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Wang X, Liu P, Zhao S, Wang F, Li X, Wang L, Yan Y, Zou GA, Xu G. Dynamic simulation and analysis of the influence of urethral morphological changes on urodynamics after benign prostatic hyperplasia surgery: A computational fluid dynamics study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 243:107915. [PMID: 37995487 DOI: 10.1016/j.cmpb.2023.107915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Computational fluid dynamics (CFD) technology has been widely used in medicine to simulate and analyse urine flow characteristics in urology. In previous studies, researchers have modelled the analysis with a simple circular urethra, ignoring the effect of the patient's true urethral morphology on the urinary flow rate. Moreover, the studies tended to be steady-state simulations rather than dynamic simulations. Therefore, this study is established a relatively realistic model of the posterior urethra based on MRI data combined with the urodynamic data of patients and analysed the urodynamic characteristics of the posterior urethra model after benign prostatic hyperplasia (BPH) surgery using a CFD dynamic simulation. METHODS Based on clinical MRI data, a three-dimensional real urethral model was established for two patients with BPH after surgery. The boundary conditions were set according to the patients' real urodynamic data, and a Reynolds averaged Navier‒Stokes model was used for transient simulations. The dynamic simulation depicted the entire urination process, and the urine flow characteristics were studied under real urethral morphology after surgery. RESULTS 1. By comparing the three-dimensional trajectory of urine and the vortex identification cloud map based on the Q criterion, we intuitively observed the distribution of the vortex in the model, and a 'gourd-shaped' urethra was more likely to generate a vortex than a 'funnel-shaped' urethra. 2. After surgery for BPH, the changes in the posterior urethral pressure were mainly concentrated in the urethral membrane, and the velocity increased while the pressure decreased. The curve of the posterior urethral pressure changes during urination was simulated and calculated. The posterior urethral pressure gradients of the two patients were 6.6 cmH2O and 5.26 cmH2O. CONCLUSIONS The complete urinary discharge process can be dynamically simulated using CFD techniques. By comparing the simulation results, the posterior urethral morphology can have an important impact on the urinary flow characteristics. Determining the location of vortex generation can lay a foundation for personalized surgical plans for patients in the future. Furthermore, numerical simulations can provide a new method for the study of non-invasive posterior urethral pressure gradients.
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Affiliation(s)
- Xihao Wang
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Pengyue Liu
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Sen Zhao
- Department of Medical Imageology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Fei Wang
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xiaodong Li
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Lianqu Wang
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Yongjun Yan
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China
| | - Guang-An Zou
- School of Mathematics and Statistics Henan University, Kaifeng, China
| | - Guoliang Xu
- Department of Urology, The First Affiliated Hospital of Henan University, Kaifeng, China.
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Chialastri P, Chialastri A, Mueller T. Does Prostatic Urethral Lift Reduce Urinary Medications? Trends in Medical Treatment Before and After Prostatic Urethral Lift. J Endourol 2021; 35:657-662. [PMID: 33198488 DOI: 10.1089/end.2020.0848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To analyze medications used to treat urinary symptoms in patients before and after prostatic urethral lift (PUL) and determine if there are any significant relationships between several patient factors and onset of overactive bladder (OAB) symptoms requiring treatment. Methods: A retrospective chart review of 226 patients who underwent PUL was performed. Data were collected on age, urinary medications, voiding questionnaires, and prostate volume from 6 months before to 6 months after the intervention. Patients were broken up into groups for analysis with age <60 age (group 1), age 60-75 years (group 2), and age >75 years (group 3). A t-test was used to obtain p-values of the changes in questionnaire answers and urinary medication use after the procedure. To look for significant linear correlations between variables, a Pearson correlation was obtained and a randomization test was performed to obtain p-values. Results: Significant International Prostate Symptom Score (IPSS) and Quality of Life (QOL) improvements were noted in all groups (p < 0.01). Total medication and Alpha-blocker decrease was significantly correlated with age (p = 0.02 and p < 0.01, respectively). Older groups had a significant increase in Beta 3 agonist usage, with a significant decrease in usage in younger patients preoperatively. However, no significant linear increase was noted with age (p = 0.147). Prostate volume correlated with preoperative alpha-blocker use (p = 0.04). Conclusions: Older patients appear to have a higher incidence of medical treatment for de novo OAB symptoms after PUL. Prolonged medical therapy may delay surgical intervention, and intervention at an earlier age, unrelated to prostate volume, is postulated to be preventative of these symptoms. Further studies are needed to delineate long-term effects of medications, obstruction, and environmental factors that may lead to OAB after the obstruction is treated as well as the effect of early intervention on obstruction.
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Affiliation(s)
- Paul Chialastri
- Department of Urology, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Alex Chialastri
- Department of Engineering, University of California, Santa Barbara, Santa Barbara, California, USA
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Bosch R, Abrams P, Averbeck MA, Finazzi Agró E, Gammie A, Marcelissen T, Solomon E. Do functional changes occur in the bladder due to bladder outlet obstruction? - ICI-RS 2018. Neurourol Urodyn 2019; 38 Suppl 5:S56-S65. [PMID: 31278801 PMCID: PMC6915908 DOI: 10.1002/nau.24076] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/27/2019] [Indexed: 01/24/2023]
Abstract
Studies on bladder dysfunction (BD), more specifically functional‐urodynamic changes in the bladder as a result of bladder outlet obstruction (BOO) have been summarized for this TT. Based on available, but limited evidence from human studies a three‐stage model can be hypothesized to characterize BOO‐induced bladder remodeling: hypertrophy, compensation (increased detrusor contractility during the voiding phase, often in combination with filling phase detrusor overactivity) followed by the phase of decompensation [detrusor underactivity]. The time between the start of compensation and eventual decompensation seems to be determined by age of onset, severity, and type of obstruction and clinical mitigating factors such as vascular and metabolic problems. Understanding the relative contributions of these factors may allow the development of personalized timelines and probabilities for these obstructed patients.
