Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study

PURPOSE

This 5-year, prospective, multicenter trial evaluated the long-term safety and efficacy of sacral neuromodulation in patients with refractory urge incontinence, urgency frequency and retention.

MATERIALS AND METHODS

A total of 17 centers worldwide enrolled 163 patients (87% female). Following test stimulation 11 patients declined implantation and 152 underwent implantation using InterStim. Of those treated with implantation 96 (63.2%) had urge incontinence, 25 (16.4%) had urgency frequency and 31 (20.4%) had retention. Voiding diaries were collected annually for 5 years. Clinical success was defined as 50% or greater improvement from baseline in primary voiding diary variable(s).

RESULTS

Data for all implanted cases were reported. For patients with urge incontinence mean leaking episodes per day decreased from 9.6 +/- 6.0 to 3.9 +/- 4.0 at 5 years. For patients with urgency frequency mean voids per day decreased from 19.3 +/- 7.0 to 14.8 +/- 7.6, and mean volume voided per void increased from 92.3 +/- 52.8 to 165.2 +/- 147.7 ml. For patients with retention the mean volume per catheterization decreased from 379.9 +/- 183.8 to 109.2 +/- 184.3 ml, and the mean number of catheterizations decreased from 5.3 +/- 2.8 to 1.9 +/- 2.8. All changes were statistically significant (p <0.001). No life threatening or irreversible adverse events occurred. In 102 patients 279 device or therapy related adverse events were observed. At 5 years after implantation 68% of patients with urge incontinence, 56% with urgency frequency and 71% with retention had successful outcomes.

CONCLUSIONS

This long-term study demonstrates that InterStim therapy is safe and effective for restoring voiding in appropriately selected cases refractory to other forms of treatment.

Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation

PURPOSE

We investigate the efficacy of sacral neurostimulation in patients with idiopathic urinary retention in a prospective, randomized multicenter trial.

MATERIALS AND METHODS

A total of 177 patients with urinary retention refractory to standard therapy were enrolled in the study. Greater than 50% improvement in baseline voiding symptoms during a 3 to 7-day percutaneous test stimulation qualified a patient for surgical implantation of an InterStim parallel system. Of the patients who qualified for implantation 37 were randomly assigned to a treatment and 31 to a control group. Patients in the treatment group underwent early surgical implantation of the sacral nerve stimulation system, while implantation was delayed in the control group for 6 months. Followup evaluations, including voiding diary analysis and temporary deactivation of the stimulator at 6 months, were conducted at 1, 3, 6, 12 and 18 months after implantation in the treatment group, and after 3 and 6 months in the control group.

RESULTS

Compared to the control group, patients implanted with the InterStim system had statistically and clinically significant reductions in the catheter volume per catheterization (p <0.0001). Of the patients treated with implants 69% eliminated catheterization at 6 months and an additional 14% had a 50% or greater reduction in catheter volume per catheterization. Therefore, successful results were achieved in 83% of the implant group with retention compared to 9% of the control group at 6 months. Temporary inactivation of sacral nerve stimulation therapy resulted in a significant increase in residual volumes (p <0.0001) but effectiveness of sacral nerve stimulation was sustained through 18 months after implant.

CONCLUSIONS

Results of this prospective, randomized clinical study demonstrate that sacral nerve stimulation is effective for restoring voiding in patients with retention who are refractory to other forms of treatment.

Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP): a prospective bi-centre study of perioperative morbidity and early functional outcome

OBJECTIVES

To compare the early follow-up and perioperative morbidity of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) in patients (pts.) suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIAL AND METHOD

101 pts. underwent PVP (n = 64) and TURP (n = 37) in a prospective, non-randomized bi-centre trial. Inclusion criteria were identical at both centres. Primary outcome parameters were maximum urinary flow rate (Q(max)), post-void residual volume (V(res)), International Prostate Symptom Score (IPSS). Secondary outcomes included intraoperative surgical parameters and perioperative and post-discharge morbidity.

RESULTS

Baseline characteristics of both groups were similar. Operating time was slightly shorter in the TURP group (p = 0.047). During TURP significant more irrigation solution was used (p < 0.001). Decrease of serum haemoglobin (p = 0.027) and serum sodium (p = 0.013) was larger after TURP. Catheter drainage was removed significant earlier after PVP than after TURP (p < 0.001). Outcome of Q(max), and IPSS were similar in both groups within 6 months. The sort of perioperative complications was different in both groups, however overall cumulative perioperative morbidity was comparable (PVP 39.1% versus TURP 43.2.1%; ns).

