Preoperative Urodynamic Findings Research Articles

Nomogram predicting early urinary incontinence after radical prostatectomy

PurposeOne of the most frequent side effects of radical prostatectomy (RP) is urinary incontinence. The primary cause of urine incontinence is usually thought to be impaired urethral sphincter function; nevertheless, the pathophysiology and recovery process of urine incontinence remains unclear. This study aimed to identify potential risk variables, build a risk prediction tool that considers preoperative urodynamic findings, and direct doctors to take necessary action to reduce the likelihood of developing early urinary incontinence.MethodsWe retrospectively screened patients who underwent radical prostatectomy between January 1, 2020 and December 31, 2023 at the First People ‘s Hospital of Nantong, China. According to nomogram results, patients who developed incontinence within three months were classified as having early incontinence. The training group’s general characteristics were first screened using univariate logistic analysis, and the LASSO method was applied for the best prediction. Multivariate logistic regression analysis was carried out to determine independent risk factors for early postoperative urine incontinence in the training group and to create nomograms that predict the likelihood of developing early urinary incontinence. The model was internally validated by computing the performance of the validation cohort. The nomogram discrimination, correction, and clinical usefulness were assessed using the c-index, receiver operating characteristic curve, correction plot, and clinical decision curve.ResultsThe study involved 142 patients in all. Multivariate logistic regression analysis following RP found seven independent risk variables for early urinary incontinence. A nomogram was constructed based on these independent risk factors. The training and validation groups’ c-indices showed that the model had high accuracy and stability. The calibration curve demonstrates that the corrective effect of the training and verification groups is perfect, and the area under the receiver operating characteristic curve indicates great identification capacity. Using a nomogram, the clinical net benefit was maximised within a probability threshold of 0.01–1, according to decision curve analysis (DCA).ConclusionThe nomogram model created in this study can offer a clear, personalised analysis of the risk of early urine incontinence following RP. It is highly discriminatory and accurate, and it can help create efficient preventative measures and identify high-risk populations.

Prognosis of lower urinary tract symptoms and function after robot-assisted radical prostatectomy in patients with preoperative low bladder contractility: A prospective, observational study.

To examine the prognosis of lower urinary tract symptoms and function after robot-assisted radical prostatectomy (RARP) in patients with low preoperative bladder contractility. A total of 115 patients who underwent RARP were enrolled and divided into two groups by preoperative urodynamic findings: normal (patients with bladder contractility index [BCI] ≥ 100; n = 70) and low contractility (patients with BCI < 100; n = 45) groups. Lower urinary tract symptoms and function parameters were prospectively evaluated at 1, 3, 6, 9, and 12 months after RARP in both groups. International Prostatic Symptom Score voiding scores 1, 3, 6, 9, and 12 months after RARP were significantly higher (p < 0.05), and the maximum flow rate (Qmax) values before and 1, 3, 9, and 12 months after RARP were significantly lower in the low contractility group (p < 0.05). Comparing preoperative and postoperative parameters, IPSS voiding scores in the normal contractility group were significantly improved from 6 months after RARP, whereas those in the low contractility group were almost unchanged. Qmax and the 1-h pad test in both groups temporarily deteriorated 1 month after RARP, whereas voided volume and postvoiding residual volume significantly decreased from 1 to 12 months after RARP. This observational study showed that patients with low preoperative bladder contractility might have a weak improvement in voiding symptoms and function after RARP.

