Role for intravesical prostatic protrusion in lower urinary tract symptom: a fluid structural interaction analysis study

Clinical Outcomes of Intravesical Prostatic Protrusion in Patients With Benign Prostatic Hyperplasia

Background Benign prostatic hyperplasia (BPH) is a disorder that is characterized by the hyperplasia of the cellular elements of the prostate, leading to an enlarged prostate. One of the parameters affecting urinary outflow is intravesical prostatic protrusion (IPP). It is a phenomenon wherein the enlargement of the prostate protrudes into the bladder along the plane of least resistance. This condition can lead to various clinical effects, including symptoms such as the feeling of incomplete void and weak, interrupted urine stream. Hence, investigating the potential associations between different grades of IPP and clinical urological outcomes holds crucial implications for optimizing patient care, refining risk stratification, and enhancing treatment approaches. Methodology We examined patients who were following up at the urology outpatient clinics due to BPH between June 1, 2021, and December 31, 2022. All patients included in this study were required to undergo a transabdominal prostate ultrasound. Patient records were reviewed for various factors, including demographic stratification, the presence of urine routine or culture with evidence of urinary tract infection (UTI) within the past two years, and whether patients were scheduled for surgical intervention. The radiological parameters were recorded by viewing the midsagittal and transverse ultrasound images retrospectively by two specialist radiology physicians. The parameters measured included IPP Grade, prostate volume (PV), presence of bladder stones, anatomical abnormalities (such as bladder diverticulum), and post-void volume. Results The total sample size was 184 patients. Out of these, 53 (28.8%) had IPP Grade I, 72 (39.1%) were classified as Grade II, 42 (22.8%) had Grade III, and 17 (9.2%) were categorized as Grade IV. The data collected also showed that 12 (6.5%) patients had bladder stones on ultrasound examination. Additionally, 17 (9.2%) patients had bladder diverticulum. Furthermore, when controlled for age and PV, multivariate analysis using logistic regression models to calculate the odds ratio (OR) showed that increasing IPP Grade is associated with an increased risk of developing UTIs, acute urinary retention, and the need for surgical intervention. The highest risk group of patients is IPP Grade IV, with odds ratios (ORs) of 6.8, 7.2, and 6.4 for developing UTIs, experiencing acute urinary retention, and requiring surgical intervention, respectively. Conclusions The results provide compelling evidence of the adverse relationships between higher grades of IPP and worsening urological outcomes and patient morbidity. Hence, we recommend further studies be conducted on the clinical effects of IPP and that these measurements should be considered as part of routine ultrasound prostate imaging to aid in the management of BPH cases.

The prostatic middle lobe: clinical significance, presentation and management

The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.

Composite urinary and sexual outcomes after Rezum: an analysis of predictive factors from an Italian multi-centric study

BACKGROUND

The Rezum system is one of the latest minimally invasive surgical treatments for benign prostatic hyperplasia.

METHODS

We retrospectively reviewed all patients who underwent the Rezum treatment in seven different Italian institutions. A successful urinary outcome was defined as: ≥50% improvement in the IPSS <7, improvement in peak flow ≥50% and/or more than 15 ml/s, ≥1-point improvement in the QoL questionnaire and in the absence of perioperative major complications (AUR, transfusion) or postoperative incontinence. A successful sexual outcome was defined as postoperative (latest follow up consultation) antegrade ejaculation or no variation in ejaculatory function and an increase, or stability or max 1 class reduction, in IIEF-5.

RESULTS

262 patients were enrolled with a follow-up period of 11 months (IQR 5-15). No early or late serious adverse events (Clavien III-IV) occurred. Early complications occurred in 39.3% of cases, with 4 cases of clot retention and one case of blood transfusion. Urge incontinence was reported by 6 patients (2.2%). A treatment failure requiring re-intervention occurred in 4 cases (1.5%). The preoperative antegrade ejaculation rate was 56.5%, and after the procedure it increased to 78.2%. The increase of ≥1-point in the QoL was achieved in 92.7% of the cases. Optimal urinary and sexual outcomes were achieved in 52.9% and 87.8%, respectively.

CONCLUSIONS

In our series, water vapor intraprostatic injections seem to be an effective and safe procedure.

Reliability and validity of assessment methods available in primary care for bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms: a systematic review

OBJECTIVES

To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS).

DESIGN

Systematic review with best evidence synthesis.

SETTING

Primary care.

PARTICIPANTS

Men with LUTS due to bladder outlet obstruction or benign prostatic obstruction.

