Baseline Urodynamic Parameters Research Articles

Intravesical Injection of Botulinum Toxin Type A in Patients with Refractory Overactive Bladder-Results between Young and Elderly Populations, and Factors Associated with Unfavorable Outcomes.

Intravesical botulinum toxin type A (BoNT-A) injection has been recognized as the standard treatment for refractory overactive bladder (OAB). However, its therapeutic efficacy and safety have not been thoroughly reviewed in elderly patients. This study aims to provide treatment outcomes for patients aged ≥75 years, and to identify factors associated with unfavorable outcomes. Patients receiving intradetrusor injections of 100 U onabotulinumtoxinA for refractory OAB between 2011 and 2021 were retrospectively reviewed. Urodynamic parameters, underlying comorbidities, subjective success, and unfavorable outcomes were assessed. A total of 192 patients were included, and 65 of them were classified into the elderly group. For the elderly group, 60.0% experienced subjective dryness, and 84.6% remained subjective success at 6 months after the injections. The prevalence rates of common unfavorable outcomes, including urinary tract infections, large post-void residual urine volume, and urinary retention, were 9.2%, 27.7%, and 12.3%, respectively. Multivariate analysis revealed that female, baseline urodynamic parameters, and diabetes mellitus were associated with unfavorable outcomes in the elderly group. Intravesical BoNT-A injections provide comparable therapeutic efficacy and safety concerns in elderly patients with refractory OAB. A thorough consultation for treatment benefits and possible adverse events is mandatory before the procedure.

Onabotulinumtoxin A (Botox): A reasonable alternative for refractory neurogenic bladder dysfunction in children and young adults.

We aimed to describe the effectiveness of Onabotulinumtoxin A (Botox) in children with neurogenic bladder (NGB) unresponsive to medical therapy to determine urodynamic parameters predictive of success. Children receiving Botox for refractory NGB, between 2008 and 2019, from a single academic center, were included in this study. Botox success was defined as improvement of incontinence and/or urodynamic parameters. Of 34 patients who received Botox, 13 (38.2%) had a positive response from their first injection, with improvement in capacity by a median of 35% of expected capacity for age compared to only a 9% increase in those who did not respond clinically. When patients were divided into groups by baseline urodynamic parameters, high-pressure (Pdetmax > 20 cm H2 O) patients had significantly greater improvement in compliance compared with low-pressure patients (p = 0.017). Low compliance patients (<10 ml/cm H2 O) had a dramatic improvement of 3.08 ml/cm H2 O in their compliance compared with minimal change in the high compliance group (p = 0.003). Finally, low-capacity (<50% of expected CC) patients had significant improvement in capacity and compliance when compared with high-capacity patients (p = 0.004 and p = 0.036, respectively). Improvement in detrusor overactivity (DO) was noted in both the clinical responders and non-responders. In our series, 38% had clinical success with intradetrusor Botox injections for refractory neurogenic bladder. When successful, improvement in capacity and compliance, DO, and/or incontinence was consistent with prior literature. While we could not determine which parameters predicted success, subdividing patients into categories based on baseline urodynamic parameters identified who would benefit from Botox treatment based on differential improvements in capacity and compliance. At least 1 injection of Botox should be considered for a subset of children with refractory NGB, before undertaking more invasive treatments.

Therapeutic Effects of Urethral Sphincter Botulinum Toxin A Injection on Dysfunctional Voiding with Different Videourodynamic Characteristics in Non-Neurogenic Women.

Although female dysfunctional voiding (DV) is common in urological practice, it is difficult to treat. This study evaluated the therapeutic efficacy of urethral botulinum toxin A (BoNT-A) on non-neurogenic female DV. Based on the videourodynamic study (VUDS), the DV was classified into three subgroups according to the obstructive site. A successful treatment outcome was defined as an improvement of voiding efficiency by 10% and reported global response assessment by ≥1. The study compared therapeutic efficacy, baseline urodynamic parameters, and changes in urodynamic parameters between the treatment success and failure groups and among three DV subgroups. Predictive factors for successful treatment were also investigated. A total of 81 women with DV were categorized into three groups: 55 (67.9%) had mid-urethral DV, 19 (23.5%) had distal urethral DV, and 7 (8.6%) had combined BN dysfunction and mid-urethral DV after BN transurethral incision. The treatment outcome was successful for 55 (67.9%) patients and failed for 26 (32.1%). Successfully treated patients had a significant decrease of detrusor pressure, post-void residual volume, and bladder outlet obstruction index, as well as an increase in voiding efficiency at follow-up versus the treatment failure group. The logistic regression of urodynamic parameters and clinical variables revealed that a greater volume of first sensation of filling predicts a successful BoNT-A treatment outcome (p = 0.047). The urethral BoNT-A injection is effective in treating non-neurogenic women with DV, with a success rate of 67.9%. The videourodynamic characteristics of DV may differ among patients but does not affect the treatment outcome.

