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

Post-Voided Residual Ratio Does Not Predict Trifecta Outcome after Transurethral Resection of Prostate

The purpose of this study was to assess the importance of the post-void residual (PVR) ratio (PVR ratio) in achieving a favorable trifecta outcome for patients suffering from lower urinary tract symptoms and benign prostatic enlargement (LUTS-BPE) who undergo transurethral resection of the prostate (TURP). Starting from 2015, a series of patients with LUTS-BPE who underwent TURP were included in a forward-looking study. These patients were assessed using the international prostate symptom score (IPSS) screening tool, uroflowmetry, and a transrectal ultrasound to measure prostate volume (TRUS). Both the PVR urine volume and the PVR ratio (PVR-R), which is the PVR as a percentage of total bladder volume (voided volume + PVR), were measured. The assessment of outcomes was based on the trifecta favorable outcome, defined as meeting all of the following criteria: (1) absence of perioperative complications, (2) a postoperative IPSS of less than eight, and (3) a postoperative maximum urinary flow rate (Qmax) greater than 15 mL/s. A total of 143 patients were included, with a median age of 70 years (interquartile range 65-73). Of these, 58% (83/143) achieved a positive trifecta outcome. Upon conducting a multivariate analysis, both IPSS and Qmax were identified as predictors of a positive trifecta outcome, whereas the PVR-R did not prove to be an independent predictor. In summary, it was found that preoperative IPSS and Qmax are indicative of a trifecta outcome following TURP, whereas PVR-R is not.

The role of intra‐operative void score during transurethral resection of prostate as a marker of efficacy: a feasibility study

Background

To assess the feasibility of a novel intra‐operative void scoring technique. To determine if intra‐operative void score (VS) could act as a marker for post‐operative success following TURP.

Methods

Fifteen patients undergoing TURP were included in this single‐centre feasibility study. All patients had indwelling urinary catheters for recurrent retention due to benign prostatic hyperplasia (BPH). In theatre, immediately before‐ and after TURP, an intra‐operative VS was measured and graded 0–5. Primary outcomes were the feasibility of measuring intra‐operative VS and its accuracy in predicting surgical outcome.

Results

A combined pre‐ and post‐score with a threshold ≥6 correctly predicted 82% of those who were catheter free (sensitivity) and 100% of those who were not catheter free (specificity) at follow up and the positive predictive value was 100% and negative predictive value 60%.

Conclusion

Intra‐operative void score during TURP is simple, reproducible, fast and requires minimal resources. In TURP it may predict successful outcomes by identifying patients who will be catheter free post‐operatively as opposed to those who will be catheter dependent despite the procedure.

Significance of a decrease in the proportion of detrusor muscle to bladder wall for non-invasive diagnosis of detrusor underactivity in men with lower urinary tract symptoms

To investigate the significance of detrusor muscle thickness (DMT) to bladder wall thickness (BWT) ratio as a detrusor-sarcopenia and a consistently applicable factor for noninvasive diagnosis of detrusor underactivity (DU). We prospectively performed a urodynamic study of 100 male with medical refractory lower-urinary-tract-symptoms during 2017–2019. The DMT, BWT and DMT/BWT ratio were measured by ultrasonography every 50 mL during bladder filling, and were analyzed for non-invasive diagnosis of DU and prediction of prostate surgery outcome with questionnaire and the maximum-flow-rate. Of the 94 patients, DU was urodynamically diagnosed in 24 (25.5%). The DMT/BWT ratio was maintained in all patients until the 50% of the maximum cystometric capacity (MCC), and then rapidly decreased. At 20% of the MCC, the DMT/BWT ratio was significantly lower in the DU group (44.0 ± 4.9% vs. 49.4 ± 6.7%, p = 0.008). The DMT/BWT ratio of less than 47.5% at 20% of the MCC showed the ideal accuracy for diagnosing DU (AUC = 0.763), and was a predictor of failure at 12 months after prostate surgery (OR 8.78, p = 0.024). A DMT/BWT ratio of less than 47.5% at 20% of the MCC is a consistently applicable factor for non-invasive diagnosis of DU and could also be considered detrusor-sarcopenia.

Modified bladder outlet obstruction index for powerful efficacy prediction of transurethral resection of prostate with benign prostatic hyperplasia

Background

The correlation between modified bladder outlet obstruction index (MBOOI) and surgical efficacy still remains unknown. The purpose of the study was to investigate the clinical value of the MBOOI and its use in predicting surgical efficacy in men receiving transurethral resection of the prostate (TURP).

Methods

A total of 403 patients with benign prostate hyperplasia (BPH) were included in this study. The International Prostate Symptom Score (IPSS), quality of life (QoL) index, transrectal ultrasonography, and pressure flow study were conducted for all patients. The bladder outlet obstruction index (BOOI) (P_detQ_max–2Q_max) and MBOOI (P_ves–2Q_max) were calculated. All patients underwent TURP, and surgical efficacy was accessed by the improvements in IPSS, QoL, and Q_max 6 months after surgery. The association between surgical efficacy and baseline factors was statistically analyzed.