REVIEW METHODS

PubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis.

RESULTS

Of the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence.

CONCLUSION

Clinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.

Intravesical Prostatic Protrusion and Prognosis of Non-Muscle Invasive Bladder Cancer: Analysis of Long-Term Data over 5 Years with Machine-Learning Algorithms

We aim to investigate the significance of intravesical prostate protrusion (IPP) on the prognosis of non-muscle invasive bladder cancer (NMIBC) after the transurethral resection of bladder tumors (TURBT). For newly diagnosed NMIBC, we retrospectively analyzed the association between prognosis and IPP for at least a 5-year follow-up. A degree of IPP over 5 mm in a preoperative CT scan was classified as severe. The primary endpoint was recurrence-free survival, and the secondary endpoint was progression-free survival. The machine learning (ML) algorithm of a support vector machine was used for predictive model development. Of a total of 122 patients, ultimately, severe IPP was observed in 33 patients (27.0%). IPP correlated positively with age, BPH, recurrence, and prognosis. Severe IPP was significantly higher in the recurrence group and reduced in the recurrence-free survival group (p = 0.038, p = 0.032). Severe IPP independently increased the risk of intravesical recurrence by 2.6 times. The addition of IPP to the known oncological risk factors in the prediction model using the ML algorithm improved the predictability of cancer recurrence by approximately 6%, to 0.803. IPP was analyzed as a potential independent risk factor for NMIBC recurrence and progression after TURBT. This anatomical feature of the prostate could affect the recurrence of bladder tumors.

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.

Is intravesical prostatic protrusion associated with more complications in benign prostatic hyperplasia patients?

OBJECTIVE

Intravesical prostatic protrusion (IPP) is a noninvasive parameter that can predict disease progression and development of complications in benign prostatic hyperplasia (BPH). This study was to determine the relationship between IPP and the presence of complications in BPH patients.

METHODS

This was a cross-sectional study of BPH patients at Enugu State University of Science and Technology Teaching Hospital, Enugu. Patients were assessed for acute urinary retention (AUR), chronic urinary retention (CUR), epididymoorchitis, hematuria, hernia, urinary tract infection (UTI), serum creatinine, and prostate-specific antigen (PSA). They also had abdominal ultrasonography assessments for IPP, total prostate volume, bladder wall thickness (BWT), postvoid residual (PVR), hydronephrosis, bladder diverticulum, and urolithiasis using Sonoscape S11 with an abdominal-probe frequency of 3.5 MHz. IPP was measured in millimeter and divided into <10 mm and ≥10 mm. Data were analyzed using SPSS version 21 and were subjected to 1-way analysis of variance, chi-square test, and Pearson correlation. The odds ratios of development of complications at an IPP cutoff of 10 mm were calculated. P < .05 was considered significant.

RESULTS

A total of 118 patients with a mean age of 64.18 ± 10.96 years and a mean IPP of 14.29 ± 10.20 mm were included. Forty-eight patients had IPP < 10 mm and seventy patients ≥10 mm. Patients with IPP ≥10 mm had significantly higher mean BWT, International Prostate Symptom Score (IPSS), PSA, and PVR (P ≤ .05) and significantly more AUR, CUR, hematuria, hydronephrosis, and UTI (P ≤ .01).

CONCLUSION

Patients with IPP ≥ 10 mm have a significantly higher incidence of some complications.

Accuracy of Clarius, Handheld Wireless Point-of-Care Ultrasound, in Evaluating Prostate Morphology and Volume Compared to Radical Prostatectomy Specimen Weight: Is There a Difference between Transabdominal vs Transrectal Approach?

Background: Prostate size estimation is a valuable clinical measure widely utilized in urology. This study evaluated the accuracy of preoperative transabdominal ultrasound (TAUS) compared to radical prostatectomy specimens and transrectal ultrasound (TRUS) in estimating prostate volume and identifying presence of median lobe, across different size groups, using the standard ellipsoid formula. The effect of median lobe on accuracy was also assessed. Materials and Methods: Ninety-eight men undergoing robot-assisted radical prostatectomy were enrolled in this study. Preoperative evaluation of prostate volume was done using measurements obtained from TAUS using the Clarius C3 handheld wireless point-of-care ultrasound (POCUS) and from TRUS Clarius EC7. Participants were grouped based on prostate size (<30, 30-60, and >60 g). Mean absolute percentage of error was used to evaluate accuracy. Mean percentage of error determined if there was an overestimation or underestimation. Correlation between each TAUS size group, true prostate weight and TRUS was assessed. Results: Irrespective of body mass index, TAUS accurately identified median lobe in all men. No statistically significant difference was found between specimen weight and TAUS prostate size for the >60 g group. Among this same group, a strong correlation was noted between specimen weight and TAUS prostate size (r = 0.911, p < 0.001). There was also a strong correlation between TAUS and TRUS measurements for this group (r = 0.950, p < 0.001). Presence of median lobe did not have an impact on measurement accuracy. Conclusions: Bedside handheld wireless POCUS provides rapid, inexpensive, noninvasive, and clinically accurate TAUS prostate assessments for larger prostates. Such features as identifying median lobes and measuring prostate volumes are valuable tools, whereas patient counseling on lower urinary tract symptoms, elevated prostate-specific antigen, and benign prostate hyperplasia are surgical options.

