[Urodynamics of the bladder diverticulum in the adult male]. / La urodinámica del diverticulo vesical en el varón adulto.

OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of adult males with BPH and bladder diverticula, and to analyze the changes in urodynamics in patients undergoing lower urinary tract surgery to relieve obstruction, with or without associated diverticulectomy. METHODS: We studied 91 patients in two groups: Group 1- BPH: 67 cases (73.6%) and Group 2-BPH + diverticulum: 24 cases (25%). Mean age was 65.04 years. All patients underwent urological physical examination and complete urodynamic study including cystogram. In addition, we studied 19 patients with BPH and bladder diverticula (mean age 64.58 years) who underwent either endoscopic surgery (1 I cases; 57.9%) or endoscopic surgery plus diverticulectomy (8 cases, 42. 1%). Complete clinical study and urodynamics (including cystogram) were performed preoperative and three months after surgery. Statistical significance was established at 0.05. RESULTS: Comparative study between group 1 (BPH) and group 2 (BPH with diverticulum): there were significant differences in clinical data: acute urinary retention (6.1% vs. 25%;p<0.01), and urinary tract infection (3.1% vs. 21.7%;p=0,004). All evaluated cases had single diverticula (8 cases). Urodynamic studies showed: 1) Post-void residual after free flowmetry: 45.9 ml vs. 221.4 ml, p = 0.008. 2) Bladder capacity on cystometrogram: 211.2 ml vs. 350.8 ml, p = 0.024. 3) Voiding pressure/flow study: a) Voiding with abdominal press 23.9% vs. 50%, p = 0.02. b) URA 36.5 cm H2O vs. 48.5 cm H2O, p= 0.04, c) post void residual 70.7ml vs. 210.3 ml, p= 0.004. d) Bladder contractility measurements (Wmax- isometric contractility- and W80, W20- isotonic contractility) did not show significant differences between groups. Bladder contractility duration was significantly decreased in group 2. In the analysis of patients undergoing surgery to relieve obstruction (Group A- Surgery without diverticulectomy; Group B Surgery with diverticulectomy) there were not differences between groups in clinical data. Urethral resistance parameters (URA) decreased in both groups. Group A: from 43 cm H20 to 26.3 cm H2O. Group B: from 60.6 cm H2O to 48 cm H2O. This decrease was similar after either TURP or myocapsulotomy. Post void residual diminished in both groups. There were no statistical differences between groups in Wmax, W 80-20, or volume, number and site of the diverticula. On the contrary, bladder contractility duration diminished after diverticulectomy. CONCLUSIONS: Bladder diverticula appear in the cases with highest ureteral resistance values (lower urinary tract obstruction). Standard bladder contractility parameters were not diminished. Duration of detrusor contraction was the only contractility parameter significantly affected in cases of bladder diverticula and presented a significant association with the use of abdominal press while voiding. Diverticulectomy showed an improvement of bladder contractility with longer detrusor contraction duration, which supports its use in cases of BPH-associated diverticula. Both TURP and transurethral incision of the prostate diminished urethral resistance in a similar way, so that they may be considered alternative options. Our data should be confirmed with a bigger sample size.

La urodinámica del divertículo vesical en el varón adulto / Urodynamics of the bladder diverticulum in the adult male

