Active Compared With Passive Voiding Trials After Midurethral Sling Surgery: A Systematic Review

OBJECTIVE

To compare active with passive voiding trials on the rate of passing a trial of void and discharge rates with catheter in women who have undergone midurethral sling for treatment of stress urinary incontinence (SUI).

DATA SOURCES

MEDLINE, EMBASE, and ClinicalTrials.gov were searched through February 24, 2023.

METHODS OF STUDY SELECTION

Our population included women undergoing midurethral sling, with or without anterior or posterior repair, for treatment of SUI. Our two primary outcomes were rate of passing voiding trial and rate of discharge with a catheter. Our secondary outcome was the rate of delayed postoperative urinary retention, when a patient initially passes a trial of void but then subsequently presents in retention.

TABULATION, INTEGRATION, AND RESULTS

Abstracts were doubly screened; full-text articles were doubly screened; and accepted articles were doubly extracted. In single-arm studies evaluating either passive or active voiding trial, random-effects meta-analyses of pooled proportions were used to assess outcomes. Of 3,033 abstracts screened, 238 full-text articles were assessed, and 26 met inclusion criteria. Ten studies including 1,370 patients reported active trial of void. Sixteen studies including 3,643 patients reported passive trial of void. We included five randomized controlled trials, five comparative retrospective studies, five prospective single group studies, and 11 retrospective single group studies. Five of the studies included patients with a concomitant anterior or posterior colporrhaphy. On proportional meta-analysis, the active trial of void group was less likely to pass the voiding trial (81.0%, 95% CI, 0.76-0.87% vs 89.0%, 95% CI, 0.84-0.9%3, P =.029) with high heterogeneity ( I2 =93.0%). Furthermore, there were more discharges with catheter in active trial of void compared with passive trial of void (19.0%, 95% CI, 0.14-0.24% vs 7.0%, 95% CI, 0.05-0.10%, P <.01). The rates of delayed postoperative urinary retention were low and not different between groups (0.6%, 95% CI, 0.00-0.02% vs 0.2%, 95% CI, 0.00-0.01%, P =.366) with low heterogeneity ( I2 =0%). Sling revisions were statistically lower in the active trial of void group (0.5%, 95% CI, 0.00-0.01% vs 1.5%, 95% CI, 0.01-0.02%, P =.035) with low heterogeneity ( I2 =10.4%).

CONCLUSION

Passive trial of void had higher passing rates and lower discharge with catheter than active trial of void. Rates of most complications were low and similar between both groups, although passive trial of void had higher sling revisions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022341318.

Safety and efficacy of an α1 -blocker plus mirabegron compared with an α1 -blocker plus antimuscarinic in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia and overactive bladder: A systematic review and network meta-analysis

AIM

Antimuscarinics and the β3-adrenoreceptor agonist, mirabegron, are commonly used for treating patients with overactive bladder (OAB) and α1 -adrenoreceptor antagonists (α1 -blockers) are the main pharmacological agents used for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). As these conditions commonly occur together, the aim of this systematic review was to identify publications that compared the use of an α1 -blocker plus mirabegron with an α1 -blocker plus antimuscarinic in men with LUTS secondary to BPH and OAB. A meta-analysis was subsequently conducted to explore the safety and efficacy of these combinations.

METHODS

Included records had to be from a parallel-group, randomized clinical trial that was ≥8 weeks in duration. Participants were male with LUTS secondary to BPH and OAB. The indirect analyses that were identified compared an α1 -blocker plus OAB agent with an α1 -blocker plus placebo. The PubMed/Medical Literature Analysis and Retrieval System Online, the Excerpta Medica Database, the Cochrane Central Register of Controlled Trials, and the ClinicalTrials.gov registry were searched for relevant records up until March 5, 2020. Safety outcomes included incidences of overall treatment-emergent adverse events (TEAEs) and urinary retention, postvoid residual volume, and maximum urinary flow (Qmax ). Primary efficacy outcomes were micturitions/day, incontinence episodes/day, and urgency episodes/day, and secondary outcomes were Overactive Bladder Symptom Score and International Prostate Symptom Score. A Bayesian network meta-analysis approach was used for the meta-analysis.

RESULTS

Out of a total of 1039 records identified, 24 were eligible for inclusion in the meta-analysis. There were no statistically significant differences between the α1 -blocker plus mirabegron and α1 -blocker plus antimuscarinic groups in terms of the comparisons identified for all the safety and efficacy analyses conducted. Numerically superior results were frequently observed for the α1 -blocker plus mirabegron group compared with the α1 -blocker plus antimuscarinic group for the safety parameters, including TEAEs, urinary retention, and Qmax . For some of the efficacy parameters, most notably micturitions/day, numerically superior results were noted for the α1 -blocker plus antimuscarinic group. Inconsistency in reporting and study variability were noted in the included records, which hindered data interpretation.

CONCLUSION

This systematic review and meta-analysis showed that an α1 -blocker plus mirabegron and an α1 -blocker plus antimuscarinic have similar safety and efficacy profiles in male patients with LUTS secondary to BPH and OAB. Patients may, therefore, benefit from the use of either combination within the clinical setting.

Reconstruction of Urethral Sphincter With Polyacrylamide Hydrogel

IMPORTANCE

Urethral bulking is an alternative to synthetic midurethral sling for the treatment of stress urinary incontinence (SUI) in women. Urethral bulking agents, which are injected in the submucosal tissues of the proximal urethra/bladder neck, have demonstrated less adverse effects with similar satisfaction rates but lower subjective and objective cure rates when compared with midurethral sling. Cystoscopic Reconstruction of External Sphincter Technique (CREST) is a novel technique, which reinforces the natural closure mechanism of the external urinary sphincter (EUS).

OBJECTIVE

The aim of the study was to provide safety and efficacy data for injecting polyacrylamide hydrogel (PAHG) in the components of the female EUS.

STUDY DESIGN

This was a retrospective chart review of patients using CREST with PAHG as initial treatment for SUI by a single surgeon from January 2022 to October 2022. Exclusion criteria are as follows: younger than 18 years, prior SUI surgery, concomitant pelvic organ prolapse or reconstructive procedure, neurological conditions, or history of radiation. Subjective and objective cure rates were measured by patient-reported symptoms and cough stress test. Urinary retention, postoperative urinary infection, and de novo urinary urgency were assessed.

RESULTS

One hundred and thirteen consecutive patients met inclusion criteria with median follow-up of 3 months. Eighty-five percent of participants reported subjective improvement, 69% reported subjective cure, and 69% demonstrated objective cure. Nine patients reported transient postoperative retention, 8 reported postoperative urinary tract infections, and 5 reported de novo urgency. There were no serious adverse events.

CONCLUSIONS

CREST is a novel technique for injection of PAHG, into the EUS to treat SUI. Our data suggest that this technique could improve urethral injection outcomes with minimal complications.

