Application of Urethral Contrast Computed Tomography Three-Dimensional Imaging in the Postoperative Assessment of Prostate Hyperplasia.

This study assesses the morphological effectiveness of benign prostatic hyperplasia (BPH) surgery using multislice spiral computed tomography three-dimensional imaging (CT3D) with urethral contrast. Twenty-five male patients with BPH and bladder outlet obstruction (BOO) who underwent bipolar transurethral resection of the prostate were selected. Preoperative and postoperative CT3D indicators of retrograde and voiding cystourethrography, including bladder neck diameter, length of the posterior urethra, and degree of prostate protrusion into the bladder and upper and lower diameter of the prostate were used to assess bladder neck and posterior urethra morphology and BOO severity. In addition, preoperative and postoperative International Prostate Symptom Scores and maximum urine flow rates were compared. Postoperative CT3D was used to evaluate changes following obstruction relief postsurgery. Preoperative CT3D indicated significant BOO, whereas postoperative imaging showed improved patency but with irregular posterior urethral lumens and varying degrees of residual glandular tissue. Comparative analysis of preoperative and postoperative bladder outlet metrics revealed significant changes (p < .05). Urethral contrast CT3D effectively visualizes the prostate, bladder neck, and prostatic urethra. It quantifies changes in the urethral lumen postsurgery, correlating the extent of posterior urethral lumen spaciousness with urinary flow rates.

Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

PURPOSE OF REVIEW: Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. RECENT FINDINGS: Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. SUMMARY: Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.

Outcomes of bladder neck botulinum toxin injection for female primary bladder neck obstruction-does subjective improvement correlate with an objective assessment?

INTRODUCTION AND HYPOTHESIS: Common options for management of primary bladder neck obstruction (PBNO) in women include medications and surgical treatment. Less invasive treatment such as bladder neck botulinum toxin injection can be an alternate therapy in patients with failed conservative management. In this study, we describe the subjective and objective outcomes, patient satisfaction, and willingness for repeat treatment with bladder neck botulinum toxin injection in females with PBNO. METHODS: A retrospective analysis of ten female PBNO patients managed with bladder neck botulinum toxin injection was performed. Subjective parameters were quantified with symptom assessment, International Prostate Symptom Score (IPSS), and Quality of life (QoL) score. Objective parameters were assessed with maximum flow rate (Qmax) in uroflowmetry and postvoid residual (PVR). RESULTS: The mean pre-treatment IPSS, QoL score, Qmax, PVR was 24.2 ± 5.0, 4.8 ± 0.63, 5.73 ± 3.18 ml/s, and 210 ± 66 ml, respectively. Seven of the ten patients subjectively improved (IPSS 12.9 ± 9.6, QoL2.9 ± 1.6, p < 0.05). Three patients improved objectively (mean Qmax 17.3 ± 2.7 ml/s, PVR 42.7 ± 7.5 ml, p < 0.05). Three patients accepted repeat botulinum toxin injection. Three patients who showed no improvement underwent bladder neck incision with resolution of symptoms. CONCLUSION: Botulinum toxin can be an intermediary therapy in female patients with PBNO who want a minimally invasive procedure.

Reliability and validity of assessment methods available in primary care for bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms: a systematic review.

OBJECTIVES: To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS). DESIGN: Systematic review with best evidence synthesis. SETTING: Primary care. PARTICIPANTS: Men with LUTS due to bladder outlet obstruction or benign prostatic obstruction. REVIEW METHODS: PubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis. RESULTS: Of the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence. CONCLUSION: Clinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.

Holmium laser prostatectomy in a tertiary Italian center: A prospective cost analysis in comparison with bipolar TURP and open prostatectomy.

