Phase I/II examination of transurethral ethanol ablation of the prostate for the treatment of symptomatic benign prostatic hyperplasia.

PURPOSE: We assessed the safety of transurethral ethanol ablation of the prostate as a treatment for men with symptomatic benign prostatic hyperplasia and determined the efficacy of this procedure. MATERIALS AND METHODS: We performed a multicenter randomized trial on 79 men, 50 to 79 years old, who had drug refractory voiding symptoms (International Prostate Symptom Score greater than 12) and prostate volumes of 30 to 80 cc. Ethanol was injected transurethrally into the prostate with a curved cystoscopic needle in men randomly assigned to 1 of 3 doses: 15%, 25% or 40% of prostate volume by transrectal ultrasound. Followup evaluations were performed 1, 3 and 6 months later. Postoperative cystoscopy was performed on all patients to evaluate ablation extent and extraprostatic effects. Transrectal ultrasound volume determinations were obtained before and 6 months after transurethral ethanol ablation of the prostate. RESULTS: Adverse events were generally mild or moderate, and included hematuria (42.9%), irritative voiding symptoms (40.3%), pain/discomfort (25.6%) and urinary retention (22.1%). No serious adverse events were reported. Statistically significant improvements were seen in International Prostate Symptom Score, quality of life, maximum flow rate and prostate volume reduction (p<0.05). Improvements were consistently observed across the 3 groups without an apparent dose effect. CONCLUSIONS: In this randomized clinical trial transurethral ethanol ablation of the prostate was safe and effective at 6-month followup. No serious adverse events were encountered. Although ethanol can safely ablate prostatic tissue, further studies will be necessary before widespread clinical application.

Does laparoscopic ureterolithotomy replace shock-wave lithotripsy or ureteroscopy for ureteral stones?

Ureteral stones are a major cause of morbidity and anxiety among urologic patients. Before the 1980s, ureteral stones were managed by open ureterolithotomy. Since then, second- and third-generation shock-wave lithotriptors, small-caliber ureteroscopes, and laparoscopic procedures have evolved as options for the treatment of ureteral calculi. Each technique is highly effective when implemented for the appropriate indication. Stone size, location, composition, and surgeon's and patient's preferences each play a major role in the decision-making process. Currently, ureteroscopy and shock-wave lithotripsy are regarded by many as the first-line treatment modalities for the management of ureteral stones, and the exact role of laparoscopic ureterolithotomy remains poorly defined. The present review addresses the most recent literature, and highlights the advantages and disadvantages of each surgical option.

Imaging of the lower urinary tract in adults.

Imaging of the lower urinary tract is an integral part of everyday urologic practice. Clinical application of less commonly used techniques is discussed to expand their usefulness in an ambulatory setting.

Voiding and sexual dysfunction after cerebrovascular accidents.

PURPOSE: We provide an up-to-date review of the urological manifestations of cerebrovascular accidents and their management, including sexual manifestations. MATERIALS AND METHODS: We performed a comprehensive MEDLINE search for peer reviewed articles using key words and incorporated these data with our experience with the treatment of patients in an acute stroke unit, rehabilitation unit and ambulatory care center. RESULTS: The knowledge of urological dysfunction after stroke is based largely on the evaluation of symptomatic patients. The predominant symptoms are urinary frequency, urgency and urge incontinence. Time after stroke has a significant influence on urological findings. Detrusor hyperreflexia is the most common urodynamic finding. Whereas the site and size of the stroke clearly have an influence on urological findings, to our knowledge the effect of the involved hemisphere is unclear. Urinary incontinence as an initial presentation in acute stroke is associated with a high mortality rate. Sexual dysfunction is common in men and women. Co-morbid conditions, such as diabetes mellitus, benign prostatic hyperplasia and urethral incontinence, may complicate evaluation and management. CONCLUSIONS: A stroke has a profound effect on lower urinary tract function, sometimes resulting in significant morbidity. In well rehabilitated patients sexual dysfunction should be assessed and treatment may be considered to improve quality of life with safety. An overall conservative approach to management is recommended in the initial 3 to 6 months since improvement is common with time.

Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent.

Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3-19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty-two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality-of-life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12-month pad weight test over 2.2 g. Quality-of-life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty-six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12-month visit.

Do prostatic stents solve the problem of retention after transurethral microwave thermotherapy?

Temporary nonmetallic stents offer an alternative to an indwelling catheter for the management of voiding problems after heat-based therapies for benign prostatic hyperplasia. Patient comfort is improved, and they are able to void immediately after the procedure. Unlike a catheter, stents function on the principle of active drainage. Thus, a functioning detrusor muscle is imperative for stent success. Single-center clinical trials have reported encouraging results; however, predictable success criteria are yet to be established. Multicenter trial data are awaited.

