American Urological Association Symptom Research Articles

Dose-Intensified Stereotactic Ablative Radiation for Localized Prostate Cancer.

PurposeStereotactic ablative radiation (SAbR) has been increasingly used in prostate cancer (PCa) given its convenience and cost efficacy. Optimal doses remain poorly defined with limited prospective comparative trials and long-term safety/efficacy data at higher dose levels. We analyzed toxicity and outcomes for SAbR in men with localized PCa at escalated 45 Gy in 5 fractions.Methods and MaterialsThis study retrospectively analyzed men from 2015 to 2019 with PCa who received linear-accelerator-based SAbR to 45 Gy in 5 fractions, along with perirectal hydrogel spacer, fiducial placement, and MRI-based planning. Disease control outcomes were calculated from end of treatment. Minimally important difference (MID) assessing patient-reported quality of life was defined as greater than a one-half standard deviation increase in American Urological Association (AUA) symptom score after SAbR.ResultsTwo-hundred and forty-nine (249) low-, intermediate-, and high-risk PCa patients with median follow-up of 14.9 months for clinical toxicity were included. Acute urinary grade II toxicity occurred in 20.4% of patients. Acute grade II GI toxicity occurred in 7.3% of patients. For follow-up > 2 years (n = 69), late GU and GI grade ≥III toxicity occurred in 5.8% and 1.5% of patients, respectively. MID was evident in 31.8%, 23.4%, 35.8%, 37.0%, 33.3%, and 26.7% of patients at 3, 6, 12, 24, 36, and 48 months, respectively. The median follow-up for biochemical recurrence was 22.6 months with biochemical failure-free survival of 100% at 1 year (n = 226) and 98.7% for years 2 (n = 113) and 3 (n = 54).ConclusionsSAbR for PCa at 45 Gy in 5 fractions shows an encouraging safety profile. Prospective studies with longer follow-up are warranted to establish this dose regimen as standard of care for PCa.

Quality of life is improved after urethroplasty in women with urethral stricture

To evaluate the quality of life (QoL) in women who underwent urethroplasty for urethral stricture. Twenty-two women who underwent ventral labium minus graft urethroplasty were included. Patients were assessed with uroflowmetry, urethral caliber and post-voiding residual urine (PVR). American Urological Association (AUA) symptom score, Urogenital Distress Inventory (UDI)-6 and Short Form-36 (SF-36) were used to evaluate QoL. Preoperative values were compared with patients' last visit data. The cure of the surgery was defined as a maximum flow rate > 15ml/s in uroflowmetry and no need for any further intervention. Median age was 55 (40-66) years. Cure was achieved in 20 (90.3%) patients with median 37 (13-52) months follow-up duration. The median Qmax increased from 4 (0-5) ml/s to 27.5 (8-55) ml/s (p < 0.001). Median post-void residual volume (PVR) decreased from 52.5 (0-120) ml to 20(0-60) ml (p = 0.011). Both AUA symptom score [from median 30 (24-35) to 4.5 (0-20), p < 0.001] and AUA-QoL score [from median 5 (4-6) to 0(0-3), p < 0.001] decreased after surgery. Median UDI summary score at the last follow-up was 0 (0-44.4), which was 33.3 (22.2-61.05) at baseline visit. Improvement was observed in all domains except the 'Energy/Fatigue' domain of the SF-36. Urethroplasty is an effective surgical method to improve patients' QoL which is impaired because of female urethral stricture.

RETROSPECTIVE MULTICENTRIC STUDY ON THE POST-SURGERY SYMPTOMATIC AND OBJECTIVE IMPROVEMENT OF BENIGN PROSTATIC HYPERPLASIA PATIENTS

