificity of only 63.7% for BPO. A constrictive flow pattern had 87.2% sensitivity, residual urine 100 mL or greater had 86.1%, TPV 40 mL or greater had 94.6%, TZI 0.5 or greater had 87.8%, and the presence of a median lobe had 87.1% sensitivity; the presence of any of these factors added 2 points to the score. The other parameters were scored as 1, 0, and -1, representing their sensitivity as slightly superior or inferior to that of LUTS. A prostate score of 3 or greater had a sensitivity of 87.2% and a specificity of 60.8% for BPO. On the basis of this prostate score, 148 patients (46%) would have been treated for BPO without the need for further investigation, of whom 19 (5.9%) would have been misdiagnosed. The remaining 176 patients (54%) would have undergone a VUDS and 93 of these patients (28.7%) were unobstructed.

CONCLUSIONS

By combining uroflowmetry and transrectal sonography of the prostate, patients with LUTS can be diagnosed with a good sensitivity and specificity. Using the parameters in the uroflow and prostate measurements, a prostate score could be established and used as an indicator of BPO for selecting patients with LUTS who require further treatment or invasive VUDS.

Perfusion sphincterometry for objective evaluation of postprostatectomy intrinsic sphincter deficiency

OBJECTIVES

Male urinary incontinence secondary to intrinsic sphincter deficiency (ISD) is a possible complication of transurethral resection of the prostate (TURP) or radical prostatectomy (RP). For objective assessment of urinary sphincteric competence, we used perfusion sphincterometry (PS) to measure the retrograde urethral perfusion pressure (RUPP).

METHODS

A retrospective and prospective analysis of 60 neurologically normal patients of varying continence status was performed. The subjects were divided into three groups: continent patients with no previous prostate surgery (group 1), continent patients after prostatectomy (group 2), and incontinent patients after prostatectomy (group 3). All patients underwent PS with the technique described. All incontinent patients (group 3) had a filling cystometrogram (CMG) to rule out detrusor instability.

RESULTS

Continent patients with no prior prostate surgery (group 1) had a mean RUPP of 101 +/- 16 cm H2O; continent postprostatectomy patients (group 2) had a mean RUPP of 77 +/- 14 cm H2O; and incontinent postprostatectomy patients (group 3) had a mean RUPP of 36 +/- 11 cm H2O. The differences were statistically significant (P <0.001). There was no statistically significant difference in RUPP when the patients in groups 2 and 3 were stratified into TURP and RP groups.

CONCLUSIONS

PS is a simple and accurate technique for objective evaluation of lower sphincter competence. Patients with stress incontinence after prostatectomy have a statistically significant decrease in RUPP compared with continent controls. In combination with cystourethroscopy and filling CMG, PS can be useful in the evaluation of postprostatectomy incontinence.