Quantifying the effect of urodynamic catheters on urine flow rate measurement.

INTRODUCTION: The effect of urodynamic catheters on urine flow rate (Q(max) ) is well documented but under-researched. Several studies show reduced Q(max) but methodologies and patient demographics differ. The aims of this study were to further quantify the effect of urodynamic catheters on Q(max) and to explore if this was consistent across different urodynamic diagnoses. METHODS: Four groups of 50 consecutive men attending for urodynamic studies (UDS) were retrospectively analyzed: Group 1 comprised 50 men with normal UDS, Group 2 was 50 men with BOO, and Group 3 contained 50 men with detrusor underactivity. Groups 1-3 had UDS performed using both 10 Fr filling and 4 Fr measuring catheters in situ. Group 4 comprised 50 men who had UDS performed with a smaller catheter assembly (8 Fr dual-lumen). Values of Q(max) with and without catheters present were compared using paired Student's t-tests. Differences between groups were compared using ANOVA. RESULTS: Q(max) measured during UDS in men from Groups 1-3 showed a mean reduction of 38% compared to Q(max) from "free" uroflowmetry. ANOVA indicated this reduction was significantly greater among men with normal UDS. Interestingly the group who underwent UDS with a smaller catheter assembly showed no significant reduction in Q(max) measured with catheters in situ. CONCLUSION: Our findings are in line with previous work suggesting that smaller calibre urethral catheters do not cause a significant obstructive effect during voiding. In addition it would appear that the reduction in Q(max) with larger urethral catheters in situ is greatest in those with normal urodynamics.

Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium.

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome. OBJECTIVE: To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium. DESIGN, SETTING, AND PARTICIPANTS: Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility. RESULTS AND LIMITATIONS: A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology. CONCLUSIONS: We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy. PATIENT SUMMARY: In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

Is low bladder compliance predictive of detrusor overactivity?

AIMS: Bladder compliance (BC) expresses the relationship between bladder volume and bladder pressure and is generally regarded as a measure of bladder stiffness or distensibility. Many types of voiding dysfunction have been associated with low BC such as detrusor overactivity (DO). It has previously been reported that the presence of DO is an independent predictor of low BC. The aim of this study was to assess the predictive value of low BC for the diagnosis of idiopathic DO using ambulatory urodynamics as the gold standard investigation for comparison. METHODS: All patients with LUTS attending a single center for both conventional and ambulatory urodynamics over a 5-year period were reviewed. The predictive value of various set levels of BC was compared using a receiver-operator characteristics (ROC) curve in an attempt to find the optimal threshold of BC for the diagnosis of DO. RESULTS: 162 patients were identified and following exclusions 143 (88%) data sets were suitable for analysis. The mean (s.d.) BC in the 99 patients with DO was 92 (80) ml/cm H(2)O compared to 112 (91) ml/cm H(2)O in those who did not show DO on ambulatory urodynamics. This difference was not statistically significant according to a non-parametric Mann-Whitney test (P = 0.22). Furthermore no set threshold of BC was able to provide sufficient accuracy for the diagnosis of DO. The area under the curve was less than 0.5 (0.47) indicating a level of accuracy less than "chance". CONCLUSIONS: Low bladder compliance is not predictive of DO in our series. It is imperative to note that our results are obtained from a cohort comprising predominantly female patients without BOO and is therefore different to previous reports concentrating on male patients with BOO.

Management of superficial G2 (pTa and pT1) bladder cancer.

A total of 143 patients with superficial G2 (pTa, pT1) bladder cancer (48 G2pTa; 95 G2pT1) presenting between 1970 through 1987 were reviewed. Of 48 patients with G2pTa followed for up to eighteen years, G3 recurrence developed only in 1 (2.0%), and invasive cancer (greater than pT2) developed only in 2 (4.2%). They both received radiotherapy and have responded completely. There have been no cancer-related deaths. In contrast, in the 95 patients in whom the basement membrane had been breached (pT1), higher grade tumor (G3) developed in 11 (11.5%), and 15 (16%) had recurrences with invasion of muscle (greater than pT2). Among these there were 7 (7.3%) cancer-related deaths.

