Urinary Outcomes Research Articles

Managing Therapeutic Competition in Patients with Heart Failure, Lower Urinary Tract Symptoms and Incontinence

Up to 50 % of heart failure patients suffer from lower urinary tract symptoms. Urinary incontinence has been associated with worse functional status in patients with heart failure, occurring three times more frequently in patients with New York Heart Association Class III and IV symptoms compared with those with milder disease. The association between heart failure and urinary symptoms may be directly attributable to worsening heart failure pathophysiology; however, medications used to treat heart failure may also indirectly provoke or exacerbate urinary symptoms. This type of drug–disease interaction, in which the treatment for heart failure precipitates incontinence, and removal of medications to relieve incontinence worsens heart failure, can be termed therapeutic competition. The mechanisms by which heart failure medication such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and β-blockers aggravate lower urinary tract symptoms are discussed. Initiation of a prescribing cascade, whereby antimuscarinic agents or β3-agonists are added to treat symptoms of urinary urgency and incontinence, is best avoided. Recommendations and practical tips are provided that outline more judicious management of heart failure patients with lower urinary tract symptoms. Compelling strategies to improve urinary outcomes include titrating diuretics, switching ACE inhibitors, treating lower urinary tract infections, appropriate fluid management, daily weighing, and uptake of pelvic floor muscle exercises.

Transcorporal artificial urinary sphincter implantation as a salvage surgical procedure for challenging cases of male stress urinary incontinence: surgical technique and functional outcomes in a contemporary series

To describe the surgical technique of transcorporal artificial urinary sphincter (AUS) implantation. To assess the efficacy of the AUS on continence and erectile function. A prospective evaluation was conducted between December 2007 and October 2012 at a tertiary referral centre of all male patients treated by transcorporal AUS (AMS800™, AmericanMedicalSystems, Minnetonka, MN, USA) implantation for stress urinary incontinence (SUI) recurrence, after failure of previous anti-incontinence surgery. Functional urinary outcomes were assessed according to daily pad use, the Urinary Symptom Profile questionnaire, and International Consultation on Incontinence Questionnaire - Short-Form. Erectile function was evaluated using the five-item International Index of Erectile Function (IIEF-5) questionnaire and patient satisfaction was assessed by Patient Global Impression of Improvement questionnaire. Data were collected by telephone interview. A total of 23 patients were included. Their mean (sd; range) age was 70 (7; 60-85) years. Of these, 18 patients had urethral atrophy and/or erosion after placement of AUS (11 patients), male sling (four patients) or both (three patients), and five patients had severe urethral atrophy after pelvic radiation therapy. The implantation of the AUS with transcorporal cuff placement was successful in all patients, with no peri-operative complications. Follow-up data over 1 year were available for 17 patients. After a median (sd; range) follow-up of 20 (15; 2-59) months, eight patients were perfectly dry (no pad use and no symptoms), five achieved social continence (less than one pad/day), and four still had SUI (required two or more pads/day). Among six patients who had good preoperative erectile function and were sexually active, four had no decrease in their IIEF-5 score. Transcorporal AUS cuff placement is a useful alternative for challenging cases of male SUI after failure of previous surgical treatment, urethral atrophy or erosion. Erectile function can be maintained despite dissection of the corporal body.

Superior Quality of Life and Improved Surgical Margins Are Achievable with Robotic Radical Prostatectomy After a Long Learning Curve: A Prospective Single-surgeon Study of 1552 Consecutive Cases

