Mean Post-void Residual Urine Research Articles

重度の心疾患や認知症によりTUR-P施行不可能とされた症例に対する光選択的前立腺蒸散術 (PVP) の安全性, 有効性の検討

TUR-P for the treatment of BPH is not performed in cases with severe heart disease due to the risk of bleeding and hyponatremia etc. Besides, in cases with severe central nerve disease and dementia, TUR-P is not performed because patients cannot take postoperative rest. We report the efficacy and the safety of Photoselective Vaporization of the Prostate (PVP) using a high-power 80 W KTP (potassiumu-titayl-phosphate) in patients for whom TUR-P cannot be performed. 312 patients underwent PVP in our hospital. Of these 312 patients, 8 patients with severe heart disease (American Society of Anesthesiology score of 3 or greater) and 4 patients with severe dementia (Performance status of 3 or greater) were evaluated. We assessed peak flow rate and post-void residual urine volume preoperatively and at 3 months postoperatively, safety of the procedure, and complication rates. The mean age was 81 years old (range 67 to 94) and the mean prostate volume was 63.8 ml (range 19 to 120). Urethral catheter was used in 8 patients because of chronic urinary retention. PVP was performed with GreenLightPV and a saline solution was used for irrigation. Upon completion of the procedure an 18Fr Foley catheter was inserted without continuous bladder irrigation and removed next morning, as a rule. In all 12 patients, PVP was performed successfully without any intraoperative complications. Mean operating time was 101 minutes (range 28 to 184), mean total laser energy was 336,853 J (range 74,396 to 550,000), and mean irrigation volume was 21 L (range 8 to 36). The hemoglobin value changed from mean 13.1 mg/dl preoperatively to 12.2 mg/dl postoperatively. Blood transfusions were not required and hyponatremia was not observed. In 1 case, the urethral catheter was removed 3 hours following surgery. In the other cases, the urethral catheter was removed next morning. All patients could urinate after catheter removal and were discharged on the day following operation. Mean peak flow rate increased to 18 ml/s and mean post-void residual urine decreased to 46.9 ml at 3 months. No postoperative complications (urinary retention, hematuria, urinary tract infection, etc.) were observed. PVP is safe and effective in high-risk patients who are not candidates for TUR-P.

Modified Transurethral Incision of the Bladder Neck Treating Primary Bladder Neck Obstruction in Young Men: A Method to Improve Voiding Function and to Preserve Antegrade Ejaculation

Objectives: To evaluate the voiding function, ejaculation status and sexual function after the novel modification of transurethral incision of the bladder neck (TIBN) treating young men with primary bladder neck obstruction (PBNO). Methods: Using a videourodynamic study, PBNO was diagnosed in 33 young men 27–50 years of age who presented with chronic lower urinary tract symptoms and low urinary flow. TIBN was performed in all patients, with the modification of preserving a portion of the supramontanal tissue during the procedure. International Prostate Symptom Score (I-PSS), quality of life, uroflowmetry, postvoid residual urine, the status of ejaculation and sexual function using the 5-item version of the International Index of Erectile Function (IIEF-5) were assessed before, 3 and 24 months after treatment. Results: Follow-up data were available in 32 (97%) and 26 (79%) patients at 3 and 24 months postoperatively, respectively. During the 2-year follow-up, mean I-PSS decreased from 20.7 to 5.9 (p < 0.01). Mean quality of life decreased from 4.2 to 2.3 (p < 0.01). Mean maximum flow increased from 10.7 to 19.2 ml/s (p < 0.01). Mean postvoiding residual urine decreased from 107 to 48 ml (p < 0.01). All patients had antegrade ejaculation postoperatively. Mean IIEF scores did not change significantly (22.6 ± 2.6 vs. 20.7 ± 4.3, p = 0.08). Successful overall outcome was achieved in 22 (84.6%) of 26 patients. Conclusions: Applying thismodified TIBN to treat the sexually active young men with PBNO had the advantage of improving voiding function and preserving both antegrade ejaculation and sexual function.

Does Position Affect Uroflowmetry Parameters in Women?

