Preoperative Maximum Flow Rate Research Articles

MP13-16 EXPERIENCE WITH 3,000 CASES OF HOLMIUM LASER ENUCLEATION OF PROSTATE IN A SINGLE INSTITUTION

You have accessJournal of UrologyCME1 Apr 2023MP13-16 EXPERIENCE WITH 3,000 CASES OF HOLMIUM LASER ENUCLEATION OF PROSTATE IN A SINGLE INSTITUTION Hyo Myoung Lee, Min Chul Cho, Sung Yong Cho, Jae-Seung Paick, and Seung-June Oh Hyo Myoung LeeHyo Myoung Lee More articles by this author , Min Chul ChoMin Chul Cho More articles by this author , Sung Yong ChoSung Yong Cho More articles by this author , Jae-Seung PaickJae-Seung Paick More articles by this author , and Seung-June OhSeung-June Oh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003233.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of HoLEP in patients with benign prostatic hyperplasia (BPH) at a single institution. METHODS: From August 2008 to June 2022, the baseline demographics, and post-operative follow-up results were retrospectively analyzed through EMR review. Patients were followed up at 2 weeks (n=2,997), 3 months (n=2,199), and 6 months (n=1,853) postoperatively under a critical pathway. Then, they were on open follow-up. RESULTS: A total of 3,000 patients (mean age 69.6±7.7 years) underwent HoLEP. Mean total prostate volume was 67.9 (±34.2) ml and the baseline total IPSS score and the quality of life score were 19.3 (±7.7) and 3.9 (±1.1), respectively. The preoperative maximum flow rate (Qmax) was 9.4 (±4.8) ml/s, and the postvoid residual urine (PVR) volume was 77.8 (±97.6) ml. The total operation time was 60.7 (±31.6) minutes, and the catheter time was 1.3 (±1.2) day. Complications within 2 weeks postoperatively included re-catheterization in 110 patients (3.7%), blood transfusion in 19 patients (0.6%), transurethral coagulation (TUC) in 16 patients (0.5%), stress urinary incontinence (SUI) in 215 (mild 204; severe 11) patients (7.2%), urgency urinary incontinence (UUI) in 174 (mild 129; severe 45) patients (5.8%). Complications at 3 months postoperatively were SUI in 128 (mild 109; severe 19) patients (5.8%), UUI in 113 (mild 74; severe 39) patients (5.1%). Complications at 6 months postoperatively included SUI in 36 (mild 34; severe 2) patients (1.9%), UUI in 25 (mild 17; severe 8) patients (1.3%), bladder neck contracture in 15 patients (0.8%), de novo prostatic fossa stone in 11 patients (0.6%), and urethral stricture in 29 patients (1.5%). A total of 61 patients (2.0%) required secondary surgery (TUC 16, 0.5%; TUI for BNC 16, 0.5%; removal of prostatic fossa stones 11, 0.4%; EIU for urethral stricture 18, 0.6%). At 3 months postoperatively, the total IPSS score was 7.9 (±5.9), Qmax was 21.8 (±11.6) ml/s, and the PVR volume was 21.0 (±38.1) ml. At 6 months postoperatively, the total IPSS score was 6.6 (±5.8), Qmax was 22.2 (±11.3) ml/s, and the PVR volume was 19.7 (±36.8) ml. CONCLUSIONS: Our mid-term follow-up results after HoLEP in BPH patients showed excellent efficacy and low complications. Unlike other previous reports, the incidence of SUI and UUI after HoLEP was low, but the occurrence of de novo stone formation in the prostatic fossa was notable. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e179 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hyo Myoung Lee More articles by this author Min Chul Cho More articles by this author Sung Yong Cho More articles by this author Jae-Seung Paick More articles by this author Seung-June Oh More articles by this author Expand All Advertisement PDF downloadLoading ...

Prevalence and predictors of postoperative detrusor underactivity after robot-assisted radical prostatectomy: A prospective observational study.