Assessment of Analgesic Efficacy of Bilateral Lumbar Erector Spinae Plane Block for Postoperative Pain following Lumbar Laminectomy: A Single-Blind, Randomized Clinical Trial

Background

The erector spinae plane (ESP) block is a novel approach to minimizing postoperative pain. We investigated the efficacy and side effects of the ultrasonography-guided bilateral ESP block in reducing pain in the first 24 hours after lumbar laminectomy.

Materials and Methods

We conducted a single-blind (statistical analyst and those responsible for recording patient information postoperation were unaware of the study groups) randomized clinical trial on 50 patients aged 18 to 65 with American Society of Anesthesiology (ASA) class I or II physical status scheduled for lumbar laminectomy surgery at Shahid Chamran Hospital, Shiraz, Iran. Patients were randomly allocated to the ESP block (26 participants) or control (24 participants) group. A bilateral ESP block was administered to patients in the first group before general anesthesia, which was provided identically to both groups. The postoperative time to the first request of analgesia, pain score, total opioid use, side effects, and patient satisfaction were compared between the groups.

Results

Compared with the control group, patients in the ESP block group had significantly more postoperative pain relief in the first hour and until 24 hours (P < 0.05). The total opioid consumption was lower in the ESP block group (P < 0.001). However, the ESP block led to a higher rate of urinary retention (P = 0.008).

Conclusion

The bilateral ESP block effectively reduces postoperative pain following lumbar laminectomy, minimizing the need for narcotics. Further research is needed to delineate ways to reduce urinary retention as its main complication. This trial is registered with IRCT20100127003213N6.

Systemic sarcoidosis presenting as a rare combination of interstitial nephritis with necrotizing vasculitis and urinary retention due to prostate involvement: a case report

BACKGROUND

Sarcoidosis affects multiple organs and exhibits diverse clinical manifestations. Although tubulointerstitial nephritis is a known feature of renal involvement, necrotizing vasculitis is rare. Furthermore, prostate involvement with urinary retention is unusual in patients with sarcoidosis. Here, we report a case of systemic sarcoidosis with a rare combination of manifestations and different acute kidney injuries.

CASE PRESENTATION

A 66-year-old man developed sudden urinary retention and fever. He was diagnosed with prostatitis and admitted to our hospital. An indwelling urethral catheter was inserted, and antimicrobial therapy was initiated; however, the prostatitis was refractory. Computed tomography revealed enlarged mediastinal lymph nodes. Analysis of transbronchoscopic lymph node and prostate biopsies showed epithelioid cell granulomas, suggesting systemic sarcoidosis. During the clinical course, the serum creatinine level rapidly increased to 2.36 mg/dL without oliguria. A kidney biopsy revealed tubulointerstitial injury with moderate lymphohistiocytic infiltration and small-vessel vasculitis in the interstitium. Following oral administration of 60 mg/day prednisolone, the patient's renal function immediately improved, and urinary retention did not recur.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of sarcoidosis with two unusual complications. Given its clinical course and pathology, this case is clinically valuable.

Comparison of Monotherapies and Combination Therapy of Tamsulosin and Tadalafil for Treating Lower Urinary Tract Symptoms Caused by Benign Prostatic Hyperplasia with or without Erectile Dysfunction: A Meta-Analysis

BACKGROUND

There is limited research into the efficacy and safety of tadalafil combined with tamsulosin for the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH), with or without erectile dysfunction (ED). Therefore, we aimed to investigate the efficacy and safety of combination therapy compared to that of monotherapy.

METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science, SinoMed, CNKI, WanFang Data Service Platform, and ClinicalTrials.gov to identify eligible studies. A total of 639 articles were retrieved, of which 12 were randomized controlled trials (RCTs) published as of February 2023 and included in this meta-analysis.

RESULTS

After screening 639 articles, 12 RCTs including 1,531 subjects were considered eligible for the meta-analysis. The results showed that the total International Prostate System Score (total IPSS), maximum flow rate (Qmax), and quality of life (QoL) in tadalafil combined with tamsulosin were significantly better than those in monotherapy. Compared with tadalafil monotherapy, combination therapy mainly improved IPSS voiding. As for postvoid residual urine (PVR), the combination therapy did not improve PVR compared to the tadalafil group, but significantly improved PVR compared to the tamsulosin group. For the International Index of Erectile Function (IIEF), the curative effect of the combined group was better than that of the tamsulosin group but not better than that of the tadalafil group. In terms of safety, the adverse reactions (AEs) in the combined treatment group were significantly higher than those in the monotherapy group. None of the 12 RCTs reported serious adverse events.

CONCLUSIONS

Tadalafil combined with tamsulosin was more effective in the treatment of male LUTS/BPH, with or without ED, on the improvement of total IPSS, QoL, and Qmax. However, the benefits of combination therapy for ED remain unclear. However, combination therapy seemed to have a higher incidence of adverse reactions.

[A multicenter study to test the reliability and validity of the frailty assessment scale for elderly patients with inguinal hernia and to evaluate the value of clinical application]

Objectives: To verify the reliability and validity of the frailty assessment scale for elderly patients with inguinal hernia and to evaluate the value of its clinical application. Methods: A convenience sampling method was used to collect 129 geriatric patients who underwent inguinal hernia surgery from January 2018 to January 2023 in nine hospitals in Liaoning Province. There were 120 males and 9 females, of whom 89 patients were 60 to <75 years old, 33 patients were 75 to <85 years old and 7 patients were ≥85 years old. The 129 patients included 11 elderly patients with inguinal hernia who had recovered from preoperative infection with COVID-19. Statistical methods such as Cronbach's coefficient, Kaiser-Meyer-Olkin test, Bartlett's test, Pearson's correlation analysis, etc. were calculated to verify the reliability indexes such as feasibility, content validity, structural validity, criterion-related validity, internal consistency reliability, and re-test reliability. Taking the 5-item modified frailty index (5-mFI) as the gold standard, the area under the curve was used to analyze the ability of the two scales to predict the occurrence of postoperative acute urinary retention, postoperative delirium, poor incision healing, operative hematoma seroma, and postoperative complications. Results: The frailty assessment scale for elderly patients with inguinal hernia showed good reliability and validity (valid completion rate of 99.2%; item content validity index of 1.000, and the scale content validity index of 1.000; exploratory factor analysis extracted a total of 1 principal component, and factor loadings of each item of 0.565 to 0.873; the AUC for frailty diagnosis using 5-mFI as the gold standard of 0.795 (P<0.01) Cronbach's coefficient of 0.916, retest reliability coefficient of 0.926), it could effectively predict postoperative acute urinary retention, delirium, hematoma seroma in the operative area and total complications (AUC of 0.746, 0.870, 0.806, and 0.738, respectively; all P<0.05), and prediction efficiency was higher than that of 5-mFI (AUC of 0.694, 0.838, 0.626 and 0.641, P<0.05 for delirium only), but both scales were inaccurate in predicting poor incision healing (AUC of 0.519, P=0.913 for the frailty assessment scale and 0.455, P=0.791 for the 5-mFI). Conclusions: The frailty assessment scale for elderly patients with inguinal hernia is reliable and significantly predicts the occurrence of postoperative adverse events in elderly inguinal hernia patients. The scale can also be used for preoperative frailty assessment in elderly patients with inguinal hernia after rehabilitation from COVID-19 infection.

