Self-expanding stent insertion for urethral strictures: a 10-year follow-up.

OBJECTIVE: To evaluate the safety and efficacy of the Urolume endourethral self-expandable metallic stent (American Medical Systems, MI, USA) in treating urethral strictures, based on a follow-up of> 10 years. PATIENTS AND METHODS: Between November 1989 and June 1990, the Urolume stent was inserted into 15 patients (aged 25-77 years) who had recurrent urethral strictures. The mean duration of stricture before stent insertion was 10.9 years. The patients (all men) were followed using a questionnaire and uroflowmetry, and if necessary, retrograde cysto-urethrography and/or urethroscopy and/or X-ray urodynamics. RESULTS: Two failures were caused by excessive tissue proliferation in the stent, which ended in stent removal or a suprapubic catheter. Another two stents were removed because of discomfort or pain. Two patients developed stenosis in the stent after 7 and 9 years. In the final evaluation only two of the 15 patients were satisfied with their stent. The mean maximum urinary flow rate at the last follow-up was 15 mL/s, and half the patients noted 'stent' incontinence. Lower urinary tract infections, urge and stress incontinence, and discomfort with ejaculation, were all symptoms perceived at the last follow-up. CONCLUSION: The long-term results of the Urolume stent in this study weaken the optimistic early results. Only two of the 15 patients were satisfied with their stent.

Symptoms, prostate volume, and urodynamic findings in elderly male volunteers without and with LUTS and in patients with LUTS suggestive of benign prostatic hyperplasia.

OBJECTIVES: To estimate the differences in symptoms, prostate volume, and urodynamic variables of symptom-free elderly volunteers, volunteers with lower urinary tract symptoms (LUTS), and urologic patients with LUTS suggestive of benign prostatic hyperplasia. METHODS: The study included 14 male volunteers without LUTS, 17 male volunteers with LUTS, and 565 urologic patients with LUTS who met the criteria of the International Consensus Committee on Benign Prostatic Hyperplasia. They were older than 50 years, they voided more than 150 mL during free uroflowmetry, their residual volume and prostate volume were estimated, and their American Urological Association symptom scores were collected. All men were also evaluated by urodynamic studies. RESULTS: The prostate volume, residual volume, urethral resistance factor, and symptom scores were significantly lower and the maximal free flow rate and effective capacity significantly higher in the symptom-free volunteers than in the volunteers and patients with LUTS. Except for prostate volume, the variables in volunteers with LUTS closely approximated those of the patients with LUTS. The volunteers with LUTS had a smaller prostate volume than did the patients with LUTS. Nevertheless, the maximal free flow rate, symptoms, degree of obstruction, and prevalence of residual volume did not differ between the two groups. Men with an unstable bladder were present in all groups. CONCLUSIONS: Symptom-free volunteers had smaller prostate volumes, less residual volume, lower symptom scores, a lower urethral resistance factor, a higher maximal free flow rate, and a higher effective capacity than those with LUTS. Except for a smaller prostate volume, the findings in the volunteers with LUTS closely approximated those of the urologic patients with LUTS.

Interactions between prostate volume, filling cystometric estimated parameters, and data from pressure-flow studies in 565 men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

The aim of this study was to establish the characteristics and to investigate the interactions between prostate volume, degree of obstruction, bladder contractility, the prevalence of residual volume, bladder compliance, bladder capacities, and the prevalence of instability in a large, well-defined group of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). The 565 consecutive men included in this study met the criteria of the International Consensus Committee on BPH and voided more than 150 mL during uroflowmetry. Their residual urine volume and prostate size were estimated, and filling cystometry and pressure-flow studies were performed. Fifty-three percent of the men appeared to have obstruction. We found a positive correlation between prostate volume and Schäfer's obstruction grade, except that mean prostate volume decreased at Schäfer's grades 5 and 6. Significant negative correlations existed between Schäfer's grade and cystometric bladder capacity and effective capacity. Bladder outlet obstruction results in incomplete emptying. Of all men, 26% had a significant residual volume ( > 20% of cystometric capacity). Thirty-nine percent did not have residual volume. Of the 565 men, 46% had an unstable bladder. In particular, patients with an unstable bladder in the sitting and lying positions have a significantly higher Schäfer's grade and contractility grade and a significantly lower cystometric and effective bladder capacity compared with patients without instability. Patients with a residual volume or instability were significantly older. We conclude that in men with LUTS suggestive of BPH, abnormalities of bladder and bladder outlet function vary greatly and have complex mutual interactions.