BackgroundComparative studies suggest functional and perioperative superiority of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP). ObjectiveTo determine whether high-volume experienced open surgeons can improve their functional and oncologic outcomes with RARP and, if so, how many cases are required to surpass ORP outcomes and reach the learning curve plateau. Design, setting, and participantsA prospective observational study compared two surgical techniques: 1552 consecutive men underwent RARP (866) or ORP (686) at a single Australian hospital from 2006 to 2012, by one surgeon with 3000 prior ORPs. Outcome measurements and statistical analysisDemographic and clinicopathologic data were collected prospectively. The Expanded Prostate Cancer Index Composite quality of life (QoL) questionnaire was administered at baseline, 1.5, 3, 6, 12, and 24 mo. Multivariate linear and logistic regression modelled the difference in QoL domains and positive surgical margin (PSM) odds ratio (OR), respectively, against case number. Results and limitationsA total of 1511 men were included in the PSM and 609 in the QoL analysis. RARP sexual function scores surpassed ORP scores after 99 RARPs and increased to a mean difference at 861st case of 11.0 points (95% confidence interval [CI], 5.9–16.1), plateauing around 600–700 RARPs. Early urinary incontinence scores for RARP surpassed ORP after 182 RARPs and increased to a mean difference of 8.4 points (95% CI, 2.1–14.7), plateauing around 700–800 RARPs. The odds of a pT2 PSM were initially higher for RARP but became lower after 108 RARPs and were 55% lower (OR: 0.45; 95% CI, 0.22–0.92) by the 866th RARP. The odds of a pT3/4 PSM were initially higher for RARP but decreased, plateauing around 200–300 RARPs with an OR of 1.15 (0.68–1.95) at the 866th RARP. Limitations include single-surgeon data and residual confounding. ConclusionsRARP had a long learning curve with inferior outcomes initially, and then showed progressively superior sexual, early urinary, and pT2 PSM outcomes and similar pT3 PSM and late urinary outcomes. Learning RARP was worthwhile for this high-volume surgeon, but the learning curve may not be justifiable for late-career/low-volume surgeons; further studies are needed.

Urinary Outcomes Are Significantly Affected by Nerve Sparing Quality During Radical Prostatectomy

To assess the effect of nerve sparing (NS) quality on self-reported patient urinary outcomes after radical prostatectomy. A total of 102 preoperatively potent men underwent laparoscopic or robotic radical prostatectomy; NS was prospectively graded at surgery using a 0-4 scale/neurovascular bundle. Urinary functional outcomes were measured by validated Expanded Prostate Cancer Index Composite questionnaire at baseline and follow-up time points (1, 3, 6, 9, and 12 months) in 99 men who underwent various degrees of NS. Mixed linear regression was used to analyze the effect of NS quality and other clinical factors on urinary outcomes. Patients with at least 1 neurovascular bundle spared completely, along with its supportive tissues (NS grade 4/4), noted significantly improved Expanded Prostate Cancer Index Composite urinary functional and continence outcomes as early as 1 month postoperatively and up to 12 months. Significantly less urinary bother was also noted in these men by 9-12 months postoperatively. Multivariate analysis revealed that bilateral or unilateral excellent NS (at least 1 bundle graded 4/4), increasing time from surgery, young patient age, and lower body mass index positively and significantly affected urinary functional outcomes, including pad use. Men who received excellent unilateral NS recovered urinary function about as well as men who had both neurovascular bundles spared in similar fashion. The quality of NS significantly influences patient-defined urinary functional convalescence. Completely sparing at least 1 neurovascular bundle along with its supportive tissues has a dramatic effect on the recovery of urinary continence and quality of life in preoperatively potent men.

Evaluation of Urinary Outcomes by International Prostate Symptom Scores (IPSS) in Intensity Modulated Radiation Therapy Combined With Androgen Deprivation Therapy for Prostate Cancer

Evaluation of Urinary Outcomes by International Prostate Symptom Scores (IPSS) in Intensity Modulated Radiation Therapy Combined With Androgen Deprivation Therapy for Prostate Cancer

Quality Gaps in Documenting Urinary Catheter Use and Infectious Outcomes

To describe the frequency of use of all types of urinary catheters, including but not limited to indwelling catheters, as well as positive cultures associated with the various types. We also determined the accuracy of catheter-days reporting at our institution. Prospective, observational trial based on patient-level review of the electronic medical record. Chart review was compared with standard methods of catheter surveillance and reporting by infection control personnel. Ten internal medicine and 5 long-term care wards in 2 tertiary care Veterans Affairs hospitals in Texas from July 2010 through June 2011. The study included 7,866 inpatients. Measurements included patient bed-days; days of use of indwelling, external, suprapubic, and intermittent urinary catheters; number of urine cultures obtained and culture results; and infection control reports of indwelling catheter-days. We observed 7,866 inpatients with 128,267 bed-days on acute medicine and extended care wards during the study. A urinary catheter was used on 36.9% of the total bed-days observed. Acute medicine wards collected more urine cultures per 1,000 bed-days than did the extended care wards (75.9 and 10.4 cultures per 1,000 bed-days, respectively; P<.001). Catheter-days were divided among indwelling-catheter-days (47.8%), external-catheter-days (48.4%), and other (intermittent- and suprapubic-catheter-days, 3.8%). External catheters contributed to 376 (37.3%) of the 1,009 catheter-associated positive urine cultures. Urinary-catheter-days reported to the infection control department missed 20.1% of the actual days of indwelling catheter use, whereas 12.0% of their reported catheter-days were false. Urinary catheter use was extremely common. External catheters accounted for a large portion of catheter-associated bacteriuria, and standard practices for tracking urinary-catheter-days were unreliable. ClinicalTrials.gov identifier: NCT01052545.