OBJETIVOS: Valorar las características clínicas y urodinámicas de una serie de varones adultos con HBP y divertículos vesicales y analizar los cambios urodinámicos en pacientes sometidos a desobstrucción del tracto urinario inferior con o sin diverticulectomía asociada. MÉTODOS: Se estudiaron 91 pacientes en 2 grupos: Grupo 1 con HBP: 67 casos (73.6%) y grupo 2 conHiperplasia Benigna de Próstata (HBP) + divertículo: 24 casos ( 25%). La edad media fue de 65.04 años. A todos ellos se les sometió a exploración física urológica y estudio urodinámico completo, incluyendo cistografías. Por otro lado, se estudiaron 19 pacientes con HBP y divertículos vesicales, (edad media de 64.58 años), a los que se sometió a cirugía endoscópica desobstructiva (11 casos; 57.9%), y cirugía endoscópica desobstructiva con diverticulectomía (8 casos, 42.1%). Se realizó un estudio clínico y urodinámico completo (incluyendo cistografías), preoperatorio, y transcurridos 3meses de la cirugía. La probabilidad de los diferentes análisis estadísticos cualitativos y cuantitativos se consideró significativa por debajo de 0.05. RESULTADOS: Estudio comparativo HPB (grupo 1) vs HPB+divertículo (grupo 2): Existieron diferencias significativas entre ambos grupos en los datos clínicos referentes a: retención aguda de orina (RAO): (HPB: 6.1%; HPB+divertículo: 25% p< 0.01), e infecciones urinarias (HPB:3.1%; HPB+divertículo: 21.7%; p = 0.004). Las características de los divertículos correspondieron a divertículos únicos en todos los casos valorados (8 casos). Los estudios urodinámicos demostraron como datos significativos: 1). residuo postmiccional de la flujometría libre (p= 0.008), 45.9 ml para grupo 1 y 221.4 ml para grupo 2. 2). Capacidad vesical de la cistomanometría (p= 0.024) 211.2 ml para grupo 1 y 350.8 ml para grupo 2. 3). Parámetros del test presión detrusor/ flujo miccional: a) micción con prensa abdominal(p= 0.02), 23.9% para grupo 1 y 50% en el grupo 2, b) URA (p= 0.04) 36.5 cm H2O para grupo1 , y 48.5 cm H2O para grupo 2, c) residuo postmiccional ( p= 0.004) 70.7 ml para grupo 1 y 210.3 ml para grupo 2. d) las medidas habituales de la contractilidad vesical ( Wmax: contractilidad isométrica y W80 - W20: contractilidad isotónica) no mostraron diferencias significativas entre ambos grupos. Por el contrario, la duración de la contractilidad vesical se encontró disminuída significativamente en el grupo 2. En el grupo de pacientes sometidos a desobstrucción (grupo A) y desobstrucción con diverticulectomia (grupo B), no se demostraron diferencias significativas en losdatos clínicos entre ambos grupos. Los parámetros de resistencia uretral (URA) disminuyeron en ambos grupos. En el grupo A, de 43 cm. de H2O a 26.3 cm H20. En el grupo B, de 60.6 cm. H2O a 48 cm. H2O. Esta disminución fue similar en los casos sometidos a RTUp y Miocapsulotomía (MC). El residuo postmiccional de la flujometría libre y del estudio presión/flujo disminuyó en ambos grupos. No se demostraron diferencias significativas entre ambos grupos en los parámetros Wmax y W80-20, así como lo relativo al volumen, número y localización de los divertículos. Por el contrario, la duración de la contractilidad vesical aumentó postdiverticulectomía. CONCLUSIONES Los divertículos vesicales se presentaron en los casos con valores más altos de resistencia uretral (obstrucción del tracto urinario inferior). Los parámetros de medida habituales de contractilidad vesical (Wmax y W80-W20), no estaban disminuidos. El único parámetro significativo de contractilidad afectado en los casos de divertículos vesicales, fue la duración de la contracción del detrusor (medido por el residuo postmiccional , en el test presión detrusor/ flujo miccional), y que presentó asociación significativa con la micción con prensa abdominal). La diverticulectomíademostró la mejoría de la contractilidad vesical con una mayor duración de la contracción del detrusor, lo que apoyaría su realización en los casos de divertículos vesicales asociados a HBP. En la cirugía endoscópica desobstructiva prostática asociada, la RTUp y MC disminuyeron similarmente la resistencia uretral, con lo que se pueden considerar técnicas alternativas.Nuestros datos deberían ser contrastados con un mayor tamaño de la muestra

OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of adult males with BPH and bladder diverticula, and to analyze the changes in urodynamics in patients ndergoing lower urinary tract surgery to relieve obstruction, with or without associated diverticulectomy. METHODS: We studied 91 patients in two groups: Group 1- BPH: 67 cases (73.6%) and Group 2-BPH + diverticulum: 24 cases (25%). Mean age was 65.04 years. All patients underwent urological physical examination and complete urodynamic study including cystogram. In addition, we studied 19 patients with BPH and bladder diverticula (mean age 64.58 years) who underwent either endoscopic surgery (11 cases; 57.9%) or endoscopic surgery plus diverticulectomy (8 cases, 42.1%). Complete clinical study and urodynamics (including cystogram) were performed preoperative and three months after surgery. Statistical significance was established at 0.05. RESULTS: Comparative study between group 1(BPH) and group 2 (BPH with diverticulum): there were significant differences in clinical data: acute urinary retention (6.1% vs. 25%;p<0.01), and urinary tract infection (3.1% vs. 21.7%;p=0,004). All evaluated cases had single diverticula(8 cases). Urodynamic studies showed: 1) Post-void residual after free flowmetry: 45.9 ml vs. 221.4 ml, p = 0.008. 2) Bladder capacity on cystometrogram: 211.2 ml vs. 350.8 ml, p = 0.024. 3) Voiding pressure/flow study: a) Voiding with abdominal press 23.9% vs. 50%, p = 0.02. b) URA 36.5 cm H2O vs. 48.5 cm H2O, p= 0.04, c) post void residual 70.7ml vs. 210.3 ml, p= 0.004. d) Bladder contractility measurements (Wmax- isometric contractility- and W 80, W20— isotonic contractility) did not show significant differences between groups. Bladder contractility duration was significantly decreased in group 2. In the analysis of patients undergoing surgery to relieve obstruction (Group A- Surgery without diverticulectomy; Group B Surgery with diverticulectomy) there were not differences between groups in clinical data. Urethral resistance parameters (URA) decreased in both groups. Group A: from 43 cm H2O to 26.3 cm H2O. Group B: from 60.6 cm H2O to 48 cm H2O. This decrease was similar after either TURP or myocapsulotomy. Post void residual diminished in both groups. There were no statistical differences between groups in Wmax, W 80-20, or volume, number and site of the diverticula. On the contrary, bladder contractility duration diminished after diverticulectomy. CONCLUSIONS: Bladder diverticula appear in the cases with highest ureteral resistance values (lower urinary tract obstruction). Standard bladder contractility parameters were not diminished. Duration of detrusor contraction was the only contractility parameter significantly affected in cases of bladder diverticula and presented a significant association with the use of abdominal press while voiding

[Factors for voiding dysfunction and cystocele]. / Factores de descompensación miccional y cistocele.

OBJECTIVES: To evaluate the clinical and urodynamic features of a series of women with post void residual urine (disbalanced voiding) and various degrees of associated cystocele. METHODS: 119 female patients were studied by clinical evaluation, urodynamics, and imaging tests (VCUG). All patients underwent history and genitourological examination (evaluating cystoceles from grade o to 3), neuro-urological examination, and complete urodynamic study. Fifty patients (42%) underwent radiological studies of the upper urinary tract. Disbalanced voiding was defined as existence of post void residual greater than 20% of the voided volume. Urethral resistance was measured by URA. Structural obstruction was characterized by PURR (CHESS classification). Functional obstruction was studied by DURR and perineal EMG (associated with flowmetry). Detrusor contractile power was evaluated by W max, W 80-20, and duration of contraction. Urodynamic terminology and measurements complied with the International Continence Society (ICS) standards. Statistical significance was established at 0.05. Statistical analysis was done by Student's t for quantitative variables, and Pearson's chi-square for non parametric variables. RESULTS: 119 patients were enrolled. Mean age was 55.84 yr. (range 15-87). Regarding post void residual (114 valid uroflowmetry studies), 25 patients were classified as voiding disbalance (21.9%) and 89 as balanced (74.8%). Regarding clinical data, there were only significant differences between groups in voiding difficulty. For uroflowmetry, only the percentile of the Maximal flow (Qmax) showed significant differences (35 vs. 22 for balanced/disbalanced voiding respectively, p = 0.02). Pressure/volume studies demonstrated bladder hyperactivity in 16 cases (64%) in the group of disbalanced voiding and 31 cases (34.8%) in the normal voiding group (p = 0.008), which presented associated with increased urethral resistance (URA)(p = 0.01) . In the pressure/flow study, there were significant differences in the URA (14.7 vs. 25.3, p = 0.001). There were statistically significant differences in the degree of constrictive (0.5 vs. 1.1, p = 0.009) and compressive (0.5 vs. 1.1; p = 0.04) obstruction (Chess classification). There were not significant differences in the analysis of isometric contractility (Wmax), but there were in the isotonic contractility (W80-20) and detrusor contraction duration. These latter differences presented significant association with the degree of cystocele. DURR and perineal EMG data did not show differences between groups. Radiological abnormalities of urethral morphology were statistically different between groups, presenting in 10% of the patients with normal voiding and 50% of the disbalanced voiding group, although there was not statistical association with obstruction (p = 0.64). The existence of cystocele did not show a statistical association with these variables either. CONCLUSIONS: Disbalanced voiding appeared with organic obstruction of the lower urinary tract (constrictive most significantly), as well as detrusor abnormal contractility, but whereas the first was not significantly associated with presence and grade of cystocele, the second showed such association.