CONCLUSION

PVP provides excellent intraoperative safety, instant tissue removal, and immediate relief from obstructive voiding symptoms, similar to TURP. Early outcomes 6-months after PVP and TURP are comparable.

Correlation of intravesical prostatic protrusion with bladder outlet obstruction

OBJECTIVES

To determine the effect of intravesical protrusion of the prostate (IPP, graded I to III) on lower urinary tract function, by correlating it with the results of a pressure-flow study.

PATIENTS AND METHODS

In a prospective study men (aged> 50 years) with lower urinary tract symptoms were initially evaluated as recommended by the International Consultation on Benign Prostatic Hyperplasia, together with the IPP and prostate volume, as measured by transabdominal ultrasonography. These variables were then correlated with the results from a pressure-flow study.

RESULTS

The IPP was a statistically significant predictor (P < 0.001) of bladder outlet obstruction (BOO) compared with other variables in the initial evaluation. In all, 125 patients had significant BOO, defined as a BOO index of> 40. Of these men, 94 had grade III and 30 had grade I-II IPP. Seventy-five patients had a BOO index of < 40; 69 had grade I-II and six grade III IPP. In patients with BOO confirmed on the pressure-flow study, grade III IPP was associated with a higher BOO index than was grade I-II (P < 0.001).

CONCLUSION

The IPP assessed by transabdominal ultrasonography is a better and more reliable predictor of BOO than the other variables assessed.

Randomised, placebo-controlled, double-blind clinical trial of beta-sitosterol in patients with benign prostatic hyperplasia. Beta-sitosterol Study Group

Medical treatments have become available for benign hypertrophy of the prostate, including alpha-receptor blocking agents and 5-alpha-reductase inhibitors. Drugs derived from plants, for which no precise mechanism of action has been described, are widely used for this purpose in Europe. In a randomised, double-blind, placebo-controlled multicentre study, 200 patients (recruited between April and October 1993) with symptomatic benign prostatic hyperplasia were treated with either 20 mg beta-sitosterol (which contains a mixture of phytosterols) three times per day or placebo. Primary end-point was a difference of modified Boyarsky score between treatment groups after 6 months; secondary end-points were changes in International Prostate Symptom Score (IPSS), urine flow, and prostate volume. Modified Boyarsky score decreased significantly with a mean of -6.7 (SD 4.0) points in the beta-sitosterol-treated group versus -2.1 (3.2) points in the placebo group p < 0.01. There was a decrease in IPSS (-7.4 [3.8] points in the beta-sitosterol-treated group vs -2.1 [3.8] points in the placebo group) and changes in urine flow parameters: beta-sitosterol treatment resulted in increasing peak flow (15.2 [5.7] mL/s from 9.9 [2.5] mL/s), and decrease of mean residual urinary volume (30.4 [39.9] mL from 65.8 [20.8] mL). These parameters did not change in the placebo group (p < 0.01). No relevant reduction of prostatic volume was observed in either group. Significant improvement in symptoms and urinary flow parameters show the effectiveness of beta-sitosterol in the treatment of benign prostatic hyperplasia.

New Sacral Neuromodulation Lead for Percutaneous Implantation Using Local Anesthesia: Description and First Experience

PURPOSE

In functional urology today chronic stimulation of the sacral nerves has become one of the most accepted methods of stimulation treatment. Many studies have described the advantage of test stimulation prior to implanting the definitive system to enable effective patient selection. We studied a method aimed at improving lead anchoring by developing a self-blocking electrode with a simple placement procedure, in the process creating a 2-stage approach to full percutaneous implantation that allows a long screening period during the first temporary stimulation stage.

MATERIALS AND METHODS

A new tined lead was specifically designed to allow minimally invasive percutaneous lead placement requiring no incision and no additional fascial anchoring. From September 2001 to November 2002, 15 consecutive patients (3 males and 12 females) 27 to 70 years old (mean age 49) underwent this procedure and were prospectively evaluated. No PNE test was performed.