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Affiliation(s)
- Ruud Bosch
- Department of Urology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Paul Abrams
- Department of Urology, Bristol Urological Institute, Bristol, United Kingdom
| | | | - Enrico Finazzi Agró
- Department of Experimental Medicine and Surgery, Department of Surgery, Policlinico Tor Vergata, University of Rome "Tor Vergata" and Urology Unit, Rome, Italy
| | - Andrew Gammie
- Bristol Urological Institute, Southmead Hospital, Bristol, United Kingdom
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Eskinder Solomon
- Department of Urology, Guy's and St Thomas' NHS Trust, London, United Kingdom
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[S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia]. Urologe A 2016; 55:184-94. [PMID: 26518303 DOI: 10.1007/s00120-015-3984-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.
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Mangera A, Chapple C. Update summarising the conclusions of the international consultation on male lower urinary tract symptoms. World J Clin Urol 2015; 4:83-91. [DOI: 10.5410/wjcu.v4.i2.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/07/2014] [Accepted: 05/11/2015] [Indexed: 02/05/2023] Open
Abstract
The International Consultation on Urological Disease have recently published comprehensive conclusions, based on evidence reviewed by eight committees, on aspects of male lower urinary tract symptoms (LUTS). In this review, we summarise the conclusions from four of the committees, namely, the evidence regarding the epidemiology of male LUTS, patient assessment, nocturia and medical management. It is indisputable that with an expanding and ageing global population the prevalence of male LUTS is likely to increase. Therefore symptom prevention and preservation of quality of life (QoL) feature highly in the guidelines. There are now a number of different medical options, proven to lead to significant improvements in symptom scores, flow rate and QoL available to men with LUTS. Meta-analyses have shown the benefits for alpha blockers, antimuscarinics, 5-α reductase and phosphodiesterase-5 inhibitors. High level evidence also exists for combinations of all of the above with alpha blockers and so men with concomitant storage symptoms, prostate volume > 30 mL, PSA > 1.4 or erectile dysfunction may be considered for combination treatment of an alpha blocker with an antimuscarinic, 5-α reductase inhibitor or phosphodiesterase-5 inhibitor respectively. In an era of personalised medicine, appropriate patient selection is likely to provide the key to the most effective clinical management strategy.
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Urodynamic Effects of Once Daily Tadalafil in Men With Lower Urinary Tract Symptoms Secondary to Clinical Benign Prostatic Hyperplasia: A Randomized, Placebo Controlled 12-Week Clinical Trial. J Urol 2013; 189:S135-40. [DOI: 10.1016/j.juro.2012.11.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 11/23/2022]
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de Kort LMO, Kok ET, Jonges TN, Rosier PFWM, Bosch JLHR. Urodynamic effects of transrectal intraprostatic Ona botulinum toxin A injections for symptomatic benign prostatic hyperplasia. Urology 2012; 80:889-93. [PMID: 22854138 DOI: 10.1016/j.urology.2012.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 05/26/2012] [Accepted: 06/02/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate urodynamic, symptomatic, and histologic effects of intraprostatic injection with Ona botulinum toxin A for benign prostatic hyperplasia. METHODS Patients >55 years with symptomatic benign prostatic hyperplasia failing medical therapy were treated. Inclusion criteria were International Prostate Symptom Score >7, prostate volume 30-50 cm(3), and urodynamic bladder outlet obstruction >Schäfer grade 2. A transrectal intraprostatic injection of 200 IU Ona botulinum toxin A was given. Filling cystometry and pressure flow studies were performed at 3, 6, and 12 months post injection. International Prostate Symptom Score, International Prostate Symptom Score quality of life, prostate-specific antigen, and prostate volume were measured up until 12 months; prostate biopsies before and after Ona botulinum toxin A injection were done for histology and cell proliferation. RESULTS Fifteen men (mean age 64.9 years) were included. Ona botulinum toxin A injection was well tolerated with few complications. Postvoid residual improved (170 to 80 mL), but maximum flow rate and bladder outlet resistance parameters did not change during follow-up. International Prostate Symptom Score and International Prostate Symptom Score quality of life improved (22 to 13 and 5 to 2, respectively), whereas prostate-specific antigen and prostate volume remained unaltered. Cell proliferation did not decrease and in 37% and 64% of pre- and posttreatment biopsies, respectively, some degree of prostatitis was found. Ten of 15 patients eventually underwent transurethral prostate resection because of persisting symptoms. CONCLUSION Intraprostatic Ona botulinum toxin A for symptomatic benign prostatic hyperplasia did not affect urodynamic outcomes, except for postvoid residual. Although symptom scores improved, we were not able to show change in prostate volume, prostate-specific antigen, or histologic outcomes. A placebo effect of intraprostatic Ona botulinum toxin A could not be ruled out.
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Affiliation(s)
- Laetitia M O de Kort
- Department of Urology, University Medical Center Utrecht, Utrecht, the Netherlands.