Bladder dysfunction does not affect long-term success rate of the retropubic suburethral sling procedure in women with stress urinary incontinence.

This study investigated the long-term success rate of retropubic suburethral sling in the treatment of women with stress urinary incontinence (SUI) and different bladder function. Surgical outcomes of women with SUI undergoing a retropubic suburethral sling procedure between October 1989 and November 2014 were analyzed retrospectively. Bladder function was evaluated in every patient preoperatively using videourodynamic studies. Patients were classified as having stable bladder, detrusor overactivity (DO), or detrusor underactivity (DU). Baseline urodynamic parameters were analyzed and long-term therapeutic outcomes were compared among these three groups. In all, 403 patients underwent sling procedure for SUI. Of these, 291 (72.2%) had a stable bladder, 78 (19.4%) had DO, and 34 (8.4%) had DU. Mean (± SD) patient age was 60.2 ± 11.8 years, and the median follow-up was 97 months (interquartile range 24-325 months). Postoperatively, the overall continence rate was 83.4% (336/403). After surgery, 71 patients (17.6%) complained of dysuria, 14 (3.5%) complained of urgency incontinence, 25 (6.2%) had recurrent SUI requiring a secondary sling procedure, and urethrolysis was performed in 13 (3.2%). In the stable bladder, DO, and DU groups, the 5-year continence rates were 88.6%, 84.1%, and 79.4%, respectively (P = 0.59), whereas the 10-year continence rates were 83.8%, 72.9%, and 79.4%, respectively. Kaplan-Meier survival analysis indicated that the long-term success rate was similar among the three groups (P = 0.39). The overall continence rate was 83.4% and the 10-year continence rate was satisfactory in all bladder function subgroups. Treatment outcomes were the same for women with SUI but different bladder function.

Long-term follow up and predictive factors for successful outcome of transurethral incision of the bladder neck in women with detrusor underactivity.

Detrusor underactivity (DU) is a common urologic problem. Our previous study revealed the transurethral incision of the bladder neck (TUI-BN) improves short-term voiding efficiency (VE) in female patients with DU. This study focused on the long-term outcomes of TUI-BN and identified the predictive factors of satisfactory outcomes. A total 50 women with DU for whom medical treatment failed underwent TUI-BN. The urodynamic parameters at baseline and follow-up visits were analyzed. Patients with VEs >50% were considered to have satisfactory outcomes. Baseline urodynamic parameters were analyzed as factors predictive of outcomes. After a mean follow up of 61.8 months, 26 of 50 patients had satisfactory outcomes. The mean VE, maximum flow rate, voided volume, detrusor pressure, and postvoid residual volume significantly improved after TUI-BN. A higher intravesical pressure [Pves, odds ratio (OR)=1.023, p=0.013] and smaller first sensation of bladder filling (OR=0.990, p=0.020) at baseline were predictive factors for satisfactory outcomes. The multivariate analysis revealed that only baseline Pves was a significant predictor of satisfactory outcomes (OR=1.024, p=0.038). The receiver operating characteristic curve analysis of baseline Pves showed that the area under the curve was 0.767 (95% confidence interval=0.624-0.876). The optimal cutoff value of Pves for a satisfactory outcome was 45 cmH2O, which had a specificity of 78.26% and acceptable sensitivity of 73.08%. TUI-BN improved VE in women with DU over the long term. A higher Pves compared to a lower Pves was predictive of satisfactory surgical outcomes.