Purpose: To investigate the effect of position on voiding using uroflowmetric variables and postvoid residual urine volume assessment in healthy normal women. Materials and Methods: 67 healthy females volunteered to participate in this study. Their mean age was 32 years. Each female attended the urodynamic suite on 2 separate days. They performed 2 voids, 1 in a sitting and another in a squatting posture each day. Maximum flow rate (Q_max), average flow rate (Q_ave), voided volume and corresponding postvoid residual urine (PVR) were compared for each position using paired Student’s t test. Results: The mean Q_max values obtained for sitting and squatting postures were 18.4 ± 3.2 and 24.8 ± 4.9 ml/s, respectively, and corresponding Q_ave values were 9.2 ± 1.9 and 12.3 ± 3.3 ml/s, respectively. Mean PVR values for sitting and squatting were 51.8 ± 22.2 and 21.6 ± 12.7 ml, respectively. Conclusion: The posture adopted for micturition affects uroflowmetric variables. The squatting posture is associated with a significantly higher maximum flow rate and a lower postvoid residue. Therefore, when low urine flow rates or high residual urine volumes are encountered during urodynamic study, the patients should be asked whether they normally micturate in a sitting or squatting position. If the former position is used, repeat studies with the patients squatting should be considered before accepting an abnormal test result as indicative of lower-urinary-tract dysfunction.

Postvoid residual urine in women with stress incontinence

To confirm the idea that women with stress incontinence can have elevated postvoid residual urine (PVR) and to examine the correlation between PVR obtained with catheterization versus that with BladderScan (BS). This is a prospective study involving 902 women referred to our urogynecology clinics because of symptoms of lower urinary tract dysfunction. Women were selected if they met all of the following conditions: (1) A main complaint of stress urinary incontinence; (2) A diagnosis of urodynamic stress incontinence; and (3) No previous pelvic surgery, advanced pelvic prolapse or neurological deficit. One hundred and seven women met all criteria and formed the basis for this study. All women in the study group underwent three-part urodynamic testing including uroflowmetry, filling (provocative) and voiding cystometry. After uroflowmetry they were scanned by a BS, and then catheterized for PVR volume before the procedure of cystometry. The mean PVR volume was 62.8 ml by BS and 38.5 ml by catheterization. 35.5% women had PVR urine higher than 50 ml and 15.9% had PVR urine greater than 100 ml. The PVR volume obtained by BS correlated significantly with catheterized volume (r = 0.625, P = 0.001) and offered a sensitivity of 64.7% and a specificity of 94.3% in detecting PVR greater than 100. The mean maximum flow rate was 22.1 ml/sec and mean detrusor contraction pressure during voiding was 21 cm H(2)O. Women in our study had low maximum flow rate (22.1 ml/sec), elevated PVR (38.5 ml) and high detrusor contraction pressure during voiding (21 cm H(2)O) indicating that women with stress incontinence have some degree of voiding dysfunction. The bladder behavior in women with stress incontinence may be more complex than we had previously considered and special care should be taken if a woman with elevated PVR is scheduled for anti-incontinence surgery. BS appears to be reasonably sensitive and specific for the detection of elevated PVR and is reliable in clinical use.

Holmium Laser Enucleation of the Prostate (HoLEP): Long-Term Results, Reoperation Rate, and Possible Impact of the Learning Curve

ObjectivesTo evaluate long-term outcomes and reoperation rate of holmium laser enucleation of the prostate (HoLEP) for patients with symptomatic enlarged prostate, including patients who were operated during the learning curve. MethodsA retrospective analysis of 118 patients who underwent HoLEP between March 1998 and February 2001 at our institution. This analysis represented our initial experience with the technique reflecting our learning curve. The voiding outcome parameters, operative duration time, enucleation time, morcellation time, eucleated tissue weight, catheterization time, hospital stay, and complications were recorded. ResultsThe mean patient age was 76.5 yr (range: 59–93) and the mean preoperative prostate volume was 59.3 cc (range: 20–172). The mean follow-up period was 49.4±28.1 mo. The mean catheter time and hospital stay was 1.3 and 1.5 d, respectively. Seventy-eight percent of the patients were discharged home within 24h after surgery. For the patients (n=26) who had objective data at 6 yr postoperatively, mean maximum flow rate increased from 6.3 to 16.2ml/s and mean postvoid residual urine decreased from 232 to 41.2ml (p<0.0001). Mean International Prostate Symptom Score improved from 17.3 to 5.6 (p<0.0001). Bladder-neck contracture and urethral stricture developed in 0.8% and 1.7% of patients, respectively. The reoperation rate for recurrent benign prostatic hyperplasia obstruction was 4.2%. ConclusionsHoLEP represents a safe and effective treatment for patients with symptomatic enlarged prostate. The improvement in outcome parameters is durable, and the late complications and reoperation rate are very low.