Prostate volume changes during permanent seed brachytherapy: an analysis of intra-operative variations, predictive factors and clinical implication

BackgroundTo determine prostate volume (Pvol) changes at 3 different time points during the course of I125 permanent seed brachytherapy (PB). To assess the impact of these changes on acute urinary retention (AUR) and dosimetric outcome.MethodsWe analyzed 149 hormone-naïve patients. Measurements of the prostate volume were done using three-dimensional transrectal ultrasound (3D-TRUS) in the operating room before insertion of any needle (V1), after the insertion of 2 fixation needles with a harpoon (V2) and upon completion of the implant (V3). The quality of the implant was analyzed with the D90 (minimum dose in Grays received by 90% of the prostate volume) at day 30.ResultsMean baseline prostate volume (V1) was 37.4 ± 9.6 cc. A volume increase of >5% was seen in 51% between V1-V2 (mean = 2.5 cc, p < 0.01), in 42% between V2-V3 (mean = 1.9 cc, p < 0.01) and in 71% between V1-V3 (mean = 4.5 cc, p < 0.01). Pvol changes caused by insertion of the fixation needles were not statistically different than those caused by the implant itself (p = 0.23).In multivariate linear regression analysis, baseline Pvol is predictive of Pvol changes between V2 and V1 and V3 and V1 but not between V3 and V2. The extent of prostate swelling had an influence on D90. An increase of 10% in prostate volume between V1 and V2 results in an increase of D90 at Day 30 by 11.7%. Baseline Pvol (V1) was the only predictor of the duration of urinary retention in both univariate and multivariate (p = 0.04) regression analysis.ConclusionsA large part of intraoperative swelling occurs already after the insertion of the fixation needles. This early prostate swelling predicts for D90 but not for AUR.

A longitudinal study of anxiety, depression and distress as predictors of sexual and urinary quality of life in men with prostate cancer

To evaluate the prevalence of depression, anxiety and distress among active surveillance (AS) and radical prostatectomy (RP) patients. To evaluate the impact of these symptoms at baseline on urinary and sexual quality of life at follow-up. Patients managed with AS or RP who completed validated questionnaires assessing levels of depression, anxiety, distress and urinary (UF) and sexual function (SF) and bother comprised the final analytic cohort. These measures were completed at baseline, within 1 year, and between 1 and 3 years from baseline. Mixed model repeated measures analysis was used to examine associations between mental health at baseline and sexual and urinary outcomes in a subset of RP patients with complete follow-up. Among 679 men who comprised the study cohort, baseline prevalence of moderate or higher levels of depression or anxiety were low (<5%), while levels of mild depression or anxiety ranged from 3-16% over time. Baseline levels of elevated distress ranged from 8-20%. Among men who provided data at baseline and follow-up, there were no significant differences between AS and RP patients in the proportion of men with elevated levels of depression, anxiety, or distress. Among 177 men who underwent RP and had complete follow-up moderate or higher levels of depression or anxiety appeared to be associated with post-treatment SF and bother, while elevated levels of distress were associated with post-treatment UF. Moderate or higher levels of depression or anxiety were low in men with localised prostate cancer but were associated with sexual outcomes, while elevated distress was associated with urinary outcomes. Greater attention should be paid to mental health symptoms among men with prostate cancer, as these symptoms may be associated with quality of life outcomes.

V1859 NERVE-SPARING RADICAL CYSTECTOMY: AN ANTEGRADE ENDOPELVIC FASCIA-SPARING APPROACH

INTRODUCTION AND OBJECTIVES: Several techniques have been proposed in an attempt to optimize the outcomes of radical cystectomy in terms of sexual and urinary functions. We report our refinement of antegrade open nerve-sparing radical cystectomy. METHODS: We describe nerve-sparing radical cystectomy utilizing an antegrade, endopelvic fascia sparing approach. After completion of bilateral extended lymphadenectomy, the superior and inferior vesical arteries are ligated and divided. The peritoneum overlying the seminal vesicles is divided in the cul de sac and the seminal vesicles are exposed. The tissues lateral to to the seminal vesicles are dissected, ligated and divided in an avascular plane leading to the base of the prostate. The endopelvic fascia is not incised and the prostatic capsule is released from the surrounding fascia preserving all the periprostatic tissues and nerves. Once the apex is reached the neuromuscular bundle can be clearly delineated and separated from the urethra. The urethra is then incised at the apex of the prostate under direct vision. RESULTS: This approach facilitates the preservation of the fascial attachments along the course of the neuromuscular bundles with minimal manipulation of the rhabdosphincter and the fascial attachments. CONCLUSIONS: The antegrade endopelvic fascia-sparing approach for radical cystectomy allows anatomic preservation of the fascial attachments along the course of the neuromuscular bundles and the striated sphincter. This may result in better sexual and urinary outcomes.