Objectives: To evaluate patients of benign prostatic hyperplasia (BPH) preoperatively and identify those who would benefit from surgery, to evaluate outcome of surgery for BPH with respect to symptomatic and objective improvement of patients, and to compare the results of different surgeries for BPH being done different hospitals at Bhopal, which included transurethral resection of the prostate (TURP), transurethral incision of prostate (TUIP)/bladder neck incision (BNI), and Freyer’s prostatectomy? Methods: The present study was carried out at different hospitals of Bhopal. Patients presenting to the surgery outpatient department with symptoms of obstruction, namely, weak urinary stream, frequency hesitancy, intermittency, urgency, nocturia, etc., were included in the study. Some of the subjects included were patients presenting during emergency timings with complaints of retention of urine or occasionally other symptoms. The American Urological Association (AUA) Symptom Index questionnaire was administered to all such patients. They were also evaluated by ultrasound examination and patients having BPH on ultrasound (USG) were further evaluated by uroflowmetry. Results: Prostatic weight correlated well with the maximum urinary flow rates with an inverse relationship. Both maximum and average urinary flow rates (Q max and Qav) were improved by all the three surgeries However, TURP and Freyer’s prostatectomy showed greater improvement as compared to TUIP/BNI. Combination of AUA scoring, USG, and uroflowmetry helped us document improvement in our BPH patients and compared it favorably with other studies. Conclusion: Uroflowmetry was a simple assessment tool easy to learn and use. It was also inexpensive and formed a useful extension to clinical examination providing objective evidence of obstruction. It also helped to indirectly quantity the severity of obstruction. Symptom severity did not correlate with prostate size. Small prostates caused symptoms in the severe range also while even large prostates sometimes caused little symptoms. Prostatic weight correlated well with the maximum urinary flow rates with an inverse relationship.

Risk of urinary morbidity associated with photoselective vaporization of the prostate (PVP) in prostate cancer patients undergoing a combined radiotherapy regimen consisting of dynamic adaptive radiotherapy (DART) and brachytherapy boost.

231 Background: Recent studies have shown PVPs to be associated with diminished perioperative and postoperative complications compared to transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). This is the first study to evaluate the timing of PVP intervention and post-treatment morbidity related to a combined regimen of DART and Pd-103 brachytherapy for treatment of prostate cancer. Methods: Between 12/05 and 04/20, 51 consecutive patients underwent Greenlight Laser (GLL) or Olympus Plasma Button (OPB) PVP after DART (median dose: 45 Gy) and before Pd-103 brachytherapy (median dose: 90 Gy). 27 patients received GLL PVP and 24 patients received OPB PVP. Peripheral seed loading designs were utilized to achieve optimal urethral sparing. The time from DART to PVP ranged from 1 to 81 days (median: 18 days). For 12 patients, the interval between DART and PVP was ≤7 days. The time from PVP to seed implant ranged from 0 to 55 days (median: 18 days). For 13 patients, the interval between PVP and implant was ≤7 days. American Urological Association (AUA) symptom scores were compiled prior to PVP and on the last post-brachytherapy follow-up. Post-implant follow-up ranged from 6 months to 15 years (median: 6.4 years). Results: No patient experienced post-implant urinary retention or incontinence. Morbidity was limited to RTOG grade 1-2 symptoms, with the exception of one patient who experienced protracted dysuria, which was identified to be secondary to a pre-existing prostate anomaly (steep urethral curvature). Only that patient required dilation for urethral stricture. AUA scores improved or remained the same in 43 of 51 patients. Only 1 patient of the remaining 8 experienced an increase in AUA &gt; 8 points. Conclusions: In our experience, there have been remarkably few adverse urinary sequelae following Pd-103 implantation in patients with prior PVP and DART. In contrast to TURPs, PVPs are safe even with short intervals between DART and brachytherapy. Based upon these results, pre-implant PVP is preferred, rather than PVPs or TURPs in the post-implant setting.

Comparison of holmium laser enucleation prostatectomy and open transvesical prostatectomy in large prostate more than 80 g in Egyptian men: a randomized controlled trial

Objective The aim was to assess the safety and efficacy of holmium laser enucleation prostatectomy (HoLEP) vs open prostatectomy (OP) for prostate of more than 80 g owing to benign prostatic hyperplasia in Egyptian men regarding micturition parameters and complications. Patients and methods A total of 110 patients were randomly divided into HoLEP (55 patients) and OP (55 patients). The inclusion criteria were American Urological Association-Symptom Score (AUA-SS) of eight or higher, maximum urinary flow rate (Qmax) of 10 ml/s or less, postvoiding residual urine (PVUR) of 50 ml or more, and a total prostate volume of 80 ml or more in transrectal ultrasound. The exclusion criteria included previous prostate or urethral surgery and non-benign prostatic hyperplasia related voiding disorders. Follow-up was done at first week, second week, first month, third month, sixth month, and 12th month postoperatively. Perioperative parameters were operative time, enucleation specimen weight, postoperative hemoglobin, length of hospital stay, and the duration of indwelling catheter. The assessment was done in the form of AUA-SS, Qmax, PVUR, and reported complications. Results Operative time was statistically significantly shorter in HoLEP compared with OP (102.45 vs 170.45 min, respectively). Drop-in hemoglobin concentration was statistically significantly higher in OP compared with HoLEP. Moreover, the duration of catheterization and hospital stay were statistically significantly shorter in HoLEP compared with OP. On the contrary, AUA-SS, PVUR, and Qmax did not reveal statistically significant differences between the two groups. Conclusion Both modalities have similar efficacy; however, HoLEP was superior to OP regarding hospital stay, the duration of catheterization, and the rate of hemoglobin concentration drop.