Endoprostatic stents for management of benign prostatic hyperplasia.

Endoprostatic stents have been developed for relieving bladder outlet obstruction secondary to benign hyperplasia of the prostate. The stents are designed either for permanent or for temporary placement. The short-term temporary stents of various biostable and biodegradable polymers are needed after minimally invasive therapy of prostate with heat. The temporary stents are a management option, whereas the permanent stents are a treatment option. Permanent stents offer immediate relief and their sustained results for 4-7 years make them ideally suited for medically compromised patients.

A new temporary catheter (ContiCath) for the treatment of temporary, reversible, postoperative urinary retention.

OBJECTIVES: To describe the initial experience of a newly designed temporary urethral catheter, ContiCath, as an aid in the management of postoperative or temporary outflow obstruction. In patients with normal detrusor and sphincter function, this catheter allows volitional voiding while maintaining an open prostatic urethra. METHODS: In a pilot study, 64 nonconsecutive patients with postoperative or temporary urinary retention, at eight clinical trial sites, were enrolled for the placement of this temporary catheter. Three patients did not have the catheter placed because of placement failure because of either a large median lobe or a urethral stricture. The remaining 61 patients were divided into three groups: those with non-neuropathic causes of retention and retention for 1 week or less (37 patients), those with non-neuropathic causes of retention and retention for longer than 1 week (19 patients), and those with neuropathic causes of retention and retention for longer than 1 week (5 patients). The ContiCath is placed in the office setting, in the same fashion as a Foley catheter. A blue prolene tether extends from the bulbar urethra to the meatus to assist in the removal of the device. Patients were then reassessed at 3 hours, and at 7, 14, 21, and 28 days, at which point the device was removed. RESULTS: In patients with a neuropathic cause for their retention (5 patients) and those with non-neuropathic causes of retention and retention for longer than 1 week (19 patients), only 3 patients were able to void after the catheter was placed. Of the 37 patients with a non-neuropathic cause and retention 1 week or less, controlled voiding was seen in 33 patients (89%). Controlled voiding was defined as the patient's volitional ability to initiate and stop his urinary stream. There were no complications with catheter placement; however, 8 patients (24.2%) had minor adverse experiences of frequency/urgency (n = 3), incontinence (n = 3), migration of the catheter (n = 1), and pain (n = 1). CONCLUSIONS: ContiCath offers an alternative to an indwelling Foley catheter in men with temporary bladder outlet obstruction and urinary retention.

Uncommon complications of permanent stents.

The UroLume endoprosthesis has been used for recurrent bulbar urethral strictures, benign prostatic hyperplasia, and detrusor-external sphincter dyssynergia. Complications of the UroLume have been described by the North American Multicenter Trial as migration, encrustation, hyperplastic tissue growth, in addition to pain and irritative voiding symptoms. Generally, complications have been minimal, and few of the stents required removal. Patients with bulbar strictures were felt to be at relatively greater risk of hyperplastic tissue reaction if their stricture was secondary to trauma or if they had a prior urethroplasty. On the other hand, patients with benign prostatic hyperplasia were at risk of developing complications if they had median lobe enlargement or a short (<2.5 cm) prostatic urethra. We describe two cases in which off-label compassionate use of UroLumes in the anterior urethra and in an irradiated urethra led to adverse reactions such as stent separation, poor epithelialization, hyperplastic tissue growth, encrustation, or obstruction necessitating removal.

Outcome of vaportrode transurethral vaporization of the prostate using pressure-flow urodynamic criteria.

OBJECTIVES: To use pressure-flow urodynamic parameters to evaluate the outcome of patients with benign prostatic hyperplasia (BPH) who were treated with transurethral vaporization of the prostate (TUVP) using the Vaportrode. METHODS: Forty consecutive patients (mean age 71.7 years) undergoing TUVP for treatment of symptomatic obstructive BPH or urinary retention were evaluated preoperatively and postoperatively with American Urological Association (AUA) Symptom Score, uroflowmetry, and pressure-flow multichannel urodynamic studies. RESULTS: Twenty-nine patients were voiding preoperatively. Eleven patients presented with urinary retention and were analyzed separately. At 3-month mean follow-up, the AUA Symptom Score decreased from 20.7 to 7.2 (n = 26). Peak uroflow rate (Qmax) increased from 8.2 to 15.5 mL/s (n = 27), whereas detrusor pressure at maximal flow (Pdet) decreased from 95.0 to 44.7 cm H2O (n = 24), indicating relief of obstruction. Postvoid residual urine volume decreased from 181.8 to 37.3 mL (n = 27). At 1-year mean follow-up, the AUA Symptom Score was 5.6 (n = 15) and Qmax was 14.3 mL/s (n = 19). The overall complication rate was 17.5% and included meatal stenosis (n = 1), bulbar urethral stricture (n = 1), refractory detrusor hyperreflexia (n = 1), dystrophic bladder neck calcification (n = 1), prostatic synechial formation requiring revision (n = 2), and residual prostatic tissue requiring revision (n = 1). CONCLUSIONS: This study provides objective evidence that TUVP is effective in providing prompt relief of bladder outlet obstruction with durable improvement in symptoms and flow rate with no acute morbidity. Accordingly, TUVP should continue to be considered as a minimally invasive surgical alternative to transurethral resection of the prostate.