Outcomes of Aquablation in Men With Acute and Chronic Urinary Retention

To compare outcomes of Aquablation in men with acute and chronic urinary retention. We conducted a retrospective review of all men undergoing Aquablation resection of the prostate between May 2021 and August 2022. Men were classified as having acute urinary retention if they required either intermittent or indwelling catheter and chronic urinary retention if they had a postvoid residual >300mL prior to surgery. We compared success rates and time to passage of trial without catheter as well as complication rates to those with no retention. A total of 113 men underwent Aquablation including 28 with acute retention and 16 with chronic retention. Failure of initial void trial was significantly higher in patients with preoperative urinary retention (40%) and chronic retention with postvoid residual >300mL (12.5%) compared to those with no retention (7.2%, P<.001). Among men with acute and chronic retention 98% were voiding spontaneously at a mean 5months follow-up. There was no difference in utilization of postoperative prostate medications, complications, International Prostate Symptom Score or uroflowmetry among men with acute, chronic, or no retention. Aquablation is an effective method for treatment of men with urinary retention, with 98% achieving spontaneous voiding regardless of preoperative urodynamic findings. Men in acute retention prior to surgery were more likely to fail their initial void trial, which may support the recommendation for a delayed trial without catheter.

Postoperative urinary retention after pelvic organ prolapse repair: Vaginal versus robotic transabdominal approach.

Postoperative urinary retention has been reported in 13-32% of patients that undergo pelvic organ prolapse (POP) repair. The purpose of our study was to compare rates of urinary retention between transvaginal and robotic transabdominal approaches and identify risk factors for postoperative urinary retention following POP repair. Medical records of patients that underwent POP repair were reviewed. Surgeries included transvaginal high uterosacral ligament suspension (HUSLS) and robotic-assisted sacral colpopexy (RASCP). All patients underwent a retrograde fill voiding trial (RGVT) postoperatively. Demographics, comorbidities, preoperative urodynamic findings, and surgical procedures were compared between women that passed their RGVT and those that did not. Out of 484 patients reviewed, 333 underwent POP repair with a transvaginal HUSLS and 151 underwent RASCP. Postoperative urinary retention was identified in 128 (26.4%) patients where 113 underwent transvaginal HUSLS and 15 underwent RASCP. The odds ratio (OR) of postoperative urinary retention following transvaginal HUSLS was 3.26 (CI 1.72-6.18; P < 0.001) compared to RASCP. Older age was also a risk factor for postoperative urinary retention (OR 1.03, CI 1.01-1.05; P = 0.012). While parity, preoperative post-void residual (PVR), and rates of concomitant transvaginal anterior/posterior repair were significantly higher in patients that developed postoperative urinary retention on univariate analysis, these factors did not demonstrate significance on multivariate analysis. Transvaginal HUSLS demonstrates a 3.26 OR for postoperative urinary retention compared to the robotic transabdominal approach. Older age is also a significant risk factor whereas parity, preoperative PVR, and rates of concomitant transvaginal anterior/posterior repair were not significant risk factors on multivariate analysis.

Preoperative Evaluation of Post-prostatectomy Urinary Incontinence: Examining the Evidence for Routine Use of Multichannel Urodynamics

Up to 10% of men after radical prostatectomy will experience persistent bothersome urinary incontinence. Multichannel urodynamics is often utilized in the preoperative assessment of men with post-prostatectomy incontinence. However, the routine use of this expensive and invasive diagnostic modality in post-prostatectomy incontinence is debatable. This review highlights the evidence either supporting or refuting the routine use of multichannel urodynamic assessment in the preoperative workup of post-prostatectomy urinary incontinence. Stress urinary incontinence symptoms elucidated on history appears to accurately reflect findings on urodynamic assessment with a positive and negative predictive value of >95 and 100%, respectively. Up to half of men with post-prostatectomy incontinence may have some element of bladder dysfunction (decreased compliance, overactivity, decreased bladder capacity, etc); however, numerous studies have failed to demonstrate an impact of preoperative bladder dysfunction on post-surgical treatment outcomes. The available evidence demonstrates that a thorough history accurately reflects findings on urodynamic assessment. Further, bladder dysfunction, regardless of type, does not appear to impact on post-surgical treatment outcomes in men with post-prostatectomy incontinence. These findings argue against the routine use of multichannel urodynamic assessment in the preoperative assessment. However, unlike female incontinence, large randomized controlled trials testing the impact of preoperative urodynamic findings on surgical treatment outcomes are lacking.