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Hutchinson RC, Thiel DD, Tavlarides AM, Diehl NN, Parker AS. The Effect of Robot-Assisted Laparoscopic Prostatectomy on Nocturia. J Endourol 2012; 26:861-5. [DOI: 10.1089/end.2011.0611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - David D. Thiel
- Department of Urology, Mayo Clinic, Jacksonville, Florida
| | | | - Nancy N. Diehl
- Department of Urology, Mayo Clinic, Jacksonville, Florida
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Yoshida M, Kudoh J, Homma Y, Kawabe K. New clinical evidence of silodosin, an α1A selective adrenoceptor antagonist, in the treatment for lower urinary tract symptoms. Int J Urol 2012; 19:306-16. [DOI: 10.1111/j.1442-2042.2011.02957.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Wagenlehner FM, Bescherer K, Wagenlehner C, Zellner M, Weidner W, Naber KG. Urodynamic Impact of Acute Urinary Retention in Patients with Benign Prostatic Hyperplasia: A 2-Year Follow-Up after Transurethral Resection of the Prostate. Urol Int 2011; 86:73-9. [DOI: 10.1159/000317308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/16/2010] [Indexed: 11/19/2022]
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Dmochowski R, Roehrborn C, Klise S, Xu L, Kaminetsky J, Kraus S. Urodynamic effects of once daily tadalafil in men with lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia: a randomized, placebo controlled 12-week clinical trial. J Urol 2010; 183:1092-7. [PMID: 20092847 DOI: 10.1016/j.juro.2009.11.014] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 12/29/2022]
Abstract
PURPOSE We explored the impact of once daily tadalafil on urodynamic measures in men with lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia via invasive and noninvasive urodynamic studies. MATERIALS AND METHODS We conducted a multicenter, randomized, double blind, placebo controlled clinical trial comparing once daily tadalafil 20 mg vs placebo during 12 weeks in men with lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia with or without bladder outlet obstruction. Invasive and noninvasive urodynamics, International Prostate Symptom Score and general safety were assessed. The primary study end point was change in detrusor pressure at maximum urinary flow rate. RESULTS Urodynamic measures remained largely unchanged during the study with no statistically significant or clinically adverse difference between tadalafil and placebo in change in detrusor pressure at maximum urinary flow rate (mean difference between treatments -2.2 cm H(2)O, p = 0.33) or any other urodynamic parameter assessed including maximum urinary flow rate, maximum detrusor pressure, bladder outlet obstruction index or bladder capacity (all measures p > or = 0.13). Treatment with tadalafil resulted in significant improvements in International Prostate Symptom Score (mean difference between treatments -4.2, p < 0.001). Tadalafil was generally well tolerated with the majority of adverse events being mild to moderate in severity and few patients discontinuing due to adverse events (tadalafil 2.0%, placebo 1.0%). CONCLUSIONS Treatment with tadalafil once daily for lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia showed no negative impact on bladder function as measured by detrusor pressure at maximum urinary flow rate or on any other urodynamic parameter assessed. Nonetheless men receiving tadalafil reported significant improvements in International Prostate Symptom Score with an adverse events profile similar to other recent studies of tadalafil for lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia.
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Affiliation(s)
- Roger Dmochowski
- Department of Urology, Vanderbilt University, Nashville, Tennessee, USA.
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Yamaguchi O, Nishizawa O, Takeda M, Yokoyama O, Homma Y, Kakizaki H, Obara K, Gotoh M, Igawa Y, Seki N, Yoshida M. Clinical guidelines for overactive bladder. Int J Urol 2009; 16:126-42. [PMID: 19228224 DOI: 10.1111/j.1442-2042.2008.02177.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Osamu Yamaguchi
- Department of Urology, Fukushima Medical University, Fukushima-shi, Fukushima, Japan.
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Wagrell L, Sundin A, Norlén B. Intraprostatic Blood-Flow Changes during ProstaLund Feedback Treatment Measured by Positron Emission Tomography. J Endourol 2005; 19:873-7. [PMID: 16190848 DOI: 10.1089/end.2005.19.873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To investigate the changes in intraprostatic blood flow during ProstaLund Feedback Treatment (PLFT) using positron emission tomography (PET). PATIENTS AND METHODS Three patients with bladder outlet obstruction caused by benign prostatic hyperplasia were treated with PLFT using the ProstaLund device, which has the ability to calculate the intraprostatic blood flow. Treatment was given for 1 hour. Five PET scans were done during each treatment to calculate the three-dimensional blood flow using [(15)O]H(2)O as the tracer. RESULTS The prostatic blood flow increased steeply at the beginning of the treatment in all three patients, by as much as 100% at 20 and 35 minutes. For patients 1 and 2, there was a fast decline in intraprostatic flow at the last scan (55 minutes), clearly seen as a large zone with circulation arrest centrally in the prostate. The intraprostatic temperature was <50 degrees C during the first 30 minutes but increased to 52 degrees to 60 degrees C during the second part of the treatment. Patient 3 had high blood flow during the entire treatment. A reduction of the blood flow was seen at the end of the treatment but not to the same extent as in the other two patients. The intraprostatic temperature did not exceed 49 degrees C for this patient. CONCLUSION The large variations seen in intraprostatic blood flow suggest that intraprostatic temperature monitoring is mandatory to optimize the treatment. The ProstaLund bioheat model calculates the change in intraprostatic blood flow accurately.
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Affiliation(s)
- Lennart Wagrell
- Department of Urology, University Hospital Uppsala, Uppsala, Sweden.
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Vesely S, Knutson T, Dicuio M, Damber JE, Dahlstrand C. Transurethral Microwave Thermotherapy: Clinical Results after 11 Years of Use. J Endourol 2005; 19:730-3. [PMID: 16053366 DOI: 10.1089/end.2005.19.730] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the durability of the effect of transurethral microwave thermotherapy (TUMT) for lower urinary-tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO). PATIENTS AND METHODS A total of 841 patients with LUTS received TUMT using the Prostatron device at Sahlgrenska University Hospital, Sweden. Two treatment programs were used: low-energy Program 2.0 and high-energy Program 3.5. A questionnaire, including International Prostate Symptom Score (IPSS), quality of life (QoL) score, and questions about general health status, was sent to all the patients. The mean followup after TUMT was 8.8 years for Program 2.0 and 2.5 years for Program 3.5. RESULTS At the end of follow-up, 67% of the patients treated with Program 2.0 were satisfied with the TUMT. During the follow-up period, 37% of patients experienced worsened symptoms, 18% various complications (e.g., hematuria), and 25% transient urinary-tract infection, and 16% went into retention. Secondary treatment (repeat TUMT, transurethral resection, medical therapy) was needed in 32% of patients. The mean IPSS was 13.5, and QoL score decreased to 2.1. With Program 3.5, 82% of the patients were satisfied, with another 17% having increased symptoms, 17% various complication, 25% urinary tract infection, and 26% retention. Only 7% of patients needed secondary treatment. The IPSS and QoL score went down to 11.4 and 1.6, respectively. CONCLUSION These long-term data show that TUMT produces durable improvement and, with its safety and low retreatment rate, presents an attractive alternative for patients with LUTS suggestive of BOO.