One 24-hour frequency-volume chart in a woman with objective urinary motor urge incontinence is sufficient.

OBJECTIVES: To determine whether one 24-hour frequency-volume (FV) chart in a woman with objective urinary motor urge incontinence is sufficient to gain insight into her voiding habits. METHODS: Retrospectively, women 18 years old and older with urodynamically confirmed urinary motor urge incontinence without neurologic disease or other urologic pathologic findings, who correctly completed two or three 24-hour FV charts during normal daily life, were studied. For each patient, we compared the voiding parameters (mean voided volume, diuria, nocturia, minimum and maximum voided volumes, and total voided volume) and fluid intake calculated from the first FV chart with the same data calculated from all the FV charts. RESULTS: Ninety-eight adult women were recruited. A marked dropout occurred, and 60 patients remained to be evaluated (mean age 54.5 +/- 15.5 years). The calculated voiding parameters agreed with those in published reports. Strong associations existed between all voiding parameters and fluid intake calculated from the first FV chart and those calculated from all FV charts (P <0.001 for all parameters). Compared with the well-known variability, the differences between the voiding parameters calculated from the first FV chart and those from all charts were small. These results agreed with studies in other patient groups (benign prostatic hyperplasia and interstitial cystitis) that analyzed the use of only one 24-hour FV chart. CONCLUSIONS: The use of only one 24-hour FV chart completed during normal daily life by a woman with objective urinary motor urge incontinence is sufficient to gain insight into her voiding habits.

Prevalence and bothersomeness of lower urinary tract symptoms in benign prostatic hyperplasia and their impact on well-being.

PURPOSE: We established the prevalence and bothersomeness of symptoms and their impact on well-being in a large group of strictly selected men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Included in our study were 475 consecutive men who met the criteria of the International Consensus Committee on BPH and voided more than 150 ml. during uroflowmetry. International Prostate Symptom Scores and quality of life score were determined. We included the 7 bothersomeness questions of the Symptom Problem Index and the 4 of the BPH Impact Index of the American Urological Association Measurement Committee. These questions refer to the degree of bothersomeness caused by urinary problems and how they affect various health domains. RESULTS: The symptoms with the highest prevalence based on mean scores were weak urinary stream, frequency and urgency. Urgency, nocturia and hesitancy were the most bothersome symptoms. Patients were only discouraged from performing normal daily activity when the symptom index exceeded 20. Incomplete emptying and frequency bothersomeness correlated strongly, and weak urinary stream and hesitancy bothersomeness correlated weakly with all health and quality of life domains. CONCLUSIONS: Weak urinary stream, frequency and urgency were the most prevalent symptoms, while urgency, nocturia and hesitancy were the most bothersome symptoms. In contrast to weak urinary stream and hesitancy, the bothersomeness of incomplete emptying and frequency was strongly associated with well-being.

Symptoms and quality of life versus age, prostate volume, and urodynamic parameters in 565 strictly selected men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

OBJECTIVES: To investigate the associations of symptoms and quality of life with age, prostate volume, and urodynamic parameters in a large group of strictly selected men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. METHODS: The 565 consecutive men met all the criteria of the International Consensus Committee on benign prostatic hyperplasia and voided more than 150 mL during uroflowmetry. The residual volumes and prostate sizes were estimated. The International Prostate Symptom Score (IPSS) and quality-of-life score were collected and urodynamic evaluations performed. RESULTS: The prostate volume and obstruction grade were not, but low detrusor contractility and low bladder capacity were, significantly associated with symptoms. Except for nocturia, older men presented with lower voiding scores on the IPSS. The presence of a residual urine volume hardly influenced patients' symptoms and quality of life. Men with an unstable bladder scored higher on frequency, urgency, and nocturia on the IPSS, but the symptom index and quality-of-life score were not affected by the presence of an unstable bladder. Because of the high variability and subjective interpretation of symptoms and because urodynamic parameters may have opposite implications than symptoms and vice versa, associations were still weak. CONCLUSIONS: Except for nocturia, older men had lower voiding scores on the IPSS. Prostate volume and obstruction grade were not, but low detrusor contractility and low capacities were, associated with the symptom index. The presence of an unstable bladder and/or residual volume was hardly associated with the symptom index or quality-of-life score. Although we used a large group of strictly selected men, the associations were still weak.

