Mean American Urological Association Research Articles

A 27-Year Experience With Day Surgery Transurethral Resection of the Prostate.

Introduction Transurethral resection of the prostate (TURP) is the standard surgical procedure forobstructive symptoms of the lower urinary tract when medical management fails. Progression in TURP procedures has led to reduced catheterization time following transurethral prostatic resection. This study describes the methods and results of TURP performed in the day surgery setting. Materials and methods This retrospective study was performed at a day surgical hospital serving a patient population of more than 200,000 people. Over a 27-year period, a total of 1,123 patients with a mean age of 73.6 years (range: 49 to 91 years) underwent same-day conventional (electrosurgical monopolar) transurethral prostatic resection. Of the procedure, 43 patients (11%) received spinal anaesthesia, and the remainder received general anaesthesia. Results Over the years, there has been an increase in the use of medication to manage bladder outflow obstructive symptoms, which has led to the preoperative post-micturition volumes of urine being increased (>200 ml) at the time of surgical intervention. The mean American Urological Association (AUA) score was 22 (range: 10-35). Due to the reduced bladder tone preoperatively and the noted intraoperative distension of the bladder, early catheter removal is contraindicated in these patients. The mean duration of catheterization was 6.4 days (range: two to 28 days). No patient was readmitted to the hospital for retention of urine. However, 11 patients in the series had re-catheterization due to failure of micturition after the removal of the catheter. No patients were admitted to the hospital for clot retention or sepsis postoperatively. This resulted in the patients being discharged home with a catheter in place, which became our standard practice. Conclusion Conventional transurethral resection of the prostate can be effectively managed in the day surgery setting with minimal morbidity. This improves the patient's quality of life as well as the burden on hospital costs. Additionally, the outpatient nature of day surgery may lead to decreased overall healthcare expenses for both the patient and the healthcare system. As healthcare systems continue to prioritize streamlined and patient-centred approaches, day surgery for TURP emerges as a viable and advantageous option.

The Role of Oxybutynin Chloride in the Management of Patientswith Benign Prostatic Hyperplasia

Objectives: To determine the efficacy and tolerability of Oxybutynin chloride in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in which previous a-blocker therapy had failed. :
 Materials and Methods: A total of 38 consecutive men with BPH complaining of LUTS in whom a mean of 6.3 months of a-blocker therapy had failed received Oxybutynin (5 mg twice daily orally) for 3 months in addition to the usual a-blocker medication. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, and adverse events. Statistical analysis was used when needed.
 Results: A total of 33 men (87%) with a mean age of 59 years completed the 3-month trial. Mean 24- hour micturition frequency decreased from 11.2 to 6.5 voids and nocturia decreased from 5.1 to 2.4 episodes nightly. Significant changes in mean American Urological Association symptom scores (- 5.31), the peak urinary flow rate (1.8 ml per second) and post-void residual volume (=21 ml) were also observed. Five men (13%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention.
 Conclusions: Treatment with Oxybutynin in carefully selected men with BPH and moderate LUTS may be a reasonable therapeutic option after failed treatment with a-blockers.

Evaluation of Lower Urinary Tract Symptoms suggestive of Benign Enlargement of the Prostate by Uroflowmetry and American Urological Association Symptom Score

Background: Uroflowmetry study is a non-invasive, simple, and inexpensive preliminary the diagnostic tool of various lower urinary tract diseases like benign prostatic hyperplasia, stricture the urethra, neurogenic bladder, etc. American Urological Association Symptom Score is the single a most important tool used in the evaluation of patients with Benign prostatic hyperplasia (BPH) and is recommended for all patients before initiation of therapy. Objectives: To evaluate lower urinary tract symptoms suggestive of Benign Enlargement of Prostate by Uroflowmetry study, measuring American Urological Symptom Score, Quality of life, and to find out correlation among Uroflowmetry parameters, age. Materials and Methods: This is a prospective study to evaluate 13 patients with lower urinary tract symptoms suggestive of benign enlargement of the prostate by performing a Uroflowmetry test. We also measured the level of symptoms by American Urological Association Symptom Score and quality of life of age group 48 to 71 years. Selected patients have gone under Uroflowmetry study recorded American Urological Association Symptom Score and quality of life by few questionnaires. Results: The mean age of the patients was 58.92+/-6.93 SD year. The mean maximum flow rate and average flow rate were found to be 16.44 and 6.99 ml/sec respectively. Voiding time and voided volume of urine was 74.53+/-44.94 SD sec, and 412.38+/- 255.66 SD ml respectively. The maximum flow rate and age were negatively correlated(R=-0.551). Time of maximum flow rate and amount of voided urine was strong positively correlated(R=0.8717, p<0.05). Voiding time and voided volume were positively correlated (p<0.05).Regarding American Urological Association Symptom Score, 53.85% of patients had severe symptoms. The mean American Urological Association Symptom Score of severe and moderate symptomatic patients were 25.14+/-3.48 SD, and 14.67+/-3.77 SD respectively. For patients of Uroflowmetry studied, 76.92% had prolonged voiding time, and 23% had normal voiding time in comparison with a normal nomogram.14 Conclusions: The uroflowmetry test and American Urological Association Symptom Score are helpful for preliminary evaluation of lower urinary tract symptoms suggestive of benign enlargement of the prostate and for further treatment. Prolong voiding time and decrease maximum flow rate can give clues for outflow obstruction for benign enlargement of the prostate. KYAMC Journal Vol. 13, No. 01, April 2022: 45-49

