Post-void Residual Volume Measurement Research Articles

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

Prostatic Artery Embolization as a Treatment Option for Symptomatic Benign Prostatic Hyperplasia: Results from the Prospective Follow-Up Study in Lithuania.

Background: The endovascular treatment of symptomatic benign prostate hypertrophy (BPH) by prostatic artery embolization (PAE) is one of the new treatments proposed. PAE is a minimally invasive alternative that has been shown to successfully treat lower urinary tract symptoms in BPH patients by causing infarction and necrosis of hyperplastic adenomatous tissue, which decompresses urethral impingement and improves obstructive symptoms. The aim of this study was to evaluate the effectiveness and efficacy of PAE in relieving symptoms in patients with symptomatic BPH. Materials and Methods: The material for the study was collected from 2019 to 2022. A total of 70 men with BPH and PAE were studied. Patients underwent an urological examination to measure the International Prostate Symptom Score (IPSS), Quality of Life score (QoL), International Index of Erectile Function short form (IIEF-5), uroflowmetry with Qmax, prostatic volume (PV), and post-void residual volume (PVR) measurements. Statistical analysis for dependent samples was applied. Measured parameters at 2 months and 6 months follow-up were compared to baseline. Results: At baseline, the age of the male (N = 70) subjects was 74 ± 9.6 years with a median of 73.8, but fluctuated from 53 to 90 years. The mean of PV was almost 111 mL and the Qmax was close to 7.7 mL/s. The average PVR was 107.6 mL. The IPSS score mean was 21.3 points and the QoL score was 4.53 points. The IIEF-5 questionnaire score was almost 1.8 points, which shows severe erectile dysfunction. The mean value of the PSA level was 5.8 ng/mL. After 2 and 6 months of PAE, all indicators and scores except erectile function significantly improved. Conclusions: The outcomes of our study show promising results for patients with benign prostatic hyperplasia after PAE. The main prostate-related parameters (PV, Qmax, PVR, IPSS) improved significantly 6 months after embolization.

PD41-01 TRENDS IN THE DIAGNOSTIC AND SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH) IN THE UNITED STATES: ANNUAL CHANGES IN THE SELECTION OF TREATMENT OPTIONS AND AVERAGE COSTS DIFFERENTIAL FOR DIAGNOSTIC/SURGICAL TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023PD41-01 TRENDS IN THE DIAGNOSTIC AND SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH) IN THE UNITED STATES: ANNUAL CHANGES IN THE SELECTION OF TREATMENT OPTIONS AND AVERAGE COSTS DIFFERENTIAL FOR DIAGNOSTIC/SURGICAL TECHNIQUE Jin-Kyu Oh, Francesco Del Giudice, Eugenio Bologna, Vincenzo Asero, Carlo Maria Scornajenghi, Ettore De Berardinis, Alessandro Sciarra, Satvir Basran, Shufeng Li, Federico Belladelli, and Benjamin I. Chung Jin-Kyu OhJin-Kyu Oh More articles by this author , Francesco Del GiudiceFrancesco Del Giudice More articles by this author , Eugenio BolognaEugenio Bologna More articles by this author , Vincenzo AseroVincenzo Asero More articles by this author , Carlo Maria ScornajenghiCarlo Maria Scornajenghi More articles by this author , Ettore De BerardinisEttore De Berardinis More articles by this author , Alessandro SciarraAlessandro Sciarra More articles by this author , Satvir BasranSatvir Basran More articles by this author , Shufeng LiShufeng Li More articles by this author , Federico BelladelliFederico Belladelli More articles by this author , and Benjamin I. ChungBenjamin I. Chung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003346.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transurethral resection of the prostate (TURP) is the gold standard treatment for benign prostatic hyperplasia (BPH). However, laser surgery techniques (e.g., photoselective vaporization of the prostate [PVP], holmium laser, thulium laser enucleation of the prostate [HoLEP or ThuLEP]), and minimally invasive treatment options (e.g., UroLift®) are increasingly replacing TURP. The aim of the study is to present the annual rates of BPH surgery and to analyze recent trends in the utilization of newer surgical modalities and any changes in medical costs related to these treatments over a 15-year period in the US. METHODS: Patient data was collected from the Optum Clinformatics® Data Mart Claims Database. Trends and distribution of surgical BPH techniques over the years of enrollment were analyzed across US regions. We then reviewed trends in adoption of diagnostic BPH methods including urodynamic studies, cystourethroscopy, transrectal ultrasound, prostatic biopsy, uroflowmetry, and the measurement of post-void residual urine volume (PVR). Finally, incidental diagnoses of prostate cancer (PCa) detected during BPH procedures were recorded over the years to depict the trends in PCa detection as well as median prostate specific antigen (PSA) values associated with BPH patients ultimately treated with a procedure. RESULTS: N=51,448 patients underwent BPH procedures from 2004 to 2017. There was a significant increase in the annual rate from 770 in 2004 to 6,571 in 2017. The mean patient age (±SD) increased from 67.6 years old (± 8.4) in 2004 to 73.4 years old (±8.4) in 2017. More than 60% of patients underwent cystourethroscopy and post-void residual urine check for workup prior to surgical management. TURP was the most common and PVP was the second most common BPH procedure. The total number of BPH diagnoses were 44,820 and the median cost for each procedure was $1459, $1875, $1419, and $3284 for TURP, PVP, HOLEP/ThULEP, Urolift, respectively. The median overall cost was $2471. With regard to the costs of treating BPH surgically, the diagnostic and treatment costs demonstrated annual increases while the detection rate of prostate cancer after BPH surgery gradually decreased from 19.87% in 2004 to 5.78% in 2017. CONCLUSIONS: We found recent trends in BPH management that demonstrates that alternative methods are starting to replace the traditional TURP technique, although TURP still remains the most common procedure. Future studies should assess whether these newer methods are both efficacious and cost effective over the long term. Of note, the cumulative incidence of PCa diagnosis was reduced over time, likely multifactorial in nature. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1058 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jin-Kyu Oh More articles by this author Francesco Del Giudice More articles by this author Eugenio Bologna More articles by this author Vincenzo Asero More articles by this author Carlo Maria Scornajenghi More articles by this author Ettore De Berardinis More articles by this author Alessandro Sciarra More articles by this author Satvir Basran More articles by this author Shufeng Li More articles by this author Federico Belladelli More articles by this author Benjamin I. Chung More articles by this author Expand All Advertisement PDF downloadLoading ...