Bladder and urodynamic changes in multiple sclerosis

BackgroundUrinary dysfunction is a common symptom during the course of multiple sclerosis (MS). Long-term follow-up of the natural history of bladder dysfunction in MS has been seldom addressed.ObjectiveTo identify the type and the course of voiding dysfunction in MS patients in relation to the urodynamic changes of the lower urinary tract (LUT)Subjects and methodsAn observational prospective study including 120 MS patients with urinary dysfunction rated by the American Urological Association (AUA) symptoms questionnaire and assessed by urodynamic studies and followed for 1 year.ResultsIrritative symptoms were the most frequently encountered symptoms (90%), whereas overactive bladder was recorded by urodynamic studies in 35% of subjects. Urinary symptoms severity score was higher in patients with initial urodynamic abnormalities by the end of the 1-year follow-up period (P < 0.001). A statistically significant relationship was found between urinary symptoms severity score and each of expanded disability status scale (EDSS) and urodynamic pattern of abnormalities (P < 0.01).ConclusionIrritative symptoms and overactive bladder seem to be the most frequent urinary dysfunction in MS patients. Urinary symptoms are related to the degree of disability. The initial urodynamic abnormalities are associated with worse urinary dysfunction outcome after 1 year.

Association between urinary symptom severity and white matter plaque distribution in women with multiple sclerosis.

Multiple sclerosis (MS) is characterized by demyelinated white matter plaque throughout the central nervous system. Plaque involvement in regions that regulate micturition may be associated with urinary symptom severity in patients with MS. The aim of this prospective study is to investigate the relationship between cerebral plaque volume (PV), location, and urinary symptoms in women with MS. We conducted a case-control pilot study of women with MS undergoing routine yearly brain MRI. Women were administered the American Urologic Association-Symptom Index (AUA-SI) and divided into two groups: severe urinary symptoms (AUA-SI ≥20) and mild symptoms (AUA-SI ≤7). PV and location in the brain were determined using a validated automated white matter lesion segmentation algorithm. This study of 36 women found that the median total PV did not differ between groups. Women with severe urinary symptoms had larger median PV in the left frontal lobe (LFL) and right limbic lobe (RLL) compared with women with mild urinary symptoms. Within the RLL, women with severe symptoms had a larger median PV in the right cingulate gyrus (RCG). There was a moderate correlation between LFL lesion volume and RLL lesion volume with the AUA emptying subscore; however, these regions did not correlate with the storage subscore. This preliminary study found urinary symptom severity in women with MS is associated with PV in the RCG and LFL, and not total cerebral PV. These findings may explain why disease burden alone is not a predictor of severity or type of voiding dysfunction in patients with MS.

Can Urethral Bulking Agents Salvage Failed Slings?

ObjectiveTo evaluate the efficacy of urethral bulking agents for stress urinary incontinence (SUI) in the setting of prior failed sling. MethodsThis is a retrospective review of patients who underwent urethral bulking agent injections for a primary complaint of SUI following prior failed sling surgery. The outcomes assessed were patient reported improvement, need for further interventions for incontinence and validated questionnaires. Values for questionnaires were obtained from the patient's preprocedure visit, at the first visit following their last injection and at their most recent visit within our system. ResultsOver the study period, 73 patients underwent urethral bulking agent injection following failed sling. Thirty-eight patients received Macroplastique injections and 35 had collagen injections. On average, patients underwent 2.6 injections. Seventy-one percent of patient reported at least partial symptom resolution at first postinjection follow-up. Validated questionnaire responses also improved at short-term follow-up (mean difference in American Urological Association Symptom Index-3.8, Michigan Incontinence Symptom Index-5.1, P <.01). Forty patients had long-term follow-up data available (mean 39.6 months postinjection). Statistically significant improvement persisted on the stress incontinence and quality of life domains of the validated questionnaires. ConclusionIn our cohort of patients with persistent or recurrent SUI following urethral sling procedure, 71% experienced short-term improvement or resolution of symptoms following urethral bulking agent injections, with SUI-specific improvement persisting at an average of 35 months in patients with available data.