Transurethral Incision of the bladder neck improves voiding efficiency in female patients with detrusor underactivity

Detrusor underactivity (DU) is a common urologic problem and usually presents with urine retention or large postvoid residual (PVR). Medical treatment of DU does not always achieve satisfactory results. We report the surgical outcomes of transurethral incision of the bladder neck (TUI-BN) in women with DU and urine retention. A total 31 woman with DU in whom medical treatment failed underwent TUI-BN and were retrospectively studied. Surgical outcome was determined by postoperative urodynamic studies and clinical presentation. Patients with postoperative voiding efficiency of >67% had excellent outcomes, those with 33-66% had moderate results, and those with <33% had poor surgical outcomes. PVR, voiding efficiency, and maximum urinary flow rate (Qmax) significantly improved after TUI-BN. PVR decreased by 56.3% overall. Intermittent catheterization was needed in 27 patients before surgery and in only seven after TUI-BN. There were 14 (45.2%), 11 (35.5%), and six (19.3%) patients with excellent, moderate, and poor surgical outcomes, respectively. Baseline urodynamic parameters, age, and etiologies did not impact surgical outcome. Three patients developed transient urinary incontinence, and one developed vesicovaginal fistula after TUI-BN. TUI-BN is an effective procedure to improve PVR, Qmax, and voiding efficiency in women with DU and urine retention. The procedure is safe and effective, even in patients with medical treatment failure, those with large PVR at baseline, and those with different etiologies.

Diabetes mellitus does not affect the efficacy and safety of intravesical onabotulinumtoxina injection in patients with refractory detrusor overactivity

To investigate the efficacy and safety of intravesical onabotulinumtoxinA injection in patients with diabetes mellitus (DM) and refractory detrusor overactivity (DO). Forty-eight type 2 DM patients with refractory DO received intravesical 100 U onabotulinumtoxinA injection. Another 48 age-matched patients were randomly selected from a non-diabetic group as controls. Video-urodynamic studies were performed at baseline and were repeated 3 months after treatment. The treatment outcomes were graded on the basis of changes in the Patient's Perception of Bladder Condition (PPBC) and a PPBC decrease of 2 or more points was considered successful. Treatment-related adverse events including acute urinary retention, large post-voiding residual (PVR) volumes, straining to void, urinary tract infection, hematuria, and general weakness were recorded. The mean ages of the diabetic and non-diabetic patients were 73.1 ± 8.8 and 72.0 ± 9.3 (P = 0.552), respectively. The changes of urodynamic parameters were comparable between the two groups. Similar successful results were noted at the 6-month follow-up (DM, 56% vs. non-DM, 61%, P = 0.128). Diabetic patients had a significantly greater incidence of large PVR volumes (DM, 60.4% vs. non-DM, 33.3%; P = 0.007) and general weakness (DM, 10.4% vs. non-DM, 0%; P = 0.03) after treatment. Baseline urodynamic parameters in diabetic patients did not predict the occurrence of adverse events. No major complication was noted in either group. Intravesical onabotulinumtoxinA injection is a safe and effective treatment for DM patients with refractory DO. Patients with DM should be informed of the increased risk of large PVR before initiation of treatment.

2314 BASELINE URODYNAMIC PARAMETERS DO NOT AFFECT THE TREATMENT OUTCOME OF INTRAVESICAL 100U ONABOTULINUMTOXINA INJECTION FOR PATIENTS WITH IDIOPATHIC DETRUSOR OVERACTIVITY

INTRODUCTION AND OBJECTIVES: Intravesical injection of onabotulinumtoxinA (BoNT-A) provides effective treatment for idiopathic detrusor overactivity (IDO). However, not all patients have successful long-term therapeutic effect. This study investigated the affect of baseline urodynamic parameters on the therapeutic effect and adverse events after injecting 100U onabotulinumtoxinA in patients with IDO refractory to antimuscarinics. METHODS: A total of 174 patients who received the first single intravesical BoNT-A 100U injection for refractory IDO were included. The success rate was determined based on patient perception of bladder condition (PPBC) improved by 2 scales. The short-term (3 months) and long-term (up to 24 months) success rates were analyzed according to the baseline urodynamic parameters including cystometric bladder capacity, maximum flow rate, postvoid residual, voiding efficiency, and DO subtypes. The BoNT-A related adverse events were also reported. RESULTS: A successful outcome was reported by 138 (79.3%) patients at 3 months. The baseline urodynamic parameters did not affect the success rates except that patients with phasic DO had a significantly higher success rate at 3 months than patients with terminal DO. Patients with a baseline PVR 100ml had a higher rate of acute urinary retention and needed straining to void. However, long-term success rates upto 24 months showed no significant difference between patients with different urodynamic parameters. CONCLUSIONS: Except for patients with phasic DO, the baseline urodynamic parameters did not affect the treatment outcome of intravesical injection of 100U onabotulinumtoxinA for IDO. However, the occurrence of AUR and difficult urination were significantly greater in patients with baseline PVR of 100ml.

Do baseline urodynamic parameters affect the treatment outcome after intravesical 100 U onabotulinumtoxinA injection in patients with idiopathic detrusor overactivity?