Impact of the presence of a median lobe on functional outcomes of greenlight photovaporization of the prostate (PVP): an analysis of the Global Greenlight Group (GGG) Database

OBJECTIVES

Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database.

METHODS

Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score.

RESULTS

A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22-10.23; p < 0.01) minutes and 2.90 (95% CI 1.02-4.78; p < 0.01) minutes longer than the control group. Men with median lobes had similar postoperative functional outcomes to those without a median lobe except for a 1.59-point greater drop in the 12-month IPSS score compared to baseline (95% CI 0.11-3.08; p = 0.04) in the median lobe group, and a decrease in PVR after 6 months which was 46.51 ml (95% CI 4.65-88.36; p = 0.03) greater in patients with median lobes compared to men without median lobes.

CONCLUSIONS

Our findings suggest that the presence of a median lobe has no clinically significant impact on procedural or postoperative outcomes for patients undergoing Greenlight PVP using the XPS-180 W system.

A pilot study of bladder voiding with real-time MRI and computational fluid dynamics

Lower urinary track symptoms (LUTS) affect many older adults. Multi-channel urodynamic studies provide information about bladder pressure and urinary flow but offer little insight into changes in bladder anatomy and detrusor muscle function. Here we present a novel method for real time MRI during bladder voiding. This was performed in a small cohort of healthy men and men with benign prostatic hyperplasia and lower urinary tract symptoms (BPH/LUTS) to demonstrate proof of principle; The MRI urodynamic protocol was successfully implemented, and bladder wall displacement and urine flow dynamics were calculated. Displacement analysis on healthy controls showed the greatest bladder wall displacement in the dome of the bladder while men with BPH/LUTS exhibited decreased and asymmetric bladder wall motion. Computational fluid dynamics of voiding showed men with BPH/LUTS had larger recirculation regions in the bladder. This study demonstrates the feasibility of performing MRI voiding studies and their potential to provide new insight into lower urinary tract function in health and disease.

The role of prostatic apex shape in voiding symptoms and urine flow: an exploratory and confirmatory study

PURPOSE

Lower urinary tract symptoms in men have previously been attributed to obstruction from an enlarged prostate. However, several factors in addition to prostate volume have been identified as impacting urine flow. Prostatic apex shape is one factor that has not been evaluated. This study evaluates the relationship between prostatic apex shape and voiding symptoms and urine flow.

METHODS

A retrospective, exploratory data review was conducted for 806 healthy men who underwent routine transrectal ultrasonography at our hospital, and data for 329 patients with uroflowmetric measurements were reviewed for the confirmatory study. Patients were categorized into four groups according to the prostatic apex shape on midsagittal ultrasonography. The association between prostatic apex shape and voiding symptoms was investigated. International Prostate Symptom Score (IPSS) and uroflowmetry were measured, and the associations between IPSS, uroflowmetry, and prostatic apex shape were analyzed.

RESULTS

Patients in group 4 (356/806, 44.2%), whose prostatic apex did not overlap the membranous urethra anteriorly or posteriorly, had a significantly lower incidence of moderate and severe lower urinary tract symptoms compared to other groups. There was a significant relationship between prostatic apex shape and total International Prostate Symptom Score. Patients in group 3, whose prostatic apex overlapped posteriorly with the membranous urethra, had lower maximum flow rates on uroflowmetry. There were significant correlations between the maximum flow rate and independent factors including age, intravesicle prostatic protrusion, and prostatic apex shape.

CONCLUSIONS

Prostatic apex shape is an independent risk factor for voiding symptom severity and low maximum flow rate.