RESULTS

Following the first stage screening phase 12 patients were implanted with the implantable pulse generator (IPG), while 3 who did not respond positively to test stimulation (neurogenic voiding dysfunction, urge incontinence and neurogenic urge incontinence in 1 each) did not undergo IPG implantation and had the tined lead removed under local anesthesia. We did not observe any lead displacement during the screening period (average 38.8 days) or during followup of IPG implanted cases (average 11 months, range 5 to 19).

CONCLUSIONS

Our results show that the new tined anchoring system is a reliable way to allow truly minimally invasive placement of the chronic lead.

Detrusor Underactivity: Clinical Features and Pathogenesis of an Underdiagnosed Geriatric Condition

Urinary incontinence and other lower urinary tract symptoms exert a major influence on the health and independence of frail older people. Detrusor underactivity (DU) is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. DU may influence the clinical presentation and impede the therapy of disorders as common and as disparate as detrusor overactivity, urinary retention, and benign prostatic hyperplasia. Urodynamically, nearly two-thirds of incontinent nursing home residents exhibit DU. The clinical diagnosis of DU when present alone or in association with other bladder conditions such as detrusor overactivity (detrusor hyperactivity with impaired contractility (DHIC)) is challenging, because symptoms lack adequate precision. A catheterized and increasingly noninvasive ultrasound-based postvoid residual assessment allows a bedside diagnosis of retention and may suggest the presence of DU in individuals (mostly women) with a low likelihood of bladder outlet obstruction (BOO). Nevertheless, it cannot differentiate primary DU from retention secondary to BOO. The management of individuals with DHIC remains unsatisfactory, because antispasmodic anticholinergic medications may worsen retention, whereas bethanechol does not improve bladder emptying. Human detrusor biopsies reveal axonal degeneration, muscle loss, and fibrosis in DU. Animal studies suggest that multiple risk factors, including retention itself, lack of estrogen, infection, inflammation, and aging, may contribute to DU. Priority areas for future research include efforts to facilitate clinical nonurodynamic diagnosis of probable DU plus translational research designed to address the pathogenesis of this complex multifactorial geriatric syndrome.

The ICS-'BPH' Study: uroflowmetry, lower urinary tract symptoms and bladder outlet obstruction

OBJECTIVE

To explore the relationship between uroflow variables and lower urinary tract symptoms (LUTS): to define performance statistics (sensitivity, specificity, positive and negative predictive values) for maximum urinary flow rate (Qmax) with respect to bladder outlet obstruction (BOO) at various threshold values; and to investigate the diagnostic value of low-volume voids.

PATIENTS AND METHODS

The study comprised 1271 men aged between 45 and 88 years recruited from 12 centres in Europe, Australia, Canada, Taiwan and Japan over a 2-year period. Symptom questionnaires, voiding diaries, uroflowmetry and pressure-flow data were recorded. The relationship between uroflow variables and symptoms, Qmax and BOO, and the diagnostic performance of low volume voids were analysed.

RESULTS

The relationship between symptoms and uroflow variables was poor. The mean difference between home-recorded and clinic-recorded voided volumes was -48 mL. Qmax was significantly lower in those with BOO (9.7 mL/s for void 1) than in those with no obstruction (12.6mL/s; P<0.001) and Qmax was negatively correlated with obstruction grade (Spearman's correlation coefficient -0.3, P<0.001), even when controlling for the negative correlation between age and Qmax (Spearman's partial correlation coefficient -0.29, P<0.001). A threshold value of Qmax of 10 mL/s had a specificity of 70%, a positive predictive value (PPV) of 70% and a sensitivity of 47% for BOO. The specificity using a threshold Qmax of 15 mL/s was 38%, the PPV 67% and the sensitivity 82%. Those voiding <150 mL (n=225) had a 72% chance of BOO (overall prevalence of BOO 60%). In those voiding >150 mL the likelihood of BOO was 56%. The addition of a specific threshold of 10 mL/s to these higher volume voiders improved the PPV for BOO to 69%.

CONCLUSION

While uroflowmetry cannot replace pressure-flow studies in the diagnosis of BOO. it can provide a valuable improvement over symptoms alone in the diagnosis of the cause of lower urinary tract dysfunction in men presenting with LUTS. This study provides performance statistics for Qmax with respect to BOO: such statistics may be used to define more accurately the presence or absence of BOO in men presenting with LUTS, so avoiding the need for formal pressure-flow studies in everyday clinical practice, while improving the likelihood of a successful outcome from prostatectomy. This study also shows that low-volume uroflowmetry can provide useful diagnostic information and that, as such, the data from such voids should not be discarded.