Urinary dysfunction in patients with vascular cognitive impairment.

Vascular cognitive impairment (VCI) is caused by vascular pathologies, with the spectrum of cognitive disorders ranging from subjective cognitive dysfunction to dementia. Particularly among older adults, cognitive impairment is often complicated with urinary dysfunction (UD); some patients may present with UD before cognitive impairment owing to stroke or even when there are white matter hyperintensities on imaging studies. Patients with cognitive impairment often have both language and movement dysfunction, and thus, UD in patients with VCI can often be underdiagnosed and remain untreated. UD has an impact on the quality of life of patients and caregivers, often leading to poor outcomes. Medical history is an important aspect and should be taken from both patients and their caregivers. Clinical assessment including urinalysis, voiding diary, scales on UD and cognitive impairment, post-void residual volume measurement, uroflowmetry, and (video-) urodynamics should be performed according to indication. Although studies on UD with VCI are few, most of them show that an overactive bladder (OAB) is the most common UD type, and urinary incontinence is the most common symptom. Normal urine storage and micturition in a specific environment are complex processes that require a sophisticated neural network. Although there are many studies on the brain-urinary circuit, the specific circuit involving VCI and UD remains unclear. Currently, there is no disease-modifying pharmacological treatment for cognitive impairment, and anti-acetylcholine drugs, which are commonly used to treat OAB, may cause cognitive impairment, leading to a vicious circle. Therefore, it is important to understand the complex interaction between UD and VCI and formulate individualized treatment plans. This review provides an overview of research advances in clinical features, imaging and pathological characteristics, and treatment options of UD in patients with VCI to increase subject awareness, facilitate research, and improve diagnosis and treatment rates.

Robot-assisted simple prostatectomy for treatment of large prostatic adenomas: surgical technique and outcomes from a high-volume robotic centre.