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Affiliation(s)
- Stepan Vesely
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Tooher R, Sutherland P, Costello A, Gilling P, Rees G, Maddern G. A Systematic Review of Holmium Laser Prostatectomy for Benign Prostatic Hyperplasia. J Urol 2004; 171:1773-81. [PMID: 15076275 DOI: 10.1097/01.ju.0000113494.03668.6d] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate. MATERIALS AND METHODS We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison. RESULTS Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia. CONCLUSIONS Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.
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Affiliation(s)
- Rebecca Tooher
- ASERNIP-S, Royal Australasian College of Surgeons, Stepney, South Australia
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Clemens JQ. The role of urodynamics in the diagnosis and treatment of benign prostatic hyperplasia. Curr Urol Rep 2003; 4:269-75. [PMID: 12882717 DOI: 10.1007/s11934-003-0083-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J Quentin Clemens
- Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Tarry 11-715, Chicago, IL 60611, USA.
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Dmochowski RR, Staskin D. Overactive bladder in men: special considerations for evaluation and management. Urology 2002; 60:56-62; discussion 62-3. [PMID: 12493356 DOI: 10.1016/s0090-4295(02)01797-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Lower urinary tract symptoms (LUTS) in men may arise from a variety of underlying causes, including benign prostatic hyperplasia. LUTS may have a significant component of storage symptoms (urgency, frequency, urge incontinence) at presentation; however, the absence of overactive bladder (OAB) symptoms does not necessarily imply pure outlet obstruction nor does their presence indicate the lack thereof. Symptomatic correlates to urodynamic findings are high when considering isolated OAB symptoms. However, mixed presentations or more overtly obstructive scenarios have less correlation with baseline symptom appraisal instruments. The ideal approach for diagnosis and management is predicated on a graded approach, with more invasive evaluation withheld for those men in whom presumptive therapy fails or who present with associated complex symptoms and in whom a higher level of intervention is being considered. The increasing incidence of LUTS with age implies a partial detrusor contribution, which must be considered in the overall management schema.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Urodynamic Patterns of Normal Male Micturition:. J Urol 2002. [DOI: 10.1097/00005392-200210010-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Urodynamic patterns of normal male micturition: influence of water consumption on urine production and detrusor function. J Urol 2002; 168:1458-63. [PMID: 12352417 DOI: 10.1016/s0022-5347(05)64473-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Urodynamic characterization of normal male micturition can be a useful standard in the analysis of data on patients complaining of voiding dysfunction. The validity of such a standard is based on the need to obtain baseline parameters of pressure flow values, an important consideration when evaluating prostatic obstruction and its treatment. While current numerical pressure flow values provide a useful summary of the voiding sequence, a more complete analysis of the pattern of normal voiding may reveal more functionally useful information concerning micturition. We establish basic experimental conditions that simulate normal voiding of physiologically produced urine by the kidneys measured at intervals representing real stages of bladder filling. We report the results of an investigation designed to study consecutive micturitions at bladder volumes determined by water consumption and endogenous circadian rhythm. Our particular focus is to examine critically the urodynamic pattern of pressure flow and obtain evidence to support the hypothesis that fluid consumption has an important role in detrusor function. MATERIALS AND METHODS Urodynamic studies were conducted on 39 asymptomatic male volunteers with a mean age of 25.8 years (range 21 to 31) and mean weight of 75.5 kg. (range 63 to 95). Volunteers were divided into 2 groups according to water consumption regimen of 30 ml./kg. daily (17 patients, group 1) and 60 ml./kg. daily (12, group 2). Bladder pressure was monitored via a suprapubic catheter and abdominal pressure was measured via a rectal balloon using an ambulatory system. Average duration of each monitoring period was 20.5 hours. Detrusor pressure and flow rate records from each subject were identified, and consecutive filling and voiding phases were averaged during the entire monitoring period using the onset of micturition as a time marker. The average pattern of pressure, flow rate, cumulative volume and contractility curves for each subject, as well each for group, was computed and graphically presented. For each group the average parameters of urethral opening pressure, maximum detrusor pressure, detrusor pressure at maximum flow rate, bladder capacity and bladder contraction strength were calculated and compared statistically. Numerical values are mean +/- SE. RESULTS Water consumption and urine production rate influenced the pattern and many of the urodynamic parameters of micturition. In both groups there was a detrusor pressure increase before voiding and numerically maximum detrusor pressure consistently occurred before micturition started. Micturition pattern showed an asymptotic relationship between pressure and flow. Doubling of water consumption increased urethral opening pressure from 51.2 +/- 3.2 to 61.5 +/- 5.1 (p <0.05), maximum detrusor pressure from 58.9 +/- 4.5 to 70.0 +/- 6.2 cm. H(2)O (p <0.01) and contractility from 15.4 +/- 1.4 to 17.7 +/- 1.4 w/m(2). There were no significant differences due to water consumption in maximum flow rate (24.4 +/- 1.4 to 25.2 +/- 1.8 ml. per second) or bladder capacity (286 +/- 20 to 329 +/- 15 ml.) but a significant increase in the number of micturitions from 5.8 +/- 0.5 to 9.8 +/- 0.5 per day (p <0.001) proportional to water consumption. CONCLUSIONS The configuration of the observed pressure flow characteristics of the normal male is suggestive of the "Starlings law" relationship and the pattern of the urodynamic parameters were markedly different from those reported in the current standardization literature, suggesting the need to revise the current concept of normal male micturition. Voiding pressure and contractility increased in accordance with water consumption and urine production.