The survey of effect of combination therapy with tamsulosin – finasteride compared with tamsulosin alone on symptom improvement of benign prostatic hypostatic

Introduction: Benign prostatic hyperplasia (BPH) is a histologic change in the prostate and one of the common diseases in middle-aged and old men. BPH, as a life-altering urinary condition requires prompt medical interventions, both medical and surgical. Alpha-1 blockers (α1-blockers) are first-line treatment for BPH. 5α-reductase inhibitors (5-ARIs), like finasteride are very effective in patients with BPH who do not respond to α1-blockers. Objectives: This study was designed to compare the effect of tamsulosin (a selective α1- blockers) on BPH with the effect of combination therapy with tamsulosin and finasteride. Patients and Methods: This randomized controlled clinical trial study was done in Isfahan. Around 120 men with BPH divided into 2 groups with 60 patients in each group. Both groups were evaluated with the American Urological Association (AUA) symptom score. Scoring form of AUA symptoms to determine the severity of symptoms resulting from BPH was developed by America Urological Association. Total of its scores was between 0 and 35. Then, one group received tamsulosin and the other group received combination therapy with finasteride and tamsulosin. After 4 weeks, the AUA symptom score was done for both of groups. Results were analyzed by the paired t test, t test and chi-square through SPSS version 16. Results: No significant differences in mean of age and the AUA symptom score distribution were seen between two groups (P > 0.05). After 4 weeks of therapy, the AUA symptom score was significantly decreased in the patients who received tamsulosin and finasteride compared with the patients who received tamsulosin alone (P < 0.05). Conclusion: The results of our study showed that tamsulosin and finasteride are effective drugs for BPH treatment. Combination therapy with finasteride and tamsulosin was significantly more effective, in our study, compared to tamsulosin alone.

Toxicity, quality of life outcomes, and dosimetric impact in phase III trial of hypofractionated or standard fractionated proton therapy for low-risk prostate cancer patients: PCG GU 002.

48 Background: The purpose of this study is to identify differences in toxicity, quality of life (QOL), and dosimetric endpoints among patients with low-risk prostate adenocarcinoma treated with either standard fractionation or hypofractionation proton-beam therapy. Methods: We analyzed the results of the first 75 patients treated in our phase III trial comparing 38Gy relative biological effectiveness (RBE) in 5 fractions (fx) (n = 46) vs. 79.2Gy (RBE) in 44 fx. (n = 29). All patients had low-risk prostate cancer and were treated with proton radiation using fiducial markers and daily image guidance. We evaluated American Urological Association (AUA) Symptom Index, adverse events (AEs), and Expanded Prostate Index Composite (EPIC) domains at pretreatment and 3, 6, 12, 18, 24, 36 and 48 months. Doses to the prostate were selected based on similar long term effects to normal tissue based on an α/β = 3.5 for an EQD2 of 76Gy. Results: The median follow-up was 36 months for both groups; 23 (30%) patients reached a follow-up of 48 months. We observed a small difference in AUA score (3.2 vs. 8.6, p = 0.002) at 1-year favoring the 79.2Gy arm. AUA scores were not statistically different at 18 months and after. Similarly, EPIC Urinary symptoms favored the 79.2Gy arm at 1 year (92.3 vs. 84.5, p = 0.009) and 18 months (92.3 vs. 85.3, p = 0.03); bother scores were not significantly different at any other time points. G2 or higher GU toxicity was similar between arms (p = 0.8). No differences in EPIC Bowel symptoms, EPIC Sexual symptoms, or bowel G2 or higher toxicities were seen. One death was observed in the 38Gy arm due to an unrelated case of multiple myeloma. The bladder V80 (79.2Gy arm, p = 0.04) and V39 (38Gy arm, p = 0.05) were predictive for G2 or higher GU AE. There was no association observed between rectal dose and G2 or higher rectal toxicity. Conclusions: Patients treated in the hypofractionated and standard arms tolerated treatment well. A small and temporary difference in the GU domain was seen favoring the standard arm. As predicted long term effects on the GU domain and bowel were similar for both arms, suggesting that the α/β is similar to 3.5 for long term effects. Clinical trial information: 01230866.

A Longitudinal Study of Predictors of Sexual Dysfunction in Men on Active Surveillance for Prostate Cancer.