OBJECTIVE: To assess the economic impact of Holmium laser enucleation of prostate (HoLEP) in comparison with transurethral resection of prostate (TURP) and open prostatectomy (OP). METHODS: Between January 2017 and January 2018, we prospectively enrolled 151 men who underwent HoLEP, TURP or OP at tertiary Italian center, due to bladder outflow obstruction symptoms. Patients with prostate volume ≤ 70 cc and those with prostate volume > 70 cc were scheduled for TURP or HoLEP and OP or HoLEP, respectively. Intraoperative and early post-operative functional outcomes were recorded up to 6 months follow up. Cost analysis was carried out considering direct costs (operating room [OR] utilization costs, nurse, surgeons and anesthesiologists' costs, OR disposable products costs and OR products sterilization costs), indirect costs (hospital stay costs and diagnostics costs) and global costs as sum of both direct and indirect plus general costs related to hospitalization. Cost analysis was performed comparing patients referred to TURP and HoLEP with prostate volume ≤ 70 cc and men underwent OP and HoLEP with prostate volume > 70 cc respectively. RESULTS: Overall, 53 (35.1%), 51 (33.7%) and 47 (31.1%) were scheduled to HoLEP, TURP and OP, respectively. Both TURP, HoLEP and OP proved to effectively improve urinary symptoms related to BPE. Considering patients with prostate volume ≤ 70 cc, median global cost of HoLEP was similar to median global cost of TURP (2151.69 € vs. 2185.61 €, respectively; p = 0.61). Considering patients with prostate volume > 70 cc, median global cost of HoLEP was found to be significantly lower than median global cost of OP (2174.15 € vs. 4064.97 €, respectively; p ≤ 0.001). CONCLUSIONS: Global costs of HoLEP are comparable to those of TURP, offering a cost saving of only 11.4 € in favor of HoLEP. Conversely, HoLEP proved to be a strong competitor of OP because of significant global cost sparing amounting to 1890.82 € in favor of HoLEP.

Antimuscarinic Use in Men Treated With Bladder Outlet Obstruction Medication Therapy.

OBJECTIVE: To assess changes over time in the use of antimuscarinics (AM) among visits in adult men treated with bladder outlet obstruction (BOO) medication therapy (ie, alpha blocker and 5-alpha reductase inhibitors). METHODS: We used the National Ambulatory Medicare Care Survey database (2006-2014) to identify men aged 40 or older, who initiated or continued on BOO medication therapy. Among these visits, we assessed the percentage of AM and evaluated trends of AM use across between 2006 and 2014 using multivariable logistic regression. RESULTS: Overall, there were 7561 patient visits in men aged 40 or older, who were treated with BOO medication therapy between 2006 and 2014 which equates to approximately 158 million visits in the United States after incorporating National Ambulatory Medicare Care Survey weights. Overall, AM was used in 3.7% of visits, among those who were treated with BOO medication therapy; use of AM increased with age. In the multivariable analysis, there was no increasing trend in the use of AM in 2006 relative to subsequent years through 2014 (P = .8104). CONCLUSION: Despite a previous study that showed an increasing trend in antimuscarinic use among patients coded for lower urinary tract symptoms or benign prostatic hyperplasia between 1993 and 2010, several recent randomized-controlled trials, and a recommendation in a clinical practice guideline in 2010, we found no increasing trend in antimuscarinic use among visits in men who were treated with BOO medication therapy in 2006 compared to subsequent years. This suggests the potential undertreatment of antimuscarinics and an area for improved prescribing.

Inverse probability of treatment-weighted competing risks analysis: an application on long-term risk of urinary adverse events after prostate cancer treatments.

BACKGROUND: To illustrate the 10-year risks of urinary adverse events (UAEs) among men diagnosed with prostate cancer and treated with different types of therapy, accounting for the competing risk of death. METHODS: Prostate cancer is the second most common malignancy among adult males in the United States. Few studies have reported the long-term post-treatment risk of UAEs and those that have, have not appropriately accounted for competing deaths. This paper conducts an inverse probability of treatment (IPT) weighted competing risks analysis to estimate the effects of different prostate cancer treatments on the risk of UAE, using a matched-cohort of prostate cancer/non-cancer control patients from the Surveillance, Epidemiology and End Results (SEER) Medicare database. RESULTS: Study dataset included men age 66 years or older that are 83% white and had a median follow-up time of 4.14 years. Patients that underwent combination radical prostatectomy and external beam radiotherapy experienced the highest risk of UAE (IPT-weighted competing risks: HR 3.65 with 95% CI (3.28, 4.07); 10-yr. cumulative incidence = 36.5%). CONCLUSIONS: Findings suggest that IPT-weighted competing risks analysis provides an accurate estimator of the cumulative incidence of UAE taking into account the competing deaths as well as measured confounding bias.