Does the Presence of Preoperative LUTS Affect Urinary Outcomes after Radical Prostatectomy?

Urinary incontinence is one of the most common adverse effects after radical prostatectomy (RP). Preoperative lower urinary tract symptoms (LUTS), which increase in prevalence with advancing age, have been hypothesized to be related to postoperative urinary continence. We review the literature on the role of preoperative LUTS on postoperative urinary function after RP in patients with clinically localized prostate cancer. The precise role of preoperative LUTS on postoperative urinary continence after RP is unclear due to conflicting conclusions from numerous reports. However, correlating preoperative LUTS to postoperative urinary incontinence may be particularly relevant in three instances: in patients with preoperative voiding or emptying LUTS, in predicting early postoperative urinary continence, and in patients with preoperative urinary incontinence. Also, RP in patients with moderate to severe preexisting LUTS may improve postoperatively as a result of relief of obstruction.

Urinary functional outcomes and toxicity five years after proton therapy for low- and intermediate-risk prostate cancer: Results of two prospective trials

Background. To assess genitourinary (GU) function and toxicity in patients treated with image-guided proton therapy (PT) for early- and intermediate-risk prostate cancer and to analyze the impact of pretreatment urinary obstructive symptoms on urinary function after PT. Material and methods. Two prospective trials accrued 171 prostate cancer patients from August 2006 to September 2007. Low-risk patients received 78 cobalt gray equivalent (CGE) in 39 fractions and intermediate-risk patients received 78–82 CGE. Median follow-up was five years. The International Prostate Symptom Score (IPSS) and GU toxicities (per CTCAE v3.0 and v4.0) were documented prospectively. Results. Five transient GU events were scored Gr 3 per CTCAE v4.0, for a cumulative late GU toxicity rate of 2.9% at five years. There were no Gr 4 or 5 events. On multivariate analysis (MVA), the only factor predictive of Gr 2 + GU toxicity was pretreatment GU symptom management (p = 0.0058). Patients with pretreatment IPSS of 15–25 had a decline (clinical improvement) in median IPSS from 18 before treatment to 10 at their 60-month follow-up. At last follow-up, 18 (54.5%) patients had a > 5-point decline, 14 (42.5%) remained stable, and two patients (3%) had a > 5-point rise (deterioration) in IPSS. Patients with IPSS < 15 had a stable median IPSS of 6 before treatment and at 60 months. Conclusion. Urologic toxicity at five years with image-guided PT has been uncommon and transient. Patients with pretreatment IPSS of < 15 had stable urinary function five years after PT, but patients with 15–25 showed substantial improvement (decline) in median IPSS, a finding not explained by initiation or dose adjustment of alpha blockers. This suggests that PT provides a minimally toxic and effective treatment for low and intermediate prostate cancer patients, including those with significant pretreatment GU dysfunction (IPSS 15–25).

Urinary Symptoms After Robotic Prostatectomy in Men with Median Lobes

We report on the natural history of lower urinary tract symptoms (LUTS) and urinary continence in patients with median lobe enlargement (MLE) after robotic radical prostatectomy (RP). Patients treated with RP from October 2008 to March 2012 completed American Urological Association symptom index (AUAI) and continence assessments at the preoperative visit and each postoperative visit. Two cohorts were established based on the presence or absence of a median lobe intraoperatively. A total of 698 validated questionnaires were completed by 175 patients with a median of 4 AUAI scores per patient. The 36 patients (21%) with MLE required a longer time to achieve urinary continence (P = .05, log-rank test), although ultimately, no difference was seen in long-term continence probability between the two cohorts (P = .63). On multivariate analysis, the presence of a median lobe reduced the odds of early continence recovery (P = .02). By use of a generalized estimating equation, the cohort-average AUAI scores after RP are presented. Patients with MLE had faster improvement in LUTS after surgery, whereas those without MLE had temporary worsening in LUTS before improvement. Patients with MLE have a different natural history of LUTS and continence after RP as compared with patients without this finding. Therefore, radiographic or cystoscopic evaluation for the presence of a median lobe before RP may improve patient counseling about urinary outcomes.