Lower urinary tract symptoms and benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is an important cause of lower urinary tract symptoms (LUTS). However, many other causes, including smooth muscle dysfunction and neurological factors may contribute to these symptoms, and accurate diagnosis is imperative before invasive treatments are chosen. Careful recording of symptoms, giving emphasis on how they interfere with the patient's quality of life, as well as the use of properly selected tests, constitutes the mainstay of making a correct diagnosis. Men with mild or moderate symptoms not experiencing complications are ideal candidates for medical treatment. For the rest with persistent symptoms or complications such as infection, bleeding, chronic retention or renal impairment further investigation and more invasive forms of treatment need to be considered. We review the patho-physiology of the disease, and current approaches and management of this common problem.

The surgical treatment of female stress urinary incontinence.

Urinary incontinence is a common symptom experienced by significant numbers of adult women. Stress urinary incontinence (SUI) is the most frequently encountered type and affects around 50% of incontinent females. Many affected women do not consult their doctors about this troublesome symptom perhaps based on a belief that they cannot be helped. Recent years have seen the development of several new and popular techniques for the surgical treatment of this condition and many of the "gold standard" procedures for stress incontinence have been challenged. Currently, evidence in favor of the use of sub-urethral tapes especially tension-free vaginal tapes suggests that a new standard of low morbidity and high efficacy surgical treatment for SUI has been set. This review is intended to examine all of the surgical options for the treatment of SUI and provide health care professionals with an overview of the vast array of currently available procedures.

Transcutaneous electrical nerve stimulation in the treatment of neurological patients with urinary symptoms.

OBJECTIVE: To determine whether transcutaneous electrical nerve stimulation (TENS) benefits patients with urinary symptoms caused by neurological diseases. PATIENTS AND METHODS: Patients with urinary symptoms from any kind of neurological disease were prospectively recruited between October 1996 and July 1998. Before attending the first assessment patients were asked to complete a week's diary recording the frequency of micturition, incontinence episodes, and frequency of pad and clothes changing. At the first assessment the patients completed the Frimodt-Moller urinary symptom questionnaire, and quality-of-life scales including the Nottingham Health Profile and Short-Form 36. Demographic and disability data (Barthel Index and Frenchay Aphasia Screening Test) were recorded, and patients underwent a neurological examination and urodynamic studies. The placing of electrode pads on the sacral dermatomes 2.5 cm either side of and 2.5 cm above the natal cleft was demonstrated, and the patient instructed to use TENS for 90 min twice a day. The current strength applied was set to that which the patient could tolerate, at a square-wave of 20 Hz and 200-micros duration. Six weeks later the patients were further assessed, where the diary exercise, questionnaires and urodynamics were repeated. In all, 44 patients (13 men and 33 women, mean age 50.8 years) were recruited. RESULTS: The commonest disease was multiple sclerosis and the commonest impairments para/tetraplegia or hemiplegia. There was no change in the neurological status of the 34 patients completing the study. Irritative voiding symptoms were significantly decreased (0.68-0.61, P = 0.003) and diaries also showed significant improvements in the 24 h frequency of micturition (P = 0.01), incontinence episodes (P = 0.04) and clothes changes (P = 0.02). Urodynamics showed detrusor hyper-reflexia in most patients. The only significant changes after TENS were an increased postvoid residual volume (from a mean of 134 mL to 160 mL, P = 0.03) and an increase in the volume leaked during the urodynamic study with TENS on (from a mean of 4.7 mL to 12 mL, P = 0.003). There were no significant changes in the quality-of-life scores. Of the 34 patients completing the study, half still reported a benefit from TENS at 1 year, although some patients found it took 3-4 weeks to work. CONCLUSION: TENS applied to the sacral dermatomes of neurological patients with urinary symptoms had a minimal effect on urodynamic data but significantly improved irritative urinary symptoms, 24-h urinary frequency, incontinence and clothes changing. The lack of effect on quality-of-life measures probably reflects the lack of sensitivity in the tools used in this group of patients. We therefore recommend using TENS in this often problematical group of patients.