Transurethral Sphincterotomy Provides Significant Relief in Autonomic Dysreflexia in Spinal Cord Injured Male Patients: Long-Term Followup Results

An evaluation of the results of transurethral sphincterotomy in spinal cord injured patients for the relief of autonomic dysreflexia is presented. The study describes experience with the treatment of 46 consecutive spinal cord injured males presenting with frequent symptoms of autonomic dysreflexia and inadequate voiding. The selection criteria include patients injured above the thoracic 6 level with subjective symptoms of autonomic dysreflexia who did not want to be catheterized or were unable to perform intermittent catheterization. Patients were studied with complex urodynamics before and at least 3 months after undergoing transurethral sphincterotomy. During cystometrogram the maximum increase in systolic and diastolic blood pressure was recorded. After transurethral sphincterotomy patients were followed for a mean of 5.4+/-3.1 years (range 1 to 12). There was subjective relief in autonomic dysreflexia following transurethral sphincterotomy in all patients, which correlated well with a significant decrease in systolic and diastolic blood pressure (p<0.0001). Mean decrease in maximal systolic and diastolic blood pressure after transurethral sphincterotomy was 55+/-25 and 29+/-17 mm Hg, respectively. Mean post-void residual urine decreased significantly from 233+/-151 to 136+/-0.34 ml after transurethral sphincterotomy. However, there was no significant change in mean maximum voiding pressures. Blood pressure monitoring during cystometrogram provides an objective assessment of the presence of autonomic dysreflexia due to neurogenic bladder dysfunction, enabling better therapeutic management to control autonomic dysreflexia. Persistence of significant autonomic dysreflexia needs urodynamic evaluation if other factors for autonomic dysreflexia have been excluded.

Ileocaecal vs ileal neobladder after radical cystectomy in patients with bladder cancer: a comparative study

To compare an ileocaecal orthotopic bladder, (which has been the standard procedure in Egypt for >30 years) with the ileal neobladder, as there is no ideal continent orthotopic bladder replacement for patients after cystectomy for bladder cancer. Between June 1999 and December 2001, 60 patients with invasive bladder cancer were randomized into two groups. Group A comprised 29 patients who had radical cystectomy and reconstruction with an ileal neobladder (median age 50 years, 27 men and two women) and group B included 31 who had an ileocaecal bladder substitution after radical cystectomy (median age 51 years, 28 men and three women). The complication rate after surgery in group A was 17%, with two deaths, one from acute myocardial infarction and the other from haematemesis. In group B, the complication rate was 13%, with two deaths, one from a massive pulmonary embolism and the other from liver cell failure. Daytime continence was achieved in 93% of patients in group A and 90% in group B. The mean (sd) postvoid residual urine volume was larger in group A than group B, at 90 (72) vs 12 (20) mL. Acidosis and hyponatraemia were evident in the patients in group A but in none in group B (P < 0.05). The pelvicalyceal systems were preserved in 85% of patients in group A and 93% in group B during the 2-year follow-up. The mean (sd) renal cortical thickness was less in group A than in group B, at 1.8 (0.5) and 1.9 (0.2) cm, respectively. Although the cystometric capacity was greater and the basal pressure less in group A than B, these were not reflected in the degree of diurnal and nocturnal continence or back pressure on the renal units. Continence in both pouches was similar but the renal units were preserved better in the ileocaecal than in the ileal neobladder. Residual urine volume was greater in the ileal neobladder, with its potential complications of infection and stone formation, and acidosis was more evident.

Placebo controlled, randomised, double blind study of the effects of botulinum A toxin on detrusor sphincter dyssynergia in multiple sclerosis patients

Objective: The purpose of the study was to evaluate the efficacy and safety of botulinum A toxin in the treatment of detrusor sphincter dyssynergia in multiple sclerosis patients. Methods: This...

