Comparison of outcomes of transurethral prostate resection in urodynamicallyobstructed versus selected urodynamicallyunobstructed or equivocal men

Comparison of Efficacy of Different Surgical Techniques for Benign Prostatic Obstruction

Purpose

We compared success rates of 3 surgical techniques (holmium laser enucleation of the prostate [HoLEP], transurethral resection of the prostate [TURP], and photoselective laser vaporization prostatectomy [PVP]) for treatment of benign prostatic obstruction (BPO). We aimed to identify preoperative clinical variables and urodynamic parameters that predict surgical success.

Methods

A total of 483 patients who underwent surgical treatment for BPO at Samsung Medical Center between 2006 and 2017 were retrospectively analyzed; of these 361, 81, and 41 patients underwent HoLEP, TURP, and PVP, respectively. Prostate-specific antigen, prostate volume, urodynamic parameters, and International Prostate Symptom Score (IPSS)/quality of life (QoL) index were evaluated preoperatively; uroflowmetry, postvoid residual urine, and IPSS/QoL index were measured 6 months postoperatively. Surgical success was defined based on IPSS, maximum flow rate, and QoL index and predictive factors were identified using multiple logistic regression analyses.

Results

Success rates of HoLEP, TURP, and PVP were 67.6%, 65.4%, and 34.1%, respectively, and the HoLEP and TURP groups were not significantly different. Regression analysis revealed prostate volume ≥50 mL and bladder outlet obstruction index (BOOI) ≥40 to be independent factors predicting HoLEP success. Only high preoperative QoL could predict the success of TURP, whereas other urodynamic parameters remained unrelated.

Conclusions

Patients treated with HoLEP and TURP displayed equivalent efficacies, but PVP was relatively less efficient than both. Preoperative variables of prostate volume ≥50 mL and BOOI ≥40 were independent predictive factors for the success of HoLEP but not of TURP.

Outcomes of transurethral resection of the prostate in unobstructed patients with concomitant detrusor underactivity

AIMS

The aim of the study was to evaluate the transurethral resection of the prostate (TURP) outcomes of unobstructed patients with detrusor underactivity (DUA), comparing the surgical results between obstructed and unobstructed males with concomitant DUA, at midterm follow-up.

METHODS

This was an observational, prospective, comparative, nonrandomized study. Candidates to TURP underwent preoperative urodynamics (UD), with a diagnosis of DUA, were divided in two cohorts: Group A unobstructed men, group B males with bladder outlet obstruction (BOO). Males were evaluated yearly with uroflowmetry (UF), post-void residual (PVR), and bladder voiding efficiency (BVE), International Prostate Symptom Score (IPSS) questionnaire, visual analogic scale (VAS) for subjective assessment of the quality of life. The degree of the variation of maximum flow rate (Qmax), PVR, BVE, IPSS, VAS between baseline and follow-up (Δ) was evaluated.

RESULTS

Patients in group A were 28 and in group B 23. Overall patient's mean ± SD age was 63.37 ± 12.41 years. Preoperative urodynamics characteristics: mean bladder contractility index (BCI) of 61.15 and 76.25 in group A and B, respectively; mean bladder outlet obstruction index (BOOI) of 17.25 and 50.15 in group A and group B, respectively. After surgery, overall patient group, group A, and group B showed a statistical improvement in IPSS score (P < .0001), Qmax (P < .0001), PVR (P < .0008), BVE (P < .03) and VAS (P < .0001).

CONCLUSIONS

BOO had an important impact on the degree of improvement of Qmax and PVR/BVE, while had a poor influence on lower urinary tract symptoms amelioration. The most relevant outcomes were found when BOO was associated with DUA, which was not a contraindication to surgery.

Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM)

BACKGROUND

Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies).

OBJECTIVE

To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included.

DESIGN, SETTING, AND PARTICIPANTS

A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments.

INTERVENTION

Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient.

RESULTS AND LIMITATIONS

Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure.

CONCLUSIONS

Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function.

PATIENT SUMMARY

We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.

Intravescical prostatic protrusion is a predictor of alpha blockers response: results from an observational study

BACKGROUND

To investigate the efficacy of tamsulosin in patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) with intravesical prostatic protrusion (IPP). Ultrasound measurement of the IPP has been previously described as an effective instrument for the evaluation of benign prostatic obstruction (BPO) and could help in clarifying the role of alpha-blockers in patients with (BPE).