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision.

Context:Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%.Aims:We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum.Patients and Methods:All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram.Statistical Analysis Used:Statistical analysis was performed by Chi-squared and Fisher's exact.Results:Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential.Conclusions:New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.

Is Occult Stress Urinary Incontinence a Reliable Predictive Marker?

Pelvic reconstructive surgery can be associated to correction, persistence, or onset of stress urinary incontinence. The aim of our study was to evaluate the incidence of stress incontinence (SI) after prolapse repair in 3 groups with different preoperative urodynamic findings and to find out the predictiveness of occult SI. Patients undergoing vaginal hysterectomy, uterus-sacral ligament colposuspension, and traditional anterior repair for pelvic prolapse were retrospectively analyzed. No patient underwent any additional anti-incontinence procedure. Preoperative evaluation included clinical history, physical examination, and urodynamic assessment with a pessary reduction test. According to urodynamic findings, women were divided into SI (A), occult SI (B), and continence (C) groups. Primary outcome was to compare the incidence of postoperative SI among groups. Secondary outcome was to assess postoperative quality of life with International Consultation on Incontinence questionnaire-short form questionnaire. One hundred fifty patients were analyzed (A: n = 30; B: n = 43; C: n = 77). Mean follow-up was 18.4 ± 0.9 months without differences among groups. Patients in group B did not have higher postoperative SI rate compared to group C. There were no differences in International Consultation on Incontinence questionnaire-short form scores in symptomatic women among groups. In our series, occult stress urinary incontinence is a poor urodynamic marker to predict the development of postoperative SI.

Improvement of overactive bladder symptoms after tension-free vaginal mesh operation in women with pelvic organ prolapse: Correlation with preoperative urodynamic findings.

To further elucidate the mechanisms of overactive bladder coexisting with pelvic organ prolapse. A total of 100 consecutive women with stage 2 or greater pelvic organ prolapse associated with cystocele were enrolled in the present prospective study. They underwent urodynamic studies and then received tension-free vaginal mesh operation. Urodynamic studies were carried out before and after the correction of pelvic organ prolapse using a single gauze pack in the vagina in the sitting position. The overactive bladder symptom score and International Prostate Symptom Score were collected before and 3 months after surgery. In 53 of 100 cases, pelvic organ prolapse was accompanied with overactive bladder, and detrusor overactivity was observed in 28 out of 53 pelvic organ prolapse with overactive bladder cases (52.8%). Detrusor overactivity was resolved in 18 and reduced in four out of 28 cases after the correction of pelvic organ prolapse by the gauze packing method. Of 53 patients who had overactive bladder preoperatively, overactive bladder symptoms disappeared in 35 cases (66.0%) and improved in six additional cases (11.3%) after tension-free vaginal mesh operation. A total of 20 of 25 cases whose overactive bladder symptoms disappeared or improved after surgery coincided with those who had shown either disappearance (n = 16) or improvement (n = 4) of detrusor overactivity after intravaginal gauze pack insertion in preoperative urodynamic studies. All scores in the overactive bladder symptom score decreased significantly after tension-free vaginal mesh, as well as the International Prostate Symptom Score, except for night-time frequency. Pelvic organ prolapse-associated overactive bladder or detrusor overactivity conditions can be reversed in most cases within a short period of time after surgical correction of pelvic organ prolapse.

Severe postprostatectomy incontinence: Is there an association between preoperative urodynamic findings and outcome of incontinence surgery?