Impact on urinary incontinence after management of complications related to a retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

The most common complications to midurethral sling (MUS) operations for stress urinary incontinence are postoperative urinary retention (POUR), vaginal MUS exposure, and urgency. They are well described but consensus regarding their management is missing. An evaluation of the treatment of POUR, exposure and urgency after the MUS procedure in our department was implemented. Incontinence status after treatment of complications was evaluated.

METHODS

A review of the medical records of women undergoing MUS procedures from 1 January 2017 to 31 December 2021 (n = 329).

RESULTS

A total of 279 women (85%) had no complications. Fifty women had one or more complications. Twenty-three women (7%) experienced POUR. Final treatment in 9 women was clean intermittent self-catheterization (CISC). All remained continent. Nine women had the MUS mobilized. This was successful in 8 women who remained continent. Six women had their MUS incised (one after unsuccessful mobilization). Four became incontinent again and 2 remained continent. Eight women had vaginal MUS exposure. Seven attempted recovering of the MUS. This was successful in 3 patients. The remaining had a partial MUS removal. Only 33% remained continent after removal. Ten patients developed de novo urge, but only 2 needed medication.

CONCLUSIONS

Mobilization of the MUS must be considered the optimal treatment for POUR when CISC fails. It is the most effective intervention with the best effect on POUR and the lowest risk of incontinence. Concerning vaginal exposure, a trial of recovering should be attempted as the risk of incontinence when undergoing a partial removal of the MUS is considerable.

Benefits and Harms of Benign Prostatic Obstruction Treatments in Renal Transplanted Patients

CONTEXT

In an increasingly ageing transplant population, timely management of benign prostatic obstruction (BPO) is key to preventing complications that result in graft dysfunction or compromise survival.

OBJECTIVE

To evaluate benefits/harms of BPO treatments in transplant patients by reviewing current literature.

EVIDENCE ACQUISITION

A computerised bibliographic search of Medline, Embase, and Cochrane databases was performed for studies reporting outcomes on BPO treatments in transplanted patients.

EVIDENCE SYNTHESIS

A total of 5021 renal transplants (RTs) performed between 1990 and 2016 were evaluated. BPO incidence was 1.61 per 1000 population per year. Overall, 264 men underwent intervention. The mean age was 58.4 yr (27-73 yr). In all, 169 patients underwent surgery (n = 114 transurethral resection of the prostate [TURP]/n = 55 transurethral incision of the prostate [TUIP]) and 95 were treated with an un-named alpha-blocker (n = 46) or doxazosin (n = 49). There was no correlation between prostate volume and treatment modality (mean prostate size = 26 cc in the surgical group where reported and 48 cc in the medical group). The mean follow-up was 31.2 mo (2-192 mo). The time from RT to BPO treatment was reported in six studies (mean: 15.4 mo, range: 0-156 mo). The time on dialysis before RT was recorded in only three studies (mean: 47.3 mo, range: 0-288 mo). There was a mean improvement in creatinine after intervention from 2.17 to 1.77 mg/dl. A total of 157 men showed an improvement in the International Prostate Symptom Score (from 18.26 to 6.89), and there was a significant reduction in postvoid residual volume in 199 (mean fall 90.6 ml). Flow improved by a mean of 10 ml/s following intervention in 199 patients. Complications included acute urinary retention (4.1%), urinary tract infections (8.4%), bladder neck contracture (2.2%), and urethral strictures (6.9%). The mean reoperation rate was 1.4%.

CONCLUSIONS

Current literature is heterogeneous and of low-level evidence. Despite this, alpha-blockers, TUIP, and TURP showed a beneficial increase in the peak urinary flow and reduced symptoms in transplants patients with BPO. Improvement in the mean graft creatinine was noted after intervention. Complications were under-reported. A multicentre comparative cohort study is needed to draw firm conclusions about the ideal treatment for BPO in RT patients.

PATIENT SUMMARY

In this report, we looked at the outcomes for transplant patients undergoing medical or surgical management of benign prostatic obstruction. Although the literature was very heterogeneous, we found that medical management and surgery with transurethral resection/incision of the prostate are beneficial for improving urinary flow and bothersome symptoms. We conclude that further prospective studies are required for better clarity about timing and modality of intervention in transplant patients.

The effect of prolapse surgery on voiding function

INTRODUCTION AND HYPOTHESIS

Of women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function.

METHODS

Retrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS.

RESULTS

Of 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m2, respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046).

CONCLUSIONS

Prolapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.

Evaluation of Quality of Life and Self-reported Complications in Patients With Clean Intermittent Catheterization: An Observational Study

PURPOSE

This study sought to determine health-related quality of life and self-reported complications associated with clean intermittent catheterization (CIC).

DESIGN

Observational, cross-sectional study.

SUBJECTS AND SETTING

The target population was patients cared for by the urology department at Hospital 12 de Octubre in Madrid, Spain, undergoing CIC for chronic urinary retention of any etiology (neurogenic bladder dysfunction, neobladder, and other). The sample comprised 50 respondents with a mean age of 49 years; a majority (66%, n = 33) were female. Participants performed an average of 4 CICs.

METHODS

All participants completed the ISC-Q (Intermittent Self-Catheterization Questionnaire) and a questionnaire about CIC-associated complications. Data were collected in February 2019.

RESULTS

A vast majority of respondents (98%, n = 49) indicated preparation for catheterization was simple, and 76% (n = 38) indicated the catheter was easy to insert. One in 5 (20%, n = 10) considered carrying catheters and supplies inconvenient, though 58% (n = 29) indicated it was easy to dispose of the catheters outside the home. Most respondents (98%, n = 49) indicated they felt self-conscious about their need to self-catheterize, and 16% (n = 8) felt that CIC created limitations when visiting friends and family. The most frequent complication was symptomatic urinary tract infections (UTIs); participants reported an average of 1.7 UTIs in the last year. Additional complications, such as epididymo-orchitis, urethral stenosis, and urethral bleeding, were reported by less than 5% (n = 2) of participants.

CONCLUSIONS

Participants managed by CIC for chronic urinary retention of any cause reported acceptable levels of satisfaction with the procedure. The reported incidence of complications was low, except for UTIs.

Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference?

PURPOSE

Our goal was to compare outcomes of early vs delayed transurethral surgery for benign prostatic hyperplasia after an episode of acute urinary retention compared to men without preoperative acute retention.

MATERIALS AND METHODS

We conducted a retrospective cohort analysis using data from the New York Statewide Planning and Research Cooperative System from 2002-2016. We identified men ≥40 years old who underwent primary ambulatory transurethral resection or photoselective vaporization of the prostate, assessing surgical failure as time to reoperation or recatheterization. We categorized presurgical acute urinary retention by number of episodes: none (reference), 1, or ≥2 precatheterizations, and time from first retention episode to surgery: none (reference), 0-6 months, and >6 months. We used Fine-Gray competing-risk models to predict surgical failure at 10 years, with presurgical acute retention as the primary predictor, adjusted for age, race, insurance, Charlson Comorbidity Index score, preoperative urinary infection, and procedure type, with death as the competing risk.