Functional Outcomes in African-Americans After Robot-Assisted Radical Prostatectomy

Previous studies have demonstrated differences in surgical outcomes after radical prostatectomy based on ethnicity. We compared sexual and urinary outcomes in African-American (AA) patients 6 and 12 months after robot-assisted radical prostatectomy (RARP) with those of non-AA patients. We reviewed our RARP database at our institution for patients with at least 12 months of follow-up. Erectile function was defined using the University of California, Los Angeles Prostate Cancer Index as erections "firm enough for masturbation and foreplay" or "firm enough for intercourse," while urinary continence was defined as being "pad free." Only patients who were potent and pad free preoperatively were included in the analysis. Multivariate logistic regression was used to compare postoperative potency and urinary pad-free status between AA and non-AA patients while controlling for pertinent demographic, clinical, and pathologic variables. In the urinary continence analysis, 140 AA patients and 576 non-AA patients were included, compared with 105 AAs and 500 non-AA patients who were included in the analysis of sexual function. At 12 months postoperatively, a smaller proportion of AA patients were potent compared with non-AA patients (60% vs 76.4%, P=0.001). Similarly, we found a lower incidence of pad-free status for AA patients at 12 months postoperatively (55.7% vs 69.8%, P=0.039). Similar functional results were found at 6 months postoperatively for both analysis groups. AA men appear to have worse urinary and sexual outcomes at 12 months after RARP compared with non-AA patients. At 6 months, there is no statistically significant difference. Further, longer-term studies are needed to validate these results.

694 ALLEVIATION VERSUS INDUCTION OF URINARY OBSTRUCTION OR INCONTINENCE BY PROSTATE CANCER TREATMENT THE PIVOTAL ROLE OF PRETREATMENT URINARY SYMPTOMS

matching. RESULTS: PS matching resulted in a cohort of 628 doublelayer and 628 single-layer controls. The standardized differences between the two groups in patient and hospital characteristics were less than 10%, indicating a high degree of similarity in the distribution of both populations. Post propensity-score matching analyses revealed that relative to single-layer patients, double-layer patients were less likely to experience a BNC (0.5 vs. 2.1%, p 0.0129). However, anastomotic leak was not affected by type of anastomosis (8.6 vs. 9.4%, p 6849). CONCLUSIONS: PR of Denonvilliers’ fascia and the periurethral tissue as part of a double-layer anastomosis is associated with a decreased rate of BNC after RARP. This is the first study to demonstrate a significant long-term benefit of PR at RARP.