The natural history of lower urinary tract dysfunction in men: the influence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10-year urodynamic follow-up

OBJECTIVES

To assess the long-term outcome of the efficacy of transurethral resection of the prostate (TURP) in men with detrusor underactivity (DUA), a cause of lower urinary tract symptoms (LUTS) in a significant minority of men.

PATIENTS AND METHODS

Neurologically intact men with LUTS, who were investigated in our department between 1972 and 1986, diagnosed with DUA and who underwent surgical intervention, were invited for a repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of the results.

RESULTS

In all, 224 men were initially diagnosed with DUA; 87 (39%) of these died in the interim and 22 followed had a TURP, with a mean follow-up since surgery of 11.3 years. There were no significantly sustained reductions in any symptoms. There was a small but significant reduction of questionable clinical significance in the bladder outlet obstruction index, but this did not translate into an improved flow rate. Comparison with 58 age-matched patients with DUA who remained untreated showed no significant advantage of surgical intervention in the long-term; on the contrary, there was more chronic retention in those who had had surgery.

CONCLUSIONS

There are no long-term symptomatic or urodynamic gains from TURP in men shown to have DUA. The results of TURP in men with DUA are important, as urologists who surgically treat patients based on the symptoms and uroflowmetry alone will do so in a significant minority of men with DUA. These results strengthen the argument for a routine preoperative urodynamic assessment.

The autonomous bladder: a view of the origin of bladder overactivity and sensory urge

Incontinence and the generation of excessive sensory urges are common problems that can seriously influence the quality of life of both men and women. The underlying causes have in some instances been associated with uncontrolled bladder activity. However, the mechanisms generating such activity are still poorly understood and pharmacological tools to control it remain relatively ineffective. There are no effective treatments for bladder overactivity possibly because the bladder mechanisms are not understand or targeted. The purpose of this short review is to raise questions and re-visit ideas from some older possibly forgotten and neglected publications, but which may shed new light on this problem.

Sacral root neuromodulation in idiopathic nonobstructive chronic urinary retention

PURPOSE

Sacral root neuromodulation is becoming a superior alternative to the standard treatment of idiopathic nonobstructive urinary retention. We report results in 20 successive patients who underwent sacral foramen implantation to restore bladder function.

MATERIALS AND METHODS

After an initial, thorough baseline assessment 20 patients 19.43 to 55.66 years old with idiopathic nonobstructive urinary retention underwent percutaneous nerve evaluation. Response was assessed by a detailed voiding diary. Responders underwent implantation with an S3 foramen implant, and were followed 1, 3 and 6 months postoperatively, and every 6 months thereafter.

RESULTS

Sacral root neuromodulation restored voiding capability in these patients. Bladders were emptied with minimal post-void residual urine, which decreased from 78.3 to 5.5 to 10.2% of the total voided volume from baseline to postoperative followup. These results were reflected in uroflowmetry and pressure-flow studies, which were almost normal after implantation. Furthermore, the urinary tract infection rate decreased significantly and associated pelvic pain improved substantially. The Beck depression inventory and SF-36 quality of life questionnaire indicated some improvement but reached significance in only 1 item. In addition, cystometrography showed no significant difference after 6 months of implantation compared with baseline values. Complications were minimal and within expectations.

CONCLUSIONS

Sacral root neuromodulation is an appealing, successful modality for nonobstructive urinary retention. Only patients who have a good response to percutaneous nerve evaluation are candidates for implantation. The high efficacy in patients who undergo implantation, relative simplicity of the procedure and low complication rate make this a treatment breakthrough in this difficult group.

TOLTERODINE EXTENDED RELEASE ATTENUATES LOWER URINARY TRACT SYMPTOMS IN MEN WITH BENIGN PROSTATIC HYPERPLASIA

PURPOSE

In this open label, prospective study we determined the efficacy and tolerability of tolterodine extended release (ER) in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in whom previous alpha-blocker therapy had failed.