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A Randomized Controlled Trial Comparing Transurethral Resection of the Prostate, Contact Laser Prostatectomy and Electrovaporization in Men with Benign Prostatic Hyperplasia: Urodynamic Effects. J Urol 2002. [DOI: 10.1097/00005392-200209000-00037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Van Melick HH, Van Venrooij GEPM, Eckhardt MD, Boon TA. A randomized controlled trial comparing transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia: urodynamic effects. J Urol 2002; 168:1058-62. [PMID: 12187222 DOI: 10.1016/s0022-5347(05)64574-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We compared urodynamic and uroflowmetry improvements in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) after transurethral prostate resection, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS A prospective randomized controlled trial was performed in men with lower urinary tract symptoms suggestive of BPH who met the criteria of the International Scientific Committee on BPH, had a prostate volume of between 20 and 65 ml., and a Schäfer obstruction grade of 2 or greater. Before and 6 months after treatment urodynamics and free uroflowmetry were performed. RESULTS A total of 50, 45 and 46 men were randomized to transurethral prostate resection, laser treatment and electrovaporization, respectively. Baseline characteristics were similar in the 3 groups. Detrusor contractility did not change in any of the treatment groups. The average maximum free flow rate increased by a factor of 2.4 after transurethral prostate resection, 2.5 after laser prostatectomy and 2.4 after electrovaporization. The Schäfer obstruction grade decreased by a factor of 0.3 in all groups. Obstruction (Schäfer grade greater than 2) was not noted after transurethral prostate resection or electrovaporization but it was evident in 2 patients after laser prostatectomy. Effective capacity increased by a factor of 1.5 or more. The incidence of detrusor instability was decreased by half in all groups. The incidence of significant post-void residual urine volume decreased in all groups. CONCLUSIONS There were no significant differences in the improvement in urodynamic and uroflowmetry parameters 6 months after treatment when comparing transurethral prostate resection, contact laser prostatectomy and electrovaporization in men with lower urinary tract symptoms suggestive of BPH.
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Affiliation(s)
- Harm H Van Melick
- Department of Urology, University Medical Center Utrecht, The Netherlands
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Constantinou CE, Damaser MS, Perkash I. Displacement sequence and elastic properties of anterior prostate/urethral interface during micturition of spinal cord injured men. ULTRASOUND IN MEDICINE & BIOLOGY 2002; 28:1157-1163. [PMID: 12401386 DOI: 10.1016/s0301-5629(02)00505-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The management of complex micturition problems frequently encountered in patients with spinal cord injury (SCI) may be facilitated by characterization of the elastic properties of the prostate. To this end, we have developed a method of evaluating changes in prostate biomechanics using ultrasound (US) images obtained during routine diagnostic urodynamic evaluations. Ultrasound video sequences of the prostate and urethra during voiding were digitized simultaneously with bladder pressure measurement on 76 patients with spinal cord injury, having a mean age of 47 +/- 16 years. Computer enhancement of the bladder/prostate/urethral interface from sequences of 2-D US images facilitated measurement of midprostatic urethral displacement during micturition. Of 76 patients, 21 were able to initiate voiding. Maximum urethral diameter was 12.0 +/- 1.3 mm, with corresponding maximum voiding pressure of 61.6 +/- 1.9 cmH(2)O. Urethral/prostatic pressure strain elastic modulus (Ep) was 960 +/- 624 N/m(2) and stiffness (beta) calculated as the inverse of compliance was 2.8 +/- 0.1. The diameter of the urethra at P(det50+), during the opening phase, was 0.4 +/- 0.1 mm and, during the closing phase, was 0.7 +/- 0.1 mm. During voiding, the anterior prostate was displaced to a greater extent than the posterior prostate. These observations suggest that distension of the prostate/urethra during micturition is hysteretic and nonuniform and indicates regional differences in compliance within the prostate/urethra interface. These regional differences lend support to the concept that the posterior prostate is implicated in the active process of micturition involving the fibromuscular stroma. Clinical application of this method could include quantification of the biomechanics of micturition consequent to spinal injury, prostatic enlargement, and the impact of targeted evaluation of pharmacological interventions.
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Van Venrooij GEPM, Van Melick HHE, Eckhardt MD, Boon TA. Correlations of urodynamic changes with changes in symptoms and well-being after transurethral resection of the prostate. J Urol 2002; 168:605-9. [PMID: 12131318 DOI: 10.1097/00005392-200208000-00042] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To establish the predictive value of urodynamics on the outcome of transurethral prostate resection for benign prostatic enlargement we correlated urodynamic changes with symptomatic improvement, decreased bother, and increased general well-being and quality of life after transurethral prostate resection. MATERIALS AND METHODS Men with lower urinary tract symptoms were selected if they met study criteria and underwent tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia, and if post-void residual urine volume and prostate size were estimated. Patients answered quality of life, symptom index, symptom problem index and benign prostatic hyperplasia impact index questions. Patients also underwent urodynamic evaluation. Men were included in analysis when transurethral prostate resection was selected as the treatment modality. Of the 132 patients included 93 were reevaluated 6 months after transurethral prostate resection. RESULTS Improvements after transurethral prostate resection were significantly associated with decreased bladder outlet obstruction (p <0.01). However, 32 cases that were unobstructed or equivocal preoperatively also benefited moderately from resection. Effective capacity, that is cystometric capacity minus post-void residual urine volume, increased by an average of 45% postoperatively. The increase in effective capacity contributed to a significant decrease in symptoms and bother, and to improved well-being. Of the men with a urodynamically proved stable bladder 90% maintained a stable bladder after prostatectomy, while in 50% with a urodynamically proved unstable bladder it became stable postoperatively. CONCLUSIONS Performing urodynamics preoperatively helps to predict the degree of symptom relief, decreased bother and increased well-being after transurethral prostate resection.