RESULTS

Among 17,474 patients undergoing transurethral surgery, 10% had preoperative acute retention with a median time to surgery of 2.4 months (IQR: 1-18). Among men with preoperative retention, 37% had ≥6 months of delay to surgery. The 10-year cumulative treatment failure rate was 17.2% among catheter naïve men vs 34.0% with ≥2 precatheterizations and 32.9% with ≥6 months delay to surgery. Delays from catheterization to surgery were associated with higher rates of treatment failure (<6 months SHR 1.49, P < .001; ≥6 months SHR 2.11, P < .001) vs catheter naïve men.

CONCLUSIONS

Preoperative acute urinary retention and delay to surgery once catheterized are associated with poorer long-term postoperative outcomes after surgery for benign prostatic hyperplasia.

Impact of Spinal/Epidural Anesthesia Versus General Anesthesia on Perioperative Outcomes in Patients Undergoing Lumbar Spine Surgery: An Updated Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To compare impact of different anesthesia techniques on perioperative outcomes in patients undergoing lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Both general anesthesia and spinal anesthesia/epidural anesthesia can be used for lumbar spine surgery. There is still much controversy that which anesthesia technique is much more suitable for lumbar spine surgery with less complications, general anesthesia or regional anesthesia.

METHODS

A comprehensive search of the literature was conducted using Excerpta Medica database (EMBASE), PubMed, and Cochrane library for randomized controlled trials and independent reviewers assessed eligibility for included studies. Primary outcomes included incidences of intraoperative hypertension, hypotension, tachycardia, and bradycardia. Secondary outcomes included postoperative analgesic requirement, postoperative nausea and vomiting (PONV), headache, urinary retention, blood loss, and length of hospital stay.

RESULTS

Ten randomized controlled trials consisting of 733 adult patients undergoing lumbar spine surgery were included. Spinal anesthesia/epidural anesthesia group had significant lower incidences of intraoperative hypertension [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.08-0.38; P <0.00001; I2 =0.0%] and tachycardia (OR, 0.45; 95% CI, 0.26-0.79; P =0.006; I2 =0.0%), analgesic requirement in postanesthesia care unit (OR, 0.13; 95% CI, 0.08-0.22; P <0.00001; I2 =0.0%), PONV within 24 hours after surgery (OR, 0.27; 95% CI, 0.16-0.46; P <0.00001; I2 =6.0%), and shorter length of postoperative hospital stay (mean difference, -0.28; 95% CI, -0.37 to -0.18; P <0.00001; I2 =32.0%). There were no significant differences in incidences of intraoperative hypotension and bradycardia, PONV in postanesthesia care unit, analgesic requirement, urinary retention, and headache within 24 hours after surgery.

CONCLUSIONS

Low to moderate quality of evidence revealed that patient undergoing lumbar spine surgery might benefit from spinal or epidural anesthesia.

[Complications of the 180 Watt XPS™ GreenLight laser-results of 1283 procedures]

BACKGROUND

The aim of this study was to classify and analyze postoperative complications under a new inspection method. This study assessed all patients who presented to the urologic ward within the first 3 months after their surgery.

METHODS

A total of 170 patients suffered from complications due to the surgery; 29 patients experienced complications that were not directly correlated with the surgery. Age, American Society of Anesthesiologists (ASA) score, the emitted laser energy of the 180 Watt XPS™ GreenLight laser measured in joules, and the complications which led to the renewed hospitalization such as hematuria, urinary retention, and infection were analyzed and compared in the two groups of patients.

RESULTS

Most complications that occurred were urinary retention and hematuria (50.6% and 49.4% of all patients, respectively). Of the patients with hematuria, 86.75% were under anticoagulant therapy medication.

CONCLUSION

Compared with the reference approval study (Goliath trial) that included 135 multicentric patients (14.07% of patients presented with a complication classified as Clavien-Dindo II), the rate of complications was similar. This outcome is surprising because the patients treated with the GreenLight laser in the present study were classified as geriatric patients not only according to their age but also in their ASA score which is an indication of multiple other pathologies and administered medications. To achieve long-term postoperative success for these patients, the interface between the ambulatory and the hospital care should be optimized.

The low dopamine hypothesis: A plausible mechanism underpinning residual urine, overactive bladder and nocturia (RON) syndrome in older patients

INTRODUCTION

Aging is associated with a combination of several lower urinary tract (LUT) signs and symptoms, including residual urine, overactive bladder and nocturia. One of the mechanisms of this LUT dysfunction that has not been discussed in dept so far is the role of dopamine (DA).

METHODS

In this narrative review, we explore the dopaminergic hypothesis in the development of this combination of LUT signs and symptoms in older adults.

RESULTS

DA is one of the neurotransmitters whose regulation and production is disrupted in aging. In synucleinopathies, altered DAergic activity is associated with the occurrence of LUTS and sleep disorders. Projections of DAergic neurons are involved in the regulation of sleep, diuresis, and bladder activity. The low dopamine hypothesis could explain the genesis of a set of LUT signs and symptoms commonly seen in this population, including elevated residual urine, Overactive bladder syndrome and Nocturia (discussed as the RON syndrome). This presentation is however also common in older patients without synucleinopathies or neurological disorders and therefore we hypothesise that altered DAergic activity because of pathological aging, and selective destruction of DAergic neurons, could underpin the presentation of this triad of LUT dysfunction in the older population.

CONCLUSION

The concept of RON syndrome helps to better understand this common phenotypic presentation in clinical practice, and therefore serves as a useful platform to diagnose and treat LUTS in older adults. Besides recognizing the synucleinopathy "red flag" symptoms, this set of multi-causal LUT signs and symptoms highlights the inevitable need for combination therapy, a challenge in older people with their comorbidities and concomitant medications.

Nascent myoma as a cause of urinary retention

We present the case of a 47-year-old woman with a bulky, nascent necrotic myoma, which at first glance appeared to be a malignant process in the cervix. It caused significant retention of urine due to compression of the bladder and ureters, hydronephrosis and deterioration of renal function. A fully developed picture of the "bulge syndrome" dominated - lymphedema of the lower limbs and lower abdomen, pain in the lower abdomen, constipation, secondary secondary urinary infection, and paradoxical ischuria. During a gynecological examination in a specula, a strong-smelling, necrotic tumour was visualized reaching half of the vagina, which was causing a bloody discharge, which brought the patient to the examination. A biopsy was taken from the tumour. A permanent urinary catheter was inserted into the urinary bladder with gradual adjustment of renal functions. Due to the difficulties and the benign histological findings from the biopsy, a simple abdominal hysterectomy with bilateral salpingectomy from a lower midline incision was indicated. The operation was complicated by an extensive adhesive process and blood loss of 1,200 mL, with a decrease in hemoglobin in the blood count from 128 g/L to 79 g/L and the need for three blood transfusions. In the postoperative period, there is a prompt recovery of spontaneous micturition with normalization of bladder function, subsidence of lymphedema and subjective complaints of the patient.