Metastasis, Mortality, and Quality of Life for Men With NCCN High and Very High Risk Localized Prostate Cancer After Surgical and/or Combined Modality Radiotherapy.

To compare metastasis-free survival, overall survival, and patient-reported quality of life (QOL) of men with National Comprehensive Cancer Network high or very high risk prostate cancer after definitive surgery and/or multimodal radiotherapy (RT). We studied a retrospective cohort study of 586 patients treated between the years 2000 and 2017 receiving radical prostatectomy with or without postoperative RT, external-beam RT (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (Brachy) boost+ ADT. Patient-reported QOL for urinary, bowel, sexual, and overall physical and mental functioning was assessed using the American Urological Association symptom scale, the Sexual Health Inventory in Men, the Rectal-Function Assessment Scale, the Expanded Prostate Cancer Index Composite, and the Veterans RAND 12-Item Health Survey. Median follow-up for survival was 5 years. No significant differences between the treatments were observed for overall survival or metastasis-free survival at the P< .05 threshold. The propensity-adjusted 5-year metastasis-free survival estimates for EBRT+ ADT, EBRT+ Brachy+ ADT, and surgery were 74.6%, 94.8%, and 83.1%, respectively. The EBRT+ Brachy+ ADT and surgery cohorts had significantly worse mean American Urological Association symptom scores at 6 months than the EBRT+ ADT cohort, which resolved by 1 year. Surgical patients had better rectal function scores than EBRT+ ADT patients at years 1 to 3, but similar function thereafter. Adjuvant or salvage RT resulted in significant declines in various Expanded Prostate Cancer Index Composite urinary, sexual, and bowel domains, and Veterans RAND 12-Item Health Survey physical but not mental domains. Men with very and/or high-risk localized prostate cancer are likely to require multimodal therapy. The overall differences in survival and long-term QOL are similar for men choosing surgical versus RT pathways.

A Prospective Study to Evaluate the Efficacy of Botulinum Toxin-A in the Management of Dysfunctional Voiding in Women.

Objectives:To assess the outcomes of Botulinum Toxin-A (BoNT-A) to the external urethral sphincter (EUS) in dysfunctional voiding (DV) refractory to standard urotherapy and bowel management.Methods:Our criteria to diagnose DV in women included neurologically normal individuals with lower urinary tract symptoms, dilated proximal urethra on voiding cystourethrogram, and high detrusor pressure (PdetQmax > 20 cm H2O) associated with increased electromyography activity during voiding in urodynamic study (UDS). A total of 16 female patients with a median age of 36 years (5-60 years) received BoNT-A from June 2014 to December 2015. Patients below and above 10 years of age received 100 units and 200 units of BoNT-A to EUS, respectively. Patients were followed up till 6 months.Results:Mean AUA (American Urological Association) symptom score decreased significantly from 11.75 ± 6.14 to 5.06 ± 5.1 and 4.25 ± 3.4 at day 14 and day 45 after BoNT-A, respectively (P < .0001). There were no significant improvements in maximal flow (Qmax) on uroflowmetry (UFM) and detrusor pressure at maximal flow (PdetQmax) in UDS. Significant reduction in post-void residual (PVR) from 69.31 ± 77.3 to 17.50 ± 22.3 mL at day 14 (P = .007) was observed, although the reduction was not significant at day 45. Although minor adverse effects were reported, none were serious or life-threatening.Conclusions:Our study showed that BoNT-A plays a role in improvement of urinary symptoms and reduces PVR at D14 in DV, but showed no improvement in UFM and urodynamic parameters, albeit with limited numbers and limited follow-up.

