Correlation Between Nitric Oxide and Urodynamics in Men With Bladder Outlet Obstruction / 대한배뇨장애요실금학회지

Purpose@#To investigate the correlation between nitric oxide (NO) and urodynamics in men with bladder outlet obstruction (BOO) by analyzing nitric oxide synthase (NOS) in the urothelium. @*Methods@#We prospectively enrolled 25 men who planned to undergo surgical treatment for benign prostatic obstruction and identified as BOO in the preoperative urodynamics. Bladder tissue was taken during surgical prostate resection. Expressions of endothelial NOS (eNOS), inducible NOS (iNOS), and neuronal NOS (nNOS) in the urothelium were analyzed, and their correlation with urodynamic parameters was also assessed in all patients. We also compared the expressions of eNOS, iNOS, and nNOS between BOO with detrusor underactivity (DU) group and BOO without DU group. @*Results@#In all patients, the level of eNOS positively correlated with maximal flow rate and with maximum cystometric capacity (MCC). The level of iNOS positively correlated with MCC. nNOS levels were positively correlated with detrusor pressure at maximal flow and with bladder contractility index in all patients. The level of eNOS, iNOS, and nNOS did not significantly differ between BOO without DU group and BOO with DU group. @*Conclusions@#This study suggests that NO was correlated with bladder dysfunction in men with BOO. Particularly, nNOS may reflect the change in detrusor function.

Management of Urinary Incontinence With Underactive Bladder: A Review / 대한배뇨장애요실금학회지

Urinary incontinence is caused by storage function failure, while underactive bladder (UAB) is caused by a decline in detrusor contractility and voiding dysfunction. As the treatment mechanisms for incontinence and UAB are contrary to each other, it is difficult to treat both incontinence and UAB, and the patient’s quality of life can be further degraded. Conventional midurethral sling (MUS), such as transobturator tape or retropubic MUS, introduces a risk of postoperative voiding dysfunction in stress urinary incontinence with UAB. However, there have been several reports about the efficacy and safety of conventional MUS. Adjustable sling procedures, such as transobturator adjustable tape or the Remeex system, have better outcomes than conventional MUS because they control tension both during and after surgery. When voiding dysfunction occurs after incontinence treatment with UAB, voiding symptoms can be improved by various therapeutic modalities. Clean intermittent catheterization is recommended for patients with significant increased postvoid residual volumes or urinary retention. Although pharmacotherapy such as with alpha-blockers or parasympathomimetics can be considered for UAB, there is insufficient evidence of their effect on incontinence with UAB. Future therapies, such as stem cell therapy or gene therapy, may be used to treat incontinence with UAB. The possibility of management urgency urinary incontinence that related to detrusor hyperactivity with impaired contractility using sacral neuromodulation has been suggested. Further research is needed to establish evidence for the efficacy and safety of treatments for incontinence with UAB and improve patient quality of life.

The Effect of Daily Low Dose Tadalafil on Cerebral Perfusion and Cognition in Patients with Erectile Dysfunction and Mild Cognitive Impairment

OBJECTIVE: The aims of this study were to investigate the effects of daily low-dose tadalafil on cognitive function and to examine whether there was a change in cerebral blood flow (CBF) in patients with erectile dysfunction (ED) and mild cognitive impairment. METHODS: Male patients aged 50 to 75 years with at least three months of ED (International Index of Erectile Function [IIEF]-5 score ≤ 21) and mild cognitive impairment (Montreal Cognitive Assessment [MoCA] score ≤ 22) were included in the study. The subjects were prescribed a low-dose PDE5 inhibitor (tadalafil 5 mg) to be taken once daily for eight weeks. Changes in MoCA score and single-photon emission computed tomography (SPECT) study between the two time-points were assessed by paired t tests. RESULTS: Overall, 30 male patients were assigned to the treatment group in this study and 25 patients completed the eight-week treatment course. Five patients were withdrawn due to adverse events such as myalgia and dizziness. Mean baseline IIEF and MoCA scores were 7.52 ± 4.84 and 18.92 ± 1.78. After the eight-week treatment, mean IIEF and MoCA scores were increased to 12.92 ± 7.27 (p < 0.05) and 21.8 ± 1.71 (p < 0.05), respectively. Patients showed increased relative regional CBF in the postcentral gyrus, precuneus, and brainstem after tadalafil administration versus at baseline (p < 0.001). CONCLUSION: The results of this prospective clinical study suggest that daily use of tadalafil 5 mg increases some regional CBF and improves cognitive function in patients with ED and mild cognitive impairment.