To identify the prevalence and predictors of postoperative detrusor underactivity during the early postoperative period after robot-assisted radical prostatectomy. We carried out a prospective observational study of 64 patients scheduled for robot-assisted radical prostatectomy using urodynamic study before and 1month after robot-assisted radical prostatectomy. Detrusor underactivity was defined as maximum flow rate ≤15mL/s and detrusor pressure at maximum flow rate ≤25cmH2 O during voiding. Incidences of pre- and postoperative detrusor underactivity were assessed, and predictors of postoperative detrusor underactivity were determined using uni- and multivariate logistic regression analyses. Factors comprised patient characteristics (age, prostate weight etc.), operative factors (surgical duration, nerve sparing etc.) and preoperative urodynamic study parameters (maximum flow rate, bladder contractile index etc.). Pre- and postoperative detrusor underactivity at 1month after robot-assisted radical prostatectomy were detected in one patient (1.6%) and 24 patients (37.5%), respectively. Univariate analysis selected preoperative maximum flow rate (P=0.02), detrusor pressure at maximum flow rate (P=0.04) and bladder contractile index (P<0.01) as predictors of postoperative detrusor underactivity (odds ratio 0.83, 0.97 and 0.94, respectively). On multivariate analyses, only preoperative bladder contractile index was associated with postoperative detrusor underactivity (P<0.01; odds ratio 0.94). A cut-off of 102.8 offered optimal accuracy in receiver operating characteristic analysis. Patient characteristics and operative factors were not significantly associated with postoperative detrusor underactivity. A comparatively high prevalence of postoperative detrusor underactivity is observed in patients at 1month after robot-assisted radical prostatectomy. Patients with preoperative low bladder contractile index have a higher probability of developing early postoperative detrusor underactivity after robot-assisted radical prostatectomy.

Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling.

IntroductionPatients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.ObjectiveThe primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.MethodsFrom 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.ResultsAbout 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).ConclusionIn conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Facteurs prédictifs de rétention aiguë d’urine ou de dysurie en postopératoire immédiat après pose de bandelette sous urétrale : revue de la littérature

Immediate postoperative urinary retention (UR) and voiding dysfunction (VD) are some factors limiting outpatient procedure for mid-urethral sling (MUS) surgery in women presenting with stress urinary incontinence. The objective of the current review was to report the main predictive factors associated with immediate postoperative UR/VD following MUS surgery in women. A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords midurethral sling; tension-free vaginal tape; TVT; transobturator tape; TOT; predicting factor; voiding dysfunction; urinary retention; postvoid residual; postoperative residue of urine. Thirteen studies were included. Main clinical predictive factors associated with immediate postoperative urinary retention (UR) and voiding dysfunction (VD) were: previous pelvic surgery (hysterectomy, incontinence or pelvic organ prolapse surgery) [OR: from 3.7 ((CI95%: 1.14-12.33); P=0.029)] to 8.93 [(CI95%:1.17-61.1); P=0.035)], previous UR [OR: 415 (CI95%: 20-8619); P<0.001], age over 65 y/o [OR: 3,72 (CI95%:1.40-9.9); P<0.01], and general anesthesia [OR: 4.5 (CI95%:1.1-18.9); P=0.02]. Urodynamic predictive factors were underactive bladder at cystometry [OR: from 2.52 ([CI95%: 1.03-6.13]; P=0.042) to 5.6 ([IC95%: 1.6-19.2]; P=0.02] and preoperative maximum flow rate (Qmax) (the prevalence of UR was ranging from 12 to 35% when Qmax was under 15ml/s, versus 0% when Qmax was over 30ml/s). Predictive factors associated with immediate postoperative UR/VD following MUS surgery in women were age over 65 y/o, previous pelvic surgery or previous UR, underactive bladder and preoperative Qmax under 15ml/s.

Ventral Oral Mucosal Onlay Graft Urethroplasty in Nontraumatic Bulbar Urethral Strictures: Surgical Technique and Multivariable Analysis of Results in 214 Patients

