Supported progressive resistance exercise training to counter the adverse side effects of robot-assisted radical prostatectomy: a randomised controlled trial

PURPOSE

To investigate the effects of a supported home-based progressive resistance exercise training (RET) programme on indices of cardiovascular health, muscular strength and health-related quality of life (HR-QoL) in prostate cancer (PCa) patients after treatment with robot-assisted radical prostatectomy (RARP).

METHODS

This study was a single-site, two-arm randomised controlled trial, with 40 participants randomised to either the intervention or control group over a 10-month period. In addition to receiving usual care, the intervention group completed three weekly RET sessions using resistance bands for 6 months. Participants performed 3 sets of 12-15 repetitions for each exercise, targeting each major muscle group. The control group received usual care only. Brachial artery flow-mediated dilatation (FMD) was the primary outcome and assessed at baseline, 3 and 6 months. Secondary outcomes included body weight, body fat, aerobic fitness, strength and blood-borne biomarkers associated with cardiometabolic risk.

RESULTS

There was no significant difference between the groups in FMD at 3 or 6 months. However, there were improvements in aerobic exercise capacity (P < 0.01) and upper- (P < 0.01) and lower-limb (P = 0.01) strength in favour of the RET group at 6 months, accompanied by greater weight loss (P = 0.04) and a reduction in body fat (P = 0.02). Improvements in HRQoL were evident in the RET group at 3 and 6 months via the PCa-specific component of the FACT-P questionnaire (both P < 0.01). Five adverse events and one serious adverse event were reported throughout the trial duration.

CONCLUSION

This study demonstrates that home-based RET is an effective and safe mode of exercise that elicits beneficial effects on aerobic exercise capacity, muscular strength and HR-QoL in men who have undergone RARP.

TRIAL REGISTRATION

ISRCTN10490647.

Cross-sectional study of patient-reported fatigue, physical activity and cardiovascular status in men after robotic-assisted radical prostatectomy

Purpose

Patient-reported fatigue after robotic-assisted radical prostatectomy (RARP) has not been characterised to date. Fatigue after other prostate cancer (PCa) treatments is known to impact on patient-reported quality of life. The aim of this study was to characterise fatigue, physical activity levels and cardiovascular status post-RARP.

Methods

Between October 2016 and March 2017, men post-RARP or on androgen deprivation therapy (ADT) were invited into the study. Participants were asked to complete the Brief Fatigue Inventory (BFI) and Stage of Change and Scottish Physical Activity Questionnaires (SPAQ) over a 2-week period. Outcome measures were patient-reported fatigue, physical activity levels and the 10-year risk of cardiovascular disease (Q-Risk). Data were analysed in SPSS.

Results

96/117 (82%) men approached consented to participate; of these, 62/96 (65%) returned complete questionnaire data (RARP n = 42, ADT n = 20). All men reported fatigue with 9/42 (21%) post-RARP reporting clinically significant fatigue. Physical activity did not correlate with fatigue. On average, both groups were overweight (BMI 27.0 ± 3.9 kg/m² and 27.8 ± 12.3 kg/m² for RARP and ADT, respectively) and the post-RARP group had an 18.1% ± 7.4% Q-Risk2 score.

Conclusions

A proportion of men is at increased risk of cardiovascular disease within 10 years post-RARP and have substantial levels of fatigue; therefore, clinicians should consider including these factors when counselling patients about RARP. Additionally, men post-RARP did not meet the recommended guidelines for resistance-based exercise. Future research is needed to establish whether interventions including resistance-based exercise can improve health and fatigue levels in this population.

Oral ciprofloxacin or trimethoprim reduces bacteriuria after flexible cystoscopy

OBJECTIVE

To report a large prospective, pragmatic, double-blind randomized controlled trial to determine whether oral prophylactic antibiotics reduce the risk of bacteriuria after flexible cystoscopy (FC), as up to 10% of patients develop urinary infection afterwards, with significant morbidity and costs for health services.

PATIENTS AND METHODS

In all, 2481 patients were recruited into a three-arm placebo controlled trial and 2083 completed it. Patients were randomly assigned to one of three treatments; (i) placebo; (ii) one oral dose of trimethoprim (200 mg); or (iii) one oral dose of ciprofloxacin (500 mg), each administered 1 h before a FC under local anaesthetic. A mid-stream urine specimen was taken before and 5 days after FC; significant bacteriuria was defined as a pure growth of >10(5) colony-forming units/mL.