Complications, Recovery, and Early Functional Outcomes and Oncologic Control Following In-bore Focal Laser Ablation of Prostate Cancer

From April 2013 to July 2014, 25 consecutive men participated in a longitudinal outcomes study following in-bore magnetic resonance imaging (MRI)-guided focal laser ablation (FLA) of prostate cancer (PCa). Eligibility criteria were clinical stage T1c and T2a disease; prostate-specific antigen (PSA) <10 ng/ml; Gleason score <8; and cancer-suspicious regions (CSRs) on multiparametric MRI harboring PCa. CSRs harboring PCa were ablated using a Visualase cooled laser applicator system. Tissue temperature was monitored throughout the ablation cycle by proton resonance frequency shift magnetic resonance thermometry from phase-sensitive images. There were no significant differences between baseline and 3-mo mean American Urological Association Symptom Score or Sexual Health Inventory in Men scores. No man required pads at any time. Overall, the mean PSA decrease between baseline and 3 mo was 2.3 ng/ml (44.2%). Of 28 sites subjected to target biopsy after FLA, 26 (96%) showed no evidence of PCa. Our study provides encouraging evidence that excellent early oncologic control of significant PCa can be achieved following FLA, with virtually no complications or adverse impact on quality of life. Longer follow-up is required to show that oncologic control is durable. Patient summaryEarly results for focal laser ablation of prostate cancer are very encouraging. Until long-term oncologic control is demonstrated, focal laser ablation must be considered an investigational treatment option.

Robotic-assisted Bladder Diverticulectomy: Assessment of Outcomes and Modifications of Technique

To present outcomes of robotic-assisted bladder diverticulectomy (RABD) and technique modifications that may improve outcomes. Sixteen consecutive RABDs were performed at our institution by 2 experienced robotic surgeons. Charts were reviewed for patient characteristics, perioperative data, and long-term functional outcomes. Eleven patients (69%) underwent RABD using an external dissection approach, whereas 5 patients (31%) underwent RABD using a modified internal dissection technique (immediate entry into the bladder diverticulum). The mean age of our cohort was 68 years (range, 59-79 years), and 15 of 16 patients (93.8%) were men. Two patients (12.5%) had known malignancy in the diverticulum. Eleven patients (69%) underwent a preoperative outlet procedure (9 transurethral resection of prostate and 2 transurethral incision of prostate) at a median time before RABD of 163.5 days (range, 26-622 days). Median operative time for external RABD was 228 minutes (range, 144-353 minutes) compared with that of 149 minutes (range, 130-189 minutes) for the internal dissection technique. No patient required blood transfusions, and there were no 30-day Clavien grade 3 or 4 complications. Median hospital stay was 2 days (range, 1-3 days). Median postvoid residual before intervention was 458 mL (range, 78-1100 mL) compared with that of 214 mL (range, 46-527 mL) after RABD. Mean American Urological Association symptom score was 18 (range, 5-29) preoperatively compared with that of 7 (range, 2-21) postoperatively. RABD is safe with a low risk of intraoperative or postoperative complications and results in both improved voiding symptoms and diminished postvoid residuals. Modifications of technique from an external dissection approach to an internal dissection approach has led to a dramatic reduction in operative time.

A Retrospective Review of Office-based 532-nm Greenlight Laser Prostatectomy in Men With Symptomatic Benign Prostatic Hyperplasia

To evaluate the feasibility, safety, and outcomes of men with symptomatic benign prostatic hyperplasia undergoing 532-nm GreenLight laser prostatectomy in the office-based setting. From September 2007 to October 2011, 47 patients underwent office-based 532-nm GreenLight laser prostatectomy by a single surgeon. Patients were enrolled prospectively and preoperative, intraoperative, and postoperative parameters were then reviewed retrospectively. Statistical analysis was performed with Wilcoxon rank sum test with a P value ≤.05 being considered statistically significant. The mean patient age was 66 (range, 49-89); 91% of men were on an alpha-blocker preoperatively; mean (standard deviation; SD) prostate volume by transrectal ultrasound was 35.8 mL (14.5); mean (SD) American Society of Anesthesiologists score was 2.33 (0.77); mean (SD) operative time was 36.73 minutes (18); mean (SD) lasing time was 19.1 minutes (8.31); mean (SD) total laser kiloJoules used was 85,387 kJ (38,885); and mean (SD) follow-up time was 8.48 months (8.24). The 1-year decrease in mean (SD) American Urologic Association Symptom Score and quality of life were 17.7 (8.3)-7 (7.3) and 4.1 (1.4)-2.27 (2) respectively. The maximal urinary flow increased from 8.1 (3.8) to 10.7 (6). Patients' postvoid residual improved from 130 mL (147) to 27 mL (55) over a 1-year period. (P <.01 for all). There were no reoperations for refractory lower urinary tract symptoms or hospital admissions. For men with small but symptomatic benign prostatic enlargement, office-based GreenLight laser prostatectomy is safe and feasible.