BackgroundThe ventral oral mucosal onlay graft is suggested in proximal bulbar strictures where the thick spongiosum provides excellent support to the graft. Some technical steps used in this technique are currently under debate in the literature. ObjectiveTo describe the surgical steps of this urethroplasty and investigate predictive factors of success using a multivariable logistic regression analysis. Design, setting, and participantsThis is a descriptive observational retrospective study of 214 patients who underwent urethroplasty for bulbar urethral strictures between May 1999 and November 2010 in a single high-volume center. Study inclusion criteria were patients presenting nontraumatic bulbar urethral strictures ranging from 1.3cm to 6.8cm in length. Exclusion criteria were traumatic strictures, panurethral strictures, lichen sclerosus, and failed hypospadias repair. Surgical procedureThe oral graft was placed on the ventral bulbar urethral surface and pushed as proximally as possible using dedicated instruments and surgical techniques. Outcome measurements and statistical analysisThe primary outcome measure was the objective result, defined as the absence of stricture recurrence at follow-up. The objective outcome was considered a failure when any postoperative instrumentation was needed. Multivariable logistic regression analysis was developed. All tests were two sided with a significance level set at 0.05. Results and limitationsMedian follow-up was 54 mo. Of the 214 patients, 183 (85.5%) were successful and 31 (14.5%) were failures. The preoperative maximum flow rate (Qmax) was a significant predictor of surgical outcome (odds ratio: 1.352; p = 0.001). Age, length, and type of stenosis, and previous treatment were not significant predictors of surgical outcome (all p > 0.05). The limitation of our survey is the absence of a subjective evaluation or the use of specific tools, such as a questionnaire. ConclusionsVentral oral graft urethroplasty represents a valid option in nontraumatic bulbar strictures. Preoperative Qmax may be predictive of urethroplasty failure.

The Successful and Novel Treatment of Non-Neurogenic Detrusor-External Sphincter Dyssynergia (DESD) with Botulinum Toxin A

Introduction: Our study aims to examine the treatment outcomes of patients with non-neurogenic detrusor-external sphincter dyssynergia (DESD) after the injection of botulinum toxin A (BTX-A, Botox®) to the external sphincter. Methods: A retrospective review of nine patients with DESD was performed. All patients were diagnosed with the aid of video urodynamic studies. Pre-operative evaluation was standardised using bladder diary, urine microscopy and culture, bedside ultrasound of the kidneys and bladder, and renal function test. Each received BTX-A injection of 50–100U to the external sphincter. The pre-operative and post-operative maximum flow rate (Qmax) and post-void residual urine (PVRU) were objectively compared using paired-samples t test. Results: All the injections were performed from December 2006 to March 2008. Of the nine patients, seven (77.8%) were female and two (22.2%) were male. The mean age was 49.2 years (range 20–64 years). The mean pre-operative maximum flow rate (Qmax) was 9.7±6.26 ml/s. A month later, the post-operative Qmax improved to 16.5±11.3 ml/s. Mean difference in Qmax was 6.76±8.1 ml/s ( P = 0.037). The mean preoperative post void residual urine (PVRU) was 179.2±86.8 ml. This improved to 45.7±44.4 ml post-operatively. The mean difference in PVRU of 133.6±77.2 ml ( P = 0.001). Conclusion: In patients with DESD, there is a significant improvement in PVRU and Qmax after the injection of BTX-A. Hence, BTX-A injection is an effective method of treatment for DESD. However, further studies and follow-up are required to further evaluate patient satisfaction, quality of life and need for repeated injections.

Changes in uroflowmetry maximum flow rates after urethral reconstructive surgery as a means to predict for stricture recurrence

Purpose: A reliable, noninvasive screening method for urethral stricture recurrence after urethroplasty is needed. We hypothesized that changes in flow rates on uroflowmetry relative to preoperative values might help predict stricture recurrence.Materials and Methods: All men who underwent urethral reconstructive surgery from 2000 to 2009 with adequate preoperative and postoperative uroflowmetry studies were included in the study. Preoperative and postoperative maximum flow rates were compared. The absolute change in maximum flow rate was compared between patients with and those without recurrence as determined by retrograde urethrogram.Results: A total of 125 patients treated with urethroplasty were included in the study. Mean ± SD preoperative maximum flow rate was 11.8 ± 9.1 ml per second, which did not vary by stricture length (p = 0.11), patient age (p = 0.46) or stricture location (p = 0.58). The change in maximum flow rate in men without recurrence was 19.2 ± 11.7 vs 0.2 ± 6.4 ml per second (p <0.0...