METHODS

Patients with BPE and LUTS were enrolled in this observational study. Intravesical prostatic protrusion was graded as grade 1 (< 5 ml), 2 (5 < IPP < 10 ml) and 3 (> 10 ml). Patients were treated with tamsulosin for twelve weeks. Evaluation was performed before and at the end of treatment by means of International Prostate Symptom Score (IPSS) and uroflowmetry. Patients were considered responders if a reduction of IPSS > 3 points was reported.

RESULTS

One hundred forty-two patients were enrolled. Twelve patients were excluded because of incomplete data. Fifty patients showed an IPP grade 1 (group A), 52 a grade 2 (group B) and 28 a grade 3 (group C). Treatment success was obtained in 82%, 38,5% and 7,1% of patients respectively; these differences (group A vs B-C and group B vs C) were highly significant. The odd ratio to obtain a treatment success was of 59 and 8.1 in group A and group B respectively, in comparison to group C. After a multivariate regression, the relationship between IPP grade and treatment success remained significant. Improvement of uroflowmetry parameters has been reported in all the groups especially in patients with a low grade IPP (p value = 0,016 group A vs group B; p value = 0,005 group A vs group C). Prostate volume seems not to influence this relationship.

CONCLUSIONS

Intravesical prostatic protrusion has found to be significantly and inversely correlated with treatment success in patients with LUTS and BPE under alpha-blockers therapy. Alpha blockers odd ratio of success is 59 times higher in patients with a low grade IPP in comparison to patients with a high grade.

Surgical treatment of detrusor underactivity: a short term proof of concept study

OBJECTIVES

To compare the surgical outcomes of men with bladder outlet obstruction (BOO) due to benign prostatic obstruction (BPO) to those with detrusor underactivity (DU) or acontractile detrusor (DA).

MATERIALS AND METHODS

This retrospective, IRB approved study included men who underwent BPO surgery for refractory LUTS or urinary retention. Patients were grouped based on videourodynamic (VUDS) findings: 1) men with BOO, 2) men with DU and 3) men with DA. The primary outcome measure was the Patient Global Impression of Improvement (PGII). Secondary outcome measures included uroflow (Qmax), post-void residual volume (PVR) and the need for clean intermittent catheterization (CIC).

RESULTS

One hundred and nineteen patients were evaluated: 1) 34 with BOO, 2) 62 with DU and 3) 23 with DA. Subjective success rate (PGII) was highest in the BOO group (97%) and those with DU (98%), while DA patients had a PGII success of 26%, (p<0.0001). After surgery, patients with BOO had the lowest PVR (68.5mL). Fifty-six patients (47%) performed CIC pre-operatively (47% of BOO, 32% of DU and 87% of DA patients). None of the patients in the BOO and DU groups required CIC post operatively compared to16/23 (69%) of patients in the DA group (p<0.0001).

CONCLUSIONS

BPO surgery is a viable treatment option in men with presumed BOO and DU while DA is a poor prognostic sign in men who do not void spontaneously pre-operatively.

Male bladder outlet obstruction: Time to re-evaluate the definition and reconsider our diagnostic pathway? ICI-RS 2015

The diagnosis of bladder outlet obstruction (BOO) in the male is dependent on measurements of pressure and flow made during urodynamic studies. The procedure of urodynamics and the indices used to delineate BOO are well standardized largely as a result of the work of the International Continence Society. The clinical utility of the diagnosis of BOO is however, less well defined and there are several shortcomings and gaps in the currently available medical literature. Consequently the International Consultation on Incontinence Research Society (ICI-RS) held a think tank session in 2015 entitled "Male bladder outlet obstruction: Time to re-evaluate the definition and reconsider our diagnostic pathway?" This manuscript details the discussions that took place within that think tank setting out the pros and cons of the current definition of BOO and exploring alternative clinical tests (alone or in combination) which may be useful in the future investigation of male patients with lower urinary tract symptoms. The think tank panel concluded that pressure-flow studies remain the diagnostic gold-standard for BOO although there is still a lack of high quality evidence. Newer, less invasive, investigations have shown promise in terms of diagnostic accuracy for BOO but similar criticisms can be levelled against these tests. Therefore, the think tank suggests further research with regard to these alternative indicators to determine their clinical utility.

Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis

PURPOSE

To investigate the diagnostic value of urodynamic bladder outlet obstruction (BOO) in the selection of patients for transurethral surgery of the prostate.

MATERIALS AND METHODS

We systematically searched online PubMed, Embase, and Cochrane Library databases from January 1989 to June 2014.