LONG-TERM URINARY CONTINENCE RATES AFTER SIMPLE SLING INCISION FOR RELIEF OF URINARY RETENTION FOLLOWING FASCIA LATA PUBOVAGINAL SLINGS

We examined long-term urinary continence rates in patients after midline simple sling incision for urinary retention following suburethral fascia lata slings. A retrospective review was completed of 13 women undergoing a simple sling incision for catheter dependent obstruction after suburethral sling surgery more than 4 years previously. Urinary continence was evaluated by use of the Groutz-Blaivas anti-incontinence surgery response score. The scores were statistically compared as binary categories at mean 111-day and 60.8-month followup. A total of 13 women underwent a simple sling incision for catheter dependent urinary retention after sling surgery, and 11 patients (mean age 73.4 years) were available for long-term followup (60.8 months). The simple sling incision procedure was completed an average of 65 days (range 36 to 235) after original sling placement. Mean post-void residual urine volume at least 1 month after sling surgery was 289 ml (range 75 to 500). At a mean followup of 60.8 months, no patient required catheterization. Of 11 patients 5 wore no pads. There was no statistical difference in leakage episodes per day (p = 1.0), pads per day (p = 0.3), or patient perceived condition (p = 0.3) during long-term followup. The mean Groutz-Blaivas score did not change statistically during the 5-year followup period (p = 0.6). Midline simple sling incision provides relief of catheter dependent obstruction following fascia lata sling surgery while preserving urinary continence in the majority of patients during a 5-year followup period.

TVT prépubien. Étude prospective longitudinale dans le traitement de l'incontinence urinaire d'effort de la femme : à propos de 164 cas

A prospective open study was conducted to evaluate the prepubic (TPP) route of TVT. 164 patients suffering from stress or mixed urinary incontinence were operated by prepubic route mainly under spinal anaesthesia. The incision is more proximal and para-uretral dissection directed more lateral to reach ischiopubic bone. The tape is introduced while keeping the needle tip close to bone to perforate between bone and ischiocavernous muscle. Then the needle is brought forwards to get its tip in vertical position and pushed under vulva to supra pubic area. A cough test is done with more pulling than in TVT since in TPP the pulling forces will act more frontally and laterally. Evaluation included detailed clinical examination with stress test, pads, endoscopic and urodynamic assessments and questionnaires in order to detect prognostic factors and to have a global treatment policy for associated low urinary tract symptoms and prolapse. Mean follow-up time was 20 months (14-30). No significant intraoperative complications occurred. All patients urinated the first day. The mean postvoid residual urine was 45 ml. Objective cure rate was achieved in 135 (82.3%) patients and 7 (4.3%) patients were improved while failure was observed in 22 (13,4%) patients. From patients'point of view success and satisfaction rates were 85.4% and 86%. No significant modification of sexual activity occurred. TPP is a simple technique with very low risks and the preliminary results are consonant with those of other published techniques.

Repeat Urethrolysis After Failed Urethrolysis for Iatrogenic Obstruction

Bladder outlet obstruction is a potential complication of all stress incontinence surgery. Urethrolysis successfully relieves 65% to 93% of cases. We determined the success of repeat urethrolysis after failed initial urethrolysis to relieve obstruction. We reviewed the charts of 24 women who underwent repeat urethrolysis for iatrogenic obstruction after at least 1 previous attempt. Aggressive repeat urethrolysis was performed via a retropubic or transvaginal route depending on the clinical scenario and surgeon discretion. Outcomes measured were patient ability to void spontaneously without catheterization, decreased post-void residual urine and resolution of lower urinary tract symptoms, particularly urge incontinence. Mean patient age was 55 years (range 38 to 80). The initial incontinence procedure was a pubovaginal sling in 10 cases, retropubic suspension in 9, needle suspension in 4 and anterior colporrhaphy in 1. A total of 23 patients had previously undergone transvaginal urethrolysis, while 1 had undergone retropubic urethrolysis. The repeat procedure was retropubic in 12 women (50%), transvaginal in 10 (42%) and combined in 2 (8%). Mean time between initial and repeat urethrolysis was 9 months (range 1 to 3). Mean followup was 14 months. Postoperatively 20 of the 22 patients (91%) who were catheter dependent no longer needed to catheterize. Post-void residual urine normalized in the 2 patients who had not been catheter dependent but who had had elevated post-void residual urine. Thus, repeat urethrolysis successfully eliminated urinary retention in 22 of the 24 cases (92%). Mean post-void residual urine before and after repeat urethrolysis was 334 versus 44 ml. (p <0.001). Irritative symptoms and urge incontinence completely resolved in 12% of cases, were improved and required medication in 69% and remained the same in 19%. No patient had new onset irritative symptoms. Stress urinary incontinence recurred in 4 of the 22 women (18%) and persisted in the 2 in whom it had been present before urethrolysis. Aggressive repeat urethrolysis can be highly successful for relieving iatrogenic retention. Complete resolution of irritative symptoms and urge incontinence is less likely. Recurrent stress urinary incontinence is similar to that after primary urethrolysis.