RESULTS

The rate of bacteriuria after FC was reduced from 9% in the placebo group to 5% and 3% in patients receiving trimethoprim and ciprofloxacin prophylaxis, respectively. When rates of bacteriuria before FC were considered the odds of developing bacteriuria after FC relative to baseline were 5, 2 and 0.5 for placebo, trimethoprim and ciprofloxacin, respectively.

CONCLUSION

This large trial shows clearly that one dose of oral ciprofloxacin significantly reduces bacteriuria after FC.

A NOMOGRAM TO CLASSIFY MEN WITH LOWER URINARY TRACT SYMPTOMS USING URINE FLOW AND NONINVASIVE MEASUREMENT OF BLADDER PRESSURE

PURPOSE

Bladder pressure during voiding can be estimated by a noninvasive technique using controlled inflation of a penile cuff. This test provides a valid and reliable estimate of isovolumetric bladder pressure but to our knowledge the role of the test for the routine clinical treatment of patients with lower urinary tract symptoms (LUTS) has yet to be demonstrated. As a first step, we evaluated a proposed nomogram for the diagnosis of bladder outlet obstruction in men with LUTS using noninvasive measurements of pressure and flow.

MATERIALS AND METHODS

Using a combination of theoretical calculation and experimental data the existing International Continence Society pressure flow nomogram was modified to allow noninvasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the nomogram for classifying obstruction was then tested in a group of 144 men with LUTS who underwent an invasive and a noninvasive pressure flow study.

RESULTS

The modified nomogram identified men with obstruction with 68% positive predictive value and 78% negative predictive value. Predictive accuracy could be improved by adding an additional criterion of obstruction, that is maximum urine flow less than 10 ml second, whereby an identifiable 69% of all cases could be classified as obstructed (88% positive predictive value) or not obstructed (86% negative predictive value). In the remaining 31% of patients invasive pressure flow studies would provide additional information, although some results would remain equivocal.

CONCLUSIONS

The proposed nomogram combined with the additional flow rate criterion can classify more than two-thirds of cases without recourse to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the treatment of men with LUTS.

NONINVASIVE ASSESSMENT OF BLADDER CONTRACTILITY IN MEN

PURPOSE

Preoperative assessment of detrusor function by pressure flow study (PFS) improves outcome from prostatectomy but is invasive and uncomfortable for the patient. We report on a large scale validation of a novel noninvasive assessment of detrusor contractility.

MATERIALS AND METHODS

A flexible cuff placed around the penis was inflated automatically during voiding until flow interruption. Cuff pressure at interruption (pcuff.int) reflects isovolumetric bladder pressure (pves.isv), a measure of detrusor contractility. For comparison 151 symptomatic men performed the cuff test with simultaneous PFS monitoring. Test/retest agreement was assessed in 91 subjects who performed a cuff test without PFS on 2 occasions.

RESULTS

For the 117 (77%) subjects with an acceptable cuff pressure flow trace, Bland Altman analysis showed that pcuff.int overestimated pves.isv by a mean (s.d.) of 16.4 (27.5) cm H2O, predominantly due to the cuff being positioned below the bladder. For test/retest analysis 52 (57%) of the men who were able to attend twice provided acceptable cuff data on both occasions with a mean (s.d.) difference in pcuff.int of -3.3 (32.0) cm H2O, improving to 0.0 (20.3) cm H2O in a subgroup of 39 subjects who voided more than 150 ml. On questionnaire assessment 121 (80%) subjects preferred the cuff test to PFS.

CONCLUSIONS

The cuff test gives a valid and reproducible estimate of isovolumetric bladder pressure in a manner acceptable to patients, although test failure and variability of agreement require improvement. The test may be of value in the assessment of urinary symptoms and may aid in patient selection for prostatectomy.

Inter-observer agreement in the estimation of bladder pressure using a penile cuff

AIMS

Objective data are useful in quantifying a patient's lower urinary tract symptoms (LUTS). We are investigating the use of an inflatable penile cuff to obstruct flow progressively during voiding, and thereby determine the pressure p(cuff,int) at which flow is interrupted. The aim of this study was to determine the agreement between experienced observers in their estimates of p(cuff,int).

METHODS

We recorded 486 cuff inflation cycles during 142 voids from 42 subjects recruited from urology out-patient's and prostate assessment clinics. Each inflation cycle was assessed independently by three experienced observers, a total of 1,458 ratings. According to our standard assessment procedure, the observers (i) indicated whether the inflation should be analyzed, (ii) estimated p(cuff,int) for those inflation cycles judged suitable for analysis, and (iii) discarded measurements that were clearly inconsistent with others from the same voiding cycle.

