Benign prostatic obstruction and parkinson's disease--should transurethral resection of the prostate be avoided?

PURPOSE: According to the literature transurethral resection of the prostate in patients with Parkinson's disease has an increased risk of postoperative urinary incontinence. However, this conclusion might have been reached because some patients with multiple system atrophy incorrectly diagnosed as Parkinson's disease were included in these reports. Therefore, we investigated the outcome of transurethral prostate resection in patients with a secure neurological diagnosis of Parkinson's disease. MATERIALS AND METHODS: A total of 23 patients with Parkinson's disease who underwent transurethral prostate resection for benign prostatic obstruction were evaluated retrospectively. Subsequent neurological developments in patients were followed, ensuring that those with multiple system atrophy had not been included in analysis. RESULTS: At transurethral prostate resection median patient age was 73 years, median duration of Parkinson's disease before the resection was 3 years, and median Hoehn and Yahr scale was 2. Of the 14 patients with a preoperative indwelling urinary catheter transurethral prostate resection restored voiding in 9 (64%) and only 5 (36%) required catheterization postoperatively. Of the 10 patients with preoperative urge urinary incontinence, continence was restored in 5 and improved in 3 following transurethral prostate resection. There were no cases of de novo urinary incontinence after transurethral prostate resection. At a median postoperative followup of 3 years transurethral prostate resection was successful in 16 of the 23 patients (70%). CONCLUSIONS: Transurethral prostate resection for benign prostatic obstruction in patients with Parkinson's disease may be successful in up to 70% and the risk of de novo urinary incontinence seems minimal. Thus, Parkinson's disease should no longer be considered a contraindication for transurethral prostate resection provided that preoperative investigations including urodynamic assessment indicate prostatic bladder outlet obstruction.

Effect of thalamic deep brain stimulation on lower urinary tract function.

OBJECTIVE: The precise mechanisms underlying cerebral regulation of lower urinary tract function are still poorly understood. In patients with disabling essential tremor (ET) refractory to pharmacotherapy, thalamic deep brain stimulation (DBS) is an effective treatment for tremor control. Here, we evaluated the effect of thalamic DBS on urodynamic parameters in patients with ET. PATIENTS AND METHODS: We investigated seven patients (two females, five males) with ET 15-85 mo after implantation of DBS leads into the ventral intermediate nucleus of the thalamus. We compared urodynamic parameters during thalamic DBS (ON state) and 30 min after turning the stimulator off (OFF state). RESULTS: In the ON compared with the OFF state, there was a significant decrease in bladder volume at first desire to void (median, 218 ml vs. 365 ml, p=0.031), at strong desire to void (median, 305 ml vs. 435 ml, p=0.031), and at maximum cystometric capacity (median, 345 ml vs. 460 ml, p=0.016). No significant differences between the ON and OFF state were detected for changes in detrusor pressure during filling cystometry, bladder compliance, maximum detrusor pressure, detrusor pressure at maximum flow rate, maximum flow rate, voided volume, and postvoid residual. CONCLUSIONS: Thalamic deep brain stimulation resulted in an earlier desire to void and decreased bladder capacity, suggesting a regulatory role of the thalamus in lower urinary tract function. Therefore, the thalamus may be a promising target for the development of new therapies for lower urinary tract dysfunction.

Treatment of urethral recurrence following radical cystectomy and ileal bladder substitution.

PURPOSE: With the introduction of orthotopic bladder substitution after radical cystectomy in patients with invasive bladder cancer urethral recurrences have become a therapeutic challenge. MATERIALS AND METHODS: We retrospectively evaluated our patients with urethral recurrences treated with a urethra sparing approach after orthotopic bladder substitution. Depending on the extension of recurrence and eventual concomitant metastases patients were treated with urethrectomy, no treatment, systemic chemotherapy or intraurethral bacillus Calmette-Guerin (BCG). Three times the common dose of BCG (ImmuCyst, Aventis, Paris, France or OncoTICE, Organon, West Orange, New Jersey) in 150 ml NaCl 0.9% was used for intraurethral BCG perfusion therapy according to an institutional protocol using a modified Foley catheter. This regimen was repeated weekly for 6 weeks and patients were followed prospectively. RESULTS: Between 1985 and 2001, 15 of 371 patients (4%) who received an orthotopic bladder substitute had urethral recurrence. Two patients were treated with systemic chemotherapy (methotrexate, vinblastine, doxorubicin and cisplatin) alone due to metastatic disease and 10 received intraurethral BCG therapy. Five of 6 patients (83%) with carcinoma in situ remained free of recurrence following treatment with BCG, while in 4 with papillary or invasive disease treatment failed. Three patients underwent urethrectomy, including 2 following failed BCG therapy for papillary disease. CONCLUSIONS: Carcinoma in situ urethral recurrence following orthotopic bladder substitution can be treated successfully with intraurethral BCG perfusion therapy in approximately 80% of patients. However, papillary and invasive transitional cell urethral recurrence should be treated with urethrectomy.

