A report of a regional service for post-prostatectomy urinary incontinence: a model for best practice?

INTRODUCTION: Post-prostatectomy incontinence (PPI) is a potentially highly significant complication of a common urological procedure. Pathophysiology may be multifactorial but most commonly involves urinary sphincter weakness. The gold standard treatment for severe incontinence is artificial urinary sphincter but multiple alternatives exist. The growing incidence of PPI has led to the development of a specialized regional service dedicated to management. PATIENTS AND METHODS: In 2004 a regional referral protocol for PPI was established with a dedicated clinic at a single centre for assessment and management including videourodynamics, pelvic floor rehabilitation, biofeedback and a consultant with a specialist interest in PPI surgery. Data regarding all in-house and tertiary referrals to this clinic between 2004 and 2011 were analysed with patients categorized by symptom severity. RESULTS: A total of 267 patients were referred to the post-prostatectomy service (mean age 66.6, range 49-83 years) with numbers increasing year on year. Two-thirds of these were tertiary referrals: 27.7% of referrals were for mild symptoms, 35.2% moderate and 33.3% severe. One-third of referrals were made within 2 years of the primary procedure. Just over half of referred patients underwent invasive treatment including 24.3 artificial sphincter (24.3%) and male slings (22.8%). 7.5% patients were managed with medication, 14.6% were managed conservatively with containment therapy only. One-fifth remain under assessment or have deferred treatment. CONCLUSION: PPI is of increasing personal and societal impact which should be identified early and supported. Investigation and management can be standardized and intervention at a high volume centre achieved by early specialist referral.

Routine urine cytology has no role in hematuria investigations.

PURPOSE: Urine cytology has been a long-standing first line investigation for hematuria and is recommended in current major guidelines. We determined the contribution of urine cytology in hematuria investigations and its cost implications. MATERIALS AND METHODS: Data were prospectively collected for 2,778 consecutive patients investigated for hematuria at a United Kingdom teaching hospital from January 1999 to September 2007 with final analysis in October 2010. All patients underwent standard hematuria investigations including urine cytology, flexible cystoscopy and renal tract ultrasound with excretory urogram or computerized tomography urogram performed in those with visible hematuria without a diagnosis after first line tests. Patients with positive urine cytology as the only finding underwent further cystoscopy, retrograde studies or ureteroscopy with biopsy under general anesthesia. Outcomes in terms of eventual diagnosis were cross-referenced with initial urine cytology results (classified as malignant, suspicious, atypical, benign or unsatisfactory). Costs of urine cytology were calculated. RESULTS: Of the patients 124 (4.5%) had malignant cells and 260 (9.4%) had atypical/suspicious results. For urothelial cancer cytology demonstrated 45.5% sensitivity and 89.5% specificity. Two patients with urine cytology as the only positive finding had urothelial malignancy on further investigation. For the entire cohort the cost of cytology was £111,120. CONCLUSIONS: Routine urine cytology is costly and of limited clinical value as a first line investigation for all patients with hematuria, and should be omitted from guidelines.

TURP and sex: patient and partner prospective 12 years follow-up study.

OBJECTIVE: • To evaluate the effect of transurethral resection of the prostate (TURP) on sexual function in the short (6 months), medium (6 years) and long (12 years) term and assess the conformity between patient and partner regarding sexual function. PATIENTS AND METHODS: • A prospective cohort study set at the Aberdeen Royal Infirmary University Hospital. • A total of 280 men referred with lower urinary tract symptoms (LUTS) to a university hospital underwent TURP between January 1993 and September 1994; 145 of their partners (partner or spouse) participated. • Assessment included American Urological Association symptom score, flow rates and validated self-reported sexual questionnaires (SQ). • Data were collected at baseline, 3 months, 6 months, 6 years and 12 years of follow-up. RESULTS: • In all, 120 (43%) men were sexually active preoperatively. At 6 months, 73 (61%) of these 120 men completed the SQ and all were sexually active. • No sexually active patient became impotent after the procedure. Moreover, 27 (15%) with pre-existing erectile dysfunction reported improved sexual activity and erection quality. • At 6 years 101 men completed the SQ and 31 (30.7%) were sexually active. At 12 years, 36 (31.9%) of 113 who completed the SQ were sexually active. • Partners agreed with the men's self assessment at all visits. • Limitations include possible attrition bias and lack of information from non-responders. CONCLUSIONS: • Erectile dysfunction associated with LUTS frequently precedes TURP. • The TURP did not adversely affect sexual function. • Pre-operative erectile dysfunction can be improved by TURP and long-term sexual function is maintained after TURP. These findings, corroborated by the partners, were statistically significant.

Partners agree that the treatment of LUTS reduces patients' bother and improves their quality of life: prospective 12 years follow-up study.

OBJECTIVES: To determine if the partner (partner or spouse) can reliably assess the quality of life (QoL) and bother of the patient suffering from lower urinary tract symptoms (LUTS) before and after treatment thereby assisting in management. METHODS: 458 men referred with LUTS to a university hospital and 219 partners were recruited into the study between January 1993 and September 1994. Assessment included AUA score, flow rates, QoL and bother validated self-reported questionnaires completed by patients and spouses throughout the study. Data were collected at baseline, 3, 6 months, 6 and 12 years of follow-up. 280 men underwent TURP and 178 were managed by medical (non-surgical) treatment. RESULTS: For the TURP group, the mean QoL for patient and partner at baseline were 8.16 and 9.90 respectively. At 6 months, 6 and 12 years, these improved to 2.43, 3.71, 3.74 and 1.76, 4.07, 4.76 respectively. For the non-surgical treatment group, the mean QoL for patient and partner at baseline were 7.08 and 8.35 respectively. At 6 months, 6 and 12 years, these improved to 5.0, 3.6, 3.28 and 5.67, 3.61, 2.81 respectively. A similar trend applied to the bother score. Improvements in QoL and bother noted by partners agreed with that of patients and were statistically significant. CONCLUSIONS: The longest prospective in-depth study has shown marked conformity between patients and partners regarding QoL and bother after treatment. Partners are affected by patients' LUTS, appreciate the improvement after treatment and may be valuable contributors in assessment.