Data from frequency-volume charts versus symptom scores and quality of life score in men with lower urinary tract symptoms due to benign prostatic hyperplasia.

OBJECTIVE: The aim is to study the relations between reported data on frequency-volume charts and the American Urological Association (AUA) symptom scores and quality of life score. METHODS: Males with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH), were consecutively included in the study if they met the criteria of the International Consensus Committee on BPH, they voided >150 ml during uroflowmetry, residual volume and prostate size were estimated and frequency-volume charts were completed correctly. From the frequency-volume charts, voiding habits and fluid intake in the daytime and at night were evaluated. RESULTS: In the included 160 men no correlation was found between total urine production at night or in the daytime and symptom index or quality of life score. Nycturia was correlated with symptom index, but surprisingly not with quality of life score. Small voided volumes at night and in daytime are attended by high symptom index and high quality of life score (= low quality of life). Diuria has a high impact on symptom index and quality of life score. Men who completed frequency-volume charts during 3 or more daytime periods (68%) had a significantly higher symptom index than those who completed only 1 or 2 daytime periods (32%). CONCLUSIONS: High diuria, and small voided volumes at night and in daytime contribute significantly to high symptoms and low quality of life. Nycturia correlated with AUA symptom index but surprisingly not with quality of life score.

Urethral resistance factor (URA) versus Schäfer's obstruction grade and Abrams-Griffiths (AG) number in the diagnosis of obstructive benign prostatic hyperplasia.

Different methods of analyzing pressure/flow plots to quantify bladder outlet resistance in men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) were developed in the past. The aims of this study were to quantify the degree of agreement between the diagnosis of obstruction by the different methods, and to compare the applicability of the different methods in the evaluation of bladder outflow conditions, in a large group of these men. In consecutive men with LUTS basic initial evaluations, recommended diagnostic tests, and urodynamic investigations were performed. From pressure/flow studies, the group-specific resistance factor (URA), Schäfer's obstruction grade, and Abrams-Griffiths (AG) number were estimated. Men with 21 cm H(2)O < or = URA < or = 29 cm H(2)O and men with Schäfer's grade equal 2 were classified as equivocal. In conformity with the provisional ICS definition, men with 20 < or = AG number < or = 40 were classified as equivocal. In 78% of the 565 included men Schäfer's classification agreed with URA classification. In 82% ICS classification agreed with URA classification. Most agreement (94%) existed between Schäfer's classification and ICS classification. All differences were near the points of intersection of the different boundaries, and a decision whether to perform surgery on a patient is not likely to be influenced by this disagreement. Males with relatively low detrusor pressure at maximum flow and relatively low maximum flow had a high prevalence among those in whom URA and Schäfer's classifications and among those in whom URA and ICS classifications differed.

Effect of diabetes mellitus on lower urinary tract symptoms and dysfunction in patients with benign prostatic hyperplasia.

This article reviews the recent literature on men with diabetes mellitus (DM) and concomitant lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Diabetes is reported to be associated with greater BPH symptom severity. Men with non-insulin-dependent diabetes had the highest median annual prostate growth rate compared with those who had other metabolic disease. Urodynamic evaluations in the reviewed studies were absent. Extensive diagnostic evaluations with urodynamics in our outpatient department revealed that patients with LUTS suggestive of BPH and with concomitant DM hardly differed from those without DM.

Analysis and reliability of data from 24-hour frequency-volume charts in men with lower urinary tract symptoms due to benign prostatic hyperplasia.