513 IMPACT OF SHORT TERM REGIONAL HYPOTHERMIA ON CONTINENCE AT ONE YEAR FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy I1 Apr 2012513 IMPACT OF SHORT TERM REGIONAL HYPOTHERMIA ON CONTINENCE AT ONE YEAR FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY Thomas Ahlering, Kathyrn Osann, Blanca Morales, and Douglas Skarecky Thomas AhleringThomas Ahlering Orange, CA More articles by this author , Kathyrn OsannKathyrn Osann Orange, CA More articles by this author , Blanca MoralesBlanca Morales Orange, CA More articles by this author , and Douglas SkareckyDouglas Skarecky Orange, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.585AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We previously developed a novel technique applying loco-regional hypothermia to the pelvis during robot-assisted radical prostatectomy (RARP) to reduce inflammatory injury (Urology 73(4) 691-696, 2009). This report examines whether short term cooling influences urinary outcomes one Year after RARP. METHODS Regional pelvic cooling was achieved with a prototype endorectal cooling balloon (ECB) during the course of RARP only, 2-3 hours on average. Clinical data was entered prospectively into an electronic database for historic (cases 1-666) and hypothermic groups (109 pts). Continence was defined as pad-free. Data were analysed using chi-square tests and Kaplan-Meier analysis. RESULTS Averages for the cooled men versus controls were age 61.6 yrs vs 61.4, Pre-PSA 6.1 vs 6.8, AUA 7.7 vs 8.7, IIEF-5 20.9 vs 18.9, and prostate weight 53.7 vs 51.9 respectively, all p- values >.17. Average follow up was 15 months cooled men. In Kaplan-Meier analysis, pad-free continence rates were significantly higher in men treated with regional pelvic cooling compared those in the non-cooled group. At 1 month, pad free continence rates were 40.4% with hypothermia compared to 30.7% in the non-cooled RLP group (p=0.048). Zero-pad continence rates at 3 months were 82.6% and 65.1% in the cooled and non-cooled groups respectively (p=0.003). At 12 months, continence rates remained significantly higher in men treated with hypothermia at 95.4% vs. 85.2% (p=0.03). After adjusting for pre-operative variables and surgeon learning-curve, hypothermic cooling is associated with shorter time to zero pad continence (HR=1.7, 95% CI: 1.3-2.2). In the cooled group, the 3 incontinent men wore either a security pad (1) or a single light pad (2) per day. In the non cooled group 10/58 men still wore multiple pads/day one year after surgery, and this represents 2% of all men who undergo non cooled radical surgery, and these numbers may be higher in other clinical settings. One man resolved his incontinence with surgical ‘sling' procedure. CONCLUSIONS Using a prototype cooling balloon, ECB hypothermia during RARP resulted in a significant durable improvement in time to pad free continence at 12 months. This could provide substantial savings in health care treatment dollars, in reducing secondary chronic treatments for urinary incontinence after surgery. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e211 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Ahlering Orange, CA More articles by this author Kathyrn Osann Orange, CA More articles by this author Blanca Morales Orange, CA More articles by this author Douglas Skarecky Orange, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1554 FEMALE URETHRAL DIVERTICULA EVALUATION OF VOIDING DYSFUNCTION BEFORE AND AFTER SURGERY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology I1 Apr 20121554 FEMALE URETHRAL DIVERTICULA EVALUATION OF VOIDING DYSFUNCTION BEFORE AND AFTER SURGERY Ailsa Wilson, Mahreen Hussain, Rizwan Hamid, Jeremy Ockrim, Julian Shah, and Tamsin Greenwell Ailsa WilsonAilsa Wilson London, United Kingdom More articles by this author , Mahreen HussainMahreen Hussain London, United Kingdom More articles by this author , Rizwan HamidRizwan Hamid London, United Kingdom More articles by this author , Jeremy OckrimJeremy Ockrim London, United Kingdom More articles by this author , Julian ShahJulian Shah London, United Kingdom More articles by this author , and Tamsin GreenwellTamsin Greenwell London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1324AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The risk of stress urinary incontinence after surgery for female urethral diverticula has lead some centres to routinely perform concomitant anti-incontinence procedures at the time of diverticulectomy. Other disturbances of bladder and voiding function are not widely reported. We aimed to establish the rate and risk factors for pre and postoperative voiding dysfunction in urethral diverticula. METHODS A single institutional review of females who underwent excision of benign urethral diverticula from 2000-2011. RESULTS 42 female patients were examined. Median follow up was 18 months (range 4 to 96 months). Most common was a horseshoe configuration (67%); 22% had circumferential and 11% a simple diverticulum. Size as measured on MRI varied up to a greatest dimension of 40 mm. Three (7%) were recurrent diverticula. Most procedures incorporated use of a Martius fat pad. Surgical morbidity was low. 75% reported preoperative voiding symptoms, equally distributed between stress incontinence, urgency and obstructive symptoms. There was some correlation with preoperative urodynamic abnormalities (stress incontinence, detrusor overactivity or obstructive voiding), which were also present in 75% of cases. In initial postoperative months half of all patients remained asymptomatic or had resolution of their preoperative symptoms. 35% had persistent symptoms. 20% who had not had symptoms before surgery developed new symptoms. Urgency was the commonest new symptom postoperatively - most resolved with time and anticholinergics, and intervention (sacral neuromodulation) required in only one case. Of those with stress incontinence post surgery two thirds had pre-existing stress incontinence. One third were de novo – half of these resolved with conservative measures within six months, and half underwent a subsequent antiincontinence procedure. Two patients developed new obstructive symptoms after surgery, with one requiring a single urethral dilatation. Although numbers were too few for detailed analysis there was a trend for a relationship of risk of pre and postoperative urinary symptoms with increased size and complexity (multiple diverticulae or ostia, circumferential, horseshoe). CONCLUSIONS The complex relationship between the presence of a urethral diverticulum and voiding symptoms makes it difficult to predict postoperative urinary outcomes. Most often de novo urgency and stress incontinence after repair is mild and will spontaneously resolve. Few require a subsequent antiincontinence procedure and as such argues against performing a combined operation. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e630 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ailsa Wilson London, United Kingdom More articles by this author Mahreen Hussain London, United Kingdom More articles by this author Rizwan Hamid London, United Kingdom More articles by this author Jeremy Ockrim London, United Kingdom More articles by this author Julian Shah London, United Kingdom More articles by this author Tamsin Greenwell London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effective parameters of urodynamic study before pelvic organ prolapse surgery and validation of concomitant surgery on urinary outcomes: Retrospective cohort study