Aim of the present study is to describe our robot-assisted simple prostatectomy technique and to report 6-month surgical and clinical outcomes. Eighty men were consecutively submitted to robot-assisted simple prostatectomy in our institution from October 2019 to October 2020. All procedures were performed by the same surgical team. Diagnostic preoperative assessment was based on history, symptoms evaluation by International Prostate Symptom Score, digital rectal examination, flowmetry with post-void residual volume measurement by abdominal ultrasound, prostatic volume estimation by MRI, PSA dosage. Under combined general and subarachnoid anesthesia, surgery was performed via a transperitoneal approach using a Da Vinci Si system in the four-arm configuration. Operative time, blood loss, hospital stay, catheterization time, intraoperative and postoperative complications were assessed. Clinical postoperative 6months of evaluation was based on physical examination, flowmetry with post-void residual volume measurement, PSA dosage, and International Prostate Symptom Score. Mean operative time was 105.29min, mean hospital staying 5.4days. Blood loss was low in all cases and only 2 patients received transfusion. Catheterization time was 7days. According to the Clavien-Dindo classification, only minor (grade I and grade II) intraoperative and postoperative complications were observed. At 6-month postoperative assessment, a statistically significant increase of urinary flow indexes and bladder capacity was recorded, as a significant reduction of urinary residual volume. No patient experienced stress urinary incontinence and the mean postoperative IPSS score was significantly reduced to 4.3. Two patients were diagnosed with incidental prostatic cancer at the histopathological examination. Data collected in our experience on a large cohort confirm efficacy and safety of Robot-Assisted Simple Prostatectomy. This procedure allows both short operative time and hospital staying, with low incidence of perioperative complications. This surgical technique can therefore be considered a valid alternative to other procedures for the surgical treatment of large volume prostates. Randomized prospective and comparative studies are warranted in the future to assess if different RASP techniques provide similar surgical and functional outcomes.

Significance of Prolapse Reduction in Measurement of Postvoid Residual Urine Volume in Pelvic Organ Prolapse Patients: A Prospective Study

Background: This study compared postvoid residual (PVR) urine volume by ultrasonography in pelvic organ prolapse (POP) patients before and after prolapse reduction to evaluate the need for prolapse reduction in accurately assessing PVR in women with POP. Methods: This was a prospective study including 128 patients. Both standard methods for measuring PVR urine volume, urethral catheterization, and portable abdominal ultrasound machines were used. An examination was performed by one urogynecologist within five minutes after the patients self-voided. The patients were divided into two groups according to pelvic organ prolapse quantification (POP-Q) stage, early prolapse stage, and advanced prolapse stage, and comparative analysis was performed. Results: Before prolapse reduction, the Pearson correlation coefficient of PVR urine volume measured by ultrasonography and PVR urine volume measured through urethral catheterization was 0.708 in the early prolapse stage and 0.949 in the advanced prolapse stage. After prolapse reduction, the Pearson correlation coefficient of PVR urine volume measured by ultrasonography and PVR urine volume measured through urethral catheterization was 0.895 in the early prolapse stage and 0.982 in the advanced prolapse stage. Conclusions: These study results showed that prolapse reduction when measuring PVR urine volume by ultrasonography in POP patients is acceptable and essential for enhancing accurate patient assessment.

Efficacy and safety of bovhyaluronidase azoximer in patients undergoing transurethral resection of the prostate