α1-Adrenergic Blockers in Young Men With Primary Bladder Neck Obstruction

We assessed the efficacy and safety of the mid term use of alpha1-adrenergic blockers for treating primary bladder neck obstruction in young and middle-aged men. Between May 1998 and February 2001 primary bladder neck obstruction was diagnosed by videourodynamic study in 28 men younger than 55 years. The degree of obstruction was graded by the Schafer nomogram. Mean patient age and mean symptom duration were 39.3 years and 18.1 months, respectively. The presenting symptom was frequency in 22 cases (78.6%), urgency in 10 (35.7%), weak stream in 9 (32.1%), nocturia greater than 2 times in 7 (25%) and hesitancy in 7 (25%). A dose of 1 to 2 mg. doxazosin was administered at bedtime for at least 3 months. International Prostate Symptom Score (I-PSS), quality of life, uroflowmetry and post-void residual urine were assessed before and 3 months after medication. Improved urine flow was defined as at least a 2.5 ml. per second increase in the maximum flow rate. Improved symptoms was defined as more than a 50% decrease in I-PSS. Successful treatment was defined as improved urine flow and symptoms. Followup data were available in 24 patients. The medication period and followup were 7 and 12 months, respectively. Mean I-PSS plus or minus standard deviation decreased from 18.3 +/- 4.6 to 11.6 +/- 5.2 (p <0.01) and mean quality of life decreased from 4.1 +/- 1.1 to 2.6 +/- 1.0 (p <0.01). Mean maximum flow increased from 11.8 +/- 3.2 to 15.9 +/- 3.9 ml. per second (p <0.01). Mean post-void residual urine decreased from 80.2 +/- 17.1 to 48.5 +/- 10.3 ml. (p <0.01). Treatment was successful in 13 patients (54.2%) and 3 (12.5%) were free of medication for at least 6 months. More successful outcomes were noted in patients with high grades III to IV obstruction than in those with low grades 0 to II obstruction (80% versus 35.7%, p = 0.03). Before treatment higher detrusor pressure at maximum flow (70.1 versus 47.8 cm. water, p = 0.01) and lower maximum flow (10.6 versus 13.3 ml. per second, p = 0.02) were observed in patients with successful versus unsuccessful treatment, respectively. Differences in patient age, I-PSS, quality of life, prostate size and post-void residual urine were not statistically significant. No significant adverse effects were noted. alpha1-Blockers were effective and safe for treating young men with primary bladder neck obstruction.

DYSFUNCTIONAL VOIDING IN WOMEN

We characterized presenting symptoms and urodynamic findings in women with dysfunctional voiding. We reviewed the charts of 26 women diagnosed with dysfunctional voiding. Those with a known or suspected history of neurological disease before evaluation were excluded from study. All patients completed an American Urological Association symptom index, and scores were classified as total, storage (irritative) and emptying (obstructive). The diagnosis of dysfunctional voiding was made on multichannel video urodynamics. There was increased external sphincter activity during voiding. Presenting symptoms and urodynamic findings in all cases were summarized. In addition, symptoms and urodynamic findings in patients later diagnosed with occult neurological disease were compared with those in patients without neurological disease. Mean patient age was 39.2 years (range 19 to 79). Mean total American Urological Association-7 score was 24.4 of 35. Frequency and urgency were the most common presenting symptoms in 82% of cases. Mean storage score was 11.3 of 15 and mean voiding score was 13.2 of 20. Urge and stress incontinence was noted in 6 (23%) and 4 patients (15%), respectively, while 11 (42%) had a history of recurrent urinary tract infection. Cystometrography revealed detrusor instability in 11 cases (42%), sensory urgency in 11 (42%) and impaired compliance in 2 (8%), including 1 with instability. There was great variability in voiding parameters. Mean maximum urinary flow plus or minus standard deviation was 10.4 +/- 6.2 cc per second, mean detrusor pressure at maximum urinary flow was 50.3 +/- 23.5 cm. water and mean post-void residual urine volume was 103.4 +/- 120.0 cc. Video urodynamics prompted neurological evaluation, which revealed occult neurological disease in 5 patients who were then reclassified with external-detrusor sphincter dyssynergia. Female patients presenting with lower urinary tract symptoms may have dysfunctional voiding patterns. Storage symptoms appear to be even more common than voiding symptoms in this study group. These patients tend to have decreased flow, increased voiding pressure and high post-void residual urine volume. However, there is wide variation in these parameters among individuals. Therefore, careful review of the voiding phase, including pelvic floor electromyography and the fluoroscopic appearance of the bladder outlet, is critical. Occult neurological disease should be suspected in patients with dysfunctional voiding.