Constipation and spina bifida occulta: is there an association?

Spina bifida occulta (SBO) is an abnormality in the posterior arch formation, most commonly found at the level of the S1 vertebra. It has recently been implicated in the aetiology of urinary voiding problems. We have therefore investigated its incidence in female patients with constipation due to outlet obstruction (anismus) and slow colonic transit. The plain abdominal radiographs of 52 females with constipation, and 48 age-matched controls were reviewed by one radiologist, looking for both the incidence of SBO and the incidence of abnormally high posterior sacral arc opening (S3 and above) in each group. Seventeen (32.6%) patients compared to 11 (22.9%) control subjects had SBO (chi 2 1.183, P = 0.4). Fourteen (26.9%) patients compared to six (12.4%) control subjects had an abnormally high posterior sacral arc opening (chi 2 2.406, P = 0.2). Three of seven patients (42.6%) with anismus were found to have SBO. Of 19 patients with slow colonic transit five (26.2%) had SBO and of seven patients with a mixed picture, three (42.6%) had SBO. There was no significant difference in the incidence of SBO in any of these three patient subgroups when compared to the control group. These results suggest that there is no association between spina bifida occulta and constipation.

Deaths and complications following prostatectomy in 1400 men in the northern region of England. Northern Regional Prostate Audit Group.

OBJECTIVE: To determine the degree of variation in mortality and major morbidity following transurethral resection of the prostate (TURP), and to assess intersite variation for mortality and morbidity over 12 sites within the Northern Region. Further, to determine whether the previously observed effects on morbidity of unit size, patient through-put and emergency admission were borne out in contemporary urological practice in the Northern Region. PATIENTS AND METHODS: For an 8 month period, 1 April 1991-31 November 1991, an independent audit of TURP was performed on 12 different hospital sites throughout the Northern Region. A constant data set was designed which was collected on each patient before and 3 months after operation by two independent clinical co-ordinators who travelled to each of the sites. All case notes were reviewed at 3 months after operation by the co-ordinators using a standard proforma, rather than depending upon self reporting by medical staff. Data on factors potentially affecting mortality and morbidity were collected, including emergency admission, diagnosis of prostate cancer, American Society of Anesthesiologists' co-morbidity scores, and age and differences in throughput in the 12 sites. The effect of through-put or 'volume' on mortality and morbidity was assessed by comparing morbidity and the number of cases performed. RESULTS: The early mean death rate was 13 of 1396 patients (0.9%), with an inter-site variation ranging from 0% to 3.8%. A mean of 2.0% of men were returned to theatre after TURP, 2.4% of patients received a blood transfusion (> 2 units) after operation, and 8.0% of patients developed post-operative sepsis; these complications varied sixfold, sevenfold and 17-fold across the different sites respectively. Those units performing < or = 100 operations over the audit period (equivalent to < 150 operation per year) had a significantly increased rate of deaths and complications which was not related to population differences, though some low volume units had good results. Elderly men who were admitted as emergencies or with prostate cancer were particularly vulnerable to complications. CONCLUSIONS: The overall early mortality rate after TURP for benign prostatic hyperplasia across the Region compares well with other reported large series. The significant variation in morbidity rates found in this study suggests that careful attention needs to be paid by Urologists, Purchasers and Providers to morbidity rates after prostatectomy.

Written consent about sexual function in men undergoing transurethral prostatectomy.