Holmium laser enucleation of the prostate combined with electrocautery resection: the mushroom technique.

PURPOSE: The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined without compromising the bloodless advantages of the laser procedure. MATERIALS AND METHODS: We treated 156 patients with benign prostatic hyperplasia using a holmium laser with the mushroom technique. Preoperatively all patients were assessed using the International Prostate Symptom Score, maximum urine flow, ultrasound estimation of prostate volume and post-void residual urine, and pressure flow study. Laser enucleation of the prostatic lobes was performed at 66 W. Instead of releasing the lobes into the bladder they were left attached at the bladder neck by a narrow mushroom-like pedicle. At that point the vascular supply was almost completely interrupted and the lobes could easily be electroresected into small pieces without bleeding. Patients were followed 6, 12 and 24 months after the procedure. RESULTS: No patient had significant blood loss or signs of the transurethral resection syndrome. A total of 19 patients were treated while under oral anticoagulation without major bleeding problems. Complete followup was available on 125 patients. Median baseline International Prostate Symptom Score decreased from 20 to 3 at 6 months (p <0.05) and remained stable at 12 and 24 months. Median maximum urine flow increased from 8 to 20 ml. per second at 6, 12 and 24 months (p <0.05). Median baseline post-void residual urine decreased from 190 to 30 ml. at 6 months (p <0.05) and remained low at 20 and 30 ml. at 12 and 24 months, respectively. Urodynamic evaluation preoperatively and 6 months postoperatively was available in 83 cases. Relief of obstruction was documented with a statistically significant decrease in median detrusor pressure at maximum urine flow from 87 to 48 cm. water (p <0.05). CONCLUSIONS: Combining holmium laser enucleation and prostate electroresection with the mushroom technique is safe, efficient and bloodless surgical treatment for benign prostatic hyperplasia with sustained relief of obstruction. With this technique there is no need for additional devices, such as a mechanical tissue morcellator.

Transurethral microwave therapy in 200 patients with a minimum followup of 2 years: urodynamic and clinical results.

PURPOSE: We investigated the long-term efficacy of the second generation Targis thermotherapy device (Urologix, Inc., Minneapolis, Minnesota) for decreasing outflow obstruction caused by benign prostatic hyperplasia. MATERIALS AND METHODS: At a minimum followup of 24 months 200 patients with bladder outlet obstruction documented on urodynamics and cystoscopy document with preserved detrusor function underwent transurethral microwave therapy while under local anesthesia. In 45% of cases the general American Society of Anesthesiologists health score was 3 or greater. RESULTS: After a median observation time of 42 months (range 2 to 72) 43 patients (22%) who required additional treatment (repeat thermotherapy, transurethral prostate resection or permanent cystostomy) were excluded from further analysis, as were 15 (7.5%) who died of causes unrelated to treatment during followup and 13 (6.5%) who were lost to followup or refused followup investigations. In the 162 patients evaluated 6 months after treatment the median International Prostate Symptom Score decreased from 23 points (range 10 to 34) before treatment to 3 (range 0 to 21) and remained stable at 12 and 24 months. Median maximum flow increased from 6 ml. per second (range 1 to 15) before treatment to 14.5 (range 4 to 50) 6 months after treatment and remained stable at 12 and 24 months. Median post-void residual urine volume decreased from 170 ml. (range 35 to 720) before treatment to 17 (range 0 to 327) after 6 months and then remained unchanged. Urodynamic evaluation in the 162 patients after 6 months showed a decrease from pretreatment median detrusor opening pressure of 87.5 to 53 cm. water. Median detrusor pressure at maximum flow decreased from 86 to 58 cm. water 6 (p <0.0001). At the 24-month followup 59 of the 129 evaluable patients agreed to undergo repeat urodynamic evaluation. Pressure flow analysis in these 59 cases revealed a decrease in median minimal urethral opening pressure from 70 to 40 cm. water at 6 months and to 38 cm. water at 24 months (p <0.0001). Median detrusor pressure at maximum flow decreased significantly from the pretreatment value of 86 to 55 cm. water at 6 months and 58 cm. water at 24 months (p <0.0001). CONCLUSIONS: In patients with a good initial response to treatment, which is achieved in approximately 80%, transurethral microwave therapy provides excellent long-term subjective and objective results. Improved urinary flow, decreased post-void residual urine volume and urodynamic parameters remain stable at 2 years. Transurethral microwave therapy with second generation microwave equipment did not compromise any conventional treatment needed in the 22% of patients who were nonresponders at 6 months.