Prospective assessment of perioperative course in 2648 patients after surgical treatment of benign prostatic obstruction.

PURPOSE: TUR-prostate (TUR-P) is considered the reference method for surgical treatment of benign prostatic obstruction (BPO); Greenlight laser photoselective vaporization (PVP) and thulium laser vapoenucleation (ThuVEP) have also been established as treatments of BPO. Objective of this prospective observation was to compare a large numbers of patients treated in everyday routine. METHODS: This prospective multicentre data collection assesses morbidity and perioperative course of consecutive men treated with BPO-related transurethral surgery between 2011 and 2014 in a German metropolis area with TUR-P, PVP or ThuVEP. RESULTS: Two thousand six hundred and forty-eight patients have been treated in the time period. All treatment options achieved immediate improvement of voiding parameters. Multivariate analyses proved shorter hospital stay after laser treatments as compared to resection (p < 0.001). In terms of hospital stay, the advantage of ThuVEP compared to TUR-P increased with prostate volume (p < 0.001). Patients with ongoing anticoagulation or bridging had prolonged hospital stay (p < 0.001). Overall adverse events were least frequent in PVP (p 0.016), as were Clavien 3b events (p < 0.001). CONCLUSIONS: Surgical treatment of BPO is effective and safe independent of the surgical procedure. Volume reduction is most effective in ThuVEP; PVP has the lowest rate of severe complications. Laser treatment is associated with shorter hospital stay. Surgery under ongoing anticoagulation prolonged the post-operative hospital stay.

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial.

BACKGROUND: Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. DESIGN: A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. DISCUSSION: The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. TRIAL REGISTRATION: Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Assessment of the urodynamic diagnosis in patients with urinary incontinence associated with normal pressure hydrocephalus.

AIMS: To assess the urodynamic patterns present in patients with adult normal pressure hydrocephalus (NPH) in our institution. METHODS: Retrospectively conducted study on patients diagnosed with NPH by the Neurosurgery Department of our institution, without etiological treatment or urogynecological disorders, who underwent an urodynamic study (UDS) performed according to methods proposed by the International Society of Continence (ICS). Clinical information, complementary tests and UDS were collected, and descriptive analysis was performed, with special focus in urodynamic final diagnosis. RESULTS: Eighty-one UDS performed between 2003 and 2013. Fifty-one Males (63%). Mean age: 74.89 ± 8.58 years old (range 52-88 years). Classical triad of symptoms: gait disturbance, dementia, and urinary incontinence (UI) presented in 48.1%. Urinary urgency in 80.9% and UI in 70%. In two cases (2.5%) UDS was not valuable. Urodynamic features of the 79 remaining studies revealed overactive detrusor (OD) in 56 patients (70.9%), being associated with Stress UI (SUI) in one case and with bladder outlet obstruction (BOO) in 19. SUI in six patients (7.6%) and BOO in five (6.3%). Detrusor underactivity in four cases (5%) and normal study in eight (10.1%). About 47.1% of males presented BOO. Cerebrospinal fluid shunt surgery was performed on 32 patients during follow-up, with subsequent clinical improvement in 90.6% of them. CONCLUSIONS: OD was the most frequent diagnosis within UDS conducted on adult NPH patients in our institution, with BOO in an elevated percentage of them. Etiological treatment led to symptomatic improvement in most of patients.

Ensuring comprehensive assessment of urinary problems in prostate cancer through patient-physician concordance.