Changes in Uroflowmetry Maximum Flow Rates After Urethral Reconstructive Surgery as a Means to Predict for Stricture Recurrence

A reliable, noninvasive screening method for urethral stricture recurrence after urethroplasty is needed. We hypothesized that changes in flow rates on uroflowmetry relative to preoperative values might help predict stricture recurrence. All men who underwent urethral reconstructive surgery from 2000 to 2009 with adequate preoperative and postoperative uroflowmetry studies were included in the study. Preoperative and postoperative maximum flow rates were compared. The absolute change in maximum flow rate was compared between patients with and those without recurrence as determined by retrograde urethrogram. A total of 125 patients treated with urethroplasty were included in the study. Mean ± SD preoperative maximum flow rate was 11.8 ± 9.1 ml per second, which did not vary by stricture length (p = 0.11), patient age (p = 0.46) or stricture location (p = 0.58). The change in maximum flow rate in men without recurrence was 19.2 ± 11.7 vs 0.2 ± 6.4 ml per second (p <0.001) in failed repairs. Setting a change in maximum flow rate of less than 10 ml per second as a screen for stricture recurrence would have resulted in a test sensitivity and specificity of 92% and 78%, respectively. There were 85 men without stricture recurrence who underwent more than 1 postoperative uroflowmetry study. Repeated maximum flow rate values achieved reasonable test reproducibility (r = 0.52), further supporting the use of uroflowmetry. Change in flow rate after urethral reconstruction represents a promising metric to screen for stricture recurrence that is noninvasive and has a high sensitivity.

7 MIDTERM OUTCOME OF COMBINED DORSAL PLUS VENTRAL DOUBLE BUCCAL MUCOSA GRAFT IN LONG ANTERIOR URETHRAL STRICTURE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 20117 MIDTERM OUTCOME OF COMBINED DORSAL PLUS VENTRAL DOUBLE BUCCAL MUCOSA GRAFT IN LONG ANTERIOR URETHRAL STRICTURE Samir Elgamal, Mohamed Abo El-Enen, Mohamed Radwan, and Tarek Gamel Samir ElgamalSamir Elgamal Tanta, Egypt More articles by this author , Mohamed Abo El-EnenMohamed Abo El-Enen Tanta, Egypt More articles by this author , Mohamed RadwanMohamed Radwan Tanta, Egypt More articles by this author , and Tarek GamelTarek Gamel Tanta, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.068AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Buccal mucosal graft (BMG) substitution urethroplasty has become the most widespread method of anterior urethral stricture repair with good results.The aim of this study is to report the medium-term results of repairing long anterior urethral strictures with combined dorsal inlay plus ventral onlay buccal mucosal grafts. METHODS Between March 2007 and January 2009, 21 patients, mean age 37.3 years, with long anterior urethral strictures underwent combined dorsal inlay plus ventral onlay buccal mucosal graft urethroplasty. The strictured urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the urethroplasty. The follow-up included uroflowmetry with an ultrasound to estimate the residual urine volume at 3 months,6 months, 1 year and yearly thereafter, or at the onset of obstructive voiding symptoms. A retrograde urethrogram with a voiding cysto-urethrogram was taken at 3 and 6 months. A successful outcome was defined as normal voiding with no stricture on the voiding cysto-urethrogram and no need for subsequent instrumentation. RESULTS The mean (range) age of the patients was 37.3 (21–62) years. The mean preoperative maximum flow rate was 7.8 mL/s with a mean residual volume of 82.7 mL. . The mean operative duration was 124 min, and the stricture length 3.3 cm. The mean dorsal and ventral buccal mucosa graft length were, respectively, 2.8 and 5.3 cm. Follow-up was available in 19 patients (90.5%) with a mean of 23 months. The overall success rate was 89.5 %. Both failures occurred within the first year and were managed successfully by internal urethrotomy. There were no medium-term donor-site complications. Postmicturition dribbling of urine was noted in 4 patients (21%). CONCLUSIONS Combined double buccal mucosa graft is performed through ventral sagittal urethrotomy approach which is easier than the dorsal urethrotomy approach and has good results especially in patients with tight strictures with very narrow and scarred urethral plate as it provides wider neourethra than a single patch graft substitution. Our medium-term results are very encouraging. However, long-term results and more randomized studies are needed to establish this technique as a procedure of choice in future. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e3 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samir Elgamal Tanta, Egypt More articles by this author Mohamed Abo El-Enen Tanta, Egypt More articles by this author Mohamed Radwan Tanta, Egypt More articles by this author Tarek Gamel Tanta, Egypt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Results of buccal mucosa grafts for repairing long bulbar urethral strictures