MATERIALS AND METHODS

A total of 43 consecutive men with BPH and LUTS in whom a mean of 5.7 months of alpha-blocker therapy had failed due to adverse events (11) or a lack of efficacy (32) received tolterodine ER (4 mg daily) for 6 months. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, total score on the erectile function domain of the International Index of Erectile Function and adverse events.

RESULTS

A total of 39 men (91%) with a mean age of 61 years completed the 6-month trial. Mean 24-hour micturition frequency decreased from 9.8 to 6.3 voids and nocturia decreased from 4.1 to 2.9 episodes nightly. Significant changes in mean American Urological Association symptom scores (-6.1), the peak urinary flow rate (1.9 ml per second) and post-void residual volume (-22 ml) were also observed. Of the men 27 (63%) were potent at baseline and 29 (67%) were potent after 6 months of tolterodine ER treatment. Mean International Index of Erectile Function erectile function domain scores increased (6.9). Four men (9%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention.

CONCLUSIONS

Treatment with tolterodine ER in men with BPH and LUTS may be a reasonable therapeutic option as initial therapy or after failed treatment with alpha-blockers.

CHANGES IN BRAIN ACTIVITY FOLLOWING SACRAL NEUROMODULATION FOR URINARY RETENTION

PURPOSE

Sacral nerve stimulation (neuromodulation) can restore bladder sensation and the ability to void in women with urinary retention due to sphincter overactivity (Fowler's syndrome). Modulation of central afferent activity is considered critical to this therapeutic effect but the neural mechanisms are poorly understood. Therefore, we undertook a functional brain imaging study to determine how neuromodulation acts on brain centers involved in the representation and control of bladder function.

MATERIALS AND METHODS

Eight patients with Fowler's syndrome and 8 healthy controls underwent brain imaging with positron emission tomography to identify regions of brain activity relating to the perception of bladder fullness and their modulation by sacral nerve stimulation.

RESULTS

In healthy controls bladder fullness enhanced activity in brainstem (midbrain) and limbic cortical regions. Women with urinary retention showed no significant brainstem activity but did show enhanced limbic cortical activity when the bladder was full in the absence of neuromodulation. Neuromodulation restored a normal pattern of midbrain activity and decreased cortical activity in this group.

CONCLUSIONS

Our study provides novel neuroimaging evidence for the existence of abnormal interaction between brainstem and cortical centers in women with urinary retention. Furthermore, we have been able to show evidence that the therapeutic effect of sacral neuromodulation is achieved through restoration of activity associated with brainstem autoregulation and attenuation of cingulate activity.

Meta-analysis of holmium laser enucleation versus transurethral resection of the prostate for symptomatic prostatic obstruction

BACKGROUND

Holmium laser enucleation (HoLEP) is an alternative to transurethral resection (TURP) of the prostate for symptomatic prostatic obstruction.

METHODS

Randomized controlled trials comparing HoLEP and TURP were identified systematically using Medline, Embase and The Cochrane Library. Primary outcomes were peak urinary flow rate (Qmax), postvoid residual volume, symptom score and quality of life. Secondary outcomes were duration of operation, hospital stay, blood loss, catheterization time and adverse events.

RESULTS

There was no statistically significant difference between HoLEP and TURP in terms of Qmax at 6 and 12 months' follow-up. HoLEP was associated with significantly less blood loss, a shorter catheterization time and a shorter hospital stay. TURP was associated with reduced operating time. The techniques were similar in terms of urethral stricture, stress incontinence, transfusion requirement and rate of reintervention.

CONCLUSION

HoLEP and TURP provide a similar improvement in Qmax. HoLEP, however, has several advantages over TURP, despite requiring more operating time. It is at least as safe as TURP in terms of adverse events.

Factors predictive of urinary retention after a tension-free vaginal tape procedure for female stress urinary incontinence

PURPOSE

We performed this study to evaluate factors related to urinary retention after a tension-free vaginal tape (TVT) procedure for female stress urinary incontinence.

MATERIALS AND METHODS

We retrospectively analyzed the records of 375 women with a followup of at least 6 months from among patients who underwent the TVT procedure between March 1999 and May 2002 at our institution. We analyzed multiple parameters, including patient characteristics, symptoms and urodynamic studies, using univariate and multivariate regression analyses with respect to postoperative urinary retention, as defined by the need for intermittent catheterization for at least 3 days after the procedure. All patients in the nonretention (343) and retention (32) groups answered a global satisfaction question.