1263 URINARY DIVERSIONS AFTER RADIATION FOR PROSTATE CANCER: INDICATIONS AND TREATMENT

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion (I)1 Apr 20131263 URINARY DIVERSIONS AFTER RADIATION FOR PROSTATE CANCER: INDICATIONS AND TREATMENT Sarah Fraumann, Melissa Kaufman, Roger Dmochowski, and Doug Milam Sarah FraumannSarah Fraumann Nashville, TN More articles by this author , Melissa KaufmanMelissa Kaufman Nashville, TN More articles by this author , Roger DmochowskiRoger Dmochowski Nashville, TN More articles by this author , and Doug MilamDoug Milam Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2617AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For treatment of localized prostate cancer, the utilization of radiotherapy has been increasing. In the radiation toxicity literature, grade 4 complications range between 0-0.4%. There is a paucity of Urologic literature on presentation and symptom progression culminating in urinary diversion after radiotherapy. We sought to better characterize these patients at a high volume tertiary care reconstructive Urology practice. METHODS Retrospective review of electronic medical records was performed for all patients between 2005 and 2011 who underwent urinary diversion for urologic complications of radiotherapy for treatment of prostate cancer. We analyzed demographics, type of radiation, presenting symptoms, diagnostic evaluation, and surgical interventions. RESULTS Of the 30 patients identified, six (20%) underwent external beam radiotherapy (EBRT), 11 (37%) had brachytherapy implants (BT) and 13 (43%) had combination EBRT/BT. The average time from radiation until presentation to our institution was 4.6 years. At presentation, the mean American Urological Association Symptom Index (AUASI) was 25 and patients wore an average of 5.8 pads per day (PPD). On cystoscopy, 10 patients (33%) were found to have a necrotic, calcified prostate with 90% of those patients having brachytherapy seeds. Overall reasons for urinary diversion included fistula (37%), end-stage bladder (20%), stricture disease (27%) and a combination of end-stage bladder and stricture disease (17%). Broken down by EBRT, BT and combination therapy, diversion rates for end-stage bladder were: 33%, 18% and 15%, stricture disease: 17%, 45% and 15%, both end-stage bladder and stricture disease: 17%, 0% and 31%, and fistula: 33%, 36% and 38% respectively. Types of diversion included cystectomy with conduit diversion (63%), conduit diversion alone (17%) and chronic indwelling suprapubic catheter (20%). Eight patients (27%) also required a bowel diversion. Patients underwent an average of 4.4 procedures prior to urinary diversion. CONCLUSIONS The reported need for urinary diversion after radiation for prostate cancer is rare and thus indications have not been well characterized. While fistula rates were similar across modalities, EBRT tended to cause a higher incidence of end-stage bladder disease whereas brachytherapy seeds resulted in an increased incidence of stricture disease and findings of calcified and necrotic prostate on cystoscopy. Surgical management included cystectomy with conduit diversion, conduit diversion alone, and indwelling suprapubic catheter. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e517 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Fraumann Nashville, TN More articles by this author Melissa Kaufman Nashville, TN More articles by this author Roger Dmochowski Nashville, TN More articles by this author Doug Milam Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Characteristics of persons with overactive bladder of presumed neurologic origin: Results from the Boston Area Community Health (BACH) survey