To report the medium-term results at our institution of repairing long bulbar urethral strictures with buccal mucosal grafts. Between January 2003 and June 2007, a buccal mucosa graft repair was used in 34 patients with recurrent bulbar strictures >2 cm. The follow-up included uroflowmetry with an ultrasonographic estimate of residual volume at 3 months, 1 year and yearly thereafter, or at the onset of obstructive voiding symptoms. A retrograde urethrogram with a voiding cysto-urethrogram was taken at 6 months. Flexible urethroscopy was used whenever a recurrent stricture was suspected. A successful outcome was defined as normal voiding with no stricture on the voiding cysto-urethrogram and no need for subsequent instrumentation. The median (range) age of the patients was 55.5 (23-74) years. The mean (sd) preoperative maximum flow rate was 6.6 (2.5) mL/s with a mean (sd) residual volume of 51.7 (89.7) mL. Seven patients (21%) had had one or more previous urethral dilatations, 15 (44%) had undergone one or more internal urethrotomies and 10 (30%) received both treatments. Eight patients (24%) had previous open urethral surgery; two had no previous treatment. A dorsal onlay technique was used in 30 patients, a ventral onlay in one, a combined technique (dorsal onlay and ventral fasciocutaneous flap) in two and a two-stage buccal mucosa urethroplasty in one. The mean (sd) operative duration was 147 (36) min, and the stricture length and buccal mucosa graft length were, respectively, 3.2 (1.2) cm and 4.4 (0.6) cm. Follow-up was available in 33 patients (97%) with a mean of 23 (15.4) months. The success rate was then 94%. Both failures occurred within the first year and were managed successfully by internal urethrotomy. The mean (sd) postoperative maximum flow rate was 20 (11) mL/s with a mean (sd) residual volume of 46 (68) mL. There were no medium-term donor-site complications. Postmicturition dribbling was noted in eight patients (24%). None of the patients had de novo impotence or urinary incontinence, and to date no patient has needed a repeat open reconstruction. Our results show that in patients with bulbar urethral strictures of >2 cm, urethroplasty using buccal mucosa is feasible, with very encouraging medium-term results. We confirm that this type of reconstruction could be considered the standard of care for bulbar strictures of >2 cm.

Transurethral Detachment Prostatectomy Using a Tissue Morcellator for Large Benign Prostatic Hyperplasia

Transurethral enucleation of the prostate (TUE) is designed for complete removal of the prostate lobes. On the basis of TUE and holmium laser enucleation of the prostate, we developed a new technique of transurethral detachment prostatectomy (TUDP) using a tissue morcellator. In TUDP, enucleation is performed with a prostate-detaching blade and the tip of a resectoscope, followed by removal of the tissue with a morcellator. This study reports our experience with TUDP in which the weight of retrieved tissue was greater than 30 g in 76 patients with benign prostate hyperplasia. The mean preoperative total prostate and adenoma volumes were 70.7 and 47.4 mL, respectively. The mean times required for enucleation, morcellation, and total operation time were 28.5, 14.4, and 66.3 minutes, respectively. The mean weight of removed prostate tissue was 61.1 g. The mean decreases in the levels hemoglobin and serum sodium were 1.73 mg/dL and 2.41 mEq/dL, respectively. The mean preoperative maximum flow rate (Qmax), International Prostate Symptom Score (IPSS), and quality of life score (QOL) improved from 9.8 mL/sec, 20.2, and 4.9, to 22.3 mL/sec, 3.1 and 1.2, respectively. Complications included mild morcellator-induced mucosal injury in 2 patients (2.6%), nausea in 4 patients (5.2%), transient urinary retention in 2 patients (2.6%), transient urge incontinence in 5 patients (6.4%), and urethral stricture in 2 patients (2.6%). The mean prostate volume and serum prostate-specific antigen level measured 6 months postoperatively in 46 patients were 10.68 mL and 0.89 ng/mL, respectively. TUDP is effective for complete removal of large prostate lobes in patients with large benign prostate hyperplasia and is associated with lower perioperative morbidity.

