The Correlation Between Urodynamic and Cystoscopic Findings in Elderly Men with Voiding Complaints

[Diagnostic work-up of benign prostatic hyperplasia : The German S2e-guideline 2023 part 1]

BACKGROUND

Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH; in German guidelines: benign prostatic syndrome [BPS]) is the most frequent urological disease in men and can result in a considerable deterioration of quality-of-life. BPS can be associated with LUTS, benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO) or benign prostatic obstruction (BPO), respectively. The expert group on BPS of the German Society of Urology has re-evaluated the tests for the assessment of BPH and provides evidence-based recommendations.

OBJECTIVES

Presentation and evidence-based rating of tests for the assessment of patients with BPS.

MATERIALS AND METHODS

Summary and overview of chapters 5, 6, and 8 of the latest long version of the German S2e guideline on BPS.

RESULTS

The diagnostic work-up should clarify (1) whether the complaints of the patient are caused by BPS, (2) how relevant the complaints are and whether treatment is necessary, (3) whether complications of the lower or upper urinary tract already exist, and (4) which treatment will be most suitable. Baseline assessment should be done in all BPS patients and include history, measurement of LUTS and quality-of-life, urinalysis, serum prostate-specific antigen, post-void residual, ultrasound of the lower urinary tract, including measurements of prostate volume, intravesical prostatic protrusion and detrusor wall thickness, and ultrasound of the upper urinary tract. Additional tests can follow when questions remain unanswered after baseline assessment. These optional tests include bladder diaries, uroflowmetry, serum creatinine, urethrocystoscopy, other noninvasive tests for the determination of BOO/BPO such as penile cuff test, condom catheter method and near-infrared spectroscopy, and other imagining tests such as X‑ray and MRI investigations.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations on the diagnostic work-up, including the assessment of the BPS components BPE, LUTS, and BOO/BPO.

Association of bladder trabeculation and neurogenic bladder with spinal cord injury

OBJECTIVE

To compare clinical findings and urodynamic parameters according to trabeculation grade and analyze their correlations with trabeculation severity in neurogenic bladder caused by suprasacral spinal cord injury (SCI).

METHODS

A retrospective chart review was performed of neurogenic bladder caused by SCI. Bladder trabeculation grade was compared with SCI-related clinical parameters and bladder-related urodynamic parameters.

RESULTS

In SCI patients, factors such as disease duration, bladder capacity, detrusor pressure, peak detrusor pressure values, and compliance were significantly different between different grades of bladder trabeculation, while neurological level of injury, completeness, and detrusor sphincter dyssynergia had no clear relationship with bladder trabeculation grade. In the correlation analysis, vesicoureteral reflux was moderately correlated with trabeculation grade (correlation coefficient 0.433), while the correlation coefficients of disease duration, involuntary detrusor contraction, and bladder filling volume were between 0.3 and 0.4.

CONCLUSION

Bladder trabeculation with suprasacral-type neurogenic bladder was graded. Although disease duration was positively correlated with bladder trabeculation grade, differences in the neurological level of injury or American Spinal Injury Association Impairment Scale score were not observed. Bladder volume, peak detrusor pressure, compliance, reflex volume, and vesicoureteral reflux also showed significant differences according to trabeculation grade. Vesicoureteral reflux was moderately correlated with trabeculation grade.

Detection of bladder trabeculation by voiding cystourethrography and sonography: observations in boys with posterior urethral valves

Background

As trabeculated bladder wall is often referred to as a sign of chronically increased intravesical pressure, we investigated whether voiding cystourethrography (VCUG) or sonography reliably predicts bladder trabeculation on later urethrocystoscopy.

Methods

A total of 76 consecutive patients (2012–2017) with cystoscopically confirmed posterior urethral valves (PUV) and pre-endoscopy VCUG were included. Sonography data were available for 68 of these patients. Radiological findings were reassessed and compared with endoscopic findings using Fisher’s exact test and Spearman’s rank assessment.