OBJECTIVES: The aims of this study were to analyse the data from frequency-volume charts and to study the reliability of these charts in men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). METHODS: Males with LUTS due to BPH were consecutively included in the study if they met the criteria of the International Consensus Committee on BPH, voided more than 150 ml during uroflowmetry, residual volume and prostate size were estimated and frequency-volume charts were completed correctly. From the frequency-volume charts, voiding habits and fluid intake were evaluated. RESULTS: 160 patients could be included. Another 28 patients who met all other criteria did not complete the frequency-volume charts correctly. Agreement exists between reported voided volumes in the literature and those found by us. We found a significant correlation (p<0.001) between nycturia and score on symptom question 7, and between diuria and score on symptom question 2 of the AUA symptom index. The difference between results obtained from frequency-volume charts completed during 24 h and those obtained from charts completed during three or more 24-hour periods was negligible with respect to the variation of data at an individual level. CONCLUSION: Frequency-volume charts are reliable in the investigation of patients with LUTS due to BPH. Reporting on frequency-volume charts during just 24 h is sufficient to gain insight into their voiding habits during normal daily life.

Recovery of storage and emptying functions of the urinary bladder after spinal anesthesia with lidocaine and with bupivacaine in men.

BACKGROUND: The aim of this study was to evaluate and compare the effects of spinal anesthesia with lidocaine and with bupivacaine on urinary bladder function in healthy men who were scheduled for minor orthopaedic surgical procedures. METHODS: Twenty men were randomly allocated to receive either bupivacaine or lidocaine. Before spinal anesthesia, filling cystometry was performed with the patient in the supine position and a pressure flow study was done with the patient in the standing position. After operation, cystometric measurements were continued until the patient could void urine spontaneously. The levels of analgesia and of motor blockade were recorded. RESULTS: The urge to void disappeared immediately after injection of the local anesthetics. There was no difference in the duration of lower extremity motor blockade between bupivacaine and lidocaine. Detrusor blockade lasted significantly longer in the bupivacaine group (means +/- SD, 460 +/- 60 min) than in the lidocaine group (235 +/- 30 min). Total fluid intake and urine volume accumulated during the detrusor blockade were significantly higher in the bupivacaine group than in the lidocaine group. In the bupivacaine group, the total volume of accumulated urine (875 +/- 385 ml) was also significantly higher than cystometric bladder capacity (505 +/- 120 ml) with the risk of over distension of the bladder. Spontaneous voiding of urine did not occur until segmental sensory analgesia had regressed to the third sacral segment. CONCLUSIONS: Spinal anesthesia with lidocaine and with bupivacaine causes a clinically significant disturbance of bladder function due to interruption of the micturition reflex. The urge to void disappears quickly and bladder function remains impaired until the block has regressed to the third sacral segment in all patients. With long-acting local anesthetics, the volume of accumulated urine may exceed the cystometric bladder capacity. With respect to recovery of urinary bladder function, the use of short-acting local anesthetics for spinal anesthesia seems to be preferable.

The value of symptom score, quality of life score, maximal urinary flow rate, residual volume and prostate size for the diagnosis of obstructive benign prostatic hyperplasia: a urodynamic analysis.

PURPOSE: We investigated which linear combination of scores for symptoms, quality of life, maximum urinary flow rate, residual volume and prostate size best discriminated men with prostatism who do and do not have obstruction. MATERIALS AND METHODS: Mandatory and recommended tests were performed in 196 men older than 50 years with prostatism. Schäfer's obstruction grade was estimated by urodynamic studies. Relative residual volume was defined as residual volume divided by cystometric capacity (times 100%). Correlation coefficients among the different parameters were estimated. Obstruction grade was correlated with linear weighted combinations of the parameters. RESULTS: Of the men 79% appeared to have obstruction. The formula, prostate size (cm.3) -3 x maximum urinary flow rate (ml. per second) + 1/4 of relative residual volume (%), correlated almost maximally with obstruction grade. Including quality of life score or symptom score in this expression had a negative outcome on the correlation. Calculation of this expression resulted in the bladder outlet obstruction number. In more than 50% of the men the bladder outlet obstruction number was greater than -2 and more than 90% had obstruction. In 25% of all men the bladder outlet obstruction number was greater than 13 and more than 95% had obstruction. CONCLUSIONS: Bladder outlet obstruction number may be calculated with an easy to use expression composed of prostate size, maximum urinary flow and relative residual volume. In 50% of the men with prostatism bladder outlet obstruction number will diagnose obstruction with a reliability of more than 90%.