To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB). Five thousand five hundred three community-dwelling persons aged 30-79 were interviewed regarding urologic symptoms (2002-2005). NOAB was defined as symptoms of urgency and/or urgency incontinence among those with a self-reported history of healthcare provider diagnosed stroke (N = 98), multiple sclerosis (N = 21), or Parkinson's disease (N = 7). N-NOAB was defined identically but occurring among those not reporting neurologic disease (ND). Prevalence estimates were weighted to reflect sampling design; chi-square, Fisher's exact, or t-tests were used to test differences. Urologic symptom interference was assessed using the Epstein scale, while the impact of urinary incontinence (UI) on health-related quality-of-life (HRQOL) was measured using a modification of the Incontinence Impact Questionnaire-7. Forty-five (31.0%) of 125 persons with ND and 994 (16.7%) of 5378 persons without ND reported OAB symptoms. The overall prevalence of NOAB and N-NOAB was 0.6% and 16.4%, respectively. Persons with NOAB had higher (worse) mean American Urologic Association Symptom Index scores (13.0 vs. 10.0, P = 0.09) compared to those with N-NOAB, and were significantly more likely to have diabetes, high blood pressure, cardiac disease, and fair/poor self-reported health (all P < 0.05). Mean symptom interference and UI HRQOL scores were significantly higher (worse) in the NOAB group compared to persons with N-NOAB (all P < 0.05). Persons with NOAB appeared to have a greater burden of urologic illness with respect to symptom interference and HRQOL compared to persons with N-NOAB.

Rapid ambulatory pathway laser prostatectomy is safe: results within the global period

What's known on the subject? and What does the study add? Laser prostatectomy is a commonly performed procedure for BOO, and has been shown to have short- and medium-term results equivalent to the gold standard procedure (i.e. TURP) in various studies. It also has an advantage over TURP in that it can be performed on patients who are taking anticoagulant medication. However, patients in most studies are admitted to the hospital overnight on continuous bladder irrigation and are discharged home the next day. The present study shows that it is safe and feasible to perform laser prostatectomy in an ambulatory fashion with discharge of patients within hours of their surgery. The discharge pathway is associated with minimal morbidity or the need for admission after surgery, and the reported short-term results are in accordance with the available literature on laser prostatectomy. To investigate the feasibility and safety of a rapid ambulatory discharge pathway after holmium laser ablation of the prostate (HoLAP) for the treatment of benign prostatic hyperplasia. The study group comprised a cohort of 65 consecutive patients undergoing HoLAP scheduled as a day surgical case by a single surgeon between January 2007 and December 2009. Patients were discharged from day surgery with a catheter in place, and returned for a voiding trial on postoperative day 3. Preoperative, intra-operative and postoperative parameters were reviewed with follow-up data for the 90-day global postoperative period. Statistical analysis employed Student's t-test with P < 0.05 (two-tailed) being considered statistically significant. The mean (range) patient age was 64 (41-87) years; mean (range) American Society of Anesthesiologists score was 2.2 (1-4); mean (sd) operation duration was 44 (17) min; and mean (sd) time after surgery until discharge was 149 (51) min. Postoperative complications included catheter occlusion (1.5%) and admission for haematuria (1.5%). There were no re-admissions after discharge from the hospital. Within the 90-day global period, 13 patients described lower urinary tract symptoms (20%), five patients had postoperative urinary retention (7.7%) and one patient had a urinary tract infection (1.5%). After surgery, mean American Urological Association Symptom Score decreased from 21.3 to 7.6 (P < 0.001); mean quality of life score decreased from 4.04 to 1.38 (P < 0.001); and mean post-void residual decreased from 190.2 to 46.4 mL (P < 0.001). In appropriately selected patients, HoLAP can be safely performed as an ambulatory case with a rapid discharge pathway and minimal morbidity during the 90-day global period.

Factors Influencing Urinary Symptoms 10 Years After Permanent Prostate Seed Implantation

We investigated the factors that influenced urinary symptoms in the first 10 years after prostate brachytherapy. A total of 1,932 men were treated with prostate brachytherapy alone or with external beam irradiation and followed a mean of 6.8 years. The influence of pretreatment American Urological Association symptom score (7 or less, 8 to 19, 20 or greater), external beam radiotherapy, (125)I or (103)Pd, biological effective dose, age, prostate size and hormone therapy on the change in American Urological Association symptom score (11,491) was compared. The mean change from initial score (7.4) was 11.4, 5.5, 3.3, 2.7, 1.5, 1.2, 1, 1, 1, 1, 1.3 and 1.4 points at 3, 6 months and 1 to 10 years, respectively (p <0.001). Factors that resulted in a greater increase in urinary symptoms at year 1 were low pretreatment score (p <0.001), no hormonal therapy (p <0.001), younger age (p = 0.046) and higher biological effective dose (p = 0.025). At 10 years patients with an initial score of 20 or greater had an average decrease of 11 points compared to a decrease of 0.9 for an initial score of 8 to 19 and an increase of 2.7 for an initial score of 7 or less (p <0.001). On linear regression the scores at 1 year were influenced by initial score (p <0.001), biological effective dose (p = 0.022), prostate size (p <0.001) and hormonal therapy (p = 0.009). At 10 years only the pretreatment score remained significant (p <0.001). There is minimal change in mean American Urological Association symptom score (1.4 points) 10 years after prostate brachytherapy. Patients presenting with high initial scores have the greatest improvement from baseline. Biological effective dose, external beam radiotherapy, hormonal therapy, isotope, patient age and prostate size do not appear to influence long-term urinary symptoms.