Introduction. Inflammation and fibrosis may have a significant role in pathogenesis of benign prostatic hyperplasia and associated lower urinary tract symptoms. Moreover, those factors may compromise the outcomes of surgical interventions for bladder outlet obstructions, such as transurethral resection of the prostate (TURP). Additional measures, such as administration of anti-fibrotic agents, may decrease the incidence of certain complications (e.g. bladder neck stenosis, urethral stricture) and improve overall outcomes of TURP. Bovhyaluronidase azoximer is an enzyme combined with high molecular mass copolymer which may inhibit surgery-related tissue remodeling and prevent excessive fibrosis.Materials and methods. Sixty-five patients undergoing monopolar TURP were enrolled in this prospective randomized open-label study. Patients in Group 1 (n = 34) received 5 intramuscular injections of bovhyaluronidase azoximer (3000 IU) on days 3, 6, 9, 12 and 15 after TURP in addition to standard therapy. Patients in Group 2 (n = 31) received conventional peri-operative therapy. All patients routinely underwent uroflowmetry and post-void residual volume measurement on follow-up 3 months after TURP. Incidence of fibrosis-associated complications was compared using Fisher’s exact test. Uroflowmetric parameters were compared using Mann-Whitney U-test.Results. One patient in Group 1 was excluded from the study due to mild allergic reaction after second injection of bovhyaluronidase azoximer. There were three cases of clinically significant fibrosis-associated complications in Group 2 which were confirmed on imaging (9.7 %). One case of stricture in bulbar urethra was later successfully managed with anastomotic urethroplasty, and two cases of bladder neck stenosis were managed with transurethral incision. No such complications were observed in Group 1 (0 %). However, the difference was not statistically significant (p = 0.1079). Otherwise, there were no adverse events in both groups. Median Qmax in Groups 1 and 2 was 24 ml/s and 22 ml/s, respectively (p = 0.08). Median Qave in Groups 1 and 2 was 15 ml/s and 9 ml/s, respectively (p <0.00001). Median of post-void residual volume in Groups 1 and 2 was 25 ml and 40 ml, respectively (p = 0.00438).Conclusion. This study was underpowered to demonstrate significant difference in incidence of fibrosis-related complications of TURP, though there was a trend towards lower risk in patients treated with bovhyaluronidase azoximer. There was also a statistically significant difference in Qave and post-void residual volume in favor of Group 1, which may demonstrate lower rates of subclinical fibrosis. Overall, treatment with bovhyaluronidase azoximer was safe. Robust studies with longer follow-up are required to confirm efficacy of bovhyaluronidase preparations in post-TURP setting.

Relevant predisposing factors for voiding in a sitting position among Japanese male adult patients

Purpose:We investigated the proportion of male patients who urinate in a sitting position and their reasons for doing so. Furthermore, we analyzed relevant predisposing factors for voiding in a sitting position using voiding questionnaires and uroflowmetric parameters. Material and methods:Study participants included 370 male patients who underwent examination of uroflowmetry and measurement of post-void residual urine volume. We asked the participants to urinate in a standing or sitting position as they would usually do at home and their reasons for the voiding posture selected. Results:Among the participants, 38.6% (143/370 cases) urinated in a sitting position. The most common reason for voiding in a sitting position was to keep the bathroom clean (54.5%, 78/143 cases). Compared with the participants who urinate in a standing position, significantly lower body mass index, and longer times of hesitancy and voiding were observed in the participants who urinate in a sitting position. Relevant predisposing factors for voiding in a sitting position were higher maximum flow rate and longer times of hesitancy and voiding. Conclusions:Uroflowmetric parameters, including maximum flow rate and longer times of hesitancy and voiding, were associated with the preference of a sitting voiding position in Japanese male adult patients.

Long-Term Results after Suprapubic ARC Procedure for the Treatment of Stress Urinary Incontinence in Women: A Retrospective Data Analysis

Introduction: The aim of this study was to evaluate long-term safety and efficacy of the suprapubic arc (SPARC) procedure for the surgical treatment of stress urinary incontinence (SUI). Materials and Methods: 139 female patients treated by SPARC were included in this retrospective analysis, whereby 126 patients were available for follow-up after 1 year, 70 after 6 years, and 41 after 9 years. The cough test, pad test, uroflowmetry, and post-void residual volume measurements were performed. Severity of bother (visual analogous scale [VAS] 0–10), continence, and the satisfaction rate were assessed. Objective cure was defined as a negative cough test and pad weight ≤1 g, subjective cure as no urine loss during daily activities and no usage of pads. The VAS, pad weight, number of pads per day, and maximal flow rate were compared preoperatively and postoperatively. Results: Objective cure rates at 1, 6, and 9 years were 78.6, 71.4, and 70.7% and subjective cure rates were 72.2, 55.7, and 65.8%, respectively. The VAS, pad weight, number of pads, and maximal flow rate decreased significantly. Study limitations include a relatively small sample size and the retrospective fashion of the analysis. Conclusions: In the long-term context, SPARC showed to represent an efficient and safe procedure for treatment of female SUI.