Factors Associated With Early Recovery of Stress Urinary Incontinence Following Holmium Laser Enucleation of the Prostate in Patients With Benign Prostatic Enlargement / 대한배뇨장애요실금학회지

PURPOSE: To investigate factors associated with early recovery of stress urinary incontinence (SUI) following holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic enlargement (BPE). METHODS: The medical records of 393 patients who underwent HoLEP for BPE were retrospectively reviewed. Patients with SUI following HoLEP were selected and divided into 2 groups: those who experienced early recovery of SUI and those who experienced persistent SUI. Recovery of SUI within 1 month after HoLEP was defined as early, and SUI that remained present after 1 month was defined as persistent. Preoperative clinical and urodynamic factors, as well as perioperative factors, were compared between groups. RESULTS: SUI following HoLEP was detected in 86 patients. Thirty-three patients exhibited recovery of SUI within 1 month, and SUI remained present in 53 patients after 1 month. Multivariate analysis showed that the transition zone prostate volume (odds ratio [OR], 5.354; 95% confidence interval [CI], 1.911–14.999; P=0.001) and the enucleation ratio (OR, 8.253; 95% CI, 1.786–38.126; P=0.007) were significantly associated with early recovery of SUI. CONCLUSIONS: Early recovery of SUI within 1 month following HoLEP was associated with transition zone prostate volume and the enucleation ratio.

Pathophysiology of lower urinary tract dysfunction in the older patient

Understanding the pathophysiology of lower urinary tract dysfunction in the elderly is necessary for the adequate management of lower urinary tract dysfunction, as aging causes anatomical and functional changes in the lower urinary tract. While epithelium atrophy of genitourinary organs and detrusor muscle changes occur in elderly women, due to estrogen decline, prostate enlargement may lead to bladder outlet obstruction and wall thickening in elderly men. Urodynamic changes that occur with aging include bladder outlet obstruction, detrusor overactivity and underactivity, decreased bladder compliance, and detrusor hyperactivity with impaired contractility. Moreover, impaired mobility, central nervous system diseases, non-genitourinary comorbidities, and various medications can also influence lower urinary tract function. Among these age-associated multifactorial conditions, adequate differentiation and management of the factors responsible for lower urinary tract dysfunction is of paramount importance in elderly patients.

The Changes of Psychometric Profiles after Medical Treatment of Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia

OBJECTIVE: To investigate the relationship of somatization and depression with the degree of lower urinary tract symptoms suggestive of benign prostate hyperplasia (LUTS/BPH) and changes in psychometric profiles including somatization and depression after treatment of LUTS/BPH. METHODS: Subjects were evaluated at baseline and at week 12 following routine treatment for LUTS/BPH using the International Prostate Symptom Score (IPSS) to measure the severity of LUTS/BPH, the Overactive Bladder Symptom Score (OABSS) to measure the severity of OAB, the Patient Health Questionnaire-9 (PHQ-9) to assess depression, and the Patient Health Questionnaire-15 (PHQ-15) to evaluate somatization. The correlation of somatization and depression with the degree of LUTS/BPH symptoms at baseline and changes in somatization and depression after LUTS/BPH treatment were assessed using relevant statistical analyses. RESULTS: One hundred and twenty patients agreed to participate in this study, and 101 (84.2%) completed the 12-week trial and responded to the study questionnaires. At baseline, total IPSS score was correlated with PHQ-9 (r=0.475, p=0.005) and PHQ-15 (r=0.596, p<0.001) scores. The results after the 12-week treatment clearly show significant improvement in both PHQ-9 (p <0.001) and PHQ-15 (p=0.019) scores, and the PHQ-9 (r=0.509, p=0.048) and PHQ-15 (r=0.541, p=0.016) scores were positively correlated with total IPSS. CONCLUSION: Our preliminary results indicated that severity of LUTS is correlated with severity of somatization and depression. Further, the improvement of LUTS after treatment may have positive impacts on somatization and depression.

Preoperative Factors Affecting Postoperative Early Quality of Life During the Learning Curve of Holmium Laser Enucleation of the Prostate / 대한배뇨장애요실금학회지