Objective.This study investigated urodynamic findings in prostate cancer patients with self-reported persistent severe postprostatectomy urinary incontinence (PPI) as well as the outcome of incontinence surgery. The main aim was to evaluate the ability of preoperative urodynamic dysfunctions to predict the outcome of incontinence surgery. The hypothesis was that preoperative bladder dysfunction was predictive of an unsuccessful surgical outcome. Materials and methods. Based on patient-reported adverse effects after radical prostatectomy (RP) in 2005–2009, 94 men with persistent severe PPI were invited in 2011 to a clinical examination including urodynamics. When indicated, surgery for PPI was offered, and by January 2014, 46 patients had been operated on with either an artificial urinary sphincter or a sling. The outcome of PPI surgery was evaluated with a follow-up questionnaire. Successful outcome was defined in two ways: patient-reported satisfaction and using one or fewer pads/day. Results.Of the 94 men with severe PPI more than 12 months after RP, 76 patients (81% response rate) met for clinical examination. Among them, 99% had intrinsic sphincter deficiency, in 67% coexisting with urodynamic bladder dysfunction. The presence of preoperative bladder dysfunction was not predictive of the outcome of PPI surgery. Preoperative use of fewer pads, less severe PPI, and a longer interval between RP and PPI surgery were associated with the successful outcome of one or fewer pads/day. Longer duration from RP to PPI surgery was the only preoperative factor associated with the successful outcome of satisfaction. Conclusions.The hypothesis was not supported as the presence of preoperative urodynamic bladder dysfunction was not predictive of the outcome of PPI surgery in this study.

1846 THE EFFECT OF MRI CONFIGURATION ON NEW ONSET URODYNAMIC STRESS URINARY INCONTINENCE FOLLOWING URETHRAL DIVERTICULUM EXCISION

INTRODUCTION AND OBJECTIVES: Excision of urethral diverticulum in females is associated with new onset urodynamic stress urinary incontinence (USUI) in up to 65%. We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between 1/5/2007 and 1/9/2012 and correlated this with the pre-operative MRI appearance of the urethral diverticulum. METHODS: 39 patients of median age 43, having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on: demographics, pre-operative MRI appearance and pre and post-operative VCMG. RESULTS: Of these 39 patients, 12 (31%) had pre-operative USUI and are not included in this study. Other pre-operative urodynamic findings included IDO in 9 (23 %) and BOO in 17 (44%). The details regarding the incidence of new onset USUI in the remaining 27 patients are as tabulated. CONCLUSIONS: New onset USUI occurs in 11% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on pre-operative MRI rising from 0% following simple urethral diverticulum excision to 22% following circumferential diverticulum excision.

1350 PRIOR RADIATION AFFECTS CONTINENCE OUTCOMES FOLLOWING ADVANCE TRANSOBTURATOR SLING PLACEMENT IN PATIENTS WITH POST-PROSTATECTOMY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence—Evaluation & Therapy1 Apr 20111350 PRIOR RADIATION AFFECTS CONTINENCE OUTCOMES FOLLOWING ADVANCE TRANSOBTURATOR SLING PLACEMENT IN PATIENTS WITH POST-PROSTATECTOMY INCONTINENCE Robert Torrey, Nitya Rajeshuni, Nora Ruel, and Kevin Chan Robert TorreyRobert Torrey Duarte, CA More articles by this author , Nitya RajeshuniNitya Rajeshuni Duarte, CA More articles by this author , Nora RuelNora Ruel Duarte, CA More articles by this author , and Kevin ChanKevin Chan Duarte, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1171AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The AdVance transobturator urethral sling is a well documented and frequently used sling in men who have undergone a radical prostatectomy for primary treatment or salvage treatment of prostate cancer. We evaluated a cohort of patients (pts) who had a history of AdVance transobturator urethral sling placement for post-prostatectomy incontinence to determine if preoperative radiation (XRT) history had an effect on their postoperative outcome. METHODS 31 pts underwent placement of an AdVance transobturator urethral sling between April 2008 and April 2010. Pt's demographical, preop, periop, and postop details were compared using t-tests for comparison of means, fisher's exact test for comparison of proportions, and descriptive statistics regarding disease history, pad usage, urodyamic findings, and some of the categorical data. RESULTS The mean follow-up was 8.5months. All pts, regardless of XRT history, were reviewed with results showing that 64.5% used no pads, 12.9% were improved, 12.9% had no change, and 9.7% were worse following surgery. Further stratification by XRT history showed no statistical difference in pts with or without a history of XRT regarding age, BMI, or age-adjusted charlson comorbidity index. Pts who had a history of XRT used statistically more pads preop than pts without XRT history (2.6 vs 1.6; p=0.037), but had no statistical difference in their preoperative urodynamic findings. However, there was a statistical difference in the continence, as defined by pad usage, between the two cohorts. Pts with no h/o XRT when compared to those with a h/o XRT showed that 79.2% vs 14.3% used no postoperative pads, 8.3% vs 28.6% were improved in regards to postoperative pad usage, 12.5% vs 14.3% had no change in postoperative pad usage, and 0% vs 42.9% were worse regarding their postoperative pad usage, respectively (p=0.003). CONCLUSIONS While the AdVance transobturator sling is an excellent option in post-prostatectomy incontinence, extreme caution is recommended when considering placement in patients with a h/o XRT regardless of pad usage. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e539 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Torrey Duarte, CA More articles by this author Nitya Rajeshuni Duarte, CA More articles by this author Nora Ruel Duarte, CA More articles by this author Kevin Chan Duarte, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preoperative Valsalva voiding increases the risk of urinary retention after midurethral sling placement