AimThe aim of this study was to examine the relationship between sexual dysfunction, repeat biopsies and other demographic and clinical factors in men on active surveillance (AS).MethodsPatient-reported outcomes (PROs) measures were administered at enrollment and every 6 months to assess quality of life (QOL), psychosocial and urological health outcomes. Using mixed-effects models, we examined the impact of repeat biopsies, total number of cores taken, anxiety, age, and comorbidity on sexual function over the first 24 months of enrolling in AS.Main Outcome MeasuresPROs included the Expanded Prostate Cancer Index Composite-26 (EPIC-26) Sexual Function (SF) subscale, the American Urological Association-Symptom Index (AUA-SI), and the Memorial Anxiety Scale for Prostate Cancer (MAX-PC).ResultsAt enrollment (n = 195), mean age was 66.5 ± 6.8 with a mean EPIC-26 SF score of 61.4 ± 30.4. EPIC-26 SF scores steadily decreased to 53.9 ± 30.7 at 24 months (P < 0.01). MAX-PC scores also progressively decreased over time (P = 0.03). Factors associated with lower EPIC-26 scores over time included age, unemployed status, diabetes, coronary artery disease, and hypertension (all P < 0.05). Higher prostate-specific antigen (PSA) was associated with a more rapid decline in EPIC-26 SF over time (P = 0.03). In multivariable analysis, age, diabetes, and PSA × time interaction remained significant predictors of diminished sexual function. Anxiety, number of biopsies, and total cores taken did not predict sexual dysfunction or change over time in our cohort.ConclusionsMen on AS experienced a gradual decline in sexual function during the first 24 months of enrollment. Older age, PSA × time, and diabetes were all independent predictors of diminished sexual function over time. Anxiety, AUA-SI, the number of cores and the number of biopsies were not predictors of reduced sexual function in men in AS.

Safety and Efficacy of Prostate Artery Embolization in Small-Volume Benign Prostatic Hyperplasia

Purpose Traditional urologic surgery of small-volume benign prostatic hyperplasia (BPH) is associated with high failure rates and complications such as bladder neck strictures and contractures. While prostate artery embolization (PAE) is postulated to be effective secondary to gland size reduction, we hypothesize that it may be equally effective in patients with small volume glands. We present our experience of PAE in prostate sizes Material and Methods An Institutional Review Board approved a retrospective study of 78 consecutive PAE patients from January 2011 to July 2014. Patients were evaluated at baseline, 1, 3, and 6 months with the American Urological Association (AUA-SI) symptom index including quality of life-related symptoms (QoL), International Index of Erectile Function (IIEF), and prostate imaging (magnetic resonance imaging, ultrasound, or computed tomography at baseline). Analysis was performed for each stratified group (Group 1, prostate volume 50 cc) individually from baseline to 1, 3, and 6 months and between groups at each follow-up to assess for differences in outcome. Results There were no significant differences in baseline age, AUA score, QoL, or IIEF between groups (mean age 65.2 years, 26.4 AUA, 4.9 Qol, 14 IIEF; n = 78). Baseline volumes were: group 1 (37.5 cc, 25.9 to 48.0 cc, n = 16) and group 2 (108.5 cc, 52.0 to 274.0 cc, n = 62 }. Technical success was achieved in 16/16 patients in Group 1 and 59/62 in Group 2, with 2 unilateral embolizations and 1 unsuccessful secondary to bilateral atherosclerotic occlusion in the latter group. A statistically significant reduction in AUA was achieved in both groups from baseline to 1, 3 and 6 months (n = 77): Group 1: Baseline 27.2 to 12.7, 12.0, and 11.2 at 1, 3, and 6m (p Conclusions PAE appears to offer similar positive clinical benefits to 6 months in patients with small-volume BPH. This may offer crucial benefit to those patients with limited surgical options. Future study aimed at evaluating recurrence rates is suggested.

Comparison of External Beam and Combination Therapy for Prostate Cancer: Patient-Reported Outcomes of Sexual Function With 5-Year Follow-up