ObjectivesIntravesical injection of onabotulinumtoxinA (BoNT-A) provides effective treatment for idiopathic detrusor overactivity (IDO). However, not all patients have successful long-term therapeutic effects. This study investigated the effects of baseline urodynamic parameters on the therapeutic outcome, after injecting 100 U BoNT-A in patients with IDO. Materials and MethodsA total of 174 patients who received a first single intravesical BoNT-A 100 U injection for refractory IDO were included. A successful outcome was defined as an improvement of at least two points on a patient perception of bladder condition scale, which was scored from 0 to 6. The short-term (3 months) and long-term (up to 24 months) success rates were analyzed according to baseline urodynamic parameters, including cystometric bladder capacity, maximum flow rate, postvoid residual, voiding efficiency, and detrusor overactivity (DO) subtypes. BoNT-A- related adverse events were also reported. ResultsA successful outcome was reported by 138 (79.3%) patients at 3 months. The baseline urodynamic parameters did not affect the success rates, except that patients with phasic DO had a significantly higher success rate at 3 months than patients with terminal DO. Patients with a baseline postvoid residual (PVR) > 100mL, had higher rates of acute urinary retention and need to strain to void. However, long-term success rates up to 24 months showed no significant differences between patients with different urodynamic parameters. ConclusionsExcept for patients with phasic DO, the baseline urodynamic parameters did not affect the treatment outcome of intravesical injection of 100 U BoNT-A for IDO. However, acute urinary retention and difficult urination occurred more often in patients with a baseline PVR of > 100mL.

Adverse Events of Intravesical Botulinum Toxin A Injections for Idiopathic Detrusor Overactivity: Risk Factors and Influence on Treatment Outcome

BackgroundIntravesical injection of botulinum toxin type A (BoNTA) provides effective treatment for detrusor overactivity and overactive bladder (OAB). However, the high rates of treatment-related adverse events (AEs) prevent its more widespread use. ObjectiveTo investigate the risk factors of increasing AEs after BoNTA injection for idiopathic detrusor overactivity (IDO). Design, setting, and participantsThis study included a total of 217 patients receiving their first intravesical BoNTA injection for refractory IDO in a tertiary university hospital from 2004 to 2009. MeasurementsAE incidence was analyzed according to gender, age, comorbidities, prostate condition in men, OAB subtype, BoNTA dose, injection site, and baseline urodynamic parameters. Successful outcome was determined based on patient perception of improvement of bladder condition at 3 mo. Results and limitationsSuccessful outcomes were reported by 144 (66.3%) patients. By multivariable analysis, male gender (p=0.013) and baseline postvoid residual (PVR) ≥100ml (p=0.003) were independent predictors of acute urinary retention (AUR). Baseline PVR ≥100ml (p=0.007) and receiving >100 U BoNTA (p=0.029) were predictors of straining to void. The incidence of large PVR after treatment was associated with comorbidity (p=0.011). Urinary tract infection occurred more frequently in women (p=0.003) and in men with retaining prostate (p=0.008). No AUR developed after bladder base/trigonal injection. Nevertheless, the occurrence of AUR or large PVR did not affect therapeutic outcome. This study is limited by nonconsecutive enrollment of patients. ConclusionsMale gender, baseline PVR ≥100ml, comorbidity, and BoNTA dose >100 U are risk factors for increasing incidence of AEs after intravesical BoNTA injection for IDO.

Editorial comment

In this article, the authors evaluate the use of botulinum toxin A (Botox) in the uncommon, but frustrating, clinical situation of a hypocontractile bladder combined with external sphincter nonrelaxation. In this novel study, 27 patients were evaluated for detrusor and voiding dysfunction with urodynamics and questionnaires before and after intraurethral Botox injections. Recovery of Detrusor Function After Urethral Botulinum A Toxin Injection in Patients with Idiopathic Low Detrusor Contractility and Voiding DysfunctionUrologyVol. 69Issue 1PreviewTo investigate the effect of urethral botulinum A toxin (BoNT-A) injection on idiopathic low detrusor contractility and the correlation of this effect with baseline urodynamic parameters. Full-Text PDF