A subset of neurologically normal females void by efficient Valsalva, not detrusor contraction. We determined the incidence of urinary retention following midurethral sling (MUS) placement in women that void by detrusor contraction versus Valsalva. Review of patients undergoing MUS insertion between 2002 and 2009 for urodynamic stress incontinence was performed. Women with concomitant pelvic surgery, previous incontinence surgery, or preoperative incomplete bladder emptying were excluded. Patients were divided into two cohorts based on preoperative urodynamic findings--those that voided with a detrusor contraction >10 cm of water and those that voided by Valsalva. One hundred seven patients were available for analysis. The postoperative urinary retention rate was 22% and 5% in the Valsalva and non-Valsalva groups, respectively (p < 0.05). Mean retention duration was 3 weeks for each cohort (range 1-6). Women voiding by Valsalva are at increased risk of urinary retention following MUS placement.

The 12‐year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery

To investigate whether bladder outlet obstruction (BOO), detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction. Of 92 patients who had TURP after a urodynamic study between 1995 and 1997, 43 (47%) were alive at the time of the survey in February 2008. Nine patients were excluded because of prostate cancer, neurological diseases and the impossibility of symptomatic examination. The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline, 3 months, 3, 7 and 12 years after surgery for 34 patients. Although the improved IPSS and QoL index at 3 months gradually deteriorated with time, patients at 12 years were still significantly better than those at baseline. The IPSS in patients without BOO deteriorated faster than in those with it, whereas neither DUA nor DO influenced the slope of change in IPSS. Regardless of the preoperative urodynamic findings, the QoL index remained improved for 12 years. Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years. The symptomatic improvement provided by TURP lasts for >10 years, although there is a gradual deterioration with time. The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings.

Incontinence and detrusor dysfunction associated with pelvic organ prolapse: clinical value of preoperative urodynamic evaluation

We examined how preoperative urodynamic findings are related to the urinary problems following surgical repair of pelvic organ prolapse (POP). The clinical records of 87 women who underwent surgery for POP were reviewed retrospectively. Preoperatively, cough stress test and urodynamic testing, including pressure-flow study, were performed with prolapse reduction. Postoperative evaluation included uroflowmetry, postvoid residuals, and symptom assessment using questionnaires. A cough stress test with simple filling was sufficient for diagnosis of occult stress urinary incontinence (SUI). The presence of detrusor overactivity was a good predictor of postoperative persistence of urgency and urge urinary incontinence. Postvoid residuals (PVR) largely increased immediately after surgery, but usually recovered within 1 month. Poor detrusor contractility was the best predictor of large PVR occurrence. Preoperative urodynamic evaluation of SUI and detrusor function was useful for predicting postoperative urinary conditions in POP patients. Its cost-effectiveness remains to be examined.