Comparison of the diagnostic yield of routine versus indicated flowmetry, ultrasound and cystoscopy in women with recurrent urinary tract infections

Introduction and hypothesisTo quantify and compare the outcomes of routine vs. urologist-requested diagnostic testing for recurrent urinary tract infections (rUTI).MethodsA retrospective cohort study of patients with rUTI referred to a large non-academic teaching hospital between 2016 and 2018 (Hospital A) and a university hospital between 2014 and 2016 (Hospital B). Electronic medical records were reviewed for baseline and diagnostic data. Women underwent the following assessments routinely: urinalysis, voiding diary, flowmetry in Hospital A and urinalysis, voiding diary, flowmetry, ultrasound, abdominal x-ray and cystoscopy in Hospital B. All other diagnostics were performed by indication in each hospital.ResultsWe included 295 women from Hospital A and 298 from Hospital B, among whom the mean age (57.6 years) and mean UTI frequency (5.6/year) were comparable, though more were postmenopausal in Hospital A. We identified abnormalities by flowmetry or post-void residual volumes in 134 patients (Hospital A: 79; Hospital B: 55), cystoscopy in 14 patients (Hospital A: 6; Hospital B: 8) and ultrasound in 42 patients (Hospital A: 16; Hospital B: 26), but these differences were not significant. Diagnostics altered treatment in 117 patients (e.g., pelvic floor muscle training, referral to another specialist, surgical intervention), mostly due to flowmetry and post-void residual volume measurement. The retrospective design and absence of follow-up data limit these results.ConclusionsThe routine use of cystoscopy and ultrasound in female patients with rUTIs should not be recommended as they yield few abnormalities and lead to additional costs.

Urinary retention is rare after colpocleisis and concomitant midurethral sling: a 10-year experience

The optimal method of managing stress urinary incontinence (SUI) in women undergoing colpocleisis remains unclear, especially in a setting of urinary retention. We aim to compare postoperative retention after colpocleisis with or without concomitant midurethral sling (MUS). A retrospective chart review of all women who underwent colpocleisis with or without MUS from October 2007 to October 2017 was performed. Women with preoperative and 2-week postoperative post-void residual volume (PVR) measurements were included. Urinary retention was defined as PVR of ≥100ml. Analysis included t tests/Wilcoxon rank, Chi-squared/Fisher's exact, and multivariate linear regression models. A total of 231 women with a mean age of 77.7years (± 6.0years SD) met the inclusion criteria. One hundred and thirty-eight women underwent colpocleisis alone, whereas 93 women had colpocleisis with MUS. Preoperative retention rates were high (44.9% vs 34.4%, for colpocleisis alone versus with MUS, p = 0.114). Postoperative retention rates were lower and similar between the groups (10.1% vs 11.8%, for colpocleisis alone vs with MUS, p = 0.69). Linear regression models showed the adjusted odds ratio for postoperative urinary retention in patients with concomitant MUS was 1.68 (95% confidence interval: 0.64-4.41) compared with patients with colpocleisis alone and this did not reach statistical significance (p = 0.292). Fortunately, after colpocleisis, women had high rates of resolution of retention, regardless of MUS (80.3% vs 90.6% for colpocleisis alone vs with MUS; p = 0.20). Few women required reoperation for retention (3.1%). Placement of an MUS at the time of colpocleisis is a safe and effective therapy. This appears to be unaffected by preoperative urinary retention status.

Clinical Safety and Cost-Effectiveness of Follow-up Virtual Clinic for Bladder Outflow Obstruction Surgery.

Introduction: Bladder outflow obstruction (BOO) surgery is among the most commonly performed urologic procedures. Postoperative assessment consists of physical measurement of uroflowmetry and post-void residual volume, but health systems worldwide have experienced pressures in demand, leading to exploration of greater efficiency in organizing clinic protocols. International Prostate Symptom Score (IPSS) questionnaire measurement has been identified as a tool to predict change in postoperative management. Our institution established a nurse-led follow-up virtual clinic (VC) for patients undergoing BOO surgery based on IPSS measurement. We present the clinical and economic outcomes of this new service. Materials and Methods: Patients with a successful postoperative trial without catheter were contacted by telephone via VC and discharged by a Urology Clinical Nurse Specialist (UCNS) if IPSS was <8. Data were analyzed for IPSS, arrangement of subsequent clinic visits, and numbers discharged. Primary outcome was the proportion of patients discharged after VC consultation. Secondary outcomes were overall discharge rate following subsequent face-to-face (FTF) appointment; and the proportion of patients re-referred from Primary Care within 3 months of discharge from VC. Cost savings were calculated based on tariffs of £135 for first attendance with UCNS, £199 for uroflowmetry, and £47.84 for VC appointment. Results: The first 50 patients to be recipients of the new VC were included. The median IPSS and quality-of-life score were 13 (interquartile range [IQR] 5) and 3 (IQR 1), respectively. Thirty-nine (78%) patients were discharged from VC; 36 (72%) had IPSS <8. Overall discharge rate following subsequent FTF appointment was 88%. Two patients discharged from VC (5.1%) were subsequently re-referred, neither of whom required additional treatment. Total cost savings with VC amounted to £10,634. Conclusion: Telephone follow-up for BOO surgery based on IPSS is clinically safe and cost-effective, providing greater efficiency for clinic protocols.