International prostate symptom score and quality of life assessment versus urodynamic parameters in men with benign prostatic hyperplasia symptoms.

In 207 men with symptomatic benign prostatic hyperplasia the international prostate symptom score and score on quality of life were collected. Cystometric tests with pressure-flow studies were performed in these patients with special attention to the assessment of obstruction grade. Of the men 24% appeared not to have obstruction. A significant correlation was found between size of the prostate and grade of obstruction. No correlation was found between obstruction grade, and any symptom score or quality of life score, while symptom score and quality of life correlated well. In 41 patients the outcome of laser prostatectomy was evaluated 6 months after the procedure. Mean symptom score decreased from 19.1 to 5.4 and mean quality of life score decreased from 3.7 to 1.3 in the 31 obstruction patients, compared to decreases of 19.6 to 10.1 and 3.6 to 2.6, respectively, in 10 without obstruction. The improvement in the obstruction patients was significantly better but nonobstruction patients will benefit from prostatectomy as well.

Laser prostatectomy for patients with benign prostatic hyperplasia: a prospective randomized study comparing two different techniques using the Prolase-II fiber.

Laser prostatectomy for patients with complaints due to benign prostatic hyperplasia is a relatively new treatment option. The most effective procedure for coagulation and vaporization of the prostate is not yet known. In a prospective randomized study of 30 patients, 2 techniques for the delivery of laser energy were compared at 40 W for 90 s. The complications were minimal and antegrade ejaculation was preserved in 15 of 18 potent men. In 24 patients urodynamics evaluation was possible. In both groups a significant reduction in the symptom score was observed. The decrease in detrusor pressure at maximal flow and the increase in flow rate were, however, disappointing. No significant difference in the results was found between the two groups. The power setting needs to be changed in further studies.

Extensive urodynamic investigation: interaction among diuresis, detrusor instability, urethral relaxation, incontinence and complaints in women with a history of urge incontinence.

In 72 women with a clinical history of frequency and/or urge incontinence and in whom during filling cystometry nearly no abnormalities were detected, cystometry was repeated not by transurethral filling but under high diuretic conditions (diuresis cystometry). The prevalence and strength of detrusor instability, and the prevalence of incontinence were significantly greater during diuresis cystometry compared to filling cystometry. The experiences of these patients during episodes of instability were similar to those in their own daily environment. Most women with motor urge incontinence on filling or diuresis cystometry are losing urine at detrusor pressures lower than would be expected from urethral closure pressure measurements at rest. Therefore, urethral relaxation may have an important role in the etiology of incontinence. Apparent low amplitude detrusor instability may cause severe incontinence when combined with urethral relaxation. Extensive urodynamic investigations (including diuresis cystometry) will improve the clinical applicability of urodynamics.

[Laser prostatectomy as alternative to transurethral prostate resection in benign prostatic hyperplasia]. / Laserprostatectomie als alternatief voor transurethrale prostaatresectie bij benigne prostaathyperplasie.

OBJECTIVE: Assessment of the results of laser prostatectomy, as a treatment for benign prostatic hyperplasia (BPH). DESIGN: Prospective case control study. SETTING: University Hospital Utrecht, the Netherlands. METHOD: Between February 1992 and May 1993, 54 men with their micturition complaints due to BPH were treated with laser prostatectomy (TULIP system). Results were assessed using the international prostatic symptom score (IPSS), the maximal flow and urodynamic tests. The results were compared retrospectively with results of transurethral resection of the prostate (TURP; n = 40): both groups were urodynamically identical. RESULTS: Of the 54 patients, 10 could not be evaluated 6 months after treatment (5 of them underwent TURP or a second laser prostatectomy). In 40 patients complete evaluation including urodynamics before and six months after treatment was possible. A significant decrease in the symptom score from 19.3 (SD: 7.6) to 6.3 (SD: 5.4) and increase of the maximal flow during pressure-flow studies from 9.6 to 15.8 ml per second were observed. The decrease of the voiding pressure at 6 months after TURP in comparison with laser prostatectomy was close to significance (p = 0.05); the other improvements after urodynamics were comparable. CONCLUSION: Laser prostatectomy is a promising new therapy for BPH.