OBJECTIVES: To examine the concordance between clinicians and men diagnosed with prostate cancer on a clinician-derived pathophysiological classification of the following self-reported urinary complications: storage (irritative), voiding (obstructive), and leakage/incontinence. MATERIALS AND METHODS: Fourteen urology experts classified 37 urinary function questionnaire items into 3 primary conceptual dimensions (e.g., storage [irritative], voiding [obstructive] and urinary leakage/incontinence) that would best reflect each item's content. In addition, 218 patient participants provided responses to the 37 items. Using classifications by experts to develop the conceptual framework, the structure was tested using confirmatory factor analyses with patient data. RESULTS: Expert consensus was achieved in the classification of 31 out of 37 items. Using the 3-factor conceptual framework and patient data, the fit indices for the overall correlated factor model suggested an acceptable overall model fit. The analyses of the separate domains showed acceptable fit for the storage/irritative domain and the leaking/incontinence domain. The dimensionality of the voiding/obstructive domain was too difficult to estimate. CONCLUSIONS: Our analysis found items that conceptually and psychometrically support 2 constructs (leaking/incontinence and storage/irritative). The consistency of this support between the groups suggests a clinical relevance that is useful in treating patients. We have conceptual support for a third hypothesis (voiding/obstructive), although there were too few items to assess this psychometrically. Relative motivating factors of bother and urinary complaints were not addressed and remain an unmet need in this field.

Two laser ablation techniques for a prostate less than 60 mL: lessons learned 70 months after a randomized controlled trial.

OBJECTIVE: To report lessons learned and predictors of long-term outcome after a randomized trial comparing 2 widely available lasers (2123 nm and 532 nm) in prostate ablation as treatment of symptomatic benign prostatic hyperplasia. METHODS: Between March 2005 and April 2007, 109 patients with a prostate volume of less than 60 mL were recruited and randomized to treatment: 57 underwent holmium laser ablation of the prostate (HOLAP) and 52 underwent photoselective vaporization of the prostate (PVP) using an 80-W potassium titanyl phosphate laser. The changes in subjective (International Prostate Symptom Score quality of life and International Index of Erectile Function-15) and objective (postvoid residual urine maximal flow rate) outcome parameters were compared. The long-term outcome, timing, and predictors of negative outcome were assessed. Cost analysis was included. RESULTS: After a median of 71.3 months, significant comparable improvement was documented in all subjective and objective urinary parameters from baseline measures at different points of follow-up. Retreatment for infravesical obstruction was 19.2% in HOLAP and 25% in PVP (P >.05). Smaller prostate volume was significantly associated with bladder neck contracture (BNC) after laser ablation, regardless the type of laser used. BNC and de novo urethral stricture seem to be the main causes for an early (first-year) reintervention. Redo treatment for recurring prostate adenoma was associated with less postoperative prostate-specific antigen reduction (<20%). Procedure costs were CaD $200.45 higher in the PVP group (P >.05). CONCLUSION: PVP and HOLAP seem to be equally effective and safe, with similar long-term outcome data, including cost. Regardless the laser wavelength, at least 1 of 5 patients will need retreatment. BNC is a more prevalent cause of early retreatment in smaller glands with both lasers. Postoperative prostate-specific antigen reduction of less than 20% warrants careful follow-up for recurrent symptoms secondary to residual prostate tissue.

[Anastomotic stricture following radical retropubic prostatectomy: insights into incidence, management and factors predisposing for occurrence].

