Three year results of the prostatic urethral L.I.F.T. study

INTRODUCTION

To report the three year results of a multi-center, randomized, patient and outcome assessor blinded trial of the Prostatic Urethral Lift (PUL) in men with bothersome lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

At 19 centers in North America and Australia, 206 subjects = 50 years old with International Prostate Symptom Score (IPSS) ≥ 13, peak flow rate (Qmax) ≤ 12 mL/s, and prostate volume between 30 cc-80 cc were randomized 2:1 to the PUL procedure or sham control. PUL involved placing permanent UroLift implants into the lateral lobes of the prostate to enlarge the urethral lumen. After randomized comparison at 3 months, PUL patients were followed to 3 years. LUTS severity (IPSS), quality of life, Qmax, sexual function, and adverse events were assessed throughout follow up.

RESULTS

The therapeutic effect of PUL regarding IPSS was 88% greater than sham at 3 months. Average improvements from baseline through 3 years were significant for total IPSS (41.1%), quality of life (48.8%), Qmax (53.1%), and individual IPSS symptoms. Symptomatic improvement was independent of prostate size. There were no de novo, sustained ejaculatory or erectile dysfunction events and all sexual function assessments showed average stability or improvement after PUL. Fifteen of the 140 patients originally randomized to PUL required surgical reintervention for treatment failure within the first 3 years.

CONCLUSIONS

PUL offers rapid improvement in voiding and storage symptoms, quality of life and flow rate that is durable to 3 years. Patients demonstrated a level of symptom relief that is associated with significant patient satisfaction. PUL, a minimally invasive procedure, is very effective in treating bothersome LUTS secondary to benign prostatic obstruction (BPO) and is unique in its ability to preserve total sexual function while offering a rapid return to normal physical activities.

Durability of the Prostatic Urethral Lift: 2-Year Results of the L.I.F.T. Study

INTRODUCTION

For a therapy to become an important part of a provider armamentarium it must be safer or better than existing therapies and be durable. The prostatic urethral lift offers rapid improvement in lower urinary tract symptoms associated with benign prostatic hyperplasia with minimal side effects. We report 2-year results of a multicenter, randomized, blinded trial of the prostatic urethral lift.

METHODS

A total of 206 men 50 years old or older with an AUA-SI of 13 or greater, a peak flow rate of 12 ml per second or less and a 30 to 80 cc prostate were randomized 2:1 between the prostatic urethral lift and sham treatment. The prostatic urethral lift is performed by placing permanent transprostatic implants to lift apart the prostate lobes and reduce urethral obstruction. Sham treatment entailed rigid cystoscopy, a blinding screen and sounds that mimicked those of the prostatic urethral lift procedure. Patients were assessed for lower urinary tract symptoms, peak flow rate, quality of life and sexual function.

RESULTS

The prostatic urethral lift reduced the AUA-SI 88% more than sham treatment (-11.1 vs -5.9, p = 0.003). Patients with the prostatic urethral lift experienced an AUA-SI reduction from 22.1 at baseline to 18.0 (-17%), 11.1 (-50%), 11.4 (-48%) and 12.5 (-42%) at 2 weeks, 3 months, and 1 and 2 years, respectively (p <0.0001). The peak flow rate was increased 4.2 ml per second at 3 months and 2 years (p <0.0001). By 2 years only 7.5% of patients required additional intervention for lower urinary tract symptoms. Adverse events were typically mild and transient. Encrustation did not develop on implants properly placed in the prostate. There was no occurrence of de novo sustained ejaculatory or erectile dysfunction.

CONCLUSIONS

The prostatic urethral lift preserves sexual function and provides rapid improvement in symptoms, flow and quality of life that are sustained to 2 years.

Retrograde ureteroscopic endopyelotomy using the holmium:YAG laser

PURPOSE

We defined the safety and efficacy of retrograde ureteroscopic endopyelotomy using the holmium:YAG laser.