RESULTS

In answer to a global satisfaction question 338 of the 375 patients (90.1%) favored the procedure. Univariate analysis demonstrated that patient mean age, parity, peak urinary flow and a history of hysterectomy predicted urinary retention. However, on multivariate analyses the peak urinary flow rate was the only significant independent predictive factor (p = 0.007). While 28 patients (87.5%) in the retention group regained normal voiding without a specific procedure, 4 required tape release or cutting within 3 month of surgery. The global satisfaction question showed a significant difference between the nonretention and retention groups (91.5% vs 75% satisfaction, p = 0.03).

CONCLUSIONS

An accurate measurement of the peak urinary flow rate could predict women at risk for postoperative urinary retention that compromises global satisfaction after the highly curative TVT procedure.

Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms?

OBJECTIVE

To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies.

DESIGN

A blinded prospective study.

SETTING

Tertiary referral unit in a London teaching hospital.

POPULATION

One hundred and twenty-eight women referred for ambulatory urodynamics with equivocal laboratory urodynamic findings or whose symptoms were not explained by the laboratory urodynamic findings.

METHODS

Transvaginal ultrasound assessment of bladder wall thickness was performed in three planes with an empty bladder prior to ambulatory urodynamics. Mean bladder wall thickness was calculated and the results analysed with respect to the ambulatory urodynamic diagnosis.

MAIN OUTCOME METHODS

Mean bladder wall thickness in women with a normal ambulatory study or a diagnosis of detrusor instability, genuine stress incontinence (GSI) or mixed incontinence.

RESULTS

Using a one way analysis of variance (ANOVA) bladder wall thickness was found to be significantly different in all diagnostic groups and this reached significance (P = 0.0001). There was no overlap in the 95% confidence intervals representing a diagnosis of detrusor instability or genuine stress incontinence.

CONCLUSIONS

Transvaginal ultrasound assessment of mean bladder wall thickness is a sensitive screening tool, which can detect detrusor instability in those women with equivocal laboratory urodynamics. In women who have no evidence of GSI on laboratory studies, a cutoff of 6.0mm is highly suggestive of detrusor instability. However, in those women with GSI then ambulatory studies probably remain the investigation of choice.

The natural history of benign prostatic hyperplasia

The progression of benign prostatic hyperplasia (BPH) can be defined as a deterioration of clinical variables such as lower urinary tract symptoms (LUTS), health-related quality of life and peak flow rate, increased prostate size, or unfavourable outcomes such as acute urinary retention (AUR) and BPH-related surgery. The natural history of BPH is best analysed from longitudinal studies of community-dwelling men. In the Olmsted county study, which followed for 12 years a randomly selected cohort of 2115 men aged 40-79 years, there was an average increase in the International Prostate Symptom Score (IPSS) of 0.18 points per year, ranging from 0.05 for men in their fifties to 0.44 for those in their seventies. There was also a decrease in peak flow rate of 2% per year and a median prostate growth of 1.9% per year. The cumulative incidence of AUR was low (2.7% over 4 years). Information can also be collected from the placebo arms of controlled studies of men with symptomatic BPH, although the strict trial inclusion criteria and indeed the taking of a placebo itself introduce biases which limit the analysis of the natural history of the disease in this way, and its applicability to the general population. Hence, in the Medical Therapy of Prostatic Symptoms study, there is clear evidence that symptom deterioration, defined by a worsening of the IPSS of > or = 4 points, was by far the most prevalent progression event (79.5%), with a cumulative incidence of 14% over a mean follow-up of 4.5 years. As in the longitudinal community-based studies, AUR was rather uncommon (14.8% of overall progression events) with a cumulative incidence of 2%. BPH-related surgery, which was a secondary criterion in the study, was required in 5% of men. Similar conclusions can be drawn from a 2-year placebo-controlled study (ALTESS) assessing the impact of alfuzosin 10 mg once daily on LUTS/BPH progression in 1522 men with symptomatic BPH at high risk of developing AUR. Symptom deterioration was clearly the main progression event, with a cumulative incidence of 16.8%, compared to BPH-related surgery (6.5%) and AUR (2.2%). Thus, there is evidence from longitudinal studies, and to a lesser extent from the placebo arms of large controlled studies, that BPH is a progressive disease. Symptom worsening is by far the most frequently occurring progression event. Identifying those patients at risk of BPH progression is crucial to optimize their management.