Tamm-Horsfall protein protects urothelial permeability barrier

Objectives To test whether the presence of Tamm-Horsfall protein (THP) can limit the injury caused by low-molecular-weight (LMW) urinary cations using an in vivo rat bladder injury model. Previous studies have shown that normal urine contains LMW cations toxic to cultured bladder cells and that THP, a ubiquitous urinary glycoprotein, protects against this cytotoxic effect. THP may sequester and subsequently neutralize these toxic urinary cations. Methods A dialysis product of LMW (greater than 100 but less than 3500) was prepared from pooled 24-hour urine samples from healthy volunteers and evaluated for urothelial cell cytotoxicity. The LMW toxic factor (TF) was instilled into the bladders of Sprague-Dawley rats (n = 9) after recording the baseline urodynamic parameters, primarily nonvoiding contractions (NVCs). We also evaluated the ability of THP to block abnormal physiologic activity indicative of bladder injury caused by exposure to the TF (greater than 100 but less than 3500 molecular weight) by co-instillation of the TF with THP. Results The TF had a significant cytotoxic effect in cultured rat ( P <0.01) and human ( P <0.01) bladder epithelial cells. Rat bladder NVCs increased significantly over baseline contractility when potassium chloride was infused after TF (1.68 ± 0.11 NVC/min; P <0.0001) but not after infusion of THP plus TF (0.28 ± 0.085 NVC/min). Conclusions Normal urine contains a cationic factor that appears to increase urothelial permeability by injuring the mucosa, allowing potassium ions to penetrate the urothelium and depolarize underlying nerves and muscle. THP appears to neutralize the LMW fraction electrostatically and attenuate urothelial damage, resulting in suppression of potassium chloride-mediated bladder hyperactivity.

Detrusor Contraction Duration May Predict Response to ·–Blocker Therapy for Lower Urinary Tract Symptoms

Objectives: Baseline pressure/flow parameters have not correlated well with response to medical therapy for lower urinary tract symptoms (LUTS). This open–label, nonrandomized retrospective study was designed to evaluate whether the urodynamic parameter duration (in seconds) of the detrusor contraction (DCD) correlates better with α–blocker response than previously described urodynamic parameters. Methods: 93 men (mean age 62.6±8.5) with LUTS underwent urodynamic evaluation prior to initiating therapy with doxazosin titrated to 8 mg and followed for 6 months. Parameters of evaluation included the AUA symptom score (AUASx), peak urinary flow rate (Q_max), maximal detrusor pressure (P_max), detrusor pressure at maximal flow (P_det) and DCD. The correlation and predictive value of therapeutic response and baseline urodynamic parameters were assessed. Results: 85 patients were evaluable at 6 months. For the entire group, AUASx decreased from 15.1±6.9 to 9.7±5.1 (–36%) and Q_max increased from 9.3±3.7 to 11.9±5.7 ml/s (+28%). Baseline P_max was 74.8±19.6 cm H₂O, P_det was 61.6±18.9 cm H₂O and DCD was 107.6±28.6 s. There was weak correlation between either baseline P_max or P_det and therapeutic response (defined as a decrease in AUASx of 40% and an increase in Q_max of 30%). Utilizing a baseline DCD of 90 s or more, there was a significant correlation to therapeutic response (r = 0.48, p = 0.002). Conclusions: These preliminary data suggest that DCD may be a useful urodynamic parameter to predict and optimize therapy with a–blockade. The potential utility and cost–effectiveness of DCD remains to be determined.

THE EFFECTS OF TRANSURETHRAL NEEDLE ABLATION AND RESECTION OF THE PROSTATE ON PRESSURE FLOW URODYNAMIC PARAMETERS: ANALYSIS OF THE UNITED STATES RANDOMIZED STUDY

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.

The Efficacy of Transurethral Resection of the Prostate in Men with Moderate Symptoms of Prostatism

Transurethral resection of the prostate represents the operation most commonly performed by urologists in the United States. The objective of this study was to determine the efficacy of transurethral prostatectomy in men with moderate symptoms of prostatism. The efficacy parameters evaluated included peak urinary flow rate, obstructive and irritative symptom scores, and the global assessment by the patient of the voiding symptomatology. The mean peak urinary flow rate improved 108% after transurethral prostatectomy, and the mean obstructive and irritative symptom scores decreased 88 and 65%, respectively. The observed changes in urinary flow rates and symptom scores were statistically and clinically significant. Over-all, 84% of the patients indicated that the voiding symptoms were markedly improved after prostatic resection. Baseline urodynamic parameters were of no value for prediction of postoperative outcome. Several investigators recently reported their clinical experience with various pharmacological approaches for the treatment of symptomatic benign prostatic hyperplasia. Over-all, the degree of improvement in urinary flow rates and symptom scores achieved after transurethral prostatectomy exceeds all other therapeutic options that presently are available for the treatment of benign prostatic hyperplasia.