Non-radical hysterectomy and the function of the lower urinary tract. I: Urodynamic quantification of changes in storage function.

The intermediate sequelae of non-radical abdominal and vaginal hysterectomies on the storage function of the lower urinary tract were studied by comparison of pre- and postoperative urodynamic parameters. A statistically significant reduction in maximum cystometric capacity after abdominal extrafascial and vaginal hysterectomies was found, together with a decline in bladder compliance. Both findings are attributed to a decrease in the musculoelastic properties of the detrusor muscle caused by edema and surgical injury. This reduction in capacity and compliance, however, appeared to have no clinical importance. Sensory innervation remained unaltered. In general no evidence was found that hysterectomy contributed to the development of involuntary detrusor contractions and motor urge incontinence. Urethral competence, assessed by urethral pressure profilometry and urethral leakage pressure measurement, remained unaffected. No increase in stress incontinence was seen after hysterectomy. Vaginal hysterectomy appeared to influence storage function slightly more than abdominal hysterectomy did. Postoperative lower urinary tract dysfunction is for the most part determined by the preoperative urological status.

Non-radical hysterectomy and the function of the lower urinary tract. II: Urodynamic quantification of changes in evacuation function.

The intermediate sequelae of non-radical abdominal and vaginal hysterectomies on the evacuation function of the lower urinary tract were studied by comparison of pre- and postoperative urodynamic parameters. No significant changes were observed in detrusor contractility or the contribution of abdominal straining after hysterectomy. Pressure-flow studies revealed no development towards obstructive patterns. Uroflowmetry did not demonstrate any changes in flow rates or in flow patterns. Except in one woman, no major variations were seen in residual urine volumes. There were no differences between abdominal and vaginal hysterectomies. It is concluded that lower urinary tract evacuation function remains unaltered by total hysterectomy.

Dynamics of the ureterovesical junction: its resistance to upper urinary tract outflow in pigs.

In pigs, upper urinary tract outflow resistance at the ureterovesical junction (UVJ) has been investigated before and after changes of capacity and compliance of the bladder with ureterovesical perfusion pressure (UV-PP) measurements and cystometry (PB). Changes of UV-PP approximately paralleled changes of PB during volume changes and compression of the bladder, and during detrusor activity. Exceptions were: detrusor activity in all bladders, being nondistended, during which UV-PP always increased more than PB; and low and high compliant, and small capacity bladders in which UV-PP may change more than PB under all conditions once these bladders are so far filled that they are distended. From these findings and UVJ anatomy it is concluded that, besides intravesical pressure, anatomical factors and forces in the bladder wall also may determine upper urinary tract outflow resistance. The clinical implications are discussed.

Dynamics of the ureterovesical junction; a qualitative analysis of the ureterovesical pressure profile in the pig.

In pigs, ureterovesical pressure profiles were analyzed by combined prevesical perfusion pressure measurement and microsensor pressure profilometry of the ureterovesical junction, which showed comparable and reproducible fast and slow pressure waves. Cystoscopy revealed that the fast pressure waves were associated with fluid spurts from the ureteral orifice and wrinkling of bladder mucosa over the ureterovesical junction. During slow pressure waves only initial decreases in outflow from the orifice may occur. After dissection of the detrusor muscle at the UVJ only fast pressure waves were recorded. At similar pressure measurements on an inactivated ureter segment which was obliquely passed through the bladder wall only slow pressure waves could be detected. It is concluded that the fast pressure waves of the ureterovesical pressure profile represent peristaltic activity which is generated at the ureterovesical junction and by which fluid may be discharged into the bladder. The slow pressure waves of the pressure profile reflect impairment of flow through the ureterovesical junction by detrusor activity.