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van Venrooij GE, van Melick HH, Eckhardt MD, Boon TA. Correlations of Urodynamic Changes With Changes in Symptoms and Well-being After Transurethral Resection of the Prostate. J Urol 2002. [DOI: 10.1016/s0022-5347(05)64688-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | - Harm H.E. van Melick
- From the Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mardy D. Eckhardt
- From the Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tom A. Boon
- From the Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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Tubaro A, Carter S, Hind A, Vicentini C, Miano L. A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. J Urol 2001. [PMID: 11435849 DOI: 10.1016/s0022-5347(05)66102-2] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We investigate the safety and efficacy of suprapubic transvesical prostatectomy, and the change in bladder wall thickness after surgery. MATERIALS AND METHODS We conducted a prospective 1 center study of 32 consecutive patients who underwent transvesical prostatectomy from December 1996 to March 1997 for benign prostatic hyperplasia with large prostate volume, who were followed for 1 year. Pressure flow study and transrectal sonography were performed at baseline and repeated at 6 months. Bladder wall thickness was measured at baseline and regular intervals postoperatively. A morbidity questionnaire was completed during the first 6 weeks after surgery. RESULTS An average of 63 gm. prostate adenoma were enucleated at surgery. An indwelling catheter was required for an average plus or minus standard deviation of 5.4 +/- 2.6 days after treatment. The International Prostate Symptom Score decreased from 19.9 +/- 4.4 to 1.5 +/- 2.7 and the quality of life score decreased from 4.9 +/- 1.0 to 0.2 +/- 0.4 at year 1, respectively. Maximum flow rate improved from 9.1 +/- 5.3 to 29.0 +/- 8.9 ml. per second. Residual urine decreased from 128 +/- 113 to 8 +/- 18 ml. Before surgery 30 patients had obstruction and 2 were in the equivocal zone of the International Continence Society nomogram. At 6 months after prostatectomy 30 patients did not have obstruction, and 2 who were subsequently operated on for bladder neck sclerosis were equivocal and had obstruction, respectively. No patient had significant postoperative bleeding and no heterologous blood transfusions were required. There were 4 men who had urinary tract infection and 1 who had wound infection. A slight decrease in erectile function was observed 6 weeks postoperatively, and no change in patient libido and quality of sex life was reported. The total complication rate was 31.3%. The bladder was unstable in 7 men before and 3 after surgery. A significant decrease in bladder wall thickness was observed from 5.2 +/- 0.7 at baseline to 2.9 +/- 0.9 mm. at year 1 postoperatively. CONCLUSIONS Our study confirms the excellent clinical outcome of transvesical prostatectomy, and rapid improvement of most subjective and objective parameters during the 4 weeks after surgery. Bladder hypertrophy appears to be significantly reduced after prostate surgery. The urodynamic results in patients who underwent open surgery probably represent the maximum obtainable relief of obstruction and should be considered the reference standard to which all other treatments, including transurethral resection, should aspire.
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Affiliation(s)
- A Tubaro
- Division of Urology, Department of Surgical Sciences, L'Aquila University School of Medicine, L'Aquila, Italy
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A PROSPECTIVE STUDY OF THE SAFETY AND EFFICACY OF SUPRAPUBIC TRANSVESICAL PROSTATECTOMY IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA. J Urol 2001. [DOI: 10.1097/00005392-200107000-00040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sonke GS, Kortmann BB, Verbeek AL, Kiemeney LA, Debruyne FM, de La Rosette JJ. Variability of pressure-flow studies in men with lower urinary tract symptoms. Neurourol Urodyn 2001; 19:637-51; discussion 651-6. [PMID: 11071695 DOI: 10.1002/1520-6777(2000)19:6<637::aid-nau2>3.0.co;2-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The objective of this study was to assess the short-term test-retest variability of pressure-flow studies (PFS) in men with lower urinary tract symptoms (LUTS). By choosing a short interval between two consecutive PFS, but notably not performing two tests within a single session, both tests represent the same routine testing procedure. Eighty-nine patients with LUTS suggestive of bladder outlet obstruction or detrusor underactivity, who received PFS, were asked to undergo a second urodynamic evaluation within 4 weeks after the initial test. At both visits, specialized physicians performed the PFS. Obstruction was quantified using the Abrams-Griffiths number (AG number). Each patient was classified as obstructed, unobstructed, or equivocally obstructed according to the International Continence Society nomogram. As expected, no systematic difference was observed in AG number between the first and the second visit at the group level. There was, however, considerable variation at the individual level. The average within-patient standard deviation was 14 cm H(2)O. This finding shows that if a patient's AG number is 30 at the first visit, his true AG number can be any value between 30 +/- 1.96 * 14 = 3 to 57, owing to random variability alone. The average within-patient standard deviation did not differ significantly between sub-groups of obstruction and other variables such as patient age, symptom score, prostate volume, or residual volume. The variability appeared to increase slightly with an increased interval between visits. Of all patients, 39% changed at least one category of obstruction at the second visit and 3% changed from definitely obstructed to definitely unobstructed or vice versa. We conclude that PFS cannot stand the test of serving as a gold standard to identify bladder outlet obstruction in patients with LUTS.
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Affiliation(s)
- G S Sonke
- Department of Urology, Medical Centre, Nijmegen, The Netherlands.
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Stoevelaar HJ, McDonnell J. Changing therapeutic regimens in benign prostatic hyperplasia. Clinical and economic considerations. PHARMACOECONOMICS 2001; 19:131-153. [PMID: 11284380 DOI: 10.2165/00019053-200119020-00003] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
About one-quarter of men aged 50 years and older experience voiding problems due to benign prostatic hyperplasia (BPH). Until about 10 years ago, surgery (particularly transurethral resection of the prostate) was the only effective treatment for symptomatic BPH. Over the last decade, several new treatments have been introduced. These include different types of medication (alpha-blockers and finasteride), thermotherapy, laser prostatectomy, needle ablation and vaporisation methods. The diffusion of these less invasive treatment modalities has resulted not only in a decrease in the age-adjusted surgery rates, but also in an increase of the total number of men treated for BPH. A large number of studies on clinical benefits and risks reveal that the conventional types of surgery remain the most effective treatments, whereas new interventional therapies require a shorter hospital stay and result in fewer short term complications. The efficacy of medication is lower than that of interventional treatments. Adverse effects include dizziness and orthostatic hypotension (alpha-blockers) and decreased sexual function (finasteride), but are generally mild. There is some evidence that medication and minimally invasive treatments may preclude eventual surgical treatment, but the precise effect is difficult to estimate because of differences in the study populations and the relatively short study periods. As a result of the dynamic nature of BPH treatment and the lack of long term data, the cost effects of the introduction of the various new treatments are also difficult to assess. Given the aging of the population and the growing percentage of patients with BPH for whom any type of treatment can be considered, a considerable increase of total costs can be expected. Long term prospective studies are necessary to gain insight into the most cost-effective treatment for different patient groups.