The Relationship Between Lower Urinary Tract Symptom Severity and Sleep Disturbance in the CAMUS Trial

Bothersome lower urinary tract symptoms, including nocturia, significantly impact general health related quality of life in men, as does sleep disturbance. However, few groups have examined the relationship between urinary symptom severity and sleep disturbance. Men enrolled in a clinical trial of saw palmetto (Serenoa repens) were studied at baseline. Lower urinary tract symptom severity, as determined by the American Urological Association symptom index and quality of life scores, and the degree of sleep disturbance were determined by the Jenkins sleep scale. Analysis was done, adjusting for baseline characteristics, to identify predictors of severe sleep disturbance. A total of 366 men with a mean ± SD age of 60.9 ± 8.3 years who had moderate-severe lower urinary tract symptoms (mean American Urological Association symptom index score 14.58 ± 4.6 points) and a mean Jenkins sleep score of 7.3 ± 4.7 points were included in analysis. Overall there were significant associations between the American Urological Association symptom index score and sleep disturbance severity. Multivariate analysis revealed that obstructive and irritative symptoms were significantly associated with severe sleep disturbance. Further analysis showed that lower serum prostate specific antigen and post-void residual urine volume were also significantly associated with the degree of sleep disturbance. Lower urinary tract symptom severity is a risk factor for severe sleep disturbance in men. While nocturia was significantly associated with sleep disturbance, other lower urinary tract symptoms were also independent predictors of sleep dysfunction.

Techniques and Results of Urethroplasty for Female Urethral Strictures: Our Experience With 17 Patients

To report our experience with urethroplasty in women with urethral stricture and discuss the therapeutic considerations and outcomes of various flap- and graft-based techniques. A total of 17 patients with mid to distal urethral stricture (urethral caliber <14F, maximal urinary flow rate <12 mL/s, and detrusor pressure >20 cm H(2)O during voiding) underwent urethroplasty from 2004 to 2010. Of the 17 patients, 7 had undergone previous instrumentation and 10 were repaired primarily. The preoperative workup included American Urological Association symptom score assessment, uroflowmetry, voiding cystourethrography, and urethrocystoscopy. Of the 17 patients, 10 received anterior vaginal wall mucosa inlay urethroplasty. Proximally, the dilated urethral mucosa was used in 1 patient. A Martius flap reinforced ventral buccal mucosa graft (BMG) onlay urethroplasty was used in 2 patients with previous synthetic midurethral slings. Two patients with an atrophic vagina received a dorsal BMG onlay. A circular BMG reconstruction was used in 2 patients with severe distal urethral stricture. The preoperative findings were compared with the postoperative data at the last follow-up using the Wilcoxon sign test. With a median follow-up of 24 months (range 6-78), an objective and subjective cure was achieved in 17 (100%) and 15 (88%) patients, respectively. At the last follow-up, the mean maximal urinary flow rate increased from 10.8 ± 3.2 mL/s preoperatively to 28.9 ± 7.4 mL/s (P = .001), and the mean postvoid residual urine volume had decreased from 120 ± 30 mL preoperatively to 30 ± 12 mL (P = .001). The mean American Urological Association score had decreased from 27.1 ± 3.9 preoperatively to 7.1 ± 3.5 postoperatively (P < .0001). Primary urethroplasty can be considered a first-line option for treatment of female urethral strictures. Local mucosal flaps will cure the problem in most situations. BMG offers an excellent alternative when viable local tissue is absent.