METHODS AND MATERIALS

Between July 1996 and December 1999 a total of 28 renal units in 21 women and 6 men 7 to 75 years old (mean age 43.5) with ureteropelvic junction obstruction were treated at our institution with retrograde ureteroscopic endopyelotomy. Ureteropelvic junction obstruction was bilateral in 1 case, primary in 20 and secondary in 8. Endoluminal ultrasound was done before endopyelotomy in all cases. Patients with renal calculi underwent antegrade percutaneous nephrostolithotomy and traditional cold knife endopyelotomy. Endoluminal ultrasound revealed posterior and lateral crossing vessels in 5 patients, who did not undergo the endoscopic approach. Retrograde endopyelotomy was performed using the holmium:YAG laser in 23 cases and electrode incision with pure cutting current in 5. Postoperatively a ureteral stent remained indwelling for an average of 6 weeks. Thereafter patients were followed with serial ultrasound, excretory urography and renal scan at 3 to 6-month intervals.

RESULTS

We evaluated 28 upper urinary tracts, including 19 (67.9%) with high insertion ureteropelvic junction obstruction and 9 with an annular stricture. As directed by ultrasound images, the incision location was posterolateral, posterior, lateral and posteromedial in 16, 5, 4 and 3 cases, respectively. Followup was available in all cases at a mean of 10 months (range 3 to 35). Success, defined as improved drainage on radiographic study and absent clinical symptoms, was achieved in 19 of the 23 patients (83%) treated with the holmium:YAG laser. Repeat laser incision resulted in a successful outcome in 2 of the 4 treatment failures. There were no acute surgical complications.

CONCLUSIONS

Retrograde ureteroscopic endopyelotomy with the holmium:YAG laser is safe and minimally invasive therapy for primary and secondary ureteropelvic junction obstruction. Endoluminal ultrasound aids in decision making when retrograde endopyelotomy is done.

Urodynamic findings in adults with the tethered cord syndrome

PURPOSE

We evaluated bladder function in adults with the tethered cord syndrome using multichannel urodynamics.

MATERIALS AND METHODS

A total of 21 patients a mean 39.6 years old (range 20 to 62) with a tethered cord were evaluated. Of the patients 13 were diagnosed with a tethered cord as an adult and 8 had undergone previous spinal surgery. The tethered cord syndrome was diagnosed by magnetic resonance imaging in 20 patients and computerized tomography myelogram in 1. All patients underwent complete neurological and urological evaluation, including multichannel urodynamics. Needle electromyography and video urodynamics were performed in select cases. Microsurgical release of the tethered cord was performed in 19 patients and 2 refused surgery. Urodynamics were done before surgery in 16 of 19 patients and a median of 12.5 months (range 1 to 40) after surgery in 14. In addition, intraoperative urodynamic monitoring and nerve root stimulation were done in 14 patients to prevent nerve root injury at surgery.

RESULTS

At presentation urgency (67%) and urge incontinence (50%) were the most common findings in 18 patients with urinary symptoms. Pretreatment urodynamics in 18 of 21 patients revealed hyperreflexia in 13 (72%), external detrusor-sphincter dyssynergia in 4 (22%), decreased sensation in 4 (22%), decreased compliance in 3 (17%) and hypocontractile detrusor in 2 (11%). Postoperative urodynamic findings were improved in 4 patients (29%) and unchanged in 10 (71%). Preoperative external detrusor-sphincter dyssynergia in 4 patients resolved postoperatively in 3 and was unchanged in 1. Urinary symptoms were improved in 19% of patients (4), unchanged in 76% (16) and worse in 5% (1). To date 7 patients require anticholinergics, 4 require clean intermittent catheterization and 1 is taking an alpha-blocker.

CONCLUSIONS

Adults with the tethered cord syndrome are less likely to have urodynamic or symptom improvement after cord release and most often present with irreversible findings which rarely become worse after surgery. These patients need to have careful and continuous followup, including urodynamic studies, due to possible re-tethering with time.