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Affiliation(s)
- H J Stoevelaar
- Institute for Health Care Policy and Management, Erasmus University, Rotterdam, The Netherlands.
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Arnold EP. Tamsulosin in men with confirmed bladder outlet obstruction: a clinical and urodynamic analysis from a single centre in New Zealand. BJU Int 2001; 87:24-30. [PMID: 11121988 DOI: 10.1046/j.1464-410x.2001.00983.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the clinical and pressure-flow effects of tamsulosin 0.4 mg once daily in patients with lower urinary tract symptoms (LUTS) caused by benign prostatic obstruction (BPO), as documented by pressure-flow studies performed according to a standardized protocol in one centre. PATIENTS AND METHODS A single-centre study was conducted with an open-label design comprising a 2-week, single-blind, placebo run-in period and a 12-week active treatment period with tamsulosin 0.4 mg once daily. Eligible patients were men (aged > or = 45 years) with LUTS (total International Prostate Symptom Score, IPSS, > or = 13) with a free-flow maximum urinary flow rate (Qmax) of > or = 4 mL/s for a voided volume of > or = 120 mL. After the 2-week placebo run-in period, only patients with BPO (i.e. in the obstructed zone of the Abrams-Griffiths, AG, nomogram) received active treatment with tamsulosin. The two primary efficacy variables were the change in detrusor pressure at maximum flow (PdetQmax) and the total IPSS, from baseline to endpoint. A standardized protocol was used for all pressure-flow studies. RESULTS In all, 42 patients were enrolled into the 2-week placebo run-in period, after which 30 received active treatment with tamsulosin 0.4 mg once daily. All 12 patients (29%) who discontinued during the placebo run-in period failed to fulfil the pressure-flow entry criterion of confirmed obstruction. The 30 patients who received tamsulosin had a high mean PdetQmax (82.1 cm H2O) and high mean AG number (68.1) at baseline, as would be expected in obstructed patients. Tamsulosin produced a significant reduction in mean PdetQmax (-10.6 cm H2O or -13%; P = 0.005 vs baseline). The mean AG number decreased accordingly (-15.5 points or -23%; P < 0.001 vs baseline). The pressure-flow mean Qmax was increased by 2.5 mL/s (36%) from 7.0 mL/s at baseline (P = 0.002 vs baseline). Urodynamic improvements were accompanied by a good symptomatic response; the mean total IPSS was reduced by 6.7 points from a baseline value of 18.1 (-37%, P < 0.001 vs baseline). At the endpoint, 67% of patients had a clinically significant symptomatic response (defined as a decrease in total IPSS of > or = 25% from baseline). Twenty-six patients (87%) were either slightly improved (13) or were much improved (13) in the opinion of the investigator. Twelve patients with LUTS who were unobstructed after the 2-week placebo run-in (PdetQmax 44.1 cm H2O) received tamsulosin treatment outside of the study protocol. Although these patients had no decrease in mean PdetQmax, the magnitude of the symptomatic response (decrease in total IPSS -6.4 or -34%, P = 0.001) was comparable with that in unobstructed patients; the free-flow Qmax was also significantly improved. Possibly or probably drug-related adverse events were reported in nine patients; one discontinued tamsulosin treatment because of a serious adverse event. CONCLUSION Tamsulosin 0.4 mg once daily can produce a significant decrease in detrusor pressure, increase in flow rate and a symptomatic improvement in patients with LUTS and confirmed obstruction. Patients with LUTS who are unobstructed and have a low initial detrusor pressure appear to have no improvement in detrusor pressure, but have similar clinical responses to those in obstructed patients. Pressure-flow studies can be reserved for those patients with LUTS who fail to respond to these agents and in whom further diagnosis and management is warranted.
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Affiliation(s)
- E P Arnold
- Department of Urology, Christchurch Hospital, Christchurch, New Zealand.
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Wheelahan J, Scott NA, Cartmill R, Marshall V, Morton RP, Nacey J, Maddern GJ. Minimally invasive non-laser thermal techniques for prostatectomy: a systematic review. The ASERNIP-S review group. BJU Int 2000; 86:977-88. [PMID: 11119089 DOI: 10.1046/j.1464-410x.2000.00976.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J Wheelahan
- Baringa Specialist Centre, Coffs Harbour, NSW, Australia
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Lynch WJ, Graber SF. Transurethral microwave thermotherapy: symptom relief v urodynamic changes. J Endourol 2000; 14:657-60. [PMID: 11083408 DOI: 10.1089/end.2000.14.657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Transurethral microwave thermotherapy (TUMT), whether in its low- or high-energy form, seems to reduce the symptoms of benign prostatic hyperplasia, with low-energy treatment resulting in less improvement than high-energy treatment. Low-energy TUMT has a minimal effect on bladder outlet obstruction, as judged by urodynamic findings, and may not be suitable to treat those patients with significant obstruction. High-energy TUMT does seem to relieve obstruction significantly, although it is not as effective as TURP. Urodynamic studies may provide the answer as to which therapy to offer the patient.