A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Urological Evaluation of Tethered Cord Syndrome.

To describe how to perform urological evaluation in children with tethered cord syndrome (TCS). Although a common manifestation of TCS is the development of neurogenic bladder in developing children, neurosurgeons often face difficulty in detecting urological problems in patients with TCS. From a urological perspective, diagnosis of TCS in developing children is further complicated due to the differentiation between neurogenic bladder dysfunctions and transient bladder dysfunctions owing to developmental problems. Due to the paucity of evidence regarding evaluation prior to and after untethering, I have shown the purpose and tools for evaluation in my own practice. This may be tailored to the types of neurogenic bladder, developmental status, and risks for deterioration. While the urodynamic study (UDS) is the gold standard test for understanding bladder function, it is not a panacea in revealing the nature of bladder dysfunction. In addition, clinicians should consider the influence of developmental processes on bladder function. Before untethering, UDS should reveal synergic urethral movement, which indicates an intact sacral reflex and lack of TCS. Postoperatively, the measurement of post-void residual urine volume is a key factor for the evaluation of spontaneous voiders. In case of elevation, fecal impaction, which is common in spinal dysraphism, should be addressed. In patients with clean intermittent catheterization, the frequency-volume chart should be monitored to assess the storage function of the bladder. Toilet training is an important sign of maturation, and its achievement should be monitored. Signs of bladder deterioration should be acknowledged, and follow-up schedule should be tailored to prevent upper urinary tract damage and also to determine an adequate timing for intervention. Neurosurgeons should be aware of urological problems related to TCS as well as urologists. Cooperation and regular discussion between the two disciplines could enhance the quality of patient care. Accumulation of experience will improve follow-up strategies.

Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome.

A prospective, observational cohort study. The aim of this study was to determine the role of pre and postvoid bladder scan in predicting cauda equina syndrome (CES). The thesis was that bladder scanning [specifically postvoid residual (PVR) volume] would have higher diagnostic accuracy than physical examination alone. CES is an ill-defined condition with a spectrum of presenting symptoms. There is neither a combination of clinical symptoms and/or signs that reliably predicts cauda equina compression nor single defining clinical criterion that has 100% predictive value to confirm or exclude CES. Patients with suspected CES admitted over a 6-month period at a single institution were prospectively assessed by physical examination (including digital rectal examination and pin prick perianal sensation) and bladder ultrasound scanning (recording pre- and PVR volume). These results were compared with the subsequent magnetic resonance imaging (MRI) scans and those patients who had emergent surgery for CES. Ninety-two patients were included in the study (52 women) with a mean age of 44.9 years.An MRI scan demonstrating causing compression of the cauda equina was present in only 18% (17/92).The sensitivity of anal tone to predict CES was 52.9%. Peri-anal numbness (either unilateral or bilateral) had sensitivity of 82.3% and negative predictive value of 92%.For nonoperated group (without CES), mean PVR was 199 mL (95% confidence interval ± 59 mL). On the basis of receiver operating curves, the optimal bladder volume cut-off for predicting CES was ≥200 mL for PVR volume. A PVR of <200 mL gave CES probability of 3.6%. If >200 mL, then the probability of having CES is 43% (P < 0.000003). A PVR <200 mL had a negative predictive value of 97%. Bladder scanning was a useful adjunct in the diagnosis of CES. It had a better negative predictive value than physical examination. 3.

Intra- and inter-rater reliability of post-void residual bladder volume with ultrasound.