Results

VCUG showed a sensitivity of 83.3% and a specificity of 30% in predicting trabeculation on a later urethrocystoscopy, with no significant difference in determining mild or severe forms (p=0.51). Sonography proved a sensitivity of 27.6% and a specificity of 70%, with no correlation between sonographic signs and trabeculation on cystoscopy (r=0.1311). In addition, vesicoureteral reflux had no significant influence as a possible pressure pop-off mechanism on the development of trabeculation in our group.

Conclusions

While VCUG predicts bladder trabeculation in children with PUV with limited reliability, sonography mostly fails to detect trabeculation. Therefore, such findings should only be used with utmost caution in relation to clinical decision-making.

Systematic review of lower urinary tract symptoms occurring with pelvic organ prolapse

Objective: To review lower urinary tract symptoms (LUTS), which include a large variety of bladder complaints, in women with simultaneous pelvic organ prolapse (POP). Methods: This article is a systematic review of the current literature on LUTS occurring simultaneously with POP following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Results: The prevalence of both conditions is high, but they occur more frequently together than can be explained by chance. It appears that POP is in some women causative of overactive bladder (OAB) symptoms, as in many women correction of the POP resolves the bladder symptoms and small studies of women with detrusor underactivity also demonstrate resolution of symptoms. The most plausible explanation for the relationship is that POP causes bladder outlet obstruction, which results in excess bladder irritability or poor contractility. However, not all women have resolution of their OAB symptoms and some women develop them de novo after POP repair, so this explanation requires more in depth study. Conclusions: Women with both LUTS and symptomatic POP should probably have their POP targeted, as its reduction either via surgery or pessary can correct the LUTS. However, no studies have addressed asymptomatic POP, so it is unclear if treating POP in these instances is of benefit. Abbreviations: BOO: bladder outlet obstruction; DO: detrusor overactivity; DU: detrusor underactivity; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; RR: relative risk; SUFU: Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction; UDS: urodynamic studies; (S)(U)UI: (stress) (urgency) urinary incontinence.

[Fake News BPH - what is really true!]

BACKGROUND

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is the fourth most common and the fifth most costly disease in men aged 50 years or older. Despite the high prevalence of LUTS/BPH in clinical practice and evidence-based guideline recommendations, there are still plenty of misconceptions on the terminology and pathophysiology of the disease, leading to false assumptions and malpractice.

OBJECTIVES

Listing of commonly used false assumptions and clarification of the correct terminology and pathophysiology.

MATERIALS AND METHODS

Critical reflection of 12 selected fake news based on PubMed search.

RESULTS

Average prostate weight in healthy men is 20 g but varies between 8-40 g. The BPH-disease does not progress in stages; therefore, the BPH-classifications according Alken or Vahlensieck should not be used anymore. There is only a weak and inconsistent relationship between bladder outlet obstruction (BOO) and prostate size, diverticula/pseudo-diverticula, postvoid residual, urinary retention or renal insufficiency, which is too unreliable for BOO-diagnosis in the individual patient. Urethro-cystoscopy with grading of the degrees of occlusion of the prostatic urethra and bladder trabeculation is insufficient for BOO-diagnosis. There is no clinically relevant reduction of BOO with licensed BPH-drugs and no convincing data that prostate resection (TURP) has to be complete until the surgical capsule in order to obtain optimal results.

CONCLUSIONS

The reasons for the persistent use of wrong terminology and pathophysiology are diverse. One reason is lack of implementation of evidence-based guidelines into clinical practice due to lack of knowledge, individual beliefs, costs, availability and reimbursement policies. Another reason is the increasing focus on oncology, coupled with underrepresented education and training on BPH.

Cystometrogram appearance in PUV is reliably quantified by the shape,wall, reflux and diverticuli (SWRD) score, and presages the need for intervention

OBJECTIVE

Radiological bladder abnormalities in boys with posterior urethral valves (PUV) are well recognised; however, the assessment is subjective. The shape, wall, reflux and diverticuli (SWRD) score objectively assesses shape, wall, reflux and diverticuli in a simple way. This study was undertaken to demonstrate that the SWRD score is reliable, reproducible and correlates with bladder outcome and videourodynamic (VUD) assessment in boys with PUV.