RESULTS

A total of 19 articles met the eligibility criteria for this systematic review. The eligible studies included a total of 2321 patients with a median number of 92 patients per study (range: 12-437). Of the 19 studies, 15 conducted conventional transurethral prostatectomy (TURP), and 7 used other or multiple modalities. In urodynamic bladder outlet obstruction (BOO) positive patients, the pooled mean difference (MD) was significant for better improvement of the International Prostate Symptom Score (IPSS) (pooled MD, 3.48; 95% confidence interval [CI], 1.72-5.24; p < 0.01; studies, 16; participants, 1726), quality of life score (QoL) (pooled MD, 0.56; 95% CI, 0.14-1.02; p = 0.010; studies, 9; participants, 1052), maximal flow rate (Qmax) (pooled MD, 3.86; 95% CI, 2.17-5.54; p < 0.01; studies, 17; participants, 1852), and post-void residual volume (PVR) (pooled MD, 32.46; 95% CI, 23.34-41.58; p < 0.01; studies, 10; participants, 1219) compared with that in non-BOO patients. Some comparisons showed between-study heterogeneity despite the strict selection criteria of the included studies. However, there was no clear evidence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis results showed a significant association between urodynamic BOO and better improvements in all treatment outcome parameters. Preoperative UDS may add insight into postoperative outcomes after surgical treatment of benign prostatic hyperplasia.

Efficacy of Holmium Laser Enucleation of the Prostate Based on Patient Preoperative Characteristics

PURPOSE

To evaluate the efficacy of holmium laser enucleation of the prostate (HoLEP) in relation to prostate size and urodynamic parameters, including bladder outlet obstruction index (BOOI), presence of detrusor overactivity, and detrusor contractility, and to investigate factors predictive of HoLEP success.

METHODS

This retrospective analysis of prospective data included 174 consecutive patients treated with HoLEP at Samsung Medical Center from 2009 to 2013. Prostate-specific antigen, prostate size, urodynamic parameters, and International Prostate Symptom Score (IPSS)/quality of life (QoL) were evaluated preoperatively, while prostate-specific antigen, uroflowmetry/postvoid residual (PVR) urine, and IPSS were measured six months after HoLEP. Two definitions of treatment success were established based on the following three variables: IPSS, maximum flow rate (Qmax), and QoL index. Factors predictive of HoLEP success were identified using multiple logistic regression analysis.

RESULTS

IPSS/QoL, Qmax, and PVR improved significantly following HoLEP. Improvements in IPSS and PVR were more significant in the BOOI≥40 group compared to the BOOI<40 group, with overall success rates of 93.7% and 73.6%, respectively. Thus, the BOOI≥40 group had a significantly higher success rate, and BOOI≥40 was a significant predictor of HoLEP success based on the multivariate analyses.

CONCLUSIONS

We found good surgical outcomes after HoLEP, and specifically patients with a higher BOOI had a greater chance of surgical success.

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.

Urodynamics in male LUTS: when are they necessary and how do we use them?

In this article, the value of urodynamic studies in the evaluation of treatment of male lower urinary tract symptoms is appraised based on current evidence. The information gained by urodynamics can be a valuable tool for counseling patients considering invasive outlet reduction procedures.

The cutoff value of bladder voiding efficiency for predicting surgical outcomes after GreenLight HPS™ laser photoselective vaporization of the prostate

PURPOSE

A large postvoid residual (PVR) has been considered to be an indicator for the need to further management. However, the threshold level of PVR has been not defined. We determined the PVR volume by using bladder voiding efficiency (BVE) that would predict surgical outcomes after GreenLight HPS™ laser photoselective vaporization of the prostate (HPS-PVP).

METHODS

A total of 193 patients who underwent HPS-PVP were divided into two groups based on BVE: >75% (group A) and ≤75% (group B). BVE was calculated by dividing voided volume by voided volume plus PVR. Surgical outcomes were assessed from the ratio of the IPSS, the difference in Qmax, and the difference in the quality of life IPSS subscore (QoL) before surgery and at 3, 12, and 36 months postoperatively.

RESULTS

There were significant improvements in all outcome measures after 3, 12, and 36 months; the improvement in Qmax was greater in group A than group B at each time point. The IPSS ratio was significantly greater in group A than group B at 3 months. There was no difference in QoL between the groups. The multivariate logistic regression analysis showed that BVE correlated significantly with short-term surgical success, but not with prostate volume or age. In the area under curve of ROC analysis, the BVE cutoff value of 75% showed the highest sensitivity and specificity for predicting the short-term success of surgical outcomes.