PURPOSE: The aim of this study was to investigate the preoperative factors related to early quality of life (QoL) in patients with benign prostatic hyperplasia after holmium laser enucleation of the prostate (HoLEP) during the surgeon's learning curve. METHODS: The medical records of 82 patients with a follow-up period of at least 3 months who were treated with HoLEP during the time of a surgeon's learning curve were analyzed retrospectively. We divided the patients into two groups on the basis of the QoL component of the International Prostate Symptom Score (IPSS) 3 months after HoLEP: the high QoL group (IPSS/QoL or =4). Preoperative factors in each group were compared, including prostate volume, prostate-specific antigen, history of acute urinary retention (AUR), urgency incontinence, IPSS, and urodynamic parameters. Detrusor underactivity was defined as a bladder contractility index less than 100 on urodynamic study. RESULTS: A total of 61 patients (74.3%) had a high QoL, whereas 21 (25.7%) had a low QoL. A history of AUR, detrusor pressure on maximal flow (PdetQmax), bladder outlet obstruction grade, bladder contractility index, and detrusor underactivity were associated with postoperative QoL in the univariate analysis. In the multivariate analysis, a history of AUR and PdetQmax were independent factors affecting postoperative QoL. CONCLUSIONS: A history of AUR and bladder contractility affect early QoL, and preoperative urodynamic study plays an important role in the proper selection of patients during the HoLEP learning curve.

Current Trends in the Management of Post-Prostatectomy Incontinence

One of the annoying complications of radical prostatectomy is urinary incontinence. Post-prostatectomy incontinence (PPI) causes a significant impact on the patient's health-related quality of life. Although PPI is stress urinary incontinence caused by intrinsic sphincter deficiency in most cases, bladder dysfunction and vesicourethral anastomotic stenosis can induce urine leakage also. Exact clinical assessments, such as a voiding diary, incontinence questionnaire, pad test, urodynamic study, and urethrocystoscopy, are necessary to determine adequate treatment. The initial management of PPI is conservative treatment including lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder training. An early start of conservative treatment is recommended during the first year. If the conservative treatment fails, surgical treatment is recommended. Surgical treatment of stress urinary incontinence after radical prostatectomy can be divided into minimally invasive and invasive treatments. Minimally invasive treatment includes injection of urethral bulking agents, male suburethral sling, and adjustable continence balloons. Invasive treatment includes artificial urinary sphincter implantation, which is still the gold standard and the most effective treatment of PPI. However, the demand for minimally invasive treatment is increasing, and many urologists consider male suburethral slings to be an acceptable treatment for PPI. The male sling is usually recommended for patients with persistent mild or moderate incontinence. It is necessary to improve our understanding of the pathophysiologic mechanisms of PPI and to compare different procedures for the development of new and potentially better treatment options.

Effect of 5-alpha Reductase Inhibitor on Storage Symptoms in Patients with Benign Prostatic Hyperplasia / 대한배뇨장애요실금학회지

PURPOSE: Many patients with benign prostatic hyperplasia (BPH) have storage symptoms. The aim of this study was to evaluate the effects of treatment with a 5-alpha reductase inhibitor (5ARI) on storage symptoms in patients with BPH. METHODS: This study was conducted in 738 patients with lower urinary tract symptoms secondary to BPH. Patients with a prostate volume of higher than 30 mL on the transrectal ultrasound were classified into two groups: group A, in which an alpha blocker was solely administered for at least 12 months, and group B, in which a combination treatment regimen of an alpha blocker plus 5ARI was used. This was followed by an analysis of the changes in parameters such as the total International Prostate Symptom Score (IPSS), voiding symptom subscore, and storage symptom subscore between the two groups. In addition, we examined whether there was a significant difference between the two groups in the degree of change in storage symptoms between before and after the pharmacological treatment. RESULTS: Of the 738 men, 331 had a prostate volume > or =30 mL, including 150 patients in group A and 181 patients in group B. Total IPSS, the voiding symptom subscore, and the storage symptom subscore were significantly lower after treatment than before treatment in both groups (P0.05). CONCLUSIONS: Alpha blocker and 5ARI combination treatment is effective for patients with BPH including storage symptoms. However, 5ARI does not exert a significant effect on storage symptoms in BPH patients.

The Difference of Pelvic Floor with Dynamic MRI before and after Tension Free Vaginal Tape Procedure in Female Stress Urinary Incontinence

PURPOSE: Tension-free vaginal tape(TVT) procedure is an effective surgical procedure for the treatment of female urinary stress incontinence. The purpose of this study was to evaluate the changes of pelvic floor MR imaging findings after tension-free vaginal tape procedure on stress urinary incontinent women. MATERIALS AND METHODS: Thirty two women with complaint of stress urinary incontinence(mean age, 56 years; age range 32~73 years) were included in this study. Pelvic floor MR imaging were performed preoperatively and one month after surgery. The position of the bladder neck in relation to the pubococcygeal line, the position of the bladder neck in relation to a perpendicular line through the posterior edge of symphysis pubis, the angle of urethral inclination were measured. We also measured the position of anterior wall of the urethra in relation to posterior edge of the symphysis pubis and cystocele during resting and pelvic straining and thickness of the anterior wall. We compared all parameters between resting and stress. RESULTS: Twenty nine patients(91%) had normal voiding pattern after TVT procedure. three patients(9%) had voiding difficulty. The position and mobility of the bladder neck during straining showed significant improvement after surgery(p<0.01). During straining, the length between the urethra and the inferior edge of the pubic symphysis with mid-urethra angulation was shorten in twenty eight patients(88%). There is no significant difference among three groups in all parameters. However, 3 patients with voiding difficulty had the significant high bladder neck and moderate cystocele. CONCLUSION: The TVT procedure provides decrease of urethral hypermobility and increase of mid-urethral angulation. MR imaging demonstrate well that urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed at stress. Postoperative voiding difficulty may be related to remaining cystocele and high bladder neck.