Normal Preoperative Urodynamic Testing Does Not Predict Voiding Dysfunction After Burch Colposuspension Versus Pubovaginal Sling

Urodynamic studies have been proposed as a means of identifying patients at risk for voiding dysfunction after surgery for stress urinary incontinence. We determined if preoperative urodynamic findings predict postoperative voiding dysfunction after pubovaginal sling or Burch colposuspension. Data were analyzed from preoperative, standardized urodynamic studies performed on participants in the Stress Incontinence Treatment Efficacy Trial, in which women with stress urinary incontinence were randomized to undergo pubovaginal sling surgery or Burch colposuspension. Voiding dysfunction was defined as use of any bladder catheter after 6 weeks, or reoperation for takedown of a pubovaginal sling or Burch colposuspension. Urodynamic study parameters examined were post-void residual urine, maximum flow during noninvasive flowmetry, maximum flow during pressure flow study, change in vesical pressure at maximum flow during pressure flow study, change in abdominal pressure at maximum flow during pressure flow study and change in detrusor pressure at maximum flow during pressure flow study. The study excluded women with a preoperative post-void residual urine volume of more than 150 ml or a maximum flow during noninvasive flowmetry of less than 12 ml per second unless advanced pelvic prolapse was also present. Of the 655 women in whom data were analyzed voiding dysfunction developed in 57 including 8 in the Burch colposuspension and 49 in the pubovaginal sling groups. There were 9 patients who could not be categorized and, thus, were excluded from the remainder of the analysis (646). A total of 38 women used a catheter beyond week 6, 3 had a surgical takedown and 16 had both. All 19 women who had surgical takedown were in the pubovaginal sling group. The statistical analysis of urodynamic predictors is based on subsets of the entire cohort, including 579 women with preoperative uroflowmetry, 378 with change in vesical pressure, and 377 with change in abdominal and detrusor pressure values. No preoperative urodynamic study findings were associated with an increased risk of voiding dysfunction in any group. Mean maximum flow during noninvasive flowmetry values were similar among women with voiding dysfunction compared to those without voiding dysfunction in the entire group (23.4 vs 25.7 ml per second, p = 0.16), in the Burch colposuspension group (25.8 vs 25.7 ml per second, p = 0.98) and in the pubovaginal sling group (23.1 vs 25.7 ml per second, p = 0.17). Voiding pressures and degree of abdominal straining were not associated with postoperative voiding dysfunction. In this carefully selected group preoperative urodynamic studies did not predict postoperative voiding dysfunction or the risk of surgical revision in the pubovaginal sling group. Our findings may be limited by the stringent exclusion criteria and studying a group believed to be at greater risk for voiding dysfunction could alter these findings. Additional analysis using subjective measures to define voiding dysfunction is warranted to further determine the ability of urodynamic studies to stratify the risk of postoperative voiding dysfunction, which appears to be limited in the current study.

A Prospective Study Evaluating the Efficacy of the Artificial Sphincter AMS 800 for the Treatment of Postradical Prostatectomy Urinary Incontinence and the Correlation Between Preoperative Urodynamic and Surgical Outcomes