Postoperative Urinary Retention in Japanese Elderly Males with a Femoral Neck or Trochanteric Fracture

We assessed risk factors for postoperative urinary retention (UR) in elderly males with femoral bone fractures: 169 Japanese males (mean age 81.95 ± 1.19 years) who had undergone hip surgery at a municipal hospital (Toyama, Japan). A multiple logistic regression analysis was used to test possible risk factors for UR: age, body mass index, serum albumin, cognitive impairment, activities of daily living (ADL), and history of diabetes mellitus (DM). UR occurred in 24 (14.2%) of the 169 patients. A multivariate logistic regression analysis with age adjustment showed that ADL (odds ratio [OR] 3.88; 95% confidence interval [CI]: 1.2-12.5, p=0.023) was significantly associated with the development of UR, and a history of DM showed marginal significance for UR occurrence (OR 0.36, 95%CI: 0.11-10, p=0.064). These results suggests that ADL is a risk factor for UR development in elderly males who have undergone surgery for femoral neck or trochanter fractures.

Intravesical Bacillus Calmette-Guerin and its complications: 12 years of learning experience in a single local institution

INTRODUCTION

Intravesical Bacillus Calmette-Guerin (BCG) therapy is the standard adjuvant treatment for non-muscle-invasive bladder carcinoma (NMIBC) with carcinoma in situ, in addition to tumour resection. We aimed to study BCG complications that preclude adequate treatment of NMIBC in an Asian population.

METHODS

This retrospective study was conducted using a large, prospectively maintained bladder cancer database. 336 patients received intravesical BCG therapy for bladder cancer in our institution between 2004 and 2016, with an average follow-up duration of 63 months.

RESULTS

The study included 258 (76.8%) male and 78 (23.2%) female patients. The median age of the patients at diagnosis of bladder cancer was 69 (range 17-94) years, and the median number of BCG instillations was 6 (range 1-27). 52 (15.5%) patients received maintenance therapy. The most common complications included urinary tract infection with/without sepsis (n = 18, 5.4%), haematuria (n = 9, 2.7%) and acute urinary retention (n = 4, 1.2%). 93.3% of the patients with complications presented early, within one month of completion of therapy. 22 out of 30 complications were Clavien-Dindo grade ≤ 2. 10 (33.3%) patients were admitted to hospital because of BCG-related adverse effects. The most common reasons for termination were urosepsis (2/30, 6.7%) and acute urinary retention (2/30, 6.7%). Patients aged ≥ 80 years at diagnosis were at higher risk of developing BCG-related complications (19.0% vs. 7.5%, p = 0.01).

CONCLUSION

This retrospective cohort and subgroup study showed that intravesical BCG therapy is well tolerated and has a low incidence of complications even in the elderly and patients with multiple comorbidities.

History of Urinary Retention Is a Risk Factor for Infection after Prostate Biopsy: A Nationwide, Population-Based Cohort Study

BACKGROUND AND AIM

Infection or bleeding after transrectal prostate biopsy remains a concern of both patients and urologists. We explored the risk of association of certain co-morbidities with both complications.

PATIENTS AND METHODS

Using the Taiwan National Health Insurance Research Database, we identified patients undergoing prostate biopsy from 2000 to 2013. We used logistic multivariable regression to search for associations between post-biopsy hospitalization and the two co-morbidities within a year after biopsy.

RESULTS

Among 3,601 prostate biopsies, 100 infections (3.77%) and 52 (1.44%) bleeding-related emergency room visits and hospitalizations were recorded within 30 days after biopsy. The group having the biopsy as an inpatient exhibited older age (p < 0.0001) and a higher percentage of having diabetes mellitus (p = 0.015) than patients without either complication. The logistic multivariable regression analysis showed that urinary retention, freedom from diabetes, and performance as an outpatient procedure were independent risk factors for infection-related hospitalization (odds ratios 1.81, 1.96, and 1.72; p values 0.031, 0.037, and 0.010, respectively).

CONCLUSION

Patients with a recent history of urinary retention have a higher probability of infection-related hospitalization after prostate biopsy.

Long-term micturition problems of asymptomatic postpartum urinary retention: a prospective case-control study

INTRODUCTION AND HYPOTHESIS

Covert (asymptomatic) postpartum urinary retention (PUR) is defined as post-void residual volume (PVRV) ≥150 mL. Although often supposed to be a common and harmless phenomenon, no data are available on the potential long-term micturition problems of increased PVRV after vaginal delivery.

METHODS

After the first spontaneous void post-vaginal delivery, PVRV was measured using a portable scanning device. Micturition symptoms were compared using validated questionnaires between women with PVRV < 150 mL and those with PVRV ≥150 mL until 1 year after delivery. Women with PVRV ≥ 150 mL were followed until complete bladder emptying was achieved.

RESULTS

Data of 105 patients with PVRV < 150 mL and 119 with PVRV ≥ 150 mL were available for analysis. 75% of all patients included had PVRV ≥ 250 mL. More primiparous patients had PVRV ≥ 150 mL (p < 0.02). 92% of women with PVRV ≥ 150 mL after delivery were able to adequately empty their bladder within 4 days. One year after delivery, no statistically significant differences were found.

CONCLUSIONS

Covert PUR according to the definition of PVRV ≥ 150 mL, is a common and transient phenomenon that does not result in more lower urinary tract symptoms 1 year after delivery. Although the current definition is not useful in identifying postpartum women with a pathological condition, we suggest that the definition of covert PUR should be change to: "PVRV≥500 mL after the first spontaneous void after (vaginal) delivery." This cut-off value is the value at which some women do need more time to normalise emptying of the bladder. The exact clinical implications of covert PUR need to be further studied in this subcategory of women.

Cervical spine arteriovenous fistula associated with hereditary haemorrhagic telangiectasia

Reported is a case of a man aged 55 years who presented with progressive spastic paraparesis. Examination demonstrated multiple cutaneous telangiectases. Subsequent development of upper limb weakness, acute urinary retention and eventual respiratory compromise resulted in the requirement for intensive care unit admission and mechanical ventilation. MRI spine revealed diffuse T2 hyperintensity in the cervical cord with enhancement and cord expansion. Immunomodulatory therapy for a presumed diagnosis of transverse myelitis yielded no response, so a vascular aetiology was suspected. Spinal angiography demonstrated an arteriovenous fistula involving the upper cervical cord. Endovascular embolisation was successfully performed and a marked clinical improvement was achieved. Cervical arteriovenous fistulas can cause progressive myelopathy, subarachnoid haemorrhage and brainstem dysfunction. Management typically comprises endovascular embolisation or surgical interruption. A clinical diagnosis of hereditary haemorrhagic telangiectasia was also made in this case, and spinal arteriovenous fistula formation has been associated with this condition.