The purpose of the present study was to test the intra- and inter-rater reliability of the measurement of post-void residual bladder volume using ultrasound. Two evaluators performed three measurements of the height, width, and length of the empty bladder using ultrasound. The voiding residual volume was calculated using the equation: volume = length × width × height × 0.52. Intraclass correlations (ICC) were calculated considering: ICC ≥ 0.75 excellent, 0.40 ≤ ICC < 0.75 satisfactory, and ICC <0.40 poor, with a significance level of 5% and analysis of confidence intervals (95% CI). Twenty women participated, with an average age of 27.95 ± 3.15years. The inter-rater ICCs for height, width, and length were 0.96 (CI 0.89-0.98), 0.88 (CI 0.71-0.95), and 0.84 (CI0.60-0.94) respectively. For the intra-rater ICCs, the values were 0.97 (CI 0.95-0.99), 0.98 (CI 0.96-0.99), and 0.97 (CI 0.94-0.99) for evaluator 1 and 0.99 (CI 0.97-0.99), 0.97 (CI 0.94-0.99), and 0.95 (CI 0.90-0.98) for evaluator 2, for height, width, and length, respectively. The residual inter-test volume was 0.96 (CI 0.90-0.99) and the intra-test volume was 0.99 (CI 0.97-0.99). All analyses presented p < 0.0001. The intra- and inter-rater reliability for both the post-void residual volume and measurement of the bladder dimensions showed excellent agreement.

Feasibility of mirabegron in the treatment of overactive bladder in patients affected by Parkinson's disease: A pilot study.

Background:We investigated the effectiveness and safety of mirabegron oral treatment in a group of patients with Parkinson’s disease (PD) and overactive bladder (OAB), refractory to antimuscarinics.Materials and methods:Thirty patients with PD and refractory OAB were prospectively included in the study. At baseline, motor symptoms, severity of disease and cognitive status were assessed with the Hoehn–Yahr Scale, the Unified Parkinson’s disease Rating Scale, the Mini Mental State examination and the Montreal Cognitive Assessment. At baseline, urinary symptoms, satisfaction with treatment and the impact of urinary incontinence on quality of life (QoL) were assessed with the 3-day voiding diary, the Visual Analogue Scale (VAS), the Incontinence–QoL questionnaire and urodynamics. Patients started assuming mirabegron 50 mg tablets once daily. Evaluation of urinary symptoms and related questionnaires, motor symptoms, severity of PD and uroflowmetry with postvoid residual volume measurement were then repeated at the 3- and 6-month follow up. Side effects were also noted.Results:At baseline, the most frequently reported urinary symptoms were: urinary urgency (present in all the patients), urge urinary incontinence in 28/30 (93.3%) and increased daytime urinary frequency in 25 (83.3%) patients. At the 3-month follow up, 7 out of the 30 patients achieved a complete urinary continence. Significant improvements in VAS and Incontinence–QoL scores were observed in 24 patients. These benefits were maintained for the whole observation period. Four patients discontinued treatment due to poor efficacy, and two due to the cost of the drug.Conclusions:Mirabegron is a safe and effective treatment in patients with PD and OAB refractory to anticholinergics in the short-term follow up.

Aquablation among novice users in Canada: A WATER II subpopulation analysis.

Surgical management options for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) associated with prostates of small to moderate volume (<80 cc) are numerous; however, for men with enlarged prostates (>80 cc), many of these options are neither safe nor effective. Recently, Aquablation (PROCEPT BioRobotics, Inc., U.S.), a precise ultrasound-guided, robotically executed prostatic ablative procedure, has become available with U.S. Food and Drug Administration approval. Herein, we present three-month safety and efficacy data from the cohort of Canadian men included in the WATER II trial. WATER II is a prospective clinical trial of the Aquablation system for the treatment of BPH in men with prostate volumes between 80 and 150 cc. Only patients from Canada were included for this analysis. At baseline, subjects completed International Prostate Symptom Score (IPSS), as well as several validated questionnaires, uroflowmetry and post-void residual volume measurements, and underwent standard laboratory blood assessment. These were repeated at one and three months post-Aquablation. A total of 19 subjects who met inclusion and exclusion criteria were enrolled at three Canadian academic sites. Mean pre-, one-month, and three-month post-treatment IPSS scores were 21.2±5.5, 9.9±6.9 (p<0.0001), and 5.0±4.5 (p<0.0001), respectively. Mean pre-, one-month, and three-month post-treatment maximum urinary flow rates (Qmax) were 6.6±3.1 ml/s, 19.5±6.1 ml/s (p<0.0001), and 23.1±9.2 ml/s (p<0.0001), respectively. The Clavien-Dindo grade 2 or higher event rate at three months was 31.6% (six events). In this short-term, three-month analysis of Canadian men, Aquablation appears to provide a strong surgical alternative in patients with LUTS/BPH due to larger prostate volumes, with impressive functional outcomes, relatively short operative time and length of hospital stay, and acceptable complication and low transfusion rates.