MATERIALS AND METHODS

Three blinded assessors determined the SWRD scores of PUV bladders from cystometrograms taken during VUD from September 2012 to October 2013. The scores were correlated with clinical outcome and VUD pressure measurements. Data were given as median (interquartile range), non-parametric tests used as appropriate (Mann-Whitney U test, or Kruskall-Wallis) and P < 0.05 was taken as significant.

RESULTS

A total of 55 boys with PUV underwent VUD assessment, for which 52 cystometrograms were available. The SWRD score for non-operative management was 1.0 (0.1-1.9) vs 2.0 (1.0-3.3) for operative intervention, P = 0.018 (Summary Figure). The SWRD score for compliant bladders was 1.1 (0.6-2.0) vs hypercompliant 1.7 (0.5-2.8) vs non-compliant 3.3 (2.8-5.0), Kruskall-Wallis P = 0.011. The hostile detrusor overactivity (DO) bladders (Pdet >40 cmH₂O) had a SWRD score of 2.0 (1.3-3.7) vs 1.0 (0.5-2.5) for low-pressure DO bladders, P < 0.05.

DISCUSSION

In this series of patients, increasingly distorted bladder shape was seen to be associated with poor bladder dynamics on VUD. Patients with poorly compliant bladders had a significantly higher SWRD score than normal or megacystis patients. Severe DO was also significantly associated with a high SWRD score. Therefore, the radiological appearance of a hostile bladder represented a marker for high intravesical pressure. VUR and bladder diverticuli may lead to spurious pressure measurements during VUD; however, the SWRD score provided an independent mechanism with which to objectively assess these patients, even in the presence of gross VUR.

CONCLUSIONS

The SWRD score is a simple and objective scoring system for the radiological abnormalities of PUV bladders. It correlates with clinical outcome and VUD assessment of compliance and DO, but is independent of pressure measurements and so not confounded by VUR acting as a 'pop-off' mechanism.

Development of Decision Support Formulas for the Prediction of Bladder Outlet Obstruction and Prostatic Surgery in Patients With Lower Urinary Tract Symptom/Benign Prostatic Hyperplasia: Part I, Development of the Formula and its Internal Validation

PURPOSE

As the elderly population increases, a growing number of patients have lower urinary tract symptom (LUTS)/benign prostatic hyperplasia (BPH). The aim of this study was to develop decision support formulas and nomograms for the prediction of bladder outlet obstruction (BOO) and for BOO-related surgical decision-making, and to validate them in patients with LUTS/BPH.

METHODS

Patient with LUTS/BPH between October 2004 and May 2014 were enrolled as a development cohort. The available variables included age, International Prostate Symptom Score, free uroflowmetry, postvoid residual volume, total prostate volume, and the results of a pressure-flow study. A causal Bayesian network analysis was used to identify relevant parameters. Using multivariate logistic regression analysis, formulas were developed to calculate the probabilities of having BOO and requiring prostatic surgery. Patients between June 2014 and December 2015 were prospectively enrolled for internal validation. Receiver operating characteristic curve analysis, calibration plots, and decision curve analysis were performed.

RESULTS

A total of 1,179 male patients with LUTS/BPH, with a mean age of 66.1 years, were included as a development cohort. Another 253 patients were enrolled as an internal validation cohort. Using multivariate logistic regression analysis, 2 and 4 formulas were established to estimate the probabilities of having BOO and requiring prostatic surgery, respectively. Our analysis of the predictive accuracy of the model revealed area under the curve values of 0.82 for BOO and 0.87 for prostatic surgery. The sensitivity and specificity were 53.6% and 87.0% for BOO, and 91.6% and 50.0% for prostatic surgery, respectively. The calibration plot indicated that these prediction models showed a good correspondence. In addition, the decision curve analysis showed a high net benefit across the entire spectrum of probability thresholds.