Incidence of recurrent frank hematuria and urological cancers: prospective 6.9 years of followup.

PURPOSE: The majority of patients presenting with frank hematuria have no diagnosis. There is a paucity of literature on the recurrence of frank hematuria and the incidence of urological cancers in these patients, and this study addresses both issues. MATERIALS AND METHODS: We performed a prospective cohort study of 578 consecutive patients referred with frank hematuria between 1999 and 2001 who underwent full investigations with a mean followup of 6.9 years. The primary outcome measure was the probability of frank hematuria recurrence after the initial negative investigations and the incidence of urological cancers in these patients. RESULTS: Diagnosis was made in 206 (35.6%) patients at initial presentation. Diagnosis was not made at initial presentation in the remaining 372 (64.4%) patients, of whom 81 died without a diagnosis during followup (32 within 2 years of presentation). A total of 81 patients (21.8%) with no diagnosis died during the followup period (32 within 2 years of the investigations). A questionnaire was mailed to the remaining 291 patients and 202 (69.4%) responded. Of the responders 41 (20.3%) reported frank hematuria recurrence (single episode in 10 and multiple episodes in 31). A significant urological diagnosis was made upon repeat evaluation in 21 (10.4%) patients which included urological malignancy in 4 (2%). CONCLUSIONS: Approximately 80% of cases cleared by initial investigation remained clear and 9.8% with frank hematuria recurrence were diagnosed with a urological malignancy. Frank hematuria recurrence requires vigilance and repeat investigations as appropriate.

Improved quality of life and enhanced satisfaction after TURP: prospective 12-year follow-up study.

OBJECTIVES: To assess the long-term clinical effectiveness, quality of life (QOL), bother, and satisfaction, using validated questionnaires, after transurethral resection of the prostate in patients with lower urinary tract symptoms due to benign prostatic enlargement. METHODS: We enrolled men referred to a tertiary university hospital for further evaluation and treatment of lower urinary tract symptoms from January 1993 to September 1994 in a prospective cohort study. A total of 280 consecutive patients underwent transurethral resection of the prostate, mainly for outflow obstructive symptoms. They were recruited into this protocol-based study using validated self-reported questionnaires. The assessments included American Urological Association symptom score, flow rates, and measurement of QOL, bother, and satisfaction. The data were collected at baseline, 3 and 6 months, and 6 and 12 years of follow-up. RESULTS: The mean QOL and bother score at baseline was 8.16 and 15.45, respectively. At 6 months, 6 years, and 12 years, the mean QOL and bother scores had improved to 2.54 and 4.84, 3.71 and 7.14, and 3.74 and 7.67, respectively. The improvements in the QOL and bother scores were consistent and statistically significant. CONCLUSIONS: Transurethral resection of the prostate not only proved to be clinically effective, but also improved patients' QOL and bother symptoms. This was associated with long-term, high patient-rated satisfaction.

An increase in N-Ras expression is associated with development of hormone refractory prostate cancer in a subset of patients.

Protein expression of H, K and N-Ras was assessed in hormone sensitive and hormone refractory prostate tumour pairs from 61 patients by immunohistochemistry. Expression of H-Ras and K- Ras was not associated with any known clinical parameters. In contrast an increase in N-Ras membrane expression in the transition from hormone sensitive to hormone refractory prostate cancer was associated with shorter time to relapse (p=0.01) and shorter disease specific survival (p=0.008). In addition, patients with an increase in N-Ras membrane expression had lower levels of PSA at relapse (p=0.02) and expression correlated with phosphorylated MAP kinase (p=0.010) and proliferation index (Ki67, p=0.02). These results suggest that in a subgroup patients N-Ras expression is associated with development of hormone refractory prostate cancer via activation of the MAP kinase cascade.

Experience with the spanner prostatic stent in patients unfit for surgery: an observational study.

BACKGROUND: Prostatic stents offer a third clinical option for patients with bladder-outlet obstruction who are unfit for surgical relief and wish to avoid long-term catheterization. We report our experience with the Abbey-Moor Spanner temporary prostatic stent in patients with acute and chronic symptoms of bladder-outlet obstruction secondary to benign or malignant disease who were unfit for surgery because of age or cardiorespiratory disease. PATIENTS AND METHODS: A series of 43 consecutive patients stented March 2004 through November 2005 were reviewed retrospectively. Stents were removed and replaced every 3 months if tolerated. RESULTS: More than half of the patients (63%) had an unsatisfactory outcome, namely, immediate or delayed retention or elective removal because of unbearable symptoms. The remaining 37% of patients had a satisfactory outcome and either continue to have the stent in situ after a mean of five changes or are stent free after a successful voiding trial. CONCLUSION: Only 21% of the patients in whom stenting was indicated continued to have a stent in situ at the end of the study. We suggest that in such patients, a temporary stent such as the AbbeyMoor Spanner should be used for only 3 months as a trial of stenting followed by a trial of stent-free voiding, with the patient converted to permanent prostatic stenting if voiding is unsuccessful.