[Acute urinary retention: a mechanical or functional emergency]

Acute urinary retention is one of the most frequent urologic emergencies. It occurs mostly in elderly males that suffer from prostate enlargement. Very rare in women, it is essentially caused by vaginal prolapse and neurologic disease. Patients with acute urinary retention suffer from lower abdominal pain and cannot void. Medical history is the cornerstone of diagnosis. Rarely palpable on abdominal examination, an overfilled bladder may be revealed by dullness on supra-pubic percussion. Acute urinary retention may lead to a decrease in kidney function, and on the long term to detrusor hypocontractility. The initial management is bladder drainage by urethral or suprapubic catheterization. Post obstructive diuresis and hematuria are possible complications. Subsequent evaluation is performed by the urologist on an ambulatory basis.

Loss of MeCP2 Causes Urological Dysfunction and Contributes to Death by Kidney Failure in Mouse Models of Rett Syndrome

Rett Syndrome (RTT) is a neurodevelopmental disorder characterized by loss of acquired skills during development, autonomic dysfunction, and an increased risk for premature lethality. Clinical experience identified a subset of individuals with RTT that present with urological dysfunction including individuals with frequent urinary tract infections, kidney stones, and urine retention requiring frequent catheterization for bladder voiding. To determine if urologic dysfunction is a feature of RTT, we queried the Rett Syndrome Natural History Study, a repository of clinical data from over 1000 individuals with RTT and found multiple instances of urological dysfunction. We then evaluated urological function in a mouse model of RTT and found an abnormal pattern of micturition. Both male and female mice possessing Mecp2 mutations show a decrease in urine output per micturition event. Furthermore, we identified signs of kidney failure secondary to urethral obstruction. Although genetic strain background significantly affects both survival and penetrance of the urethral obstruction phenotype, survival and penetrance of urethral obstruction do not directly correlate. We have identified an additional phenotype caused by loss of MeCP2, urological dysfunction. Furthermore, we urge caution in the interpretation of survival data as an endpoint in preclinical studies, especially where causes of mortality are poorly characterized.

Terminal restlessness as perceived by hospice professionals

Any hospice professional can identify the syndrome known as terminal restlessness, and all would agree that it is extremely distressing to patients as well as their families and care-givers. Often, caregivers cannot ameliorate the anguish many patients experience at life’s end. Many clinicians assert that the causes are physical resulting from medication toxicity, organ shutdown and the associated metabolic changes, pain, urinary or fecal retention, dyspnea and related hypoxia, and sepsis. Yet, many also credit psychosocial and spiritual distress as precipitating factors.

The purposes of this study were twofold: to compare the perceptions of practicing hospice clinicians with the literature related to terminal restlessness, and to determine if their experience with terminal restlessness agreed with the components of the one established scale for terminal restlessness found in the literature.

In general, the study findings corresponded to the literature in regards to frequency, definition, causes, and behavioral manifestations of terminal restlessness. The clinicians in the study supported the impact of psychosocial and spiritual causes of terminal restlessness and defined the phenomenon in terms of time period; emotional, physical, and spiritual distress; changes in consciousness; and increased activity. However, the study did not support the inclusion of impaired consciousness and withdrawal as comprised in the terminal restlessness scale.

[Histological changes of the prostate and acute urinary retention in patients with benign prostatic hyperplasia]

OBJECTIVE

To investigate the roles of prostatic infarction, prostatic inflammation and the type of prostatic hyperplasia in acute urinary retention (AUR) in patients with benign prostatic hyperplasia (BPH).

METHODS

We retrospectively analyzed 102 cases of BPH, 49 complicated by AUR and the other 53 without AUR. We compared the incidences of prostatic infarction and prostatic inflammation, the types of prostatic hyperplasia, the patients' age, the level of prostate specific antigen (PSA), the prostate volume, and international prostate symptom score (IPSS) between the AUR and non-AUR groups.

RESULTS

The PSA level was significantly increased in the AUR group as compared with the non-AUR group (P < 0.05). There were no statistically significant differences between the two groups in the mean age, prostate volume and IPSS (P > 0.05). The type of prostatic hyperplasia showed no correlation with AUR. The incidence rate of AUR was 5.620 and 2.326 times higher in the BPH patients with prostatic infarction and prostatic inflammation respectively than in those without (P < 0.05).

CONCLUSION

Prostatic infarction and prostatic inflammation are important risk factors of AUR in BPH patients.

[Urinary retention]

Urinary retention is a lack of ability to urinate. In acute case of urinary retention, some associated symptoms are present such as lower abdominal distention and pain. It is usually a common complication of benign prostatic hyperplasia, prostatic cancer, urethral stricture, neurogenic bladder or medications (including anticholinergics and antidepressants). The ultrasound examination is useful for the diagnosis and shows massive increase in bladder capacity. The treatment requires urgent placement of a urinary catheter into the bladder. However, in case of difficulty for indwelling a catheter, the patient should be sent to the urologist.

Imperforate hymen presenting with massive haematocolpos and acute urinary retention in a teenage girl: A case report

Imperforate hymen is relatively rare but it is the most frequently encountered obstructive anomaly of the female lower genital tract. The clinical presentation vary significantly from patient to patient depending on the age at diagnosis but in most cases the diagnosis is missed in early childhood and therefore the diagnosis is made after puberty when the patient present with haematocolpos, heamatometra.or both. When this happens, the presentation could even be tricky because the patient may presents with unlikely symptoms apart from cryptomenorhoea like, urinary retention or bowel obstruction or both. Here we present a 16 years old girl with imperforate hymen and presented with history of lower abdominal pain and distension associated with acute urinary retention. She was treated by hymenotomy and improved dramatically and was discharge 6th day post operatively. This case report is presented to address to clinicians the possibility of imperforate hymen with haematocolpos as a differential diagnosis in adolescent girls particularly those who have not started having their menses in their teens and present with acute urinary retention so that their external genitalia are carefully examined to exclude the possibility of imperforate hymen as a cause of acute urinary retention due to the haematocolpos.

Syncope in a patient with giant bladder diverticulum

Syncope is common in clinical practice, but the cause is often difficult to diagnose. We report a 75-year-old man who was referred to the emergency department because of syncope after an urgent sensation of urinating during jogging. He was finally diagnosed as having a giant bladder diverticulum due to prostatic hyperplasia accompanied by neurally mediated syncope. Excessive urinary retention is a possible cause of not only giant bladder diverticula but also syncope due to vagal enhancement.

[Relationship of acute urinary retention, bladder ischemia and metabolic changes in bladder wall and urine during infravesical obstruction due to benign prostatic hyperplasia]

Decrease of enzyme activity in the bladder wall in combination with increase of enzyme activity in the urine, affirm that exactly the bladder is the source of enzymuria increase and it is related with marked damage. Taking into consideration, that from the bladder wall not only cytoplazmatic enzymes come out but also enzymes connected with cell membranes, it is expected that high enzymuria is not only because of increase permeability of cytoplazmatic membrane for large molecules but also is connected with cell parts distruction. Similarity of changes during acute urinary retention and bladder wall ischemia let us assume vital value of the factor of changes of bladder wall blood supply during acute urinary retention and its role in the development of metabolic and functional changes.