Intravesical prostatic protrusion is not always the same shape: Evaluation by preoperative cystoscopy and outcome in HoLEP

AIMS

To examine how morphological differences in intravesical prostatic protrusion (IPP) predict outcome of Holmium laser enucleation of prostate (HoLEP) treatment.

METHODS

We analyzed 173 patients who had undergone HoLEP in our hospital. The protrusion shape was evaluated by outpatient preoperative flexible cystoscopy and classified into five groups: A, no protrusion; B, middle lobe only; C, unilateral lobe only; D, bilateral lobes; and E, B + C or B + D. Paired-match analysis that adjusted for preoperative International Prostate Symptom Score (IPSS) voiding/storage subscores and IPP was performed between the group with middle lobe protrusion (B + E) and the group without it (C + D).

RESULTS

Type A prostate shape was found in 23 patients, type B in 14, type C in 31, type D in 71, and type E in 34. Groups with middle lobe protrusion (B and E) had better changes in the total IPSS (P < 0.05) and the IPSS storage subscore (P < 0.01). Pair matching identified 37 patients each with or without middle lobe protrusion. The group with middle lobe protrusion had significantly more improved total IPSS (-17.5 ± 7.5 vs -13.5 ± 8.3, P < 0.05) and IPSS storage subscore (-6.9 ± 3.4 vs -4.8 ± 3.3, P < 0.05) than did those without middle lobe protrusion.

CONCLUSIONS

Patients with middle lobe protrusion had greater IPSS improvement after HoLEP than those having comparable-length IPP but without middle lobe protrusion. IPP is not always the same shape and should be clinically divided into at least two groups.

Clinical Considerations for Intravesical Prostatic Protrusion in the Evaluation and Management of Bladder Outlet Obstruction Secondary to Benign Prostatic Hyperplasia

Background

Intravesical prostatic protrusion (IPP) is a manifestation of benign prostatic hyperplasia marked by overgrowth of the prostatic median lobe into the bladder, producing bladder outlet obstruction and related storage and voiding symptoms.

Methods

A MEDLINE® database search of the current literature was guided using combination of "prostate" with the following terms: intravesical prostatic protrusion, bladder trabeculation, bladder outlet obstruction, lower urinary tract symptoms, alpha blockers, transrectal ultrasonography, and prostatectomy.

Results

Although IPP can be identified via a variety of imaging modalities, it is easily detected via transrectal ultrasonography (TRUS). Failing to detect IPP promptly by TRUS may result in refractory symptoms of benign prostatic hyperplasia, as the condition may not respond to typical α₁-adrenoceptor antagonist therapy. In addition, depending on grade, IPP can influence outcomes and complications of prostatectomies.

Conclusion

Upon report of lower urinary tract symptoms, initial performance of TRUS along with digital rectal examination prevents delay in the appropriate evaluation and management of prostatic diseases.

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.

Management of BPH then 2000 and now 2016 - From BPH to BPO

The diagnosis and treatment of benign prostatic obstruction (BPO) is based on a number of well-known lower urinary tract symptoms (LUTS) feared by all ageing males with functional testes. The ascent of modern urology turned this disease from lethal into an annoying but treatable health problem in the previous century. We are able to relieve the great majority of patients from their bothersome symptoms to a respectable quality of life by medication or removal of the obstructive part of the enlarged prostate. We can be proud of some progress made in the new millennium to reach a correct diagnosis and subsequent choice of treatment aiming for quality of life and cost-efficiency for public health. Still it remains symptomatic treatment and we expect the new generation of urologists to close some gaps in our knowledge on the regulation of prostatic growth to focus on prevention and elimination of the disease in the foreseeable future.

Clinical value of intravesical prostatic protrusion in the evaluation and management of prostatic and other lower urinary tract diseases

Intravesical prostatic protrusion (IPP) has emerged as a new prostatic morphometric parameter of significance to aid the clinicians in various aspects of managing the patients with some diseases of the lower urinary tract and the prostate. These include but may not be limited to its role in such conditions as: bladder outlet obstruction, trial without catheter, medical treatment effect, progression of lower urinary tract symptoms related to benign prostatic hypertrophy (LUTS/BPH), risk factor for bladder stone in BPH, overactive bladder, prostate carcinoma, and early urinary continence recovery after laparoscopic radical prostatectomy. In this review, I will try to summarize the different researchers' efforts on the potential practical application of this clinical tool. Technology is ever evolving to help us in the diagnosis and management of our patients. However, we as clinicians should contemplate their cost and possible suffering for the patient by wise and judicious utilization based on our clinical experience and tools. IPP seems to be one such promising clinical tool.