prostate and proximal seminal vesicles as defined on non-contrast CT and fused T2 MRI with a 3 mm posterior margin and a 5 mm margin in all other directions. Patients were instructed to empty their bladder prior to simulation and treatment, and the entire bladder and its contents were contoured as a single structure. Inverse plans were generated with a prescription dose (PD) of 35 to 36.25 Gy in 5 fractions to the PTVusing 6 MV photons. QOL surveys including the American Urological Association (AUA) Symptom Index were conducted before and after treatment every 3 months for the first year and then every 6 months. Late urinary flare was defined as an AUA score > 15 with an increase 5 above baseline with subsequent return to baseline within 2 years. Phenomenologic NTCP models were fit to bladder DVHs and late urinary flare outcome data using maximum likelihood estimation. Results: Twenty-nine patients experienced late urinary flare within 2 years of completion of prostate SBRT. Fitting of urinary bladder DVH data to a Lyman NTCP model resulted in parameter estimates of m, TD50, and n of 0.19 (-0.09 to 0.47), 38.7 Gy (31.1 to 46.4), and 0.13 (-0.14 to 0.41), respectively. Subsequent fits to threshold dose and hottest volume probit models revealed a significant association of late urinary flare with volume of bladder receiving doses greater than 36.6 Gy as well as dose to the hottest 12.7% of bladder volume. Similar results were obtained using a dose-volume cutoff model that additionally demonstrated a significant association of volume of bladder receiving at least 50% of the PD with late toxicity. The hottest volume probit model demonstrated the best fit of the data and suggests dose-volume cutoffs for D12.7% of 30 and 33.5 Gy in five fractions for a predicted complication rate of 5% and 10% at 2 years, respectively. Conclusions: NTCP modeling of late urinary flare after prostate SBRT demonstrates a relatively small volume effect for dose to the urinary bladder, suggesting that reduction of volume receiving elevated dose will result in decreased incidence of late urinary toxicity. Future studies will be needed to examine the impact of dose to the prostatic urethra. Author Disclosure: T.P. Kole: None. B. Wu: None. M. Tong: None. S. Lei: None. L.N. Chen: None. S. Suy: None. A. Dritschilo: None. E.D. Yorke: None. S.P. Collins: G. Consultant; Accuray, Inc.

Nocturia and its impact on health-related quality of life and health care seeking behaviour in German community-dwelling men aged 50 years or older.

To evaluate the prevalence of nocturia/nocturnal voiding frequency and its impact on overall physical and mental health status in German community-dwelling men and determine which lower urinary tract symptom (LUTS) is responsible for medical consultations in the 2-year follow-up period. A sample of German men aged 50-80 years from a community-dwelling study was chosen for re-evaluation 2 years after initial assessment. Men were clinically investigated and completed the International Prostate Symptom Score, American Urology Association-Symptom Problem Index (AUA-SPI), and the Short-Form Health Survey (SF-12). In total, 1,562 men were eligible for analysis. Mean nocturnal voiding frequency was 2.3 for all men and increased with ageing. SF-12 data indicated that physical but not mental health status was lower than in the average population. LUTS severity reduced both physical and mental health status (p < 0.001). Clinically relevant nocturia (≥ 2 voids/night) was present in 43 % of men and reduced both physical and mental health status (p < 0.001), whereas both HRQoL scales were not significantly reduced in men without or only one nocturnal void. In multivariate regression analysis using patient-reported bother (AUA-SPI) from LUTS, only bother from nocturnal voiding was significantly associated with medical consultations in the investigated 2-year follow-up period (odds ratio 2.6; 95 % confidence interval 1.6-4.2; p < 0.001). Our study confirmed that nocturnal voiding is highly prevalent in community-dwelling men and reduce both physical and mental health status. Bother from nocturnal voiding is the most relevant component of LUTS responsible for medical consultations in German men.

The changes of voiding pattern after midurethral sling between pure stress urinary incontinence and stress urinary incontinence with overactive bladder group.

PurposeThe purpose of this study is to compare changes in voiding pattern after midurethral sling surgery (MUS) between the stress urinary incontinence (SUI) group and the overactive bladder (OAB)+SUI group.Materials and MethodsFrom January 2008 to February 2011, a retrospective survey was conducted of 225 female patients who had been diagnosed with SUI and undergone MUS. The subjects were divided into the SUI group and the OAB+SUI group. Changes in the overactive bladder symptom score (OABSS) and American Urological Association-Symptom Index (AUA-SI) before and three months after the MUS were compared.ResultsOf the 225 patients, 165 patients (73.3%) were classified as SUI group, and 60 patients (26.7%) were classified as OAB+SUI group. The mean age of the subjects was 54.7 years (range, 31-80 years), and the mean age of patients was 53.9 years (range, 34-80 years), and 56.8 years (range, 31-78 years) in the SUI group and OAB+SUI group. In SUI group, voiding symptom and storage symptom among the AUA-SI were significantly increased (p<0.05). OABSS were slight increased, but was statistically insignificant (p=0.847). In OAB+SUI group, voiding symptom score and OABSS showed a significant increase (p<0.05), but storage symptom score showed an insignificant increase (p=0.790).ConclusionsOAB may occur in approximately 18% of SUI patients who undergo MUS surgery, and voiding dysfunctions with deteriorated voiding symptom and storage symptom may also occur. The deteriorated OAB was shown in 45% of SUI patients with OAB after the surgery.