Pubovaginal sling using polypropylene mesh and Vesica bone anchors.

OBJECTIVES: To report preliminary results from a modified pubovaginal sling procedure using polypropylene mesh as the sling suspended by nonabsorbable sutures anchored to the pubic tubercle with Vesica bone anchors. METHODS: Thirty-five women with type III stress urinary incontinence (SUI) (with or without associated urethral hypermobility) or type II SUI with additional risk factors such as obesity, chronic obstructive pulmonary disease, or failed prior incontinence-correcting procedures underwent this modified pubovaginal sling procedure. Postoperative voiding status was evaluated during office follow-up visits and telephone surveys. RESULTS: With a mean follow-up of 8.4 months (range 2 to 18), 32 women (91.4%) were dry, 1 improved, and 2 remained incontinent. The pubovaginal sling procedure was the only operation performed in 46% of patients, with a mean operative time of 72 minutes, a mean estimated blood loss of 137 mL, and a mean hospital period of 2.3 days. Patients on whom concomitant gynecologic procedures were performed had a mean duration of surgery of 122 minutes, a mean estimated blood loss of 202 mL, and a mean hospitalization period of 2.9 days. Thirteen women had preoperative urgency that persisted in 31% of patients. De novo urgency developed in 3 patients. Seven women required prolonged suprapubic tube drainage but no patient remained in permanent retention. There has been no infection or erosion. CONCLUSIONS: Our experience with this modified pubovaginal sling procedure using polypropylene mesh and Vesica bone anchors showed excellent results with greater technical ease, minimal morbidity, and decreased hospitalization period when compared to a traditional pubovaginal sling performed in our hands. Additional follow-up will be needed to assess long-term efficacy.

Use of multiple urolume endourethral prostheses in complex bulbar urethral strictures.

PURPOSE: We evaluated patients who received multiple UroLume Wallstents during the North American UroLume trial for the treatment of recurrent bulbar urethral strictures. MATERIALS AND METHODS: A total of 41 patients received multiple UroLume stents. The clinical histories and therapeutic outcomes of these patients were reviewed. RESULTS: Of the patients 23% required placement of multiple urethral stents. Stents placed at the initial procedure were required for strictures longer than 2.5 cm. and for multiple, separate strictures. Indications for secondary insertion included recurrent stricture adjacent to the stent, hyperplastic tissue growth within the stent and gaps between previously adjacent stents. The repeat treatment rate was 43.9% versus 14.3% for the study group overall. Urine flow rates and symptom scores in the multiple stent group showed improvement similar to that of the study group overall. CONCLUSIONS: Patients who required multiple stents had greater rates of repeat treatment but similarly improved urine flows and symptom scores, which were maintained at 2 years.

Sphincteric incontinence: the primary cause of post-prostatectomy incontinence in patients with prostate cancer.

Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty-seven patients (69%) had VLPP less than 103 cmH2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post-prostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence.

Role of permanent stents.

The application of permanent stents in the urinary tract followed their success in the vascular system. Permanent metal stents have been used in the treatment of urethral stenosis, bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), and detrusor-sphincter dyssynergia. In addition, stents are used in the ureter for ureteroileal strictures and malignant obstruction. Despite the favorable early results, concerns have been raised about their biocompatibility, hyperplastic tissue response, encrustation, and carcinogenicity. This paper reviews the long-term data on permanent stents, primarily the Urolume device, which has been studied extensively in multicenter trials in North America and was recently approved for use in the urethra and for the treatment of bladder outlet obstruction secondary to BPH.

Epithelialization of permanent stents.

The permanent Urolume Wallstent has been used for the relief of bladder outlet obstruction (BOO), detrusor-external sphincter dyssnergia (DESD), and recurrent bulbar urethral strictures. Because of its woven construction, it allows ingrowth of urothelial tissue, resulting in complete epithelialization by 6 to 12 months. Certain risk factors are associated with poor epithelialization that may lead to hyperplastic tissue growth and occlusion of the urethral lumen. We review the literature and discuss the 5-year results of the North American Multicenter Urolume Trial with regard to epithelialization, hyperplastic tissue growth, and treatment of hyperplastic growth.