We have evaluated prospectively the long-term efficacy of the artificial urinary sphincter (AUS) AMS 800 for the treatment postradical prostatectomy urinary incontinence (PRPUI) patients. We also evaluated the correlation between preoperative urodynamic findings and surgical outcomes. From May 1997 to April 2003, 40 consecutive patients with PRPUI caused by intrinsic sphincter deficiency (ISD) were treated with the AMS 800. Mean age was 68.3 +/- 6.3 years. Continence status was evaluated on the basis of pad count, impact of urinary incontinence on the quality of life, complications, and surgical revisions. Preoperative urodynamic findings were correlated with surgical outcomes. Follow-up ranged from 27 to 132 months (mean = 53.4 +/- 21.4 months). There was a significant reduction in pad count from 4.0 +/- 0.9 to 0.62 +/- 1.07 diapers per day (P <0.001) leading to continence in 90%. There was a significant reduction on the impact of incontinence decreasing from 5.0 +/- 0.7 to 1.4 +/- 0.93 (P <0.001) in a visual analogue scale (VAS). Surgical revision rate was 20%. Preoperative urodynamics was useful to identify sphincter deficiency. Except by a tendency of worse results in patients with reduced bladder compliance (RBC), other urodynamic parameters did not correlate with a worse surgical outcome. The AMS 800 offers good long-term continence to most PRPUI patients. Preoperative findings like detrusor hyperactivity (DH), impaired detrusor contraction (IDC), low Valsalva leak point pressure, bladder outlet obstruction (BOO), and mild RBC were not associated with worse surgical outcomes.

A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse

The objective of this study was to evaluate the impact of transvaginal prolapse surgery on overactive bladder symptoms in elderly women. Women (> or = 65 years old) with stage III or IV prolapse who enrolled in a prospective study that compared vaginal reconstructive surgery (n = 39) to obliterative surgery (n = 26) and who underwent preoperative urodynamics are the subjects of this study. The women completed the Pelvic Floor Distress Inventory at baseline and again 6 months and 12 months after surgery. Postoperative changes in symptoms of urinary urgency, frequency, and urge urinary incontinence were assessed. The association between a baseline urodynamic diagnosis of detrusor overactivity and pre- and postoperative overactive bladder symptoms was also determined. Data were analyzed from 65 subjects with a mean age of 75.3 years (range, 65.5-87.0 years). Detrusor overactivity was documented in 25% of subjects. There was no difference in the proportion of baseline urge incontinence (P = .38), urinary frequency (P = .53), or urgency (P = .76) in comparing women with and without detrusor overactivity. Surgery resulted in a significant reduction of urgency and frequency symptoms 6 months after surgery and a similar significant reduction in urgency and urge incontinence at 1 year after surgery. Overall, a clinically and statistically significant improvement in the irritative subscale of the Pelvic Floor Distress Inventory was noted at 6 months (18.3%; P < .0001) and 12 months (17.6%; P < .0001) after surgery. In our cohort, performance of a mid urethral sling, a bladder neck sling, or a Kelly plication was not associated with a reduction in postoperative symptoms of urgency, frequency, or urge incontinence (P = .48). Likewise, there was no difference in postoperative symptom reduction (urgency, frequency, or urge incontinence) between women who received reconstructive surgery vs women who had obliterative surgery (P = .84). Vaginal surgery for stage III or IV pelvic organ prolapse significantly reduces overactive bladder symptoms in elderly women. In our cohort, symptom reduction was unrelated to the type of vaginal surgery (obliterative vs reconstructive) or the inclusion of a procedure to treat stress incontinence. Furthermore, preoperative urodynamic findings did not correlate with the presence or absence of overactive bladder symptoms.

A randomized trial of colpopexy and urinary reduction efforts (CARE): design and methods

The primary aim of this randomized clinical trial is to evaluate whether a standardized modified Burch colposuspension, when added to planned abdominal sacrocolpopexy for the treatment of pelvic organ prolapse, improves the rate of urinary stress continence in subjects without preoperative symptoms of stress urinary incontinence. Secondary aims include comparison of immediate and short-term complications, overall urinary tract function, and other aspects of pelvic health between subjects with and without a concomitant Burch. The value of preoperative urodynamic testing with prolapse reduction will also be compared between subjects with and without a concomitant Burch. This trial is performed through the Pelvic Floor Disorders Network, which is funded by the National Institutes of Health–National Institute of Child Health and Human Development. Subjects will be enrolled at seven clinical centers across the United States and data will be analyzed by the central data coordinating center. Standardized questionnaires and physical observations and measurements will be obtained. The surgical team is masked to the preoperative urodynamic findings, and the patient and research coordinator are masked to treatment assignment. The primary outcome will be determined at 3 months after surgery. Stress continence is defined as absence of stress incontinence symptoms by questionnaire, a negative standardized stress test, and no treatment for stress incontinence other than the study intervention. Additional follow-up occurs at 6, 12, and 24 months. Accrual began in April 2002 and is projected to take 3 years. As of March 6, 2003, 91 patients have been randomized. This article highlights the scientific aspects of trial design for this pivotal clinical trial. The optimal approach to the urinary tract in women treated surgically for prolapse is not known. This trial is designed to provide pelvic surgeons and their patients with scientific data regarding the utility of urodynamics with and without prolapse reduction and the role of colposuspension with sacrocolpopexy.