PURPOSE: Anastomotic stricture (AS) following radical prostatectomy (RP) decreases patients' quality of life. It occurs in 0.5% to 32% of men after open radical retropubic prostatectomy (RRP), although its etiology is poorly understood. In a series of patients who received RRP, we analyzed the incidence, possible predisposing factors, and management of AS after RP. MATERIALS & METHODS: Between April 1997 and March 2006, 129 consecutive patients underwent RRP in our hospital. Anastomosis between the bladder neck and urethra was performed with interrupted anastomosis using four 2-0 absorbable sutures. AS was diagnosed when a 16Fr. panendoscope could not be passed. We assessed the relationship between the management method for AS and time interval between the surgical procedure and diagnosis of the stricture. The relationships between comorbidities identified preoperatively (hypertension [HT], diabetes mellitus [DM], cardiovascular disease [CVD], cerebral infarction [CI] and smoking history) and the incidence of AS were determined. Risk factors, including age, body mass index [BMI], preoperative PSA, total prostate volume, operative time, blood loss, Foley duration, amount of stress urinary incontinence (SUI) per day, amount of drain output, pathological T stage, Gleason sum and surgical margin status were also assessed. RESULTS: The rate of AS after RRP was 10.9% (14/129). In 10 patients (72%), AS occurred within 3 months of surgery, in 2 (14%) it occurred at 4-12 months after surgery and in 2 (14%) more than 12 months after surgery. In univariate and multivariate analyses, intraoperative bleeding of 1,800 ml or more was independently the strongest predictor of AS. In two patients a urethral bougie was used and 11 underwent internal urethrotomy. Only 1 patient underwent transurethral resection. Of the 8 patients whose strictures were diagnosed within 3 months after surgery and underwent internal urethrotomy, 6 had recurrent anastomotic strictures. CONCLUSIONS: Risk factors for AS are thought to be multifactorial. Intraoperative blood loss was significantly associated with the development of anastomotic stricture. We should understand that anastomotic stricture following radical retropubic prostatectomy is not a rare morbidity and should inform patients about the possibility of postoperative AS.

Conventional monopolar resection or bipolar resection in saline for the management of large (>60 g) benign prostatic hyperplasia: an evaluation of morbidity.

The objective of this study was to compare the efficacy and safety of bipolar transurethral resection in saline (TURIS) and conventional monopolar transurethral resection (TURP) in men with voiding difficulties due to high volume (>60g) benign prostatic hyperplasia. Between May 2005 and January 2009, 66 men with bladder outlet obstruction due to large benign hyperplasia (BPH) (>60 g) underwent transurethral resection, either by Olympus monopolar or Olympus bipolar TURIS technique. Perioperative and outcome data were recorded and compared. There was no significant difference in patient age, prostate size, PSA, uroflow rate, post voiding residual urine, operation time, catheterization time, and hospital stay. In the monopolar TURP group, an important drop in serum sodium was observed (3.12 mmol/L), statistically significantly different (p = 0.012) from the 1.30 mmol/L drop in the bipolar TURIS group. One case of clinical TUR syndrome was observed in the conventional monopolar TURP group. Early and late complications such as clot retention, urinary retention, bladder neck stenosis, and urethral stricture were identical in both groups. The bipolar TURIS device is a valid treatment option for patients with BPH-related voiding disorders due to high volume BPH. Obviating the risk of TUR syndrome, this minimally invasive procedure may be a good surgical option in the urologist's armamentarium.

Ultrasound assessment of intravesical prostatic protrusion and detrusor wall thickness--new standards for noninvasive bladder outlet obstruction diagnosis?

PURPOSE: We evaluated the accuracy of detrusor wall thickness and intravesical prostatic protrusion, and the association of each test to diagnose bladder prostatic obstruction in patients with lower urinary tract symptoms. MATERIALS AND METHODS: We enrolled in the study 100 consecutive patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Baseline parameters were International Prostate Symptom Score, prostate volume, urinary flow rate, intravesical prostatic protrusion, detrusor wall thickness, Schaefer obstruction class, minimal urethral opening pressure and the urethral resistance algorithm bladder outlet obstruction index. A ROC curve was produced to calculate AUC and evaluate the diagnostic performance of intravesical prostatic protrusion, detrusor wall thickness and prostate volume for bladder prostatic obstruction. RESULTS: We noted a highly significant correlation between intravesical prostatic protrusion and the bladder outlet obstruction index (Spearman's rho = 0.49, p = 0.001), and Schaefer obstruction class (Spearman's rho = 0.51, p = 0.001). A highly significant correlation was also observed for detrusor wall thickness and the bladder outlet obstruction index (Spearman's rho = 0.57, p = 0.001), detrusor wall thickness and Schaefer obstruction class (Spearman's rho = 0.432, p = 0.02). On multivariate analysis intravesical prostatic protrusion and detrusor wall thickness were the only parameters associated with bladder prostatic obstruction (p = 0.015). The AUC for intravesical prostatic protrusion was 0.835 (95% CI 0.756-0.915) and for detrusor wall thickness it was 0.845 (95% CI 0.78-0.91). The association of intravesical prostatic protrusion and detrusor wall thickness produced the best diagnostic accuracy (87%) when the 2 tests were done consecutively. CONCLUSIONS: Suprapubic ultrasound of detrusor wall thickness and intravesical prostatic protrusion is a simple, noninvasive, accurate system to assess bladder prostatic obstruction in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.