OBJECTIVE: To review the written recording of consent about possible sexual dysfunction after transurethral resection of the prostate (TURP), and the incidence of sexual dysfunction in sexually active men after TURP, from a large scale audit of transurethral prostatectomy held in 12 hospital sites in the Northern Region. PATIENTS AND METHODS: Over an 8-month period data were collected from 12 separate hospital sites within the Northern Region by two independent nurse co-ordinators who travelled to each of the sites. Information was gathered from medical records, operation lists and theatre books using a standard proforma. The Nottingham Health Profile (NHP) was used as a quality of life instrument in a subgroup of patients who were asked about sexual function before and after operation. RESULTS: Advice about retrograde ejaculation was recorded infrequently, with only 30% of case notes including a statement about this (inter-site variations 0-78%). The mean age of patients in whom a written record was made was lower (70 [0.44 SEM] years) than those in whom there was no recording (72 [0.25] years; P < 0.001), but marital status did not appear to be a significant factor. No significant differences in NHP were found comparing men who did or who did not have written evidence about consent regarding retrograde ejaculation. In addition, in a subset of men who had been asked pre-operatively about sexual function, no significant differences were found in overall NHP measurements in those who did or who did not develop retrograde ejaculation. In men who were sexually active before operation, the incidence of major sexual problems, impotence and retrograde ejaculation were 12%, 11% and 24% respectively. CONCLUSION: The incidence of sexual dysfunction following TURP in this audit concurred with previously reported studies (4-40%), but despite this most urologists in our audit were not recording that they had advised their patients about this possible outcome.

Nottingham health profile measurement in the assessment of clinical outcome after prostatectomy. Northern Regional Prostate Audit Group.

OBJECTIVE: To compare the changes in pre- and post-operative symptom scores with changes in Nottingham health profile (NHP) scoring, and thus determine whether NHP scoring offers a reliable assessment of outcome after transurethral resection of the prostate (TURP), and whether NHP scoring could usefully supplement the more traditional method of symptom scoring in this assessment. PATIENTS AND METHODS: An 8-month audit of 1396 TURPs, involving 12 hospital sites, was performed in the Northern region between April 1 and November 31, 1991. A cohort of 371 of these patients, for whom pre- and post-operative NHPs and irritative and obstructive voiding symptoms had been recorded, were investigated. RESULTS: There was a significant decrease in both obstructive and irritative voiding symptom scores 3 months after TURP and a significant fall in the NHP scores for all stations except social isolation. There were significantly higher irritative symptom scores both before and after operation in men with prostate cancer compared with those with benign prostatic hypertrophy, and significantly higher post-operative obstructive symptom scores in men with prostate cancer. However, there were no significant differences in the pre- and post-operative NHP scores for these two subgroups of patients. In patients who had a good outcome on symptom scoring, there was a significant reduction in NHP scores for all stations except social isolation. However, in those patients who had a poor outcome on symptom score, there was no correlation with changes in the NHP scores, with some NHP stations showing a significant reduction after operation. CONCLUSION: NHP quality-of-life scoring cannot replace symptom scoring in the assessment of outcome after TURP and when used alone, added little further information. However, for a comprehensive assessment of outcome, symptom scores and quality-of-life assessments should be used together.

Evidence from dynamic integrated proctography to redefine anismus.

The role of anismus in the aetiology of defective rectal evacuation was investigated by dynamic integrated proctography in 20 controls and 71 constipated patients. Normal parameters were defined and compared between 21 constipated patients with poor evacuation during proctography (< 40 per cent of contrast evacuated; group 1) and 50 who evacuated fully (> 90 per cent of contrast evacuated; group 2). Nine patients in group 1 failed to evacuate. Radiological abnormalities of the rectum were recorded in all groups but obstructed evacuation was not observed. Anismus (defined as a recruitment of puborectalis electromyogram (EMG) activity of > 50 per cent) was significantly more common in group 1 than group 2 patients (14 of 21 versus 12 of 50, P < 0.01) and present in seven of those unable to evacuate. Eight patients in group 1 failed to raise intrarectal pressure > 50 cmH2O compared with two in group 2 (P < 0.001). Six patients in group 1 demonstrated both anismus and inability to raise intrarectal pressure, which may combine to cause defective evacuation. EMG recruitment alone is insufficient to diagnose anismus. Definition should be based on three criteria: demonstration of puborectalis EMG recruitment of > 50 per cent; evidence of an adequate level of intrarectal pressure (> 50 cmH2O) on straining; and presence of defective evacuation.

Simultaneous dynamic electromyographic proctography and cystometrography.