Urodynamic testing predicts long-term urological complications following simultaneous pancreas-kidney transplantation.

Combined pancreas-kidney transplantation is the treatment of choice for patients with type I diabetes mellitus associated with chronic renal failure. The introduction of the bladder drainage technique constituted a marked improvement of the surgical technique with a reduction of life-threatening complications. However, drainage of pancreatic secretions via the urinary bladder causes urological complications leading, in some cases, to cystoenteric conversion. We retrospectively analysed whether pre-operative urodynamic findings may predict the subsequent development of urological complications and influence the choice of exocrine secretion drainage. From 1987 to 1997, 39 bladder-drained simultaneous pancreas-kidney transplantations were performed in 16 men and 23 women with a mean age of 38.5 yr. All patients underwent a complete urological assessment prior to surgery, including medical history, physical examination, urethrocystography and urodynamic assessment. Twenty-eight patients are alive with a mean follow-up of 62 +/- 8 months. In 60% of cases, both kidney and pancreas remain functional. Seven patients experienced recurrent lower urinary tract infections. Six patients suffered from chemical urethritis (four men and two women) and six suffered from recurrent haematuria (blood transfusions were required in two patients). One patient had incrusted stones at the site of duodenal staples. Urological complications were mostly observed in the 22 patients (79%) with abnormal urodynamic characteristics (Relative risk: 5.1). Intravenous Somatostatin failed to definitively cure these complications in most cases. Seven patients (17%) (five with urethritis, two with haematuria) required cystoenteric conversion. Two patients developed post-operative ileal fistula, one cutaneous and one into the bladder. All urinary symptoms resolved in these seven patients. The frequency of specific urinary complications is high (28%) in bladder-drained simultaneous pancreas-kidney transplantation patients. These complications are statistically more frequent in the case of an abnormal pre-transplant urodynamic assessment.

Detrusor instability with equivocal obstruction: A predictor of unfavorable symptomatic outcomes after transurethral prostatectomy.

To elucidate whether preoperative urodynamic findings can predict outcomes of transurethral resection of the prostate (TUR-P). Sixty-two patients with symptomatic benign prostatic hyperplasia were categorized in three different ways based on findings of preoperative pressure-flow study (PFS) and cystometry: urodynamic obstruction (determined by the Abrams-Griffiths nomogram), detrusor instability (DI), and combination of both. Outcomes of TUR-P regarding symptom, function, and quality of life (QOL) were analyzed by changes in the International Prostate Symptom Score (I-PSS), maximum flow rate in uroflowmetry, and QOL index before and after TUR-P, respectively. Overall outcome was defined as success when all of the three categories showed successful improvement. Neither urodynamic obstruction alone nor DI alone predicted outcomes of TUR-P. However, symptomatic and overall outcomes were significantly worse in patients who were not obstructed but had DI. Postoperative persistent DI was more frequently noted in patients without clear obstruction (60%) than in those with obstruction (27%). Patients with equivocal obstruction showed less satisfactory symptomatic outcomes of TUR-P when DI was accompanied. Persistent DI might be the principle cause of unfavorable outcomes. Preoperative evaluation of DI is of benefit because it enhances predictive value of the PFS.