Single‐port transvesical enucleation of the prostate: a clinical report of 34 cases

To present our experience with single-port transvesical enucleation of the prostate (STEP) in 34 patients with large-volume benign prostatic hyperplasia (BPH). We performed STEP in 34 patients with large volume (>60 g) BPH (mean age 69 years, body mass index 26 kg/m(2), and American Society of Anesthesiology class 2). The mean prostate volume estimated by transrectal ultrasonography was 102.5 mL and the mean baseline prostate-specific antigen level was 6.7 ng/mL. A novel single-port device was inserted percutaneously into the bladder through a 2-3 cm incision in the suprapubic skin crease. After establishing pneumovesicum, the prostate adenoma was enucleated transvesically using standard laparoscopic instruments, and the adenoma was extracted in pieces through the port. Digital assistance expedited enucleation of the apical adenoma in 19 (55%) cases. Transvesical enucleation was completed in all 34 cases; the mean operative duration was 116 min, and the estimated blood loss was 460 mL. There was one death from postoperative bleeding from uncontrolled coagulopathy in a Jehovah's Witness who refused a transfusion of blood and blood products. There were three complications during STEP (one death, one bowel injury and one haemorrhage) and five afterwards (four bleeding, one epididymo-orchitis). Open conversion was necessary in two patients for complications, and extension of the skin incision by 1-2 cm was necessary in two to expedite apical digital enucleation. The mean hospital stay was 3 days and mean analogue pain score at discharge was 2. All 33 patients (excluding the patient who died) were voiding spontaneously at a maximum follow-up of 8 months, with a mean American Urologic Association symptom score of 3, a maximum urinary flow rate of 44 mL/s, and a postvoid residual of 30 mL at the latest follow-up. No patient developed urinary incontinence. STEP is an effective treatment option for selected patients with large-volume obstructive BPH. Under pneumovesicum using laparoscopic visualization, the entire adenoma can be effectively enucleated and expeditiously extracted through the novel single port. Comparison of the STEP procedure with other open and transurethral techniques will determine its place in the surgical treatment of large-volume BPH.

Holmium Laser Enucleation of the Prostate for Prostates Larger Than 175 Grams

Open simple prostatectomy has been considered the treatment of choice for symptomatic benign prostatic hyperplasia (BPH) of large prostates because traditional endoscopic techniques have not proven either effective or feasible. We present our experience with holmium laser enucleation of the prostate (HoLEP) for glands >175 cc. An Institutional Review Board approved prospective database has been maintained since January 1999 for all HoLEP procedures. The database was reviewed retrospectively for patients who underwent HoLEP for BPH with a preoperative transrectal ultrasonography (TRUS) volume of >175 cc. From January 1999 to November 2008, we identified 57 patients with a mean pretreatment TRUS volume of 217.8 cc (range 175-391 cc). Preoperative retention was present in 30 patients. Preoperative mean prostate-specific antigen level was 14.6 ng/mL, mean American Urological Association (AUA) symptom index was 19.0, and mean peak flow (Qmax) was 8.2 mL/sec. Mean hospital stay was 26 hours, and postoperative catheterization was 18.5 hours (range 6-96 hrs). All patients were able to void after catheter removal. Mean enucleated tissue weight was 176.4 g (range 48-532.2 g). At 6-month follow-up, AUA symptom index was 6.5, mean PSA level was 0.78 ng/mL, and Qmax was 18.5. During the follow-up period, no patient needed catheterization or had persistent incontinence. Even in the large prostate gland, HoLEP provides a satisfactory outcome with low morbidity. HoLEP is the only endoscopic technique that allows for tissue removal comparable to that of open prostatectomy for such patients.

Holmium Laser Enucleation of Prostate: Outcome and Complications of Self-taught Learning Curve

To analyze the self-learning curve of a single surgeon with holmium laser enucleation of the prostate and to evaluate the safety, effectiveness, and outcome of the procedure after 2 years of experience. The data from the first 125 patients who underwent holmium laser enucleation of the prostate were retrospectively analyzed. The patients were assessed preoperatively and at 1, 3, 12, and 24 months postoperatively. The patient evaluations included serum prostate-specific antigen measurement, peak urinary flow rate determination, postvoid residual volume measurement, and symptom scores. To assess the effect of the learning curve on the perioperative data and complications, the patients were divided into subgroups of 25 consecutive patients. The mean patient age was 71.4 years. The average prostate volume was 75.8 mL, and the mean weight of the enucleated tissue was 46.7 g. The average operative time was 109.8 minutes. The operative times and enucleation and morcellation efficiency rates improved significantly during the learning process. The mean hemoglobin loss was 1.7 g/dL. The median catheter time and hospital stay was 44 and 30 hours, respectively. Compared with baseline, at 1 year postoperatively, the median postvoid residual urine volume had declined by 99 mL, the mean peak urinary flow rate had increased by 19 mL/s, and the mean American Urological Association symptom score had decreased by 16.5 points. All changes observed were significant and regardless of the prostate size. Persistent stress urinary incontinence (4.8%) occurred with the first enucleations of large-size prostates. Other complications included bladder neck contracture (4%) in small-size prostates and bulbar urethra stricture (1.6%). Holmium laser enucleation of the prostate is a safe, reproducible and effective surgical modality. Case selection is necessary to avoid the morbidity associated with the first stages of the self-taught learning curve, mainly urinary incontinence.