Congenital pelvic arteriovenous malformation presenting with urinary retention: a case report

OBJECTIVE

To report a case of congenital pelvic arteriovenous malformation (pAVM) with urinary retention.

CLINICAL PRESENTATION AND INTERVENTION

A 39-year-old male patient presented with inability to void urine for 8 h. He did not have a history of dysuria or fever, but had increasing urinary frequency and difficulty in voiding over 2 years. Examination revealed a suprapubic mass without external signs of vascular anomaly. A huge, soft, irregular, non-pulsating mass was felt rectally. This mass did not disappear on urinary bladder decompression. Subsequent ultrasound and CT scan revealed pAVMs filling most of the pelvic cavity.

CONCLUSION

To our knowledge, this is the first report of a male patient with congenital pAVM presenting with urinary retention, emphasizing the need for a high index of suspicion for pAVM to avoid potential severe bleeding during suprapubic catheterization for urinary drainage.

Can bedside ultrasound assist in determining whether serum creatinine is elevated in cases of acute urinary retention?

BACKGROUND

There are no guidelines to determine which patients with acute urinary retention (AUR) require blood testing (i.e., serum creatinine) to assess for renal failure.

OBJECTIVE

To determine if hydronephrosis on bedside ultrasound correlates with an abnormal serum creatinine (Cr) level in cases of AUR.

METHODS

This was a prospective, observational study of subjects clinically diagnosed with AUR at two associated urban academic centers from October 2004 through August 2006. Emergency physicians completed a data form and performed a bedside ultrasound to determine the presence or absence of hydronephrosis. The data collected included suspected cause of AUR, amount of urinary output after Foley insertion, and blood test results. Follow-up was obtained by telephone and electronic medical record for 1 month. Standard statistics were employed.

RESULTS

Among 96 enrolled subjects with AUR, 43 had a serum Cr level obtained on the initial visit, and 10 (23%; 95% confidence interval [CI] 11-36) of these had an elevated Cr (10% [95% CI 4-16] of the study cohort). The test characteristics of hydronephrosis on bedside ultrasound to detect elevation in Cr were a sensitivity, specificity, positive predictive value, and negative predictive value of 70%, 67%, 39%, and 88%, respectively.

CONCLUSION

In cases of AUR, the prevalence of elevated creatinine is high, and hydronephrosis based on bedside ultrasonography does not correlate with elevation in creatinine.

[Post void residual volume in patients at geriatric ward]

INTRODUCTION

Post Void Residual Volume (PVRV) is a known risk factor for urinary infection, incontinence and renal insufficiency. Disposing for the condition is high age, immobility, constipation, neurological and metabolic disease. The objectives of this study were to determine the prevalence and to examine risk factors for high PVRV among geriatric patients.

MATERIAL AND METHODS

In a prospective study 100 consecutive patients admitted to a geriatric ward had an ultrasound bladder scan (UB) performed three times during the first two days of stay. The following background parameters were registered: age, gender, Mini Mental-State Examination (MMSE), modified Barthel score, bacteriuria, urinary incontinence and constipation.

EXCLUSION CRITERIA

urinary catheter, incapability of giving informed consent. Patients could only be included once.

RESULTS

A total of 142 patients were screened, among whom 100 were included (81 women and 19 men). The mean age was 83.9 years (range: 65-101 years). Background parameters: constipation 29%, urinary incontinence 41%, bacteriuria 37%. Barthel (maximum score 100): 12% score < 26, 25% score 26-49, 41% score 50-79 and 20% score > 79. MMSE: 12% < 15.37% 15-24 and 39% > 24. UB results: A total of 48 patients had a PVRV < 100 ml in all three UB, and 14 patients had a PVRV > 150 ml in all three UB. In all, 38 patients had a PVRV between 100 and 150 ml or diverging results. Barthel score (p = 0.03) and bacteriuria (p = 0.04) varied significantly between patients with a PVRV > 150 ml and a PVRV < 100 ml.

CONCLUSION

PVRV is a common condition in geriatric populations and is positively correlated with bacteriuria and low functional performance. It is feasible to implement UB as a screening procedure in geriatric wards.

[First experience of using lantox (botulinum toxin A) in chronic pelvic pain syndrome combined with bladder emptying dysfunction]

Chronic pelvic pain syndrome (CPPS), often observed in practical urology, in some cases is accompanied with obstructive voiding due to inadequate relaxation of the urethral striped sphincter. TUR of the bladder neck in such cases is low effective and patients have to do intermittent autocatherization. Lantox, a botulinic toxin A, was used in a woman suffering from CPPS for 24 years. The patient has undergone two TURs of the bladder cervix. As the effect was insignificant she had to do regular intermittent autocatheterization of the bladder for 4 years. A lantox injection (100 units) was made in the external urethral sphincter. A subjective response (a 73.3% reduction of pain intensity) and voiding improvement shown by an urodynamic investigation were achieved as well as the absence of residual urine which abolished the need in autocatheterisation. The case demonstrates high efficacy of lantox both in relief of CPPS and improvement of voiding.

Herbal medicine-induced meningitis-retention syndrome

A 73-year-old woman developed subacute meningitis-retention syndrome (MRS), dermatitis, and latent pneumonitis likely due to the herbal medicines Shinbu-Tou and Rikkunshi-Tou. The responsible site of lesions for urinary retention seemed to be the spinal micturition pathways and, to a lesser extent, the sacral spinal cord. All of her clinical manifestations were successfully ameliorated within three weeks of discontinuation of the herbal remedies.

[Administration of two uroselective alpha-adrenoblockers in pharmacological treatment of acute urinary retention in patients with prostatic adenoma]

Acute urinary retention in males is often caused by infravesical obstruction due to enlargement of the prostatic gland. Recently it was found that alpha-adrenoblockers promote recovery of physiological voiding in patients with benign prostatic hyperplasia. In our study urinary bladder draining with urethral catheter in 136 patients with acute urinary retention was immediately followed by simultaneous administration of two alpha1-adrenoblockers--alfuzosine (10 mg once a day) (dalfaz CP) and tamsulosine (0.4 mg once a day) (omnik okas). The control group of 96 patients received monotherapy with alfuzosine. Physiological voiding recovered in 42.7% patients on alfuzosine monotherapy and in 64% patients on alfuzosine+tamsulosine.

Relation between acute urinary retention, chronic prostatic inflammation and accompanying elevated prostate-specific antigen

OBJECTIVE

To determine if there is a relationship between acute urinary retention (AUR), the prostate-specific antigen (PSA) level and chronic inflammation of the prostate. We therefore studied patients with benign prostatic obstruction (BPO) with (n = 64) or without (n = 168) acute urinary retention (AUR) who underwent transurethral resection of the prostate (TURP) in a retrospective case control study.