Results

A comparison of effective and ineffective groups based on the overall efficacy showed that significant differences were observed in PSA, P_ves, P_detQ_max, P_abd, BOOI, MBOOI, TZV, TZI, IPSS-t, IPSS-v, IPSS-s, Q_max, and PVR at baseline (p < 0.05). Binary logistic regression analysis suggested that MBOOI was the only baseline parameter correlated with the improvements in IPSS, QoL, Q_max, and the overall efficacy. Additionally, the ROC analysis further verified that MBOOI was more optimal than BOOI, TZV and TZI in predicting the surgical efficacy.

Conclusion

Although both MBOOI and BOOI can predict the clinical symptoms and surgical efficacy of BPH patients to a certain extent, however, compared to BOOI, MBOOI may be a more useful factor that can be used to predict the surgical efficacy of TURP.

Trial registration retrospectively registered.

Correlation of Intravesical Prostatic Protrusion in Benign Prostate Hyperplasia and Residual Lower Urinary Tract Symptoms After Surgery: A Systematic Review

Context: Intravesical prostatic protrusion (IPP) is a potential candidate for the initial evaluation of patients with lower urinary tract symptoms (LUTS). Intravesical prostatic protrusion is also known to predict the outcome of trials without a catheter and medical treatment outcomes and to determine bladder outlet obstructions. Objectives: This study aimed to determine whether IPP influences the residual LUTS after surgery in patients with benign prostate hyperplasia who have undergone prostate surgery. Evidence Acquisition: An online database search was conducted regarding the prognosis of postoperative benign prostate hyperplasia patients with intravesical prostatic protrusions. The selected databases comprised PubMed, ScienceDirect, EBSCO, and Cochrane Library. Randomized controlled trial, cohort, or case control studies that were written in English or Bahasa and published up until November 2020 were included. We reviewed postoperative outcomes, including subjective symptoms, based on the International Prostate Symptom Score and objective signs, such as Qmax and post voiding residue. Results: Our initial database search yielded 143 papers. After exclusion from abstract screening, seven papers were considered for full-text analysis. Five of these studies showed higher preoperative intravesical prostatic protrusion within successful postoperative outcomes. Some studies showed that patients with significant intravesical prostatic protrusions had more significant International Prostate Symptom Score decrements. However, two studies demonstrated that intravesical prostatic protrusion was not a significant prognostic factor. Conclusions: Most studies suggested that intravesical prostatic protrusion can predict better post-surgery lower urinary tract symptom outcomes. Further research using information about the risk of bias in ultrasound examination and more homogeneous surgical techniques and considering the duration of patients’ illness before they receive surgical management is needed.

Non-invasive evaluation of lower urinary tract symptoms (LUTS) in men

Lower urinary tract symptoms (LUTS) are common in males over the age of 40 years old and are likely to increase with an aging population. Currently urodynamic studies are the gold standard to determine the aetiology of voiding dysfunction and LUTS. However, due to its invasive nature, a great number of non-invasive ultrasound based investigations have been developed to assess patients with symptomatic LUTS. The clinical application of non-invasive tests could potentially stratify patients who would require more invasive investigations and allow more precise patient directed treatment. A PubMed literature review was performed and we will discuss the non-invasive investigations that have been developed thus far, focusing on bladder wall and detrusor wall thickness (BWT & DWT), ultrasound estimated bladder weight (UEBW) and intravesical prostatic protrusion (IPP).

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial

BACKGROUND

Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS.

DESIGN

A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome.

DISCUSSION

The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction.

TRIAL REGISTRATION

Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Establishment and value assessment of efficacy prediction model about transurethral prostatectomy

OBJECTIVES

To establish and to evaluate discriminant models to predict the outcomes of transurethral prostatectomy.

METHODS

Clinical data of patients treated with transurethral prostatectomy between January and December 2013 were collected, including medical history, symptoms, biochemical tests, ultrasonography and urodynamics. Surgical efficacy was evaluated at 6-month follow up. Predictive models were constructed by logistic regression. Receiver operating characteristic curve and diagnostic tests were used to test the accuracy of models before the predictive value between models was compared.

RESULTS

A total of 182 patients were included, with 73.6% having an effective outcome. History of recurrent urinary tract infection (OR 1.33), score of storage phase (OR 2.58), maximum flow rate (OR 2.11) and detrusor overactivity (OR 3.13) were found to be risk factors. International Prostate Symptom Score (OR 0.13), transitional zone index (OR 0.58), resistive index of prostatic artery (OR 0.46), bladder wall thickness (OR 0.78), ultrasonic estimation of bladder weight (OR 0.28), bladder outlet obstruction index (OR 0.20) and bladder contractility index (OR 0.83) were found to be protective factors. The areas under the curve of models using factors from ultrasonography and urodynamics were 0.792 and 0.829 respectively, with no significant difference being found between them (P = 0.348).

CONCLUSIONS

Surgical efficacy of transurethral prostatectomy is positively correlated to severe voiding phase symptoms, outlet obstruction and better detrusor contractility, and negative correlated with urinary infection, severe storage phase symptoms and excessive detrusor contractibility. Ultrasonography might replace urodynamics in selecting patients for whom transurethral prostatectomy is more likely to be beneficial.