CONCLUSIONS

Our results suggest that a large PVR may predict relatively slight improvements in short-term surgical outcomes after HPS-PVP. The cutoff value of PVR in predicting surgical success is 25% or more of residual fraction.

Effect of transurethral resection of the prostate based on the degree of obstruction seen in urodynamic study

Purpose

We retrospectively investigated the effect of transurethral resection of the prostate (TURP) on the basis of the degree of obstruction seen in preoperative urodynamic study in patients with benign prostatic hyperplasia (BPH) who complained of lower urinary tract symptoms (LUTS).

Materials and Methods

The subjects of this study were 285 patients who were diagnosed with BPH with LUTS and who subsequently underwent TURP. The Abrams-Griffiths number was calculated from the urodynamic results to divide the patients into the following groups: unobstructed, equivocal, and obstructed. There were 26 patients (9.1%) in the unobstructed group, 98 patients (34.4%) in the equivocal group, and 161 patients (56.5%) in the obstructed group. The preoperative and postoperative uroflowmetry, residual urine, International Prostate Symptom Score (IPSS), and quality of life (QoL) score were compared between the three groups to evaluate the outcome of the treatment.

Results

The reduction in the IPSS was 14.4 in the obstructed group, which was higher than the reductions of 12.7 in the equivocal group and 9.5 in the unobstructed group, but this difference was not statistically significant (p=0.227). The QoL score was also not significantly different across the three groups (p=0.533). The postoperative maximum flow rate was significantly improved in all three groups. The obstructed group had an improvement of 7.8±7.2 mL/s, which was higher than the improvement of 3.7±6.2 mL/s in the unobstructed group (p=0.049) but was not significantly different from the improvement of 5.6±6.9 mL/s in the equivocal group (p=0.141).

Conclusions

TURP led to an improvement in the maximum flow rate and LUTS even in BPH patients without BOO. Therefore, TURP can be expected to improve LUTS in BPH patients without definite urodynamic obstruction.

Transitional zone index and intravesical prostatic protrusion in benign prostatic hyperplasia patients: correlations according to treatment received and other clinical data

Purpose

The aim of this research was to assess the value of the transitional zone index (TZI) and intravesical prostatic protrusion (IPP) from transrectal ultrasonography in evaluating the severity and progression of disease by analyzing the relationship between the 2 parameters and symptoms, clinical history, and urodynamics in benign prostatic hyperplasia (BPH) patients undergoing different treatment.

Materials and Methods

A total of 203 patients receiving medication and 162 patients who underwent transurethral resection of the prostate because of BPH were enrolled in this retrospective analysis. The clinical history and subjective and objective examination results of all patients were recorded and compared after being classified by TZI and IPP level. Linear regression was used to find correlations between IPP, TZI, and urodynamics.

Results

The 2 parameters were found to differ significantly between patients receiving medication and patients undergoing surgical therapy (p<0.05). PSA, maximum flow rate (Qmax), detrusor pressure at Qmax (PdetQmax), and the bladder outlet obstruction index (BOOI) differed according to various TZI levels (p<0.05). In addition, the voiding symptom score, Qmax, and BOOI of subgroups with various IPP levels were also significantly different (p<0.05). Both TZI and IPP had significant effects on Qmax, BOOI, and PdetQmax (p<0.05) and the incidence of acute urinary retention (p=0.000).

Conclusions

The results demonstrated that both TZI and IPP had favorable value for assessing severity and progression in patients with BPH. Further studies are needed to confirm whether the two parameters have predictive value in the efficacy of BPH treatment and could be considered as factors in the selection of therapy.

Bladder contractility and urethral resistance relation: what does a pressure flow study tell us?

Hydrodynamic analysis of a pressure flow study is the only reliable method to determine the presence or absence of a bladder outlet obstruction, especially benign prostatic obstruction. To interpret the results of pressure flow study in benign prostatic obstruction, understanding the outlines of the basic theory about evaluation of the relationship between bladder contractility and urethral resistance relation is of paramount importance. In contrast, hydrodynamic analysis of pressure flow study in conditions other than benign prostatic obstruction is complicated by the limits of theories about the hydrodynamics of the lower urinary tract. In this review, the proposed hydrodynamic theories about the relationship between bladder contractility and urethral resistance relation are outlined. Then, problems encountered in the application of hydrodynamic analysis of pressure flow study to diseases other than benign prostatic obstruction are discussed.