The Overactive Bladder Symptom Score, International Prostate Symptom Score-Storage Subscore, and Urgency Severity Score in Patients With Overactive Bladder and Hypersensitive Bladder: Which Scoring System is Best?

PurposeTo evaluate the correlations among the Overactive Bladder Symptom Score (OABSS), International Prostate Symptom Score–Storage Subscore (IPSS-S), and the modified Urgency Severity Scale (USS) in patients with overactive bladder (OAB) and hypersensitive bladder (HSB) and to identify the most useful diagnostic tool for classifying the severity of OAB.MethodsWe retrospectively reviewed the charts of consecutive patients with OAB who visited our urologic clinics for treatment. All patients underwent a detailed history, physical examination, urinalysis, uroflowmetry, and postvoid residual volume measurement, and completed a 3-day voiding diary. All patients answered the Chinese versions of the IPSS, OABSS, and USS, according to which they were classified as having wet or dry OAB based on whether their chief complaint was urgency urinary incontinence or urgency without incontinence. HSB was defined as a functional bladder capacity <350 mL and a USS of 0 or 1.ResultsThe records of 325 OAB patients (99 women and 226 men) were reviewed. The OAB subgroups included HSB (n=31), OAB-dry (n=74), and OAB-wet (n=220). One-way analysis of variance showed significant differences among the OAB subgroups evaluated using each scoring system. Each scoring system was significantly correlated with the OAB subgroups. The Spearman rho was 0.983 for the USS, 0.651 for the OABSS, and 0.428 for the IPSS-S.ConclusionsThe IPSS-S, OABSS, and USS showed good correlations with the OAB subgroups. Their ranking in terms of discriminant ability for classifying OAB severity as HSB, OAB-dry, and OAB-wet was USS>OABSS>IPSS-S. The simplest survey, the USS, with a single item scored from 0 to 4, had the strongest correlation with the OAB severity subgroups.

Does Post-Void Residual Volume Predict Worsening Urological Symptoms in Patients with Multiple Sclerosis?

Our goal was to examine how post-void residual urine volume relates to urinary symptoms in patients with multiple sclerosis. We retrospectively reviewed the records of patients with multiple sclerosis who had lower urinary tract symptoms and presented to a tertiary neurourology clinic. Patients for whom post-void residual volume was recorded at the initial urological assessment were included in our analysis. Results of the AUA (American Urological Association) SI (Symptom Index) and the M-ISI (Michigan Incontinence Symptom Index) completed at this visit were analyzed to assess the severity of lower urinary tract symptoms and incontinence. A chart review was performed to obtain information on demographics and documented urinary tract infections. Between 2014 and 2017, 110 patients diagnosed with multiple sclerosis underwent post-void residual volume measurement at our clinic. Average post-void residual volume was 123.4 cc (range 0 to 650 cc). The mean AUA symptom score was 19.1 with an average bother score of 4.1. Analysis of post-void residual volume as a continuous variable did not show an association between increasing post-void residual volume and an increasing AUA SI or bother score (p= 0.53 and 0.44, respectively). When evaluated by post-void residual volume tertile, no relationship was found between post-void residual volume, and the AUA SI and the M-ISI (p = 0.54 and 0.57, respectively). No correlation was also found between increasing post-void residual volume and a recent history of recurrent urinary tract infections (p = 0.27). Post-void residual volume was not associated with worsening obstructive lower urinary tract symptoms as assessed by the AUA SI, worsening incontinence as measured by the M-ISI score or an increased risk of recurrent urinary tract infections in select patients with multiple sclerosis and lower urinary tract symptoms.