CONCLUSIONS

We established nomograms for the prediction of BOO and BOO-related prostatic surgery in patients with LUTS/BPH. Internal validation of the nomograms demonstrated that they predicted both having BOO and requiring prostatic surgery very well.

Simple Modification of the Bladder Outlet Obstruction Index for Better Prediction of Endoscopically-Proven Prostatic Obstruction: A Preliminary Study

Purpose

The bladder outlet obstruction index (BOOI), also known as the Abrams-Griffiths (AG) number, is the most widely used index for predicting BOO. However, the obstructed prostatic urethra determined by the BOOI is often inconsistent with endoscopically-proven obstruction. We assessed abdominal straining pattern as a novel parameter for improving the prediction of BOO.

Materials and Methods

We retrospectively reviewed the pressure-flow studies (PFS) and cystourethroscopy in 176 BPH/LUTS patients who were unresponsive to medical therapy. During PFS, some groups of patients tried to urinate with abdominal straining, which can increases intravesical pressure and underestimate BOOI theoretically. Accordingly, the modified BOOI was defined as (P_detQ_max+ΔP_abd)-2Q_max.

Results

Ultimately, 130 patients were eligible for the analysis. In PFS, ΔP_abd (P_abdQ_max-initial P_abd) was 11.81±13.04 cmH₂O, and it was 0–9 cmH₂O in 75 (57.7%), 10–19 cmH₂O in 23 (17.7%) and ≥20 cmH₂O in 32 (24.6%) patients. An endoscopically obstructed prostatic urethra in 92 patients was correctly determined in 47 patients (51.1%) by the original BOOI versus 72 patients (78.3%) based on the modified BOOI. Meanwhile, an “unobstructed” urethra according to the original BOOI was present in 11 patients (12.0%), whereas according to the modified BOOI, only 2 (2.1%) would be labeled as “unobstructed”. In receiver operating characteristic curves, the area under the curve was 0.906 using the modified BOOI number versus 0.849 in the original BOOI (p<0.05).

Conclusions

The change in abdominal pressure was correlated with endoscopically-proven obstruction. Our simple modification of the BOOI on the basis of this finding better predicted bladder outlet obstruction and, therefore, should be considered when evaluating BOO in patients with LUTS/BPH.

Management of Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) commonly affect older men. Age-related changes associated with metabolic disturbances, changes in hormone balance, and chronic inflammation may cause BPH development. The diagnosis of BPH hinges on a thorough medical history and focused physical examination, with attention to other conditions that may be causing LUTS. Digital rectal examination and urinalysis should be performed. Other testing may be considered depending on presentation of symptoms, including prostate-specific antigen, serum creatinine, urine cytology, imaging, cystourethroscopy, post-void residual, and pressure-flow studies. Many medical and surgical treatment options exist. Surgery should be reserved for patients who either have failed medical management or have complications from BPH, such as recurrent urinary tract infections, refractory urinary retention, bladder stones, or renal insufficiency as a result of obstructive uropathy.

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.

The fish-hook configuration of the distal ureter indicates bladder outlet obstruction due to benign prostatic hyperplasia

PURPOSE

The aim of this retrospective study was to evaluate in a historical series of patients whether morphological changes of the urinary tract imaged on intravenous urography (IVU) are associated with clinical or urodynamic data.

METHODS

During a 1-year period, every man 45 years or older with lower urinary tract symptoms suggestive of benign prostatic hyperplasia was systematically evaluated with multi-channel computer-urodynamic investigation and IVU. Men with urinary retention, known bladder stones or diverticula, severely impaired renal function, or allergy to iodine contrast media were excluded. Structural alterations of the urinary tract were correlated with clinical and urodynamic data using logistic regression analysis.