Sacral neuromodulation for women with Fowler's syndrome

Neuromodulation of the sacral nerves has been found to be an effective therapy for a variety of lower urinary tract dysfunctions. The reported success rate for the period of trial stimulation (peripheral nerve evaluation test) prior to permanent implantation of a sacral nerve stimulator is variable, but generally reported to be in the region of 30-50%. We present here the results of the peripheral nerve evaluation test in 38 patients with urinary retention. 34 of the 38 had been found to have an abnormality of their striated urethral sphincter on electromyography using a concentric needle electrode, i.e., they had the disorder which was described by Fowler and coworkers in 1988. The overall success rate in this group was 68%. We believe that our relatively high success rate is due to sacral neuromodulation working via a mechanism which involves the urethral sphincter, an abnormality which had been demonstrated in 89% of these patients. Twelve of the patients subsequently underwent permanent implantation of a sacral nerve stimulator, and all of them have experienced a return of voiding. However, in 2 patients, there is a persisting need for self-catheterization. There is, however, a high reoperation rate.

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE

Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy.

MATERIALS AND METHODS

International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively.

RESULTS

At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery.

CONCLUSIONS

Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.

Long Term Results of Neuromodulation by Sacral Nerve Stimulation for Lower Urinary Tract Symptoms: A Retrospective Single Center Study

OBJECTIVE

To analyse the influence of technical improvements of Sacral Nerve Stimulation (SNS) on the incidence of surgical interventions and subjective long-term results of SNS.

METHODS

Retrospective, transversal study analyzing records of implanted patients at our department of Urology.

RESULTS

Of 149 patients analyzed, 107 had overactive bladder symptoms and 42 had urinary retention. Mean follow-up was 64,2 (sd = 38,5) months. In the whole group 194 adverse events occurred. 6 Patients had infection in their implanted system, one was explanted for infection. Most events could be solved by giving advice or by reprogramming the stimulator. 129 reoperations have been performed and 21 patients had their system explanted. Analysis of the data shows a striking difference in the incidence of reoperations, but small differences in subjective results in the groups of patients implanted before or after 1996, suggesting that a proactive approach towards adverse events is worthwhile.

CONCLUSIONS

SNS gives lasting benefit in patients with refractory symptoms of overactive bladder and non-obstructive urinary retention. The differences in outcomes and incidence of reoperation can be attributed to the learning curve and technical and surgical improvements in the application of SNS.

Long-term results of sacral neuromodulation for women with urinary retention

OBJECTIVE ; To review the long-term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6-year period at one tertiary referral centre.

PATIENTS AND METHODS

Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow-up, complications and revision procedures, and the most recent uroflowmetry results.

RESULTS

There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant-related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s.

CONCLUSION

In young women with retention, for whom there is still no alternative to lifelong self-catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.

Delayed treatment of bladder outlet obstruction after sling surgery: association with irreversible bladder dysfunction

PURPOSE

Our urethrolysis cohort demonstrated an unusual delay time to surgical treatment of bladder outlet obstruction. We determined whether urethrolysis outcomes, ie persistent bladder symptoms, were associated with time between sling and urethrolysis surgeries.

MATERIALS AND METHODS

Retrospective analysis of all patients who underwent urethrolysis for post-sling voiding dysfunction between June 1997 and June 2002 was performed. We excluded from study 6 patients with a known history of overactive bladder symptoms, neurogenic bladder dysfunction and use of anticholinergic pharmacotherapy before stress incontinence surgery. The remaining 15 patients were stratified into 2 outcomes groups based upon the absence or presence of post-urethrolysis bladder storage symptoms. Patients (7) in group 1 have no current bladder symptoms. Patients (8) in group 2 still require anticholinergic drug therapy for significant bladder symptoms of frequency and urgency. Data collected for the 2 groups included mean age, existence of urinary retention before urethrolysis, mean time to urethrolysis in months, urethrolysis outcome based upon subjective bladder symptoms and followup duration. For comparison of mean age between groups the standard t test was used. Fisher's exact test was used to compare frequency of urinary retention before urethrolysis between groups. Lastly the Mann-Whitney U test was conducted to compare time to urethrolysis between groups. All statistical analyses were conducted using the SPSS software package (SPSS, Inc., Chicago, Illinois).