Long-term Functional Outcomes in Patients With a W-shaped Ileal Orthotopic Neobladder With No Antireflux Mechanism

To evaluate the long-term renal function, continence, and voiding function in 64 patients, surviving for 5 or more years after W-shaped ileal neobladder with a short afferent limb and refluxing ureterointestinal anastomoses. Kidney morphology and function were evaluated using nuclear renography, creatinine, and glomerular filtration rate. Continence and voiding function were evaluated with a diary on frequency, voided volumes, number of pads, and with the incontinence severity index (ISI) questionnaire, the American Urological Association-Symptom Index (AUA-SI), and the American Urological Association-Symptom Problem Index. The renal scan showed a dilatation of the upper urinary tract in 4.8% of renoureteral units. Of the patients, 12.5% voided with intermittent or permanent catheterization. The remaining 87.5% voided spontaneously; 75% did not use pads, 12.5% used protection for safety, 7.1% 1 pad, and 5.4% more than 1 pad, during the day; during night, 55.3% did not use pads, 23.2% used protection for safety, and 12.6% and 8.9% 1 or more than 1 pad. The ISI questionnaire showed that 35.7% were fully continent, whereas 41%, 12.5%, and 10.8% had slight, moderate, and severe incontinence. The AUA-SI showed that 50% had mild, 39.3% moderate, and 10.7% severe lower urinary tract symptoms. Urinary incontinence, daytime frequency, and nocturia correlated positively with the age of patients at follow-up and negatively with voided volume. Long-term detrimental effect on renal function of orthotopic neobladder with no antireflux anastomoses is limited. Long-term continence and voiding function results are satisfactory. The ISI questionnaire might be useful to evaluate and grade incontinence in patients with orthotopic neobladder, whereas the AUA-SI has many limitations.

The Clinical Spectrum of the Presenting Signs and Symptoms of Anterior Urethral Stricture: Detailed Analysis of a Single Institutional Cohort

To accurately delineate the presentation of anterior urethral stricture in an economically developed patient cohort. It is widely assumed that patients with urethral stricture typically present with lower urinary tract symptoms (LUTS). There is a paucity of data examining this assumption. With no uniformly accepted clinical definition or measure of treatment success, a clear clinical description of urethral stricture is important. Retrospective detailed analysis was performed on 611 patients presenting with anterior urethral stricture from July 2004 to June 2010. Both the presenting complaint and associated signs and symptoms were classified according to one of 10 clinical categories. The most common presenting complaint was LUTS typical of those found on the American Urological Association-Symptom Score (54.3%) and another 23.4% of patients presented initially with acute urinary retention (AUR). Symptoms other than LUTS or urinary retention accounted for 22.3% of presenting complaints. In addition, 22.9% of patients had genitourinary pain, 50.7% of patients required emergent urologic treatment, and 7.4% of patients presented with renal insufficiency or urethral abscess/necrotizing fasciitis directly related to urethral stricture. Although many patients with urethral stricture present initially with LUTS or AUR, almost one quarter of patients have a different presenting complaint. Defining successful treatment of anterior urethral stricture should include more than improvement in LUTS or absence of urinary retention. Urethral stricture is not just a "quality of life" condition because >50% of patients require emergent treatment and 7.4% have a life-threatening condition directly related to the stricture.

1511 OUTCOMES OF SACRAL NERVE STIMULATION IN PATIENTS WITH OR WITHOUT INTERSTITIAL CYSTITIS/CHRONIC PELVIC PAIN SYNDROME

INTRODUCTION AND OBJECTIVES: Sacral nerve stimulation (SNS) is approved for urinary urgency/frequency, urge urinary incontinence and non-obstructive idiopathic urinary retention. Many of these patients also have conditions such as interstitial cystitis (IC) or chronic pelvic pain syndrome (CPPS). Although IC/CPPS is not a primary indication for SNS, anecdotal reports suggest some patients have symptomatic improvements. This study examined clinical outcomes of SNS using a validated instrument, and compared results in those with and without IC/CPPS. METHODS: Prospective data were collected in patients undergoing SNS by a single surgeon. Subjects completed the American Urological Association (AUA) Symptom Index at each preand postoperative visit. Patients were divided into two groups based on whether or not they also had an established diagnosis of IC/CPPS. Total AUA Symptom Score (AUA-SS), quality of life (AUA-QoL) and filling and voiding subscores (AUA-F; AUA-V) were analyzed. Within group analyses were performed using paired t-tests and repeated measures ANOVA. Between group analyses used two-sample t-tests for means, and one-way and factorial ANOVA. Results were considered significant at p 0.05. RESULTS: Sixty-eight subjects (19 men, 49 women), median age 58 (range 21– 86), underwent SNS for clinically indicated symptoms and met inclusion criteria. Group 1 (n 26) also had IC/CPPS, and Group 2 (n 42) did not. Median followup was 4.4 years. Mean AUA-SS improved from 27.3 to 14.9 in Group 1 and 21.7 to 12.1 in Group 2 (both, p 0.0001). Overall, 20 (29%) patients experienced 15 points improvement in total AUA-SS. Mean preoperative AUA-F subscores were worse in Group 1 (13.6) versus Group 2 (10.7) (p 0.0001). Other preoperative parameters were equivalent between groups. Within-group analyses showed improvements in all postoperative variables (AUA-SS, AUA-QoL, AUA-F, AUA-V) for both groups (p 0.0001). Despite statistically significant improvement within groups, mean postoperative AUA-F subscores remained higher in Group 1 versus Group 2 (p 0.038). CONCLUSIONS: To our knowledge, this is the largest study to prospectively compare voiding outcomes after SNS in patients with or without IC/CPPS with a validated instrument. These data demonstrated both groups experienced significant improvement in almost all voiding parameters measured by AUA-SS and its component subscores. Patients should be counseled regarding realistic goals that can be potentially achieved using SNS for voiding symptoms based on presence or absence of IC/CPPS.