Predictive value of resistive index, detrusor wall thickness and ultrasound estimated bladder weight regarding the outcome after transurethral prostatectomy for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction

OBJECTIVES

To evaluate the value of three parameters from preoperative ultrasonography in predicting the outcome of transurethral prostatectomy in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.

METHODS

A total of 239 patients with lower urinary tract symptoms suggestive of benign prostatic obstruction entering our department for surgical therapy were prospectively recruited. All of them underwent both ultrasound and urodynamics before receiving standard transurethral prostatectomy by the same team of surgeons. For 202 patients, 6-month follow-up data were available after the surgery, including the International Prostate Symptom Score, the Quality of Life score and the maximum flow rate. Preoperative data stratified by different degree of recovery were compared and the influence of ultrasound parameters on the surgical outcome was analyzed by using logistic regression and receiver-operator characteristic curve analyses.

RESULTS

Baseline transitional zone index, intravesical prostatic protrusion, resistive index, detrusor wall thickness and ultrasonic estimation of bladder weight were significantly different between patients with an effective outcome and those with an ineffective outcome (P < 0.05). Resistive index, detrusor wall thickness and ultrasonic estimation of bladder weight were selected as independent factors correlated with the efficacy of transurethral prostatectomy by logistic regression (P < 0.05). All three factors had adequate area under receiver-operator characteristic curve with resistive index having the largest area (0.816, 95% CI 0.759-0.874). The combined positive predictive value in effective surgical outcome of resistive index, detrusor wall thickness and ultrasonic estimation was 96.3%.

CONCLUSIONS

Resistive index, detrusor wall thickness and ultrasonic estimation adequately predict the outcome of transurethral prostatectomy. Measuring these parameters by preoperative ultrasound might aid in determining the need for surgical intervention.

Is there a correlation between the outcome of transurethral resection of prostate and preoperative degree of bladder outlet obstruction?

To compare the impact of transurethral resection of prostate (TURP) on symptom scores and maximal flow rates (Qmax) in patients with equivocal bladder outlet obstruction (BOO) and definite BOO and to assess the relationship between the surgical outcomes and degree of preoperative BOO, we prospectively evaluated men with lower urinary tract symptoms and bladder outlet obstruction index (BOOI) greater than 20, who were refractory to conventional medical treatment and underwent TURP. Urodynamic evaluation, International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual volume (PVR) check and transrectal ultrasound were performed. 20<BOOI<40 was defined as equivocal BOO and BOOI≥40 as definite BOO. Changes of IPSS, Qmax, PVR and correlation analysis was performed between the degree of improvement of Qmax, subdomains of IPSS and BOOI. Fifty-four patients showed equivocal BOO and 80 patients showed definite BOO. Preoperatively equivocal BOO group and definite BOO group showed significant differences in maximal bladder capacity and prevalence of detrusor overactivity, whereas no difference was noted in prostate volume. Postoperatively both groups showed improvements in Qmax, obstructive (IPSSO) and irritative (IPSSI) subdomain of IPSS, but the degree of improvement in Qmax and IPSSI subdomain was statistically significantly greater in definite BOO group. The degree of improvement of Qmax and IPSSI showed weak correlation with preoperative BOOI. As a weak correlation was identified between preoperative degree of BOO and outcome of TURP, other factors other than BOOI such as severity of patients' symptoms should be considered in deciding treatment modality.

Overactive bladder and outlet obstruction in men

Lower urinary tract symptoms (LUTS), overactive bladder, (OAB), and benign prostatic hyperplasia (BPH) are very commonly experienced in men. The mainstay of pharmacotherapy for OAB is the antimuscarinic class of drugs. There has been reluctance to prescribe these agents to men with BPH due to the risk of precipitating urinary retention. Several trials have supported the efficacy and safety of antimuscarinics in treating men with LUTS, alone, or in combination with α-blocker therapy. The combination of 5-α-reductase inhibitors with antimuscarinic agents or surgery are other effective treatments for men with BPH and OAB.

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.

The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index

OBJECTIVES

We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment.

METHODS

Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution, we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations. According to the bladder outlet obstruction index and the bladder contractility index, the patients were divided into 2 groups: group A (25 patients) with unobstructed and weak bladder contractility, and group B (46 patients) with obstructed and/or normal bladder contractility. We investigated the differences of International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Q(max)), postvoid residuals (PVR), and the patient subjective satisfaction between the 2 groups after the TUR-P.

RESULTS

Mean follow-up period after TUR-P was 19 months (range 12 to 55 months). After the TUR-P, the IPSS/QoL, and PVR were significantly improved in group A and all parameters in group B. Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A.