RESULTS

Data on 203 consecutive patients were available for analysis. Multivariate analysis demonstrated that the "fish-hook" configuration of the distal ureter (also known as "hockey-stick", or "J-shaped" ureter) was the only sign significantly associated with benign prostatic obstruction (BPO) (odds-ratio 3.64; 95% confidence interval 1.69-7.83; P < 0.001). The sensitivity, specificity, positive and negative predictive values of the "fish-hook" ureter configuration sign to detect BPO was 53, 76, 61 and 70%, respectively. Bladder trabeculation, upper urinary tract dilatation, or bladder base elevation were not associated with BPO, detrusor overactivity, detrusor underactivity, bladder low-compliance or any clinical data.

CONCLUSIONS

The "fish-hook" shape of the distal ureter(s) indicates BPO and may be a result of prostate median lobe enlargement.

Clinical significance of intravesical prostatic protrusion in patients with benign prostatic enlargement

OBJECTIVES

We evaluated a noninvasive method to predict bladder outlet obstruction (BOO) and bladder function in patients with benign prostatic enlargement (BPE) based on intravesical prostatic protrusion (IPP) using transabdominal ultrasound.

METHODS

The records of 206 first-visit patients with BPE were reviewed. We divided patients into two groups based on the degree of IPP: the significant IPP group (greater than 10 mm) and the no significant IPP group (10 mm or less). We analyzed clinical data and urodynamic findings of the two groups to define the clinical significance of IPP.

RESULTS

In the clinical data, increased prostate volume, serum prostate specific antigen, postvoiding residual urine volume (PVR), incidence of acute urine residual (AUR), and bladder trabeculation appeared more often in the significant IPP group (P <0.05). Positive correlation was found between IPP and prostate volume as well as PVR (Spearman's rho = 0.401 and 0.342, respectively). In the urodynamic findings, significantly lower peak flow rate (Qmax) and higher incidence of detrusor overactivity and low bladder compliance both existed in the significant IPP group (P <0.0l). In addition, maximum detrusor pressure (Pdet.max) and BOO index (BOOI) were significantly higher in the significant IPP group (P <0.05). The correlation coefficient (Spearman's rho) between IPP and Qmax, Pdet.max, and BOOI was -0.284, 0.252, and 0.456, respectively.

CONCLUSIONS

Intravesical prostatic protrusion is a useful predictor for evaluating BOO and detrusor function. BOO and impaired detrusor function in significant IPP patients are more severe. The significant IPP patients, especially those presenting with AUR, may benefit from early surgical intervention.

The significance of bladder trabeculation in the female lower urinary system: an objective evaluation by urodynamic studies

This study aimed to investigate the relationship between bladder trabeculation, urinary function, and the stage of pelvic organ prolapse (POP). The medical records of 104 patients with POP who underwent cystoscopies and urodynamic studies were reviewed retrospectively. Age, incidence of detrusor instability, stage and site of POP, and the parameters of urodynamic studies of patients with and without bladder trabeculation were compared. The difference in the incidence of bladder trabeculation was estimated between patients with and without a suspected bladder outlet obstruction. There were significant differences in the patients' age, stage of POP, and maximal voiding velocity. Patients with a suspected bladder outlet obstruction had a significantly higher incidence of bladder trabeculation. In addition, patients with advanced stages of POP were also found to have a higher incidence of bladder trabeculation.

Acupuncture reflexotherapy in the treatment of sensory urgency that persists after transurethral resection of the prostate: a preliminary report

AIMS

In this study, we wanted to evaluate whether acupuncture reflexotherapy is able to treat the sensory irritative components of LUTS (lower urinary tract symptoms) that persist after transurethral resection of the prostate.

METHODS

We have evaluated 42 patients, randomly selected into three groups: 14 patients received placebo, 15 patients received oxybutynin, and 13 patient were treated with electrostimulation by acupuncture reflexotherapy.