목적 본 연구는 골반장기탈출증을 가진 환자들의 수술 전에 시행하는 요역동학 검사에서 수술 후 결과 및 합병증과 관련된 유용한 지표를 알아보고, 골반장기탈출증 교정술과 복압성 요실금교정술을 동시에 시행하는 경우 그 타당성을 입증하기 위한 목적으로 시행되었다. 연구방법 2006년 1월부터 2010년 12월까지 연세대학교 세브란스병원에 등록된 수술 전 요역동학 검사 및 골반장기탈출증 수술을 시행한 308명의 환자를 대상으로 후향적 코호트 연구를 시행하였다. 결과 수술 후 복압성 요실금의 유병률은 수술 전 요역동학 검사상 복압성 요실금을 진단받지 않아 골반장기탈출증 수술만 시행한 그룹 2 (3.1%, 4명)에서 복압성 요실금을 진단받아 요실금교정 수술을 동시에 시행한 그룹 1 (1.7%, 3명)보다 높게 나타났으나 통계적으로 유의한 차이는 없었다. 우리는 valsalva 유발 요누출 시 복압, 최대요도 폐쇄압, 최대요속, 최대요속 시 배뇨근압력, 최대 방광용적의 5가지 요역동학 검사 지표를 비교하였다. 수술 후 복압성 요실금에서는 최대요속 시 배뇨근압력(교차비, 1.029; 95% 신뢰구간, 1.001-1.038)이, 절박성 요실금의 경우 최대요도 폐쇄압(교차비, 0.969; 95% 신뢰구간, 0.942-0.996)이 통계적으로 유의한 지표로 나타났다. 결론 수술 후 합병증의 유병률에 중점을 두면, 동시 수술은 골반장기탈출증 수술만 하는 경우보다 더 나은 결과를 나타내며 수술 전 요역동학 검사에서도 의미 있는 지표가 있어 그 시행이 필요하다.

Conservative prevention and management of pelvic organ prolapse in women

Pelvic organ prolapse is common, and some degree of prolapse is seen in 50% of parous women. Women with prolapse can experience a variety of pelvic floor symptoms. Treatments include surgery, mechanical devices and conservative management. Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training (PFMT), are often used in cases of mild to moderate prolapse. This is an update of a Cochrane review first published in 2004, and previously updated in 2006. To determine the effects of conservative management (physical and lifestyle interventions) for the prevention or treatment of pelvic organ prolapse in comparison with no treatment or other treatment options (such as mechanical devices or surgery). We searched the Cochrane Incontinence Group Specialised Trials Register (searched 6 May 2010), EMBASE (1 January 1996 to 6 May 2010), CINAHL (1 January 1982 to 10 May 2010), PEDro (January 2009), the UK National Research Register (January 2009), ClinicalTrials.gov (April 2009), Current Controlled Trials register (April 2009), CENTRAL (Issue 1, 2009) and ZETOC (January 2009) and the reference lists of relevant articles. Randomised and quasi-randomised trials in women with pelvic organ prolapse that included a physical or lifestyle intervention in at least one arm of the trial. Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Six trials were included; three of these trials are new to this update. Four trials were small (less than 25 women per arm) and two had moderate to high risk of bias. Four trials compared PFMT as a treatment for prolapse against a control group (n = 857 women); two trials included women having surgery for prolapse and compared PFMT as an adjunct to surgery versus surgery alone (n = 118 women).PFMT versus controlThere was a significant risk of bias in two out four trials in this comparison. Prolapse symptoms and women's reports of treatment outcomes (primary outcomes) were measured differently in the three trials where this was reported: all three indicated greater improvement in symptoms in the PFMT group compared to the control group. Pooling data on severity of prolapse from two trials indicated that PFMT increases the chance of an improvement in prolapse stage by 17% compared to no PFMT. The two trials which measured pelvic floor muscle function found better function (or improvement in function) in the PFMT group compared to the control group; measurements were not known to be blinded. Two out of three trials which measured urinary outcomes (urodynamics, frequency and bother of symptoms, or symptom score) reported differences between groups in favour of the PFMT group. One trial reported bowel outcomes, showing less frequency and bother with symptoms in the PFMT group compared to the control group.PFMT supplementing surgery versus surgery aloneBoth trials were small and neither measured prolapse-specific outcomes. Pelvic floor muscle function findings differed between the trials: one found no difference between trial groups in muscle strength, whilst the other found a benefit for the PFMT group in terms of stronger muscles. Similarly findings relating to urinary outcomes were contradictory: one trial found no difference in symptom score change between groups, whilst the other found more improvement in urinary symptoms and a reduction in diurnal frequency in the PFMT group compared to the control group. There is now some evidence available indicating a positive effect of PFMT for prolapse symptoms and severity. The largest most rigorous trial to date suggests that six months of supervised PFMT has benefits in terms of anatomical and symptom improvement (if symptomatic) immediately post-intervention. Further evidence relating to effectiveness and cost-effectiveness of PFMT, of different intensities, for symptomatic prolapse in the medium and long term is needed. A large trial of PFMT supplementing surgery is needed to give clear evidence about the usefulness of combining these treatments. Other comparisons which have not been addressed in trials to date and warrant consideration include those involving lifestyle change interventions, and trials aimed at prolapse prevention.