Quantitative and Qualitative Assessment of Flowmetrograms in Patients with Prostatodynia

Objectives: Prostatodynia (type III–B according to the classification of the National Institute of Diabetes and Digestive and Kidney Diseases) represents a major part of all chronic prostatitis syndromes. Uroflowmetry changes in these patients were rarely described, and discrepancies exist about the prevalence of urodynamic abnormalities. The aim of this study was to describe both qualitative and quantitative flowmetrogram characteristics in these patients.Methods: Two hundred and thirty–eight flowmetrograms from patients diagnosed as having prostatodynia and 71 flowmetrograms from control males with matched age but without lower urinary tract problems were evaluated. Two to three flowmetric analyses were done for each individual, and the best one, i.e., representing the individual’s voiding and no artefact (e.g., wag artefact), was chosen. A minimal voided volume of 150 ml was required to be included. Diagnosis of prostatodynia followed the routine criteria. For all patients the postvoiding residual urine was assessed by ultrasound (Bladder Scan). Qualitative study was done according to a classification using flow–time ratio (T_Qm/T100×100) and flow ratio (Q_ave/Q_max×100) for continuous flow. Interrupted flow was classified separately. Descriptive statistical analysis was used.Results: The age range was 18–49 (mean ± SD, 34.2±7.8) years. The symptom duration ranged from 3 to 84 (16.5±27.7) months. Out of 238 patients 196 had uninterrupted flow. Thirty–six patients showed interrupted flow due to external sphincter contraction ≤2 s, and 6 patients showed interrupted flow with abdominal muscle straining. Out of the 196 patients, 73 showed Q_max >15 ml/s, and 67 showed a voided volume <200 ml. For this group the Q_max was 13.3±5.3 ml/s, Q_ave was 7.6±3.0 ml/s, and the mean postvoiding residual urine was 29.9 (range 0–234) ml. Type I flowmetry pattern was present in 39.7%, type II in 38.7%, type III in 5%, type IV in 16%, and type V in 0.5% of the patients with continuous flow (see Patients and Methods). The control group showed a Q_max of 19.5±3.8 ml/s, a Q_ave of 11.1±2.6 ml/s, a voided volume of 311.9±106.9 ml, and a postvoiding residual urine of 14.3±29.3 ml/s. Pattern I was seen in 89%, pattern II in 8%, and pattern IV in 3% of the controls.Conclusion: Most patients with prostatodynia had abnormal flowmetry parameters, and different patterns were shown, confirming that many have urinary flow disorders. Flowmetry should be part of the prostatodynia patient diagnostic workup, as this might add to the understanding of patient problems and may help in the selection of more appropriate methods in order to define the pathophysiologic basis of the symptoms and to perform treatment accordingly.

Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results.

We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity. Included in our prospective nonrandomized study done at 2 clinics were 31 patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (10 units per ml. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, 16 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week 1 after treatment. Of the 21 patients 19 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and 11 at 16 and 36 weeks. At the 6-week followup complete continence was restored in 17 of 19 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 215.8 +/- 90.4 ml. to 415.7 +/- 211.1 (p <0.016) and 296.3 +/- 145.2 to 480.5 +/- 134.1 (p <0.016), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. 1 (p <0.016). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 261.8 +/- 241.3 ml. to 490.5 +/- 204.8 (p <0.016). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at 16 and 36 weeks. Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.