RESULTS

Before treatment, the mean maximum flow rate (Qmax) was 21.0 +/- 3.2 mL/sec, the mean International Prostate Symptom Score (I-PSS) score was 12.9 +/- 4.2, the mean I-PSS Quality of Life (IPSS QoL) score was 3.6 +/- 1.2. At the first check-up performed after 3 months, we could observe that the I-PSS and QoL scores were 12.6 +/- 4.3 and 3.8 +/- 1.3 in the group who received placebo; the scores decreased to 11.1 +/- 3.2 and to 3.1 +/- 1.0, respectively, in the 15 patients treated with oxybutynin and decreased to 6.1 +/- 2.6 and 1.3 +/- 1.1, respectively, in the 13 patients who underwent acupuncture reflexotherapy. At 1-year follow-up, these parameters were practically similar. The voiding diaries allowed us to deduce that the average number of daytime voidings decreased by 8% in patients who received oxybutynin and decreased by 20% in 13 patients who underwent reflexotherapy; the average number of nocturnal micturitions decreased by approximately 20% and 60%, respectively, in patients who received oxybutynin and reflexotherapy.

CONCLUSIONS

This study has pointed out that acupuncture reflexotherapy has a real benefit in patients with sensory urgency that persists after transurethral resection of the prostate.

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.

Ultrasonic measurement of bladder weight as a possible predictor of acute urinary retention in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

Acute urinary retention (AUR) is one of the most undesirable events for elderly men with benign prostatic hyperplasia (BPH). This study was designed to test the clinical utility of ultrasonic measurement of bladder weight as a predictor of AUR. A total number of 160 men visited our clinic with lower urinary tract symptoms (LUTS) suggestive of BPH and underwent urodynamic studies, including transrectal ultrasonography of the prostate and the measurement of ultrasound (US) estimated bladder weight (UEBW). Among them, 31 (19.4%) presented to our clinic with AUR. From the thickness of the anterior bladder wall measured by transabdominal ultrasonography and the intravesical volume, UEBW was calculated, supposing the bladder to be a sphere. Between patients with and without AUR, there were significant differences for age (75.4 vs. 71.1 years, p < 0.005), prostatic volume (45.5 vs. 35.8 g, p < 0.05), transition zone (TZ) volume (29.4 vs. 20.2 g, p < 0.05), TZ index (0.606 vs. 0.493, p < 0.005) and UEBW (50.3 vs. 34.7 g, p < 0.0001). A receiver-operating characteristic curve analysis demonstrated UEBW to be superior to the other prostatic ultrasonic measures in identifying AUR. Patients with LUTS suggestive of BPH having UEBW greater than 35.0 g were 13.4 times as likely to suffer from AUR. The significant association of UEBW with an increased risk of AUR suggests that it would be promising as a noninvasive urodynamic parameter capable of identifying patients at increased risk of AUR.

Urinary morbidity in brachytherapy patients with median lobe hyperplasia

PURPOSE

To investigate clinical course of prostate brachytherapy patients with radiographic evidence of median lobe hyperplasia (MLH).

METHODS AND MATERIALS

Fifteen patients with median lobe hyperplasia were identified during our routine brachytherapy practice and implanted between June 1998 and March 2000, representing approximately 6% of the 245 brachytherapy patients treated during that time. Each patient was contacted at the time of this report preparation to update postimplant morbidity information, with follow-up ranging from 6 to 30 months (median: 18 months).

RESULTS

Three of the 15 patients developed acute, postimplant urinary retention. The preimplant prostate volume, dMLH, and preimplant AUA scores were similar between patients who did or did not develop prolonged urinary retention. Compared with a control group of 62 control patients treated during a similar time interval at the University of Washington, patients with MLH had significantly higher AUA scores at last follow-up. There was no correlation between the change in AUA scores at last follow-up.

CONCLUSIONS

Based on the data reported here, we consider MLH to be a weak contraindication to prostate brachytherapy. Considering that even patients with prolonged retention have gradually improved spontaneously, we do not advocate prophylactic prebrachytherapy resection of hypertrophic tissue in MLH patients.

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.