RESULTS

There was no statistically significant difference between the groups with respect to age or frequency of urinary retention before urethrolysis. Time to urethrolysis for the whole cohort ranged from 2 to 66 months. Mean followup after urethrolysis was 17.3 +/- 22.9 months. Comparison of mean time between incontinence and urethrolysis surgeries between group 1 (9.0 +/- 10.1 months) and group 2 (31.25 +/- 21.9 months) demonstrated a statistically significant difference (p = 0.01).

CONCLUSIONS

This urethrolysis population demonstrated an unusual delay time to surgical treatment of bladder outlet obstruction. We categorized the cohort according to absence or presence of persistent bladder storage symptoms, and found a strong association between persistent bladder symptoms and greater delay to urethrolysis.

A comparison of lycopene and orchidectomy vs orchidectomy alone in the management of advanced prostate cancer

OBJECTIVE

To compare the efficacy of lycopene plus orchidectomy with orchidectomy alone in the management of advanced prostate cancer.

PATIENTS AND METHODS

Fifty-four patients with histologically confirmed metastatic prostatic cancer (M1b or D2) and a performance status of 0-2 (World Health Organization) were entered into the trial between March 2000 and June 2002. The trial comprised two treatment arms, i.e. patients were randomized to orchidectomy alone or orchidectomy plus lycopene (OL), each of 27 patients. Lycopene was started on the day of orchidectomy at 2 mg twice daily. Patients were evaluated clinically before and every 3 months after the intervention, with measurements of prostate-specific antigen (PSA), a bone scan and uroflowmetry, with the clinical response assessed as the change in these variables.

RESULTS

At 6 months there was a significant reduction in PSA level in both treatments, but more marked in the OL group (mean 9.1 and 26.4 ng/mL, P = 0.9). After 2 years these changes were more consistent in the OL group (mean 3.01 and 9.02 ng/mL; P < 0.001). Eleven (40%) patients in orchidectomy and 21 (78%) in the OL group had a complete PSA response (P < 0.05), with a partial response in nine (33%) and four (15%), and progression in seven (25%) and two (7%), respectively (P < 0.05). Bone scans showed that in the orchidectomy arm only four (15%) patients had a complete response, vs eight (30%) in the OL group (P < 0.02), with a partial response in 19 (70%) and 17 (63%), and progression in four (15%) and two (7%), respectively (P < 0.02). There was a significant improvement in peak flow rate in the OL group, with a mean difference of +1.17 mL/s (P < 0.04). Of the 54 patients who entered the trial, 19 (35%) died, 12 (22%) in orchidectomy and seven (13%) in OL group (P < 0.001).

CONCLUSION

Adding lycopene to orchidectomy produced a more reliable and consistent decrease in serum PSA level; it not only shrinks the primary tumour but also diminishes the secondary tumours, providing better relief from bone pain and lower urinary tract symptoms, and improving survival compared with orchidectomy alone.

Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery

OBJECTIVE

This study was undertaken to determine the incidence of clinically overt postpartum urinary retention after vaginal delivery and to examine what maternal, fetal, and obstetric factors are associated with this problem.

STUDY DESIGN

This was a retrospective case-controlled study of women who had overt postpartum urinary retention after vaginal delivery from August 1992 through April 2000.

RESULTS

Fifty-one of 11,332 (0.45%) vaginal deliveries were complicated by clinically overt postpartum urinary retention. In most cases (80.4%), the problem had resolved before hospital dismissal. Persons with urinary retention were more likely than control subjects to be primiparous (66.7% vs 40.0%; P <.001), to have had an instrument-assisted delivery (47.1% vs 12.4%; P <.001), to have received regional analgesia (98.0% vs 68.8%; P <.001), and to have had a mediolateral episiotomy (39.2% vs 12.5%; P <.001). On multivariate logistic regression analysis, of these 4 variables, only instrument-assisted delivery and regional analgesia were significant independent risk factors.

CONCLUSION

Clinically overt postpartum urinary retention complicates approximately 1 in 200 vaginal deliveries, with most resolving before hospital dismissal. Factors that are independently associated with its occurrence include instrument-assisted delivery and regional analgesia.