SPHINCTERIC STENT VERSUS EXTERNAL SPHINCTEROTOMY IN SPINAL CORD INJURED MEN: PROSPECTIVE RANDOMIZED MULTICENTER TRIAL

Purpose In a prospective randomized multicenter trial we compared the treatment results of conventional external sphincterotomy with those of UroLume [section] sphincteric stent prosthesis placement in men with spinal cord injury and external detrusor-sphincter dyssynergia. Materials and Methods We randomized 57 men with spinal cord injury in whom urodynamics verified external detrusor-sphincter dyssynergia into 2 groups to undergo either sphincter defeating procedure. We compared the primary urodynamic parameter of maximum detrusor pressure, and secondary urodynamic parameters of bladder capacity and post-void residual urine volume in men who underwent sphincterotomy or sphincteric stent placement. Parameters were measured preoperatively, and 3, 6, 12 and 24 months postoperatively. Patients completed questionnaires regarding voiding sensation and quality of life issues at each followup visit. Results Demographic data of the 26 patients treated with sphincterotomy and the 31 treated with sphincteric stent placement were statistically similar. Preoperatively mean maximum detrusor pressure plus or minus standard deviation in sphincterotomy and stent cases was 98.3 +/- 27.6 and 95.7 +/- 27.7 cm. water, respectively (p = 0.73). At 12 months mean maximum detrusor pressure decreased to 48.9 +/- 16.4 and 52.6 +/- 31.6 cm. water in the sphincterotomy and stent groups, respectively (p = 0). Preoperatively mean bladder capacity in sphincterotomy and stent cases was 245 +/- 158 and 251 +/- 145 ml., respectively (p = 0.87). Bladder capacity did not change significantly in either treatment group throughout followup. Preoperatively mean post-void residual urine volume in the sphincterotomy and stent groups was 212 +/- 163 and 168 +/- 114 ml., respectively (p = 0.33). Residual urine volume decreased in each group at some but not all followup evaluations. The duration of hospitalization was greater for sphincterotomy than stenting (p = 0.036). Six stents required explantation. Conclusions The UroLume stent is as effective as conventional external sphincterotomy for treating external detrusor-sphincter dyssynergia. However, sphincteric stent placement is advantageous because it involves shorter hospitalization and is potentially reversible.

Dehydroepiandrosterone in the treatment of erectile dysfunction: a prospective, double-blind, randomized, placebo-controlled study

Objectives. In 1994, the Massachusetts Male Aging Study presented an inverse correlation of the serum levels of dehydroepiandrosterone (DHEA) and the incidence of erectile dysfunction (ED). We evaluated the efficacy of DHEA replacement in the treatment of ED in a prospective, double-blind, randomized, placebo-controlled study. Methods. The inclusion criteria included ED, normal physical and neurologic examinations, serum levels of testosterone, dihydrotestosterone, prolactin, and prostate-specific antigen (PSA) within the normal range, and a serum DHEA sulfate level below 1.5 μmol/L. Also all patients had a full erection after a pharmacologic erection test with 10 μg prostaglandin E 1; pharmacocavernosography showed no visualization in corporeal venous structures. Forty patients from our impotence clinic were recruited and randomly divided into two groups of 20 patients each. Group 1 was treated with an oral dose of 50 mg DHEA and group 2 with a placebo one time a day for 6 months. The International Index of Erectile Function (IIEF), a 15-item questionnaire, was used to rate the success of this therapy. Results. Therapy response was defined as the ability to achieve or maintain an erection sufficient for satisfactory sexual performance according to the National Institutes of Health Consensus Development Panel on Impotence. DHEA treatment was associated with higher mean scores for all five domains of the IIEF. There was no impact of DHEA treatment on the mean serum levels of PSA, prolactin, testosterone, the mean prostate volume, and the mean postvoid residual urine volume. Conclusions. Our results suggest that oral DHEA treatment may be of benefit in the treatment of ED. Although our patient data base is too small to do relevant statistical analysis, we believe that our data show a biologically obvious trend that justifies further extended studies.