Office evaluation of men with lower urinary tract symptoms

In the past decade, the symptom score has been considered the essential part of the evaluation of patients with lower urinary tract symptoms (LUTS). At the University of Wisconsin, the author's have stopped routine use of symptom scores because of their limited utility in dealing with the patient's concerns. Except from men electing invasive treatment, the authors do not serve the patients better with urodynamic testing either. Bothersomeness, not symptom score or objective measures is what drives the decision making process in benign prostatic hyperplasia (BPH) management. Generally, the authors now select patients for treatment according to the degree to which they are bothered by their LUTS.

Alterations in constituent urinary proteins in response to bladder outlet obstruction in rats

PURPOSE

Benign prostatic hyperplasia, resulting in bladder outflow obstruction, induces well recognized clinical symptoms and morphologic bladder changes. Despite these phenomenon, relatively little is known with regard to the precise molecular events occurring in the bladder as a consequence of obstruction. In an effort to screen for alterations in bladder gene expression induced by obstruction, and/or alterations in uroepithelial integrity, this study compared pre- and post-obstructive constituent urinary proteins in an animal model.

MATERIALS AND METHODS

Outlet obstruction was created using a previously established model system. Experimental animals were surgically obstructed for either 2 or 7 days, at which time the urine was aspirated and the bladders removed and weighed. Urinary proteins were separated using 2-D PAGE. Following comparison of sham versus experimental animals, microsequencing was performed on proteins that were down regulated.

RESULTS

Duplicate experiments confirmed the presence of outflow obstruction. Statistically significant increases (p <0.01) in bladder weights were seen at 2 and 7 days in the obstructed groups as compared with both sham and control groups. 2-D PAGE demonstrated a down regulation of three urinary proteins post-obstruction. Microsequencing identified these proteins as prostatic steroid-binding protein C3 precursor (pI=5.5, MW=15000), glandular kallikrein 9 (S3) precursor (pI=6.2, MW=19000), and glandular kallikrein 8 (P1) precursor (pI=6.2, MW=33000).

CONCLUSIONS

Bladder outflow obstruction alters constituent urinary protein composition in an animal model system. The precise etiology of these alterations remains to be defined.

Prediction of prostatic obstruction with a combination of isometric detrusor contraction pressure and maximum urinary flow rate

OBJECTIVES

Because isometric detrusor contraction pressure (Piso) increases with outlet obstruction and maximum urinary flow rate (Qmax) tends to decrease with obstruction, we hypothesize that specific criteria consisting of a combination of high Piso and low Qmax may be able to differentiate obstructive from nonobstructive voiding dysfunction better than either parameter alone.

METHODS

Two hundred five men with lower urinary tract symptoms underwent uroflowmetry and videourodynamics, including cystometry, continuous outlet occlusion test, and micturitional urethral pressure profilometry. Combined threshold values of Qmax of less than 12 mL/s and Piso of 100 cm H2O or greater were used to predict obstruction, whereas threshold values of Qmax of at least 12 mL/s and Piso less than 100 cm H2O were used to predict nonobstruction.

RESULTS

Of the 205 patients, 103 (50%) were significantly obstructed and 102 (50%) were only mildly obstructed or nonobstructed. Of the total population, 151 patients (74%) were categorized by the combined flow and contractility criteria. Of the categorized patients, 141 (93%) were correctly diagnosed with regard to infravesical obstruction (sensitivity 89%, specificity 97%, positive predictive value 97%, and negative predictive value 91%).

CONCLUSIONS

A combination of Qmax and Piso criteria can predict obstructive and nonobstructive voiding dysfunctions with high positive and negative predictive values in most patients with lower urinary tract symptoms. Combining the results of uroflowmetry and isometric tests may help to guide treatment strategies that may improve the outcome of selected therapeutic options compared with strategies based on symptoms or uroflowmetry alone. Furthermore, this approach forms a basis for interpreting various noninvasive methods that have recently been introduced for the purpose of diagnosing bladder outlet obstruction.