MATERIAL AND METHODS

Between 2001 and 2004, a total of 232 patients underwent TURP due to BPO with or without AUR. The mean values of age, prostate volume, weight of resected prostate and PSA level and the histopathologic results of patients with and without AUR were compared. Chi(2) analysis was used to examine the relationship between prostatic inflammation and AUR. The contribution of each variable to AUR was assessed by means of multiple linear regression.

RESULTS

A total of 64 patients (28%) were operated on for AUR due to BPO. There were no statistical differences between patients with or without AUR with respect to the mean values of PSA, percent free PSA, prostate size or weight of the resected prostate tissue. Elevated PSA values (>or=4.0 ng/ml) were detected in 64% and 38% of the patients in the AUR and non-AUR groups, respectively (p = 0.01). Histopathological re-evaluation demonstrated that chronic prostatic inflammation was present in 56% and 37% of the specimens in the AUR and non-AUR groups, respectively (p = 0.014). In the AUR group, the mean PSA level was significantly higher in patients with than without prostatic inflammation (7.75+/-5.26 vs 5.07+/-3.21 ng/ml; p = 0.022). The odds ratio of AUR for patients with chronic prostatic inflammation and elevated PSA was determined as 4.14 (95% CI 1.65-10.41). Multiple linear regression revealed that prostatic inflammation made a significant contribution to AUR.

CONCLUSIONS

Chronic prostatic inflammation may be histopathological evidence of both elevated PSA level and AUR; hence it may play a role in the pathophysiology of AUR.

Long‐term results of contact laser versus transurethral resection of the prostate in the treatment of benign prostatic hyperplasia with small or moderately enlarged prostates

OBJECTIVE

To evaluate the long-term results of contact laser vaporization (CLV) of the prostate and transurethral resection of the prostate (TURP) in patients with symptomatic bladder outflow obstruction (BOO) caused by benign prostatic hyperplasia (BPH) with prostates smaller than 40 ml.

MATERIAL AND METHODS

A total of 52 patients with lower urinary tract symptoms (LUTS) and urodynamically confirmed BOO caused by BPH with glands smaller than 40 ml were treated by means of CLV or TURP in a randomized trial. Changes in symptom score, urodynamics and prostate volume were evaluated during a 4-year follow-up period.

RESULTS

A total of 42 (81%) of the patients were available for review at 4 years. The re-operation rate was 1/26 for each treatment. A sustained improvement in median Danish Prostate Symptom Score was seen in the laser group from 18 (range 5-54) to 5 (0-34) and in the TURP group from 18 (4-46) to 4 (0-18) (p<0.001 for both). A sustained improvement in maximum urinary flow rate was also seen in the laser group from 8.3 (4.8-19.6) ml/s to 14.3 (10.1-33.6) ml/s (p<0.001) and in the TURP group from 8.6 (5.0-15.9) ml/s to 16.1 (7.7-39.6) ml/s (p<0.01), without differences between the study groups. Median detrusor pressure at maximum urinary flow rate decreased significantly after both treatments, in the CLV group from 64 (32-112) cmH2O to 38 (18-65) cmH2O and in the TURP group from 57 (40-137) cmH2O to 28 (9-44) cmH2O (p<0.001 for both), and at 48 months was significantly higher in the laser group (p<0.01). At 4 years, 7/22 (32%) of the laser patients and 2/20 (10%) of the TURP patients were urodynamically obstructed. Post-void residual at 48 months was significantly lower in the TURP group than in the CLV group. Median prostate volume was smaller after TURP at 6 and 48 months (p<0.05).

CONCLUSIONS

Long-term data of CLV and TURP treatments for BPH with small or moderately enlarged prostates indicate no significant difference in the relief of symptoms or in the rate of re-operations. However, the number of patients in this study was small and consequently the power to detect differences between the study groups was low. Regarding most objective outcome parameters, long-term follow-up revealed a slight advantage of TURP over CLV.

[Amlodipine combined with terazosin reduces postvoid residual and the risk of acute urinary retention]

OBJECTIVE

This prospective randomized double-blinded clinical trial was designed to explore the effects of amlodipine and the combination of amlodipine with terazosin in improving postvoid residual (PVR) in patients with lower urinary tract symptoms (LUTS) and concomitant hypertension.

METHODS

We randomly divided 360 LUTS patients with concomitant hypertension into a 5 mg amlodipine group, a 2 mg terazosin group and a 5 mg amlodipine plus 2 mg terazosin group, and measured PVR at the baseline and 4 weeks after the treatment.

RESULTS

For male patients with LUTS associate with hypertension, all of amlodipine (APVR = 6.8) , terazosin (APVR = 7. 6), and combination group (APVR = 8.8) can significant reduced the PVR (P < . 0.1), but no significant difference was found among three groups.

CONCLUSION

Amlodipine alone or combined with terazosin can improve the PVR of the LUTS patient effectively, but had no significant difference compared with terazosin.

[The changes of prostate specific antigen (PSA) after treatment with alpha 1-adrenergic receptor antagonists in men with 4.0-9.9 ng/ml PSA level--a study for comparison of benign prostatic hyperplasia/lower urinary tract symptom (BPH/LUTS) and prostate cancer]

The aims of this study were to define the relationships between prostate-specific antigen (PSA) and alpha 1-adrenergic receptor antagonist (alpha 1 blocker). A prospective clinical study of 48 male patients examined between May 2004 and December 2007 was performed. 4.0-9.9 ng/ml PSA level who had no notable clinical findings of urinary retention, urinary tract infections and prostate cancer (PC) received tamusulosin 0.2 mg once daily for 3 months, and then received prostate biopsy. We divided the patients into two groups: PC and benign prostate hyperplasia (BPH)/lower urinary tract symptom (LUTS) group. In total, the PSA level showed no significant change after treatment. In the PC group, PSA significantly increased after treatment. However, PSA decreased in the BPH/LUTS group. The alpha 1 blocker significantly improved urination status (the subjective symptoms and urodynamics parameters) in the BPH/LUTS group. In two groups, prostate volume showed no significant difference. Among those patients in the BPH/LUTS group, their urination status was significantly improved with alpha 1 blocker and their PSA level dropped slightly. On the other hand, the PSA level was significantly increased in the PC group. This study shows that by using an alpha 1 blocker, it may be possible to avoid conducting the prostate biopsy at an early stage or indeed one may not be needed at all for patients with only slight increases in PSA.

Acute colonic obstruction due to benign prostatic hypertrophy

A seventy two year old man presented to the Emergency Department with clinical features of colonic obstruction. Subsequent radiological investigations confirmed this impression and revealed the aetiology to be compression of the sigmoid colon against the sacrum by a massively distended urinary bladder. Chronic urinary retention due to benign prostatic hypertrophy is an extremely unusual cause of large bowel obstruction. Little in this patient's clinical findings suggested this aetiology. We reviewed the literature in this area and highlight the benefits of CT scanning over contrast studies.