RESULTS

Overall, 689 of the 1,458 ratings (45%) were excluded, with just 4% of all ratings discarded for inconsistency. For 385 of the 486 inflation cycles (79%) there was complete agreement that the cycle should or should not be analyzed. Thereafter, for the 262 inflation cycles analyzed by two or three observers, the overall SD error in measurements of p(cuff,int) was 4.6 cm H(2)O.

CONCLUSIONS

We conclude that there is good agreement between experienced observers in their interpretation of data from the cuff test. For practical purposes, there is no need for multiple observers in the clinical application of the cuff method.

Noninvasive measurement of bladder pressure. Does mechanical interruption of the urinary stream inhibit detrusor contraction?

PURPOSE

As part of developing a noninvasive method to measure bladder pressure using an inflatable penile cuff, we tested the hypothesis that detrusor contraction is maintained without inhibition during the test.

MATERIALS AND METHODS

Five healthy volunteers and 26 male patients with lower urinary tract symptoms underwent interruption of established urine flow by controlled inflation of a cuff placed around the penis with simultaneous invasive bladder pressure monitoring. After interruption of flow the cuff was rapidly deflated and voiding was allowed to resume. The bladder pressure was recorded before, during and after interruption of flow by cuff inflation.

RESULTS

During flow interruption an isovolumetric increase in detrusor pressure was observed. When the cuff was deflated the detrusor pressure quickly returned to preinflation values and urine flow immediately resumed. Intra-abdominal pressure did not change during the cuff inflation cycle.

CONCLUSIONS

Mechanical interruption of urine flow by controlled inflation of a penile cuff during voiding does not inhibit detrusor contraction. This finding further validates our noninvasive technique of bladder pressure measurement and supports ongoing studies into its clinical usefulness.

Transcutaneous electrical nerve stimulation and temporary S3 neuromodulation in idiopathic detrusor instability

PURPOSE

We studied the effects of electrical stimulation on idiopathic detrusor instability.

MATERIALS AND METHODS

Between January 1993 and December 1994, 30 men and 41 women (mean age plus or minus standard deviation 48 +/- 16 years) underwent transcutaneous electrical nerve stimulation (TENS) of the S2-S3 dermatomes, and 13 men and 22 women (mean age 48 +/- 12 years) underwent S3 neuromodulation. Subjective assessment was performed using a diary and symptom score of 0 to 14. Objective outcome was analyzed with urodynamic studies.

RESULTS

Mean duration of TENS was 3 +/- 1 weeks (range 2 to 4). Although there were no major complications 31% of the patients reported local skin irritation. The overall urinary symptom scores improved from 10 +/- 2 (range 5 to 14) before the study to 7 +/- 3 (range 1 to 14) during stimulation. Urodynamic analysis revealed significant (p < 0.05) improvements in total bladder capacity and voided volume, and decreases in the number and frequency of unstable contractions. Mean duration of S3 neuromodulation was 6 +/- 1 days (range 4 to 8 days). Four procedures failed due to electrode displacement in 3 cases and procedure intolerance in 1. Hemorrhage from the puncture site occurred in 1 patient. Overall urinary symptom scores were 10 +/- 3 (range 5 to 14) before the study and 5 +/- 2 (range 2 to 10) during stimulation. Although symptomatic relief was more pronounced with S3 neuromodulation, no statistically significant differences were found regarding urinary symptoms compared to TENS.

CONCLUSIONS

In patients with severe detrusor instability refractory to conservative treatments the use of TENS and S3 neuromodulation produced significant changes in urodynamic parameters and presenting symptoms. Our results appear to justify evaluation with neuromodulatory techniques before definitive surgical intervention in these patients.

Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction

OBJECTIVE

To study the long-term outcome of patients undergoing enterocystoplasty.

PATIENTS AND METHODS

The study comprised 48 patients (17 men and 31 women; mean age 46 years) who underwent enterocystoplasty for idiopathic detrusor instability (DI, 35 patients) or neurogenic bladder dysfunction (13 patients). Symptoms were scored from 0 to 14 and the overall outcome and generic quality of life were assessed using a Visick grading system (groups A to E) and the Nottingham Health Profile (NHP). These assessments were carried out before, 3 months after operation and at the final follow-up (38 +/- 18 months, range 13-78). Urodynamic studies were performed before and after operation.