Early versus delayed internal urethrotomy for recurrent urethral stricture after urethroplasty in children.

Our aim was to evaluate the results of early versus delayed internal urethrotomy for management of recurrent urethral strictures after posterior urethroplasty in children. Twenty boys with proven posterior urethral strictures were treated by perineal posterior urethroplasty. Of these, 12 required internal urethrotomy. Each radiograph demonstrated a patent but irregular urethra with a decrease in diameter at the point of repair (fair results). Patients were then divided into 2 groups: 6 underwent early (within 6 weeks from urethroplasty), and 6 underwent delayed (after 12 weeks from urethroplasty), internal urethrotomy with the cold knife as a complementary treatment. The groups were comparable in terms of patient age, etiology of the primary urethral stricture, number of recurrences, length and site of the actual stricture, and preoperative maximum flow rate. Mean follow-up was 5 years. Kaplan-Meier analyses showed that the stricture-free rate was 66.6% after early, and 33.3% after delayed, internal urethrotomy (P = .03). Early internal urethrotomy should be considered in boys with recurrent urethral stricture after urethroplasty.

Long-term predictive role of urodynamics: an 8-year follow-up of prostatic surgery for lower urinary tract symptoms.

To investigate the long-term predictive value of urodynamics for the outcome of patients undergoing prostatic surgery for lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO) and to determine the long-term effectiveness on symptoms, maximum flow rate and the rate of re-operation. Of 139 elderly men who had undergone prostatic surgery, selected without reference to urodynamic assessment but having extensive (blinded) urodynamic testing included in their evaluation, 79 were followed for 8 years using a history, symptom score analysis, uroflowmetry and review of their records. Comparing the results in groups of men with a pre-operative maximum flow rate < or > or = 15 mL/s, there was a similar difference in the rate of success to that noted 6 months post-operatively. Similar results were obtained when comparing those with BOO or a normal bladder outlet function. However, although the tendency was clear it was not statistically significant because of the small sample size (type-2 error). There was a significant reduction in all symptom scores from those assessed pre-operatively and during the 8 years (P < 0.001). The median pre-operative maximum flow rate was 8.5 mL/s, compared with 12.5 mL/s after 8 years (P < 0.001). Of the 79 patients, 14 (18%) had 28 re-operations during the 8-year follow-up, 12 being repeat resections of the prostate, giving a repeat resection rate of 1.8% per year and a success rate of 71%. During the 8 years, 82% of the patients had an unchanged overall evaluation of the post-operative outcome. In general, those having an unsatisfactory outcome were slightly younger than the whole group. Uroflowmetry and pressure-flow studies can predict to some degree the long-term result after prostatic surgery. There was a durable effect on symptom scores and maximum flow rates after the operation. The annual rate of repeat resection (1.8%) was relatively low.

The "Wallstent": a new stent for the treatment of urethral strictures.

Ten patients have been reviewed in whom urethral stents were implanted for treatment of urethral stricture. Their urethral strictures had been treated with a median of 4.2 endoscopic urethrotomies under direct vision without success. The patients were first treated with optical urethrotomy, and dilatation to 30 F--after which the stents were inserted under direct endoscopic control. A total of 12 stents were inserted. All patients had a 30 mm stent inserted first, and two patients had an additional 20 mm stent inserted because of recurrent stricture at the distal or proximal end of the first stent. One patient had a urethrotomy 12 months after insertion of the stent because of a short recurrent stricture at its distal end. The median length of follow up was 24 months. The median preoperative maximum flow rate was 6.5 ml/s, and the median postoperative maximum flow rate was 20.3 ml/s. Half the patients had postmicturition dribbling postoperatively. The stents were covered with epithelium after 6-18 months, most between 12 and 18 months.