Resistive index of prostatic capsular arteries as a predictor of prostate cancer in patients undergoing initial prostate biopsy

To evaluate the value of resistive index (RI) of prostatic capsular arteries in diagnosis and evaluation of prostate cancer (PCa) in Chinese patients undergoing initial prostate biopsy. A total of 532 consecutive patients undergoing prostate biopsy were enrolled in this study. RI was measured on the largest transverse section of prostate for each individual. The predictive value of RI was evaluated using multivariate logistic regression and receiver operating characteristic (ROC) curve analyses. PCa was identified in 217 (40.79%) patients. RI was 0.69 ± 0.08 and 0.8 ± 0.08 for patients without and with PCa (p < 0.01). On logistic regression RI was significantly associated with PCa (p < 0.01). Using ROC analysis RI outperformed tPSA in prediction of PCa in all patients [area under ROC curve (AUC) = 0.83, 0.78, respectively]. With the cutoff value of 0.73, RI discriminated PCa from non-PCa patients with 81.9% sensitivity, 75.9% specificity and 77.63% diagnostic accuracy. Furthermore, The AUC for RI in the discrimination of PCa from non-PCa patients in a subset with PSA of 4 to 10 ng/ml, high grade from non-high grade PCa patients and advanced from localized PCa patients was 0.70, 0.77 and 0.80, higher than other parameters (p < 0.05). RI is proved a practicable parameter in identifying patients at risk for PCa and predicting the grade and stage of PCa before initial prostate biopsy. The value of RI should be further explored in the future.

Application of guidelines to the evaluation of the male patient with urgency and/or incontinence

PURPOSE OF REVIEW

To review and evaluate the evidence from contemporary evidence-based guidelines regarding the assessment of men with urinary urgency and/or incontinence.

RECENT FINDINGS

There are a number of evidence-based guidelines which describe the pathways for assessing men with the symptoms of urgency and/or incontinence. We summarize the conclusions of the European Association of Urology, American Urological Association and National Institute of Clinical Excellence guidelines.

SUMMARY

All guidelines recommend a directed history, examination (including digital rectal examination), urinalysis and bladder diary as being essential in the assessment of men with lower urinary tract symptoms, although there are no high levels of evidence studies to support this. Creatinine estimation and prostate-specific antigen are recommended in selected groups of men, the latter after appropriate counselling. Uroflowmetry with postvoid residual assessment is recommended for at specialist assessment. Pad tests may be useful to quantify leakage. Ultrasound assessment of prostatic size and protrusion into the bladder base may be useful. Cystometry is recommended for men considering prostatic surgery, although there is a poor level of evidence underpinning this. Noninvasive surrogates for cystometry, such as penile plethysmography, lack sufficient evidence to allow recommendations to be made.

Assessment of BPH/BOO

The assessment of men with bladder outflow obstruction relies on an adequate history and examination. Uroflowmetry and post-void residue estimation are very revealing and may be sufficient in the majority of men. The prostate-specific antigen test may be used to select men who are at a high risk of progression. In specific situations, cystometry may be required. We discuss the use of cystometry and the newer less-invasive methods of assessment that have emerged over the last few years, including ultrasound estimation of intravesical prostatic protrusion, prostatic urethra angle, detrusor wall thickness, ultrasound-estimated bladder weight, near-infrared spectroscopy and the condom catheter and penile cuff tests. Although these techniques show promise, they still require further modifications, standardization and testing in larger populations. In addition, they should be used in men where only specific questions need to be answered.

Noninvasive urodynamic evaluation

The longevity of the world's population is increasing, and among male patients, complaints of lower urinary tract symptoms (LUTS) are growing. Testing to diagnose LUTS and to differentiate between the various causes should be quick, easy, cheap, specific, not too bothersome for the patient, and noninvasive or minimally so. Urodynamic evaluation is the gold standard for diagnosing bladder outlet obstruction (BOO) but presents some inconveniences such as embarrassment, pain, and dysuria; furthermore, 19% of cases experience urinary retention, macroscopic hematuria, or urinary tract infection. A greater number of resources in the diagnostic armamentarium could increase the opportunity for selecting less invasive tests. A number of groups have risen to this challenge and have formulated and developed ideas and technologies to improve noninvasive methods to diagnosis BOO. These techniques start with flowmetry, an increase in the interest of ultrasound, and finally the performance of urodynamic evaluation without a urethral catheter. Flowmetry is not sufficient for confirming a diagnosis of BOO. Ultrasound of the prostate and the bladder can help to assess BOO noninvasively in all men and can be useful for evaluating the value of BOO at assessment and during treatment of benign prostatic hyperplasia patients in the future. The great advantages of noninvasive urodynamics are as follows: minimal discomfort, minimal risk of urinary tract infection, and low cost. This method can be repeated many times, permitting the evaluation of obstruction during clinical treatment. A urethral connector should be used to diagnose BOO, in evaluation for surgery, and in screening for treatment. In the future, noninvasive urodynamics can be used to identify patients with BOO to initiate early medical treatment and evaluate the results. This approach permits the possibility of performing surgery before detrusor damage occurs.