RESULTS

No patient died after operation and there was minimal early morbidity. Late complications (> 30 days) included incisional hernia (3), anastomotic perforation (1), calculus formation (1) and urethral stricture (1). Clean intermittent self-catheterization (CISC) was performed by 36 (75%) patients. Early symptomatic outcome was good in 40 (83%) patients, moderate in seven (15%) and unsatisfactory in one (2%) patient. The mean symptom scores before and 3 months after surgery were 10 (range 2-14) and 3 (range 2-14), respectively (P < 0.001). There was a significant increase in total bladder capacity (307 +/- 140 to 588 +/- 217 mL; P < 0.001) and bladder compliance (37 +/- 50 to 169 +/- 162 mL/cm H2O; P < 0.001). DI persisted in 15 (31%) patients. NHP scores revealed significant improvements in all domains. Final assessment showed a less satisfactory situation, with recurrent urinary tract infection (UTI) in 17 (37%) patients, a need for long-term antibiotic therapy in seven (15%) and a change in bowel habit in 15 (33%) (13 DI, two with neurogenic bladder dysfunction). CISC was performed by 39 (85%) patients. The long-term outcome was good or moderate in 12 patients (92%) with neurogenic bladder dysfunction and good or moderate in only 19 patients (58%) with DI.

CONCLUSION

Clam enterocystoplasty remains an effective management option in some patients with DI, but most patients with neurogenic bladder dysfunction do well. The procedure is, however, associated with long-term complications such as disturbance of bowel habit and recurrent UTIs, which impair the outcome in the long-term in patients with DI despite general improvements in irritative bladder symptoms.

Outcome of endoscopic bladder transection

OBJECTIVE

To determine the clinical, symptomatic and objective urodynamic outcome of patients undergoing endoscopic bladder transection.

PATIENTS AND METHODS

The study included 20 men and 30 women (mean age of 50 +/- 15 years, range 20-86) who underwent endoscopic bladder transection. Their underlying diagnoses were idiopathic detrusor instability (41), enuresis with instability (6), multiple sclerosis (2) and Parkinson's disease (1). A full-thickness endoscopic transection of the bladder was performed under general anaesthesia. Subjective assessment was performed using symptom scores (0-14 points) and a Visick grading system (group A-E). Objective assessment was carried out using urodynamic studies. The mean follow-up period was 6 years (57 +/- 22 months, range 6-85).

RESULTS

The mean hospital stay was 8 +/- 3 days (range 3-22). No patients died after the operation. Postoperative complications included extra-peritoneal extravasation (2), recurrent urinary tract infection (5) and urethral stricture (1). Symptom scores before and after the operation were 9 +/- 2 (range 4-14) and 8 +/- 3 (range 1-14) points respectively. The overall outcome of the procedure was satisfactory in only eight (16%) patients. The mean duration of symptomatic relief was 17 weeks (range 3-53). There was no significant difference between urodynamic results before and after the operation. Bladder instability observed in all patients before operating was demonstrated in 93% of patients after the operation.

CONCLUSION

The results of our study suggests that endoscopic bladder transection produces only a transient symptomatic relief in a few of those patients who have failed to respond to pharmacological manipulations. We do not feel that its continued role is justified.

Effect of DDE, DDT and calcium on the performance of adult Japanese quail (Coturnix coturnix japonica)

Two experiments were conducted to determine the effects of DDE, DDT and calcium on performance of quail. The quail received diets containing 0 or 100 p.p.m. of DDE for eight 28-day periods in Exp. 1 and 0, 100 or 300 p.p.m. of DDE or 100 p.p.m of DDT for six periods in Exp. 2. Diets containing either 0.5 or 3% calcium were used with each pesticide level. No differences in egg shell thickness, cracked eggs, egg production, feed consumption, egg weights, female body weights, fertility or hatchability were obtained from DDE or DDT up to 100 p.p.m. Three hundred p.p.m. of DDE did result in a decrease in female body weights and in fertility on the low calcium diet. Egg shell thickness, cracked eggs, egg production and hatchability were affected by the lower calcium level. Male body weights were adversely affected from 100 p.p.m. or more of DDE. Mortality increased as the level of DDE increased for females, while no effect was observed with DDT. Males appeared more sensitive to 100 p.p.m. of DDE in Exp. 1 and 300 p.p.m of DDE and 100 p.p.m. of DDT in Exp. 2. Livability and growth of chicks from hens receiving rations containing DDE AND DDT were unaffected by maternal treatment. In summary, DDE and DDT were without effect on egg shell quality or most other reproductive factors, but DDE at 300 p.p.m. did exert a detrimental effect on adult body weights, fertility and mortality.