The rectum and bladder share a common origin and work in harmony; disturbance in one may lead to a similar problem in the other. The two have, however, not previously been investigated dynamically and simultaneously. A new system has been devised allowing dynamic integrated electromyographic proctography to be performed simultaneously with cystometrography in 41 patients (28 women and 13 men). Of 16 women with chronic constipation who underwent the combined study, ten were shown to have obstructed micturition. Eight of these ten women exhibited an inappropriate contraction of the puborectalis muscle during micturition, compared with one of the six with normal micturition (P = 0.02). Of the patients with obstructed micturition, seven of eight women with a rectocele also had anismus, compared with none of four women with a rectocele among those who were able to micturate normally (P = 0.02). Eight of the ten women with obstructed micturition thus had a proctological abnormality that explained the urological symptoms. Of 12 women with idiopathic faecal incontinence who underwent the combined study, eight were shown to have genuine stress incontinence of urine. In seven of these the severity was shown to be of type 2a or greater, indicating that pelvic floor dysfunction may be the causal factor of both rectal and urinary symptoms. The combined study shows abnormalities in one system that could explain similar symptoms in the other.

Pelvic floor physiology in women with faecal incontinence and urinary symptoms.

Anorectal manometry, balloon proctometrography, measurement of anorectal angles and videourodynamics were used to investigate 45 asymptomatic women and 13 with faecal incontinence and urinary symptoms, nine of whom also had stress urinary incontinence. The anorectal angle was measured and videourodynamics performed on 17 constipated women with urinary symptoms. Mean (s.e.m.) values obtained with anorectal manometry were lower in women with faecal incontinence and urinary symptoms than in controls (maximum resting pressure 42.5(8.1) versus 82.5(9.3) cmH2O, P = 0.001; maximum attained pressure 80.5(13.7) versus 216.2(11.2) cmH2O, P = 0.001; maximum squeeze increment 35.3(7.5) versus 141.6(10.0) cmH2O, P = 0.001), indicating a weakened puborectalis and external anal sphincter. Mean(s.e.m.) anorectal angles at rest, squeeze and strain were all significantly greater in the doubly incontinent women than in those with constipation (114(3.8) versus 93(5.9) degrees, P = 0.01; 103(2.5) versus 78(3.5) degrees, P < 0.001; 120(2.9) versus 104(4.2) degrees, P = 0.01). Urinary incontinence was worse in the doubly incontinent than in the constipated women (eight of nine versus one of eight with grade 2a or higher, P = 0.002). These results suggest that doubly incontinent women have a significantly weakened pelvic floor and that this should be taken into account before any planned surgery for urinary incontinence.

Transurethral prostatic resection or laser therapy for men with acute urinary retention: the ClasP randomized trial.

PURPOSE: Transurethral resection of the prostate is the standard operation for acute urinary retention, although laser prostatectomy is reportedly effective and safe. The ClasP (conservative management, laser, transurethral resection of the prostate) study compared transurethral prostatic resection and noncontact neodymium (Nd):YAG visual laser assisted prostatectomy for treatment of acute urinary retention. MATERIALS AND METHODS: This study was a multicenter randomized controlled trial, analyses were by intention to treat and followup was at 7.5 months after randomization. Primary outcomes were treatment failure, and included International Prostate Symptom Score, International Prostate Symptom Score quality of life score, residual urine and flow rate. Secondary outcomes included complications, and duration of catheterization and hospitalization. RESULTS: A total of 148 men were randomized to transurethral prostatic resection (74) and laser (74). There were fewer treatment failures after prostatic resection (p = 0.008) and fewer men after resection required secondary surgery for poor results (1 versus 7, p = 0.029). Maximum flow rates after transurethral prostatic resection were better than after laser (mean difference 4.4 ml. per second). Comparison of symptom and quality of life scores demonstrated that any clinically significant advantage for laser could be ruled out. Patients stayed a mean of 2 extra days in the hospital after resection. The duration of catheterization was greater after laser but significantly fewer major treatment complications were found with laser therapy. CONCLUSIONS: Transurethral prostatic resection was more effective, resulted in fewer failures than laser treatment and remains the procedure of choice for men with acute urinary retention.