CONCLUSIONS

There were significant improvements in IPSS/QoL and PVR after TUR-P in patients with weak bladder contractility and more than 60% were satisfied with the results of the surgery. TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment.

The Pattern and Progression of Lower Urinary Tract Symptoms after Transurethral Prostatectomy Compared with Those Seen in the General Population

OBJECTIVES

Men undergoing transurethral prostatectomy (TURP) often have some level of residual symptoms after this operation. Reliance on symptom scores to assess outcomes means there is relatively little information on the exact pattern of such symptoms. The aim of this study was to describe the pattern, progression, and associated bother of lower urinary tract symptoms after TURP.

METHODS

Detailed information on urinary symptoms, prostatectomy status, and associated bother was obtained from a randomly selected sample of community-dwelling men by using a postal questionnaire. Rates of individual urinary symptoms in the postprostatectomy population were calculated, and compared with those in the background population and those in secondary care.

RESULTS

Of 7640 men who responded, 422 had undergone prostatectomy. Symptom levels remained significantly higher in the postoperative group than the background population, with 19.4% experiencing four or more symptoms on a weekly basis. The pattern of symptoms was similar to that seen in the general population. Men in the post-TURP group experienced greater levels of bother when symptom level (odds ratio: 2.69; 95%CI, 1.80-4.01) was controlled. Both symptom and bother, however, were significantly lower than those in people referred for secondary care treatment of their symptoms.

CONCLUSIONS

Men with a previous prostatectomy still report high levels of urinary symptoms and appear to experience greater levels of bother from these symptoms than men in the general population.

Can the outcome of transurethral resection of the prostate be predicted preoperatively?

OBJECTIVES

To establish a formula for predicting the outcome of transurethral resection of the prostate using noninvasive parameters of preoperative evaluation.

METHODS

The data of 54 men with a mean age of 57 years (range 43 to 78) were retrospectively analyzed. The International Prostate Symptom Score, quality-of-life score of the International Prostate Symptom Score questionnaire, maximal flow rate (Qmax) recorded during uroflowmetry, age, prostate volume calculated by transrectal ultrasonography, postvoid residual urine volume, and results of pressure-flow studies were evaluated to find a formula that would predict the outcome of transurethral resection of the prostate. The patients were evaluated by uroflowmetry, postvoid residual urine volume determination, and International Prostate Symptom Score questionnaire at 3 months postoperatively. Four different success criteria were investigated with the calculated equations.

RESULTS

According to the discriminant analysis, two new scores were calculated as S(1) = (0.169 x age) - (0.0075 x Qmax) and S2 = (0.168 x age) - (0.095 x Qmax) - (0.007 x detrusor pressure at Qmax). For the four success criteria, the optimal cutoff, obtained from the receiver operating characteristic curves of S(1) and S(2), was 8.83 and 9.21, respectively. A statistically significant difference was not found between S1 and S2. The S1 formula had a sensitivity between 71.8% and 85.2%, specificity between 71.4% and 86.7%, and positive predictive value between 72.2% and 92.9% for the four different criteria using two simple variables (Qmax of uroflowmetry and age).

CONCLUSIONS

Because urodynamic parameters did not add benefit to the formula consisting of age and Qmax of uroflowmetry with considerable sensitivity and specificity, performing urodynamic studies might not be useful for predicting the outcome of transurethral resection of the prostate.

Protection of urinary bladder function by grape suspension

Urinary bladder dysfunction secondary to BPH is a major affliction of aging men. A rabbit model of partial outlet obstruction was used to evaluate the ability of a standardized grape suspension to protect the bladder against obstructive bladder dysfunction.Twenty-four New Zealand White rabbits were separated into four groups of six rabbits each. Groups 1 and 3 were pretreated by oral gavage for 3 weeks with a standardized grape suspension suspended in water; groups 2 and 4 were treated with vehicle. Groups 1 and 3 received sham operations after 3 weeks of treatment; groups 2 and 4 received partial outlet obstruction by surgically placing a silk ligature loosely around the urethra. At 3 weeks following surgery, in vivo and in vitro bladder functions were evaluated. Based on both in vivo and in vitro studies, the grape suspension significantly reduced the severity of obstructed bladder dysfunction. This is consistent with the hypothesis that ischemia is a major etiological factor in obstructive dysfunction, and treatment with antioxidants and membrane stabilization compounds such as those in the grape suspension can be effective in the treatment of obstructive bladder pathology.