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Affiliation(s)
- W J Lynch
- Department of Urology, The St George Hospital, Sydney, NSW, Australia
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Roehrborn CG, Burkhard FC, Bruskewitz RC, Issa MM, Perez-Marrero R, Naslund MJ, Shumaker BP. The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study. J Urol 1999; 162:92-7. [PMID: 10379748 DOI: 10.1097/00005392-199907000-00023] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated the effects of transurethral needle ablation and prostate resection on pressure flow urodynamic parameters in men with benign prostatic hyperplasia (BPH), compared symptomatic and objective parameters of efficacy 6 months after initial treatment, and determined whether urodynamic assessment may predict symptomatic improvement. MATERIALS AND METHODS We enrolled 121 patients with clinical BPH, American Urological Association symptom index of 13 or greater and maximum urinary flow of 12 ml. per second or less in a randomized study comparing transurethral needle ablation to prostate resection at 7 institutions in the United States. Patients underwent baseline and followup assessments at 6 months, including pressure flow studies. RESULTS Patients who underwent each procedure had statistically and clinically significant improvement in symptom index, BPH impact index and quality of life score. After needle ablation and prostate resection maximum flow improved from 8.8 to 13.5 (p<0.0001) and 8.8 to 20.8 ml. per second (p<0.0001), detrusor pressure at maximum flow decreased from 78.7 to 64.5 (p = 0.036) and 75.8 to 54.9 cm. water (p<0.001), and the Abrams-Griffiths number decreased from 61.2 to 37.2 (p<0.001) and 58.3 to 10.9 (p<0.001), respectively. At 6 months the differences in transurethral needle ablation and prostate resection were significant in terms of maximum flow (p<0.001) and the Abrams-Griffiths number (p<0.001) but not detrusor pressure at maximum flow or symptom assessment tools. The presence or absence of urinary obstruction at baseline did not predict the degree of symptomatic improvement in either treatment group. CONCLUSIONS Transurethral needle ablation and prostate resection induce statistically and clinically significant improvement in various quantitative symptom assessment questionnaires at 6 months. The parameters of free flow rates and invasive pressure flow studies also significantly improve after each treatment. However, transurethral prostate resection induces a significantly greater decrease in the parameters of obstruction. Baseline urodynamic parameters do not predict the degree of symptomatic improvement and they may not be helpful in patient selection for transurethral needle ablation.
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Affiliation(s)
- C G Roehrborn
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, USA
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van Swol CF, van Vliet RJ, Verdaasdonk RM, Boon TA. Electrovaporization as a treatment modality for transurethral resection of the prostate: influence of generator type. Urology 1999; 53:317-21. [PMID: 9933047 DOI: 10.1016/s0090-4295(98)00496-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To study the influence of the electrosurgical generator on the vaporization efficacy during electrovaporization (EVAP) using different vaporization elements. METHODS Electrical properties of human prostatic (in vivo) and bovine myocardium (in vitro) tissue were measured under electroresection and electrovaporization conditions. The effective output power of four different generators ("old generation" Force 4 and Force 40 and "new generation" Force 300 and Force FX) was measured at different impedance loads. In vitro, the coagulation and vaporization capabilities of the electrosurgical generators in combination with resection and vaporization elements were studied on homogeneous tissue (bovine myocardium). RESULTS The electrical impedance of human prostatic tissue and bovine myocardium increases from 400 to 1000 ohms when coagulated. The effective output power of the old generation electrosurgical devices depends strongly on tissue impedance. This implies that working on already coagulated tissue using such devices is not well controlled and not reproducible. By contrast, new generation electrosurgical devices correct for the higher impedance of coagulated tissue, thus delivering constant output power and corresponding tissue effects. CONCLUSIONS For an effective application of the EVAP technique, the use of a new generation impedance independent electrosurgical unit is highly recommended.
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Affiliation(s)
- C F van Swol
- Department of Urology, University Hospital Utrecht, The Netherlands
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Tubaro A. The use of voiding studies (flowmetry and urodynamics) in the assessment and follow-up of patients. Curr Opin Urol 1999; 9:15-20. [PMID: 10726067 DOI: 10.1097/00042307-199901000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The role of urinary flow measurement and pressure-flow studies in the diagnostic work-up of men presenting with lower urinary tract symptoms suggestive of benign prostatic obstruction is still an unresolved issue. In this paper, evidence from the peer-reviewed literature of the last 12 months is critically reviewed in the light of the recent recommendations of the 4th International Consultation on benign prostatic hyperplasia.
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Affiliation(s)
- A Tubaro
- Dipartimento di Discipline Chirurgiche, Università degli Studi, L'Aquila, Italy
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Sonke GS, Kiemeney LA. Diagnostic research in benign prostatic hyperplasia--from sensitivity to neural networks. Curr Opin Urol 1999; 9:31-7. [PMID: 10726069 DOI: 10.1097/00042307-199901000-00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Establishing the diagnosis in patients with lower urinary tract symptoms is complicated. Several tests have been developed, but the importance of each of these tests in the diagnostic process is not well understood. This paper describes the methods used to evaluate diagnostic tests, ranging from traditional sensitivity and specificity to more sophisticated techniques such as logistic regression and neural networks.
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Affiliation(s)
- G S Sonke
- Centre for Epidemiologic Urology, University Hospital Nijmegen, The Netherlands
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Eliasson T, Damber JE, Teriö H. Pressure-flow studies before and after transurethral microwave thermotherapy of benign prostatic hyperplasia using low- and high-energy protocols. BRITISH JOURNAL OF UROLOGY 1998; 82:513-9. [PMID: 9806179 DOI: 10.1046/j.1464-410x.1998.00770.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare pressure-flow results before and 3 months after transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia (BPH), performed with lower and higher energy protocols. PATIENTS AND METHODS Twenty-four patients were treated using a high-energy protocol performed with a heatshock strategy, i.e. a rapid increase in intraprostatic temperatures to a maximum of 55-67 degrees C. A helical antenna was used which produced maximum heating at the base of the prostate. A further 25 patients were treated using a lower energy protocol with a slow increase in intraprostatic temperatures to a maximum of 45-53 degrees C. A first-generation filament antenna was used with the maximum heat produced at the prostatic apex. All treatments were performed as single-session outpatient procedures of 60-70 min duration. RESULTS There was a significantly greater improvement in pressure-flow variables, i.e. maximum urinary flow rate, detrusor pressure at maximum flow and minimal urethral opening pressure, in those treated with higher energy TUMT than in those receiving the lower energy protocol. The Madsen and quality-of-life scores, and maximum urinary flow rate on uroflowmetry, were also significantly better in the higher energy group. CONCLUSION Higher energy TUMT performed using a heat-shock strategy provides a better pressure-flow outcome than lower energy thermotherapy. Compared with previously published results, the outcome after higher energy TUMT is at least similar to other treatment alternatives for BPH.
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Affiliation(s)
- T Eliasson
- Department of Urology and Andrology, Umeå University, Sweden
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