Bladder dysfunction in spinal tuberculosis: clinical, urodynamic and MRI study

An observational study. We report clinical, MRI and urodynamic findings in spinal tuberculosis. Tertiary care teaching hospital. Patients with spinal tuberculosis having micturition disturbances or high postvoidal residual (PVR) urine were subjected to clinical evaluation, urodynamic and spinal MRI. Urinary symptoms were scored as per the American Urological Association Symptom (AUAS) Index. The outcome was defined at 12 months into complete, partial and poor. Of 30 spinal tuberculosis patients, 15 had micturition disturbance and included urinary retention in 4, stress incontinence in 2, hesitancy in 6, urgency in 11 and urge incontinence in 9 patients. Thirteen patients had paraparesis and one had quadriparesis. Spinal MRI revealed granuloma in 2, dorsal vertebral involvement in 12 and cervical and lumbar vertebral involvement in 1 patient each. On urodynamic study, detrusor hyperreflexia (DH) with high-pressure voiding was present in six, detrusor areflexia (DA) in four, normal study in one and increased PVR urine in the remaining patients. AUAS score improved on follow-up. DA changed to DH with high-pressure voiding in one patient. The 15 patients without micturition disturbance had no horizontal sensory level, milder or no weakness and only 2 had spinal cord signal changes. Patients with micturition disturbances had poorer functional recovery at 1 year compared to those without micturition disturbances. Bladder symptoms were present in 50% of the admitted patients with spinal tuberculosis and related to severity of paraplegia, horizontal sensory level, cord signal abnormality and poorer outcome compared to those without spinal tuberculosis. Urodynamic study helped in categorization and management.

Bladder dysfunction in subacute combined degeneration

In view of the paucity of studies on micturition disturbance in subacute combined degeneration (SACD), this prospective study reports micturition disturbance in SACD and correlations with urodynamic and MRI findings. SACD was diagnosed by clinical features and low serum B12 level (< 211 pg/ml) and/or megaloblastic bone marrow. Micturition disturbances were categorized into voiding and storage symptoms and scored using the American Urological Association Symptoms (AUAS) score. Spinal MRI and urodynamic studies were carried out. Patients were treated with vitamin B12 1000 microg daily i.m. and outcome was defined at 6 months into complete, partial and poor. Eight patients with SACD aged 53.8 (44-70) years were included; 2 of whom were females. The mean duration of illness was 2.2 (1-120) months. All had walking difficulty, 2 were wheelchair bound and 4 bedridden. Lower limb spasticity and joint position impairment were present in all; ankle reflex was absent and pinprick sensation reduced distally in 4 patients each. T2 hyperintensity in the posterior spinal cord was present in 5 and in subcortical white matter in 2 patients. Five patients had storage, 7 voiding and 4 had both dysfunctions. AUAS score was 14.63 (4-35). On urodynamic study, detrusor areflexia was present in 2, neurogenic detrusor overactivity with high pressure voiding in 3 and normal in 2 patients. The urinary symptoms improved in all (AUAS score 3.67). Repeat urodynamic study in 2 patients, who had detrusor areflexia improved. At 6 mo, 3 patients had complete, 4 partial and 1 poor recovery. Bladder symptoms occur in advanced cases of SACD; both detrusor areflexia and neurogenic detrusor overactivity with high pressure voiding occur and respond to B12 therapy.