Role of Transurethral Resection of the Prostate in the Diagnosis of Prostate Cancer for Patients with Lower Urinary Tract Symptoms and Serum PSA 4-10ng/ml with a Negative Repeat Transrectal Needle Biopsy of Prostat / 대한비뇨기과학회지

PURPOSE: Transrectal needle biopsy of the prostate is a definitive diagnostic procedure for prostate cancer. However, the sensitivity of a third biopsy is very low in patients with serum prostate-specific antigen(PSA) 4-10 ng/ml and negative repeat prostate biopsy. In addition, multiple prostate biopsies usually have low patient compliance due to the pain and complications associated with the procedure. The aim of this study was to evaluate the role of transurethral resection of the prostate(TURP) for the diagnosis of prostate cancer in patients with lower urinary tract symptoms and clinical suspicion but with negative repeat biopsy samples. MATERIALS AND METHODS: From January 2000 to December 2006, 51 patients less than 80 years old underwent TURP at our institution for lower urinary tract symptoms with a serum PSA 4-10ng/ml and negative repeat transrectal needle biopsy of the prostate. We examined their first serum PSA, serum PSA before the TURP, PSA density, as well as their age, prostate size and digital rectal exam findings. The probability for the detection of prostate cancer by TURP was investigated retrospectively. RESULTS: Prostate cancer was detected in seven patients(13.7%). The total Gleason score for the biopsy specimens was 5 in two patients, 6 in one patient and 7 in four patients. There were significant differences between the prostate cancer group and the benign prostate hypertrophy group with regard to the PSA density and prostate volume. However there were no significant differences between the first serum PSA and the serum PSA before TURP in the two groups. CONCLUSIONS: In case with a high suspicion for prostate cancer, the TURP helps in the diagnosis of prostate cancer in those patients with a negative repeat biopsy and a serum PSA 4-10ng/ml and improvement of their lower urinary tract symptoms.

Comparison of the Complications and Urodynamic Parameters for Orthotopic Bladder Substitution with using Ileocolic or Ileal Segments after Radical Cystectomy / 대한비뇨기과학회지

PURPOSE: The objective of this study was to compare the complications and urodynamic parameters of the patients who underwent orthotopic bladder substitution with using ileocolic or ileal segments after radical cystectomy for treating invasive bladder cancer. MATERIALS AND METHODS: Between January 1990 and April 2006, 260 patients with invasive bladder cancer underwent radical cystectomy and construction of the urinary diversion; ileal conduit, indiana pouch, ileocolic neobladder, ileal neobladder were all done at St. Mary's Hospital. The mean age of the patient was 61.8 years (range: 46-86). The ratio of male and female was 88%/12%. Forty nine patients received an orthotopic ileocolic neobladder and 45 patients received an orthotopic ileal neobladder. The complications and urodynamic parameters were compared in both groups. RESULTS: The orthotopic ileocolic neobladder after radical cystectomy for treating invasive bladder cancer has been performed between 1990 and 1996 and the orthotopic ileal neobladder has been performed between 1996 and 2006. Ileocolic neobladder related complications developed in 10 patients; neobladder leakage in 1 (2%), neobladder rupture in 1 (2%), stricture of the ureteroenteric anastomosis site in 4 (8.2%), and stricture of the urethral anastomosis site in 4 (8.2%). Ileal neobladder related complications developed in 11 patients; ureteroenteric stricture in 7 (15.5%), stricture of the urethral anastomosis site in 3 (6.6%) and acute pyelonephritis in 1 (2.2%). The results of the mean maximal flow rate and mean postvoid residual volume were better in the ileal neobladder group than those in the ileocolic neobladder group. CONCLUSIONS: There were no significant differences in complications between ileocolic neobladder and ileal neobladder. The maximal uroflow and residual urine volume of the ileal neobladder were superior to those of the ileocolic neobladder on urodynamic study.