Endoscopic Treatment of Urinary Incontinence in Children With Primary Epispadias

Subjects and methods The study included 83 infants and children (51 boys and 32 girls, aged 3 days to 12 years) with no neurological and lower urinary tract pathology but who had undergone or were about to undergo surgery for upper urinary tract or other pathology. They were evaluated using slow-filling cystometry, with simultaneous electromyography recorded using surface electrodes on the perineum. The voiding variables were compared among groups categorized by age, sex and body weight. Results In boys and girls, respectively, the mean (SD) post-void residual urine volume (PVR) was 6.3 (3.9) and 5.4 (4.8) mL. the maximum detrusor pressure duringvoiding was 66.1 (13.1) and 56.6 (14.7) cmH,O and the maximum voiding pressure was 73.9 (16.6) and 62.7 (16.2) cmH,O. There was no significant difference in these variables between the sexes or between infants and children (P >0.05). Detrusor instability (DI) was apparent in nine of 83 (10.8%) infants and children and occurred in the late filling phase. Bladder capacity increased with age and body weight (from 30 mL in neonates to 350 mL in 12-year-old children), and mean (SD) bladder compliance increased with age, from 3.6 (0.5) mUcmH,O in infants to 13.3 (3.0) mL/cmH,O in older children, a t a filling rate of 5-7 mumin. Conclusions In these infants and children with no apparent voiding symptoms, most bladders were stable. DI could occur in the late filling phase of cystometry, voiding was nearly complete, the PVR being usually <10 mL, and bladder capacity increased with age and body weight.

Transurethral Microwave Thermotherapy for Management of Benign Prostatic Hyperplasia: A Single-Institution Experience

Objectives. This is the first and largest single institution retrospective study in the United States to examine the effects of transurethral microwave thermotherapy (TUMT) for the treatment of benign prostatic hyperplasia (BPH). Methods. From September 1996 to June 1997, 78 men with moderate to severe symptomatic BPH were treated with the Prostatron at our institution. Patient age ranged from 52 to 85 years. Prostate volume ranged from 23 to 110 cc, and mean total energy applied during the treatment was 156.17 kJ. Patients were re-evaluated at 3 months and were asked to answer a questionnaire regarding their opinion about the treatment. Results. At 3 months there was a significant decrease in mean symptom score from 19.6 to 11.2 ( P <0.0001). Mean peak flow rate increased from 8.5 to 12.8 mL/s ( P <0.0001). Mean postvoid residual urine decreased from 56.8 to 22.0 mL ( P <0.0001). We did not observe any severe complications. Unlike prior studies, we removed the Foley catheter, and patients performed clean intermittent catheterization (CIC) when necessary. There was no significant differences in subjective and objective parameters between these patients and those who did not need CIC. Patient opinion about the treatment was not affected by CIC. About two thirds (67.2%) of the patients in the study group were satisfied with the results of treatment, and 60.3% would undergo the same procedure again. Conclusions. TUMT of the prostate is an effective, safe, and acceptable form of treatment for patients with BPH. Longer follow-up is needed to examine the durability of TUMT treatment.

Cystometry in infants and children with no apparent voiding symptoms.

To evaluate bladder function in infants and children with no apparent voiding symptoms. The study included 83 infants and children (51 boys and 32 girls, aged 3 days to 12 years) with no neurological and lower urinary tract pathology but who had undergone or were about to undergo surgery for upper urinary tract or other pathology. They were evaluated using slow-filling cystometry, with simultaneous electromyography recorded using surface electrodes on the perineum. The voiding variables were compared among groups categorized by age, sex and body weight. In boys and girls, respectively, the mean (SD) post-void residual urine volume (PVR) was 6.3 (3.9) and 5.4 (4.8) mL, the maximum detrusor pressure during voiding was 66.1 (13.1) and 56.6 (14.7) cmH2O and the maximum voiding pressure was 73.9 (16.6) and 62.7 (16.2) cmH2O. There was no significant difference in these variables between the sexes or between infants and children (P > 0.05). Detrusor instability (DI) was apparent in nine of 83 (10.8%) infants and children and occurred in the late filling phase. Bladder capacity increased with age and body weight (from 30 mL in neonates to 350 mL in 12-year-old children), and mean (SD) bladder compliance increased with age, from 3.6 (0.5) mL/cmH2O in infants to 13.3 (3.0) mL/cmH2O in older children, at a filling rate of 5-7 mL/min. In these infants and children with no apparent voiding symptoms, most bladders were stable, DI could occur in the late filling phase of cystometry, voiding was nearly complete, the PVR being usually < 10 mL, and bladder capacity increased with age and body weight.