Treatment of Recurrent Urethral Stricture by Internal Urethrotomy and Intermittent Self-Catheterization: A Controlled Study of a New Therapy

A controlled study of the effect of treatment of recurrent urethral stricture by internal urethrotomy followed by clean intermittent self-catheterization for 3 months is reported. There were 28 men (median age 70 years, range 18 to 75) allocated to internal urethrotomy and clean intermittent self-catheterization for 3 months (treatment group) and 33 (median age 76 years, range 36 to 87) were randomized to undergo internal urethrotomy only (observation group). The groups were comparable in terms of patient age, etiology of the primary stricture, number of recurrences, length and site of the actual stricture, and preoperative maximum flow rate (p <0.01). After termination of the treatment all patients from both groups were evaluated by uroflowmetry 2, 4, 6 and 12 months later, and a new recurrenceTreatment results were not significantly different (p <0.01). Of the patients in the treatment and observation groups 78% and 82%, respectively, had a new stricture. The median interval for this to occur was 4 months for both groups. Since no patient had clinical signs of stricture during clean intermittent self-catheterization, we conclude that for the treatment of recurrent urethral stricture clean intermittent self-catheterization following internal urethrotomy should be continued for a long duration, possibly permanently.

Prediction of postoperative retention in elderly patients undergoing nonprostatic surgery by preoperative uroflowmetry.

500 patients above 50 years of age, undergoing lower abdominal/perineal surgery and having no urinary complaints were assessed by measuring the preoperative maximum flow rate (Qmax). They were subsequently observed for urinary retention in the postoperative period. The analysis of the results has shown a definite relation between the preoperative Qmax and the probability of urinary retention in the postoperative period and uroflowmetry has been found to be a good screening procedure for the detection of cases which could possibly have urinary trouble requiring significant intervention in the postoperative phase, thereby changing the priority of surgical attention.

Urodynamics in Prostatism: I. Prognostic Value of Uroflowmetry

A prospective study was undertaken to examine the prognostic value for the symptomatic outcome of prostatic surgery of preoperative urodynamic testing in patients with prostatism. The study design included selection of patients for prostatic surgery by means of classic non-urodynamic urologic investigations such as history, residual urine, serum creatinine, cystoscopy and possibly intravenous urography. In addition an extensive urodynamic work-up (uroflowmetry, cystometry and pressure-flow study with stop-test) was included. The results of the urodynamic studies were unknown to the surgeon selecting the patients for operation. This evaluation was repeated 6 months postoperatively. Totally 139 patients entered the study. The patients were classified according to the preoperative maximum flow rate (Qmax) and in spite of preoperative differences in uroflow, pressure-flow variables and symptom scores, no differences of clinical significance were noted postoperatively among the groups. However, the high-flow group (preoperative Qmax greater than or equal to 15 ml/sec) had a statistically significant lower success rate as judged by the patients subjective evaluation of the outcome of surgery. An analysis of diagnostic sensitivity and specificity indicated Qmax = 15 ml/sec as a relevant cut-off value regarding preoperative identification of patients at risk of a less favourable outcome of surgery. This group of patients was characterized by a higher incidence of persistent uninhibited detrusor contractions at follow-up and a lower incidence of preoperative infravesical obstruction. In conclusion we recommend uroflowmetry in the preoperative evaluation of patients with prostatism.

Predictive value of low maximum flow rate in benign prostatic hyperplasia

Among 84 patients with prostatism selected for transurethral resection of the prostate, 18 had a maximum flow at spontaneous uroflowmetry ⪯ 7 ml/sec. Preoperatively there was no significant difference between patients with maximum flow ⪯ 7 ml/sec (Group 1) and patients with maximum flow > 7 ml/sec (Group 2) in age, duration of symptoms, symptom scores, bladder volume, residual urine, and detrusor pressure at maximum flow. Patients in Group 1, however, had significantly lower urethral resistance and bladder volume independent maximum flow than patients in Group 2. Postoperatively, patients with preoperative maximum flow < 7 ml/sec improved significantly in symptom scores and urodynamic findings apart from bladder volume and detrusor pressure at maximum flow. There were no significant differences between groups in postoperative symptom scores or urodynamic findings. We conclude that preoperative maximum flow rates ⪯ 7 ml/sec at spontaneous uroflowmetry were related to high urethral resistance and not detrusor decompensation among patients with prostatism, and that patients with maximum flow rates ⪯ 7 ml/sec fared as well postoperatively as patients with maximum flow > 7 ml/sec.