Acute cerebrovascular accident and lower urinary tract dysfunction: a prospective correlation of the site of brain injury with urodynamic findings.

PURPOSE: We evaluated the effects of an acute cerebrovascular accident on the lower urinary tract and correlated the site of cerebrovascular accident with findings on urodynamic study. MATERIALS AND METHODS: A total of 45 men and 15 women underwent a complete urodynamic study with electromyography within 72 hours of a cerebrovascular accident. Patients were divided into 5 different groups based on urodynamic findings. RESULTS: The majority of cortical and internal capsule lesions resulted in detrusor hyperreflexia. A total of 28 patients (47%) had urinary retention, mainly due to detrusor areflexia (75%). Of 20 patients with hemorrhagic infarcts 17 (85%) had areflexia, compared to only 4 of 40 (10%) with ischemic infarcts. All 6 patients with cerebellar infarction had detrusor areflexia. CONCLUSIONS: Our results confirm many previously reported findings. In addition, there was a specific correlation of cerebellar and hemorrhagic infarctions with detrusor areflexia.

A computerized voiding diary.

OBJECTIVE: To examine a group of subject and control patient's preferences and compliance with regard to the Compu-Void (CV) electronic voiding diary as compared to the written diary (WD) and to compare the two methods with respect to the type of information obtained and whether the order of use of each method influenced results in the subject group. STUDY DESIGN: Thirty-six women between the ages of 20 and 84 with bladder symptoms were compared to a group of 36 age-matched women. RESULTS: In 100% of subjects and 95% of control patients, CV entries exceeded the number made with the WD in voiding events and, in subjects, in incontinence episodes recorded (P < .005 and P < .005, respectively). Over 98% of subjects and over 80% of controls preferred the CV (P < .0005). The order of use of each method in subjects made no significant difference with regard to the volume of information obtained (P < .407), number of leakage events recorded (P < .494) or fluid intake patterns (P < .410). Patients' compliance with each method was not affected by the order of use. CONCLUSION: Our results suggest an increased volume of data and greater patient compliance in reporting bladder symptoms and events using the CV and that the order of use is not important.

Evaluation of transurethral vaporization of prostate with pressure-flow analysis and other clinical measures.

Transurethral vaporization of the prostate (TUVP) is a promising new alternative modality for resection of obstructing adenomatous prostatic tissue. We evaluated the efficacy of TUVP for treatment of symptomatic benign hyperplasia (BPH) or urinary retention using pressure-flow analysis and other clinical measures. Twenty-seven men (mean age 72) with symptomatic BPH (N = 21) or urinary retention (N = 6) underwent TUVP using the VaporTrode loop. Patients were evaluated both preoperatively and postoperatively by subjective and objective criteria including AUA symptom score, uroflowmetry, postvoiding residual volume (PVR), and detrusor pressure (Pdet) at maximum flow. Complete follow-up data were available in 19 patients with an average follow-up of 9 weeks (range 4-32). The average symptom score was reduced from 19.9 to 5.58 (p < 0.0001). The average peak uroflow rate (Qmax) improved from 7.0 ml/sec to 18.1 mL/sec (p < 0.001). The average PVR was reduced from 163 mL to 14 mL (p < 0.003), and there was a similar reduction in Pdet at maximum flow from 96 cm H2O to 44 cm H2O (p < 0.001). The overall complication rate was 11%. These included meatal stenosis (N = 1), temporary urinary retention (N = 1), and residual prostate tissue causing obstruction (N = 1). In conclusion, TUVP with the VaporTrode yields a significant improvement in AUA symptom score, peak uroflow rate, PVR, and detrusor pressure at maximum flow, denoting relief of bladder outlet obstruction. This review of our experience with TUVP provides additional evidence for the use of the VaporTrode as a safe and effective alternative surgical modality for the treatment of symptomatic BPH.

Effects of cerebrovascular accident on micturition.

A functionally oriented approach to acute stroke care should take place in conjunction with traditional medical management, because the medical care provided during the first days and weeks after a stroke affects the ultimate disability status of the patient.10 New onset voiding dysfunction after a stroke is a difficult problem for all involved in the care of the patient. Urinary incontinence and retention are socially unacceptable and can be very embarrassing for the patient. They can interfere with patient discharge and complicate patient rehabilitation.13 With the high incidence of stroke, geriatricians and urologists will come across many patients with this condition, and they must approach the problem of voiding dysfunction in concert if they expect to achieve the optimal outcome for the patient. Therefore, proper diagnosis and management of voiding dysfunction in the poststroke patient are important for improved patient well being, increased patient survival, and decreased disability as well as a reduction in the national health care expenditures.