Avaliação dos parâmetros diagnósticos da obstrução infravesical na mulher / Bladder outlet obstruction in women: diagnostic assessment

A obstrução infravesical feminina é considerada quando se está diante de contração do detrusor de adequada magnitude associada a baixo fluxo urinário. Sua real prevalência é desconhecida, podendo ter causas funcionais ou anatômicas. O diagnóstico é algo desafiador e deve se basear na anamnese e no exame físico detalhados, bem como na avaliação complementar. Apesar da existência de vários estudos tentando estabelecer níveis de corte, até o presente, não há consenso no tocante aos critérios diagnósticos da obstrução infravesical feminina. Vale ressaltar, no entanto, a grande importância da suspeita, inclusive em pacientes com sintomas de armazenamento, para que se institua terapêutica apropriada

Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: an inpatient cost analysis.

OBJECTIVES: To compare the cost of open transvesical prostatectomy (OP) with that of holmium laser enucleation (HoLEP) in the treatment of bladder outlet obstruction (BOO) attributed to benign prostatic hyperplasia. METHODS: From February to May 2004, 63 consecutive patients with symptomatic benign prostatic hyperplasia in a large prostate (70 to 220 g) and documented BOO were randomized to surgical treatment with OP (29 in group 1) or HoLEP (34 in group 2). All costs associated with the procedures during the hospital stay were recorded prospectively, and a cost-effectiveness analysis of the critical perioperative (ie, intraoperative and postoperative to hospital discharge) data was performed. RESULTS: The cost analysis showed a mean perioperative cost of 2868.9 euros (3556.3 dollars) for group 1 and 2356.5 euros (2919.4 dollars) for group 2. A direct comparison analysis showed that the most significant cost factors were the operative time (average 16.1% and 25.1% to the cost of OP and HoLEP, respectively), operating room surgical setup/disposables, including laser fiber and resectoscope loop in group 2 (average 13.3% and 29.3% to the cost of OP and HoLEP, respectively), and length of postoperative hospital stay (average 53.3% and 32.0% to the cost of OP and HoLEP, respectively). Overall, the hospitalization cost of HoLEP was 9.6% less than that for OP. CONCLUSIONS: Our data have demonstrated that HoLEP is associated with a significant hospital net cost savings compared with OP in patients undergoing surgery for symptomatic benign prostatic hyperplasia in large glands.

Noninvasive assessment of prostatic obstruction in elderly men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVES: To investigate what combination of easily available parameters allows the noninvasive prediction of infravesical obstruction in optimal agreement with urodynamic classification. Urodynamically, men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia are classified as nonobstructed or obstructed. METHODS: Mandatory and recommended tests were performed in 160 consecutive men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. The classification of the International Continence Society, the group-specific urethral resistance factor, and Schäfer's obstruction grade were estimated from urodynamic studies. The frequency-volume charts were analyzed. A separate group of 173 consecutive men was used for validation. RESULTS: The formula, prostate volume (in cubic centimeters) - 3 x maximal urinary free flow rate (in milliliters per second) - 0.2 x mean voided volume (in milliliters; as estimated from frequency-volume charts), was optimal in the classification compared with the urodynamic classification. Extension of this formula to more than three parameters did not result in better selection. As estimated from receiver operating characteristic curves, the accuracy of the formula appeared to be good. The method of quantifying urethral resistance minimally affected the classification that resulted from the combination. From the results, a diagram was created presenting the probability of an individual to have infravesical obstruction. The validation results were satisfactory. CONCLUSIONS: The prediction of the probability of a man with lower urinary tract symptoms suggestive of benign prostatic hyperplasia to have infravesical obstruction can be deduced from a diagram based on a formula composed of three readily available parameters: prostate volume, maximal urinary free flow rate, and mean voided volume.