Comparative Study Of Permanent Prostate Brachytherapy In Patients With And Without Median Lobe Hyperplasia: Evaluation Of Dosimetric Factors, Acute Urinary Toxicity And Biochemical Outcomes

Purpose/Objective(s): Median Lobe Hyperplasia (MLH) is a known relative contraindication for permanent prostate brachytherapy (PPB). We wanted to evaluate the effects of MLH with regards to acute toxicity and outcome and compared them to patients without MLH, treated during the same time-period. Materials/Methods: In our center, we had 26 patients who had a prominent median lobe out of 89 patients who received PPB between Jan’ 2007 to Dec’ 2009. The patients having MLH were carefully implanted by judicious placement of seeds, limiting the dose to the bladder neck area. We retrospectively analysed these patients along with randomly selected 36 patients who did not have MLH and underwent PPB during the same period. Their dosimetric parameters, acute urinary toxicity and outcomes were comparatively evaluated. Results: The median IPSS at presentation for patients with MLH was 7 while for patients without MLH was 8. The mean PSA values were 7.15 and 10.2 for patients with and without MLH respectively. The mean prostatic CT volumes in patients with MLH was 52.12cc (including mean ML volume 15.54cc) compared to 28.19cc for patients without MLH. Among patients with MLH, 50% received hormonal therapy, and 15% received external beam radiation in addition to PPB. Similarly, 47% patients without MLH received hormones and external beam radiation. The dosimetric parameters evaluated are described in Table. None of the dose differences between MLH and non-MLH patients were statistically significant. As per treatment related acute toxicity, 3 patients (11.5%) who had MLH developed acute urinary retention(AUR). Two of these patients recovered urinary function by the 3-month follow-up period. None of the patients without MLH had any incidence of AUR but one patient developed retention three months later and is on intermittent self-catheterisation. Biochemical failure rate at the end of the mean follow-up of 21 months in patients with and without MLH was 4% and 5.5%, while median IPSS was 7 and 10 respectively. Conclusions: The dosimetric and biochemical outcomes among patients with or without MLH was comparable. Although the AUR rate was higher in the patient group with MLH, it was still within the reported incidence of AUR , published for patients without MLH. Careful attention to seed placement in patients with MLH results in comparable outcomes and toxicity.

Combination Surgery for Erectile Dysfunction and Male Incontinence

With favorable prognosis, radical therapy for pelvic malignancy no longer is just about oncological control, but is important in achieving the trifecta of oncological clearance with acceptable sexual function and urinary outcomes. As we face the prospect of escalating urogenital dysfunction following our radical interventions, we need to carefully assess these functional outcomes and their impact on the quality of life of our patients. In men, this includes urinary impairments with stress urinary incontinence, various types of voiding dysfunction, and sexual impairments (primarily erectile dysfunction and orgasmic dysfunction). Based on appropriate clinical and diagnostic assessments of severity of adverse outcomes depending on patient preference, combination surgery for treatment of erectile dysfunction and stress urinary incontinence is effective and durable and has an established, definitive role to address this not uncommon problem. This article reviews the prevalence of the problem, the available therapeutic options, and evidence of efficacy of these therapies in combination.