Tolterodine Extended Release Attenuates Lower Urinary Tract Symptoms in Men With Benign Prostatic Hyperplasia

In this open label, prospective study we determined the efficacy and tolerability of tolterodine extended release (ER) in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in whom previous alpha-blocker therapy had failed. A total of 43 consecutive men with BPH and LUTS in whom a mean of 5.7 months of alpha-blocker therapy had failed due to adverse events (11) or a lack of efficacy (32) received tolterodine ER (4 mg daily) for 6 months. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, total score on the erectile function domain of the International Index of Erectile Function and adverse events. A total of 39 men (91%) with a mean age of 61 years completed the 6-month trial. Mean 24-hour micturition frequency decreased from 9.8 to 6.3 voids and nocturia decreased from 4.1 to 2.9 episodes nightly. Significant changes in mean American Urological Association symptom scores (-6.1), the peak urinary flow rate (1.9 ml per second) and post-void residual volume (-22 ml) were also observed. Of the men 27 (63%) were potent at baseline and 29 (67%) were potent after 6 months of tolterodine ER treatment. Mean International Index of Erectile Function erectile function domain scores increased (6.9). Four men (9%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention. Treatment with tolterodine ER in men with BPH and LUTS may be a reasonable therapeutic option as initial therapy or after failed treatment with alpha-blockers.

The Short-Term and Long-Term Effects of Radical Prostatectomy on Lower Urinary Tract Symptoms

We determined the long-term effect of radical prostatectomy on lower urinary tract symptoms. Between October 1, 2000 and January 30, 2003, 587 men underwent open radical retropubic prostatectomy. Of these men 453 completed the American Urological Association symptom index at baseline, and 12 and 48 months. Mean changes in American Urological Association total, voiding and storage symptom scores were ascertained between baseline and 12 months (short term), baseline and 48 months (long term), and between 12 and 48 months (natural history of lower urinary tract symptoms without a prostate). Symptom scores were ascertained independently for men with baseline mild vs moderate/severe lower urinary tract symptoms. Clinically and statistically significant short-term and long-term improvements were observed in mean American Urological Association total, storage and voiding symptom scores for men presenting with moderate/severe lower urinary tract symptoms. The previously reported progression of lower urinary tract symptoms in the general population of men older than 40 years was not observed in our patients with an absent prostate. The current study provides compelling evidence that radical prostatectomy prevents the progression of lower urinary tract symptoms in men with and without baseline clinically significant lower urinary tract symptoms. This beneficial effect of radical prostatectomy on the natural history of lower urinary tract symptoms should be considered when weighing the risks and benefit of the treatment option for localized prostate cancer.

Efficacy and safety of tamsulosin for benign prostatic hyperplasia: clinical experience in the primary care setting

ABSTRACTObjective: This study evaluated the efficacy and safety of the α1A/α1D subtype-selective blocker tamsulosin for the increasingly common treatment of benign prostatic hyperplasia (BPH) in the primary care setting.Methods: A total of 493 men (age ≥ 45 years), 99.6% of whom had moderate or severe BPH at baseline, were given tamsulosin 0.4 mg/day in a multicenter, open-label study conducted over 45 days by 42 primary care physicians and two urologists.Results: Mean American Urological Association (AUA) Symptom Score decreased by 7.5 from a baseline of 20.0 on day 4, representing a 37.5% improvement over baseline ( p < 0.001). AUA Obstructive and Irritative Scores declined significantly by day 4 (–4.7 and –2.7, respectively), as did AUA Bother Score (–5.4, p < 0.001) and mean BPH Impact Score (–2.5, p < 0.001). The Investigator's Global Assessment showed slight or greater improvement in 77.2% of patients (13.7% markedly improved). Effects were maintained from day 4 through day 45.Conclusions: Overall, patients treated with tamsulosin in a primary care setting experienced rapid, significant improvement in their signs and symptoms of BPH, based upon the change in the AUA Symptom Score. Tamsulosin was well tolerated; no new safety concerns were observed. Tamsulosin was not associated with significant effects on blood pressure or first-dose hypotension.