Alteraciones de la fase de llenado vesical y cistocele / Filling phase abnormalities and cystocele

OBJETIVOS: Valorar las características clínicas y urodinámicas de una serie de mujeres con sintomatologíadel tracto urinario inferior (de la fase de llenadovesical) y que presentaban diversos grados de cistocele. MÉTODOS: Se estudiaron 119 pacientes de sexo femenino, siendo la edad media de las mismas de 55,8 años (rango 15-87). A todas ellas se les sometió a exploración física uroginecológica (valorando el grado de cistocele ,al valsalva, de 0 a 3), y estudio urodinámico completo. La terminología urodinámica y medidas siguieron las normas de la International Continence Society (ICS). La probabilidad de los diferentes análisis estadísticos se consideró significativa por debajo de 0.05, analizándose las variables cuantitativas mediante el test de la T de Student y las variables no paramétricas, mediante la chi cuadrado de Pearson. RESULTADOS: El síntoma mas frecuentemente referido fue la incontinencia urinaria con la tos (77 de 118, 65,3%), seguido de la incontinencia precedida de urgencia miccional (71 pacientes, 60,2%). El grado de cistocele fue 0 en el 31,1%, 1 en el 25,2%, 2 en el 26,1%, y 3 en el 17,6%. Se observó relación estadísticaentre grado de cistocele y el síntoma “bulto en vagina”(p=0,00002). La presencia de cistocele no presentórelación estadística alguna con los síntomas funcionalesde almacenamiento del tracto urinario inferior.La capacidad vesical cistomanométrica tuvo un promediode 224,8 ml. Se demostraron contracciones involuntariasdel detrusor en 38 casos (31,9%), incontinenciaurinaria de esfuerzo en 19 (16%), mixta en 8 (6,7%) y no demostración de incontinencia urinaria en 58 casos (48,7%). Las pacientes con urgencia miccional tuvieron una capacidad vesical menor que aquellas sin este síntoma (p=0,02), al igual que las pacientes con el síntoma urgencia incontinencia (p=0,01). Se relacionó significativamente la nicturia (p=0,005), la urgencia miccional (p=0,02) y la urgencia incontinencia (p=0,01) con la disminución de la capacidad vesical. Se relacionó estadísticamente la existencia de contracciones involuntarias con el síntoma urgencia incontinencia(p=0,01). Las pacientes con contraccionesinvoluntarias en el llenado presentaron un incrementode la frecuencia miccional diurna (p=0,02), así comoen el caso de ausencia de incontinencia urinaria deesfuerzo (p=0,04). El síntoma incontinencia a la tos serelacionó significativamente (p=0,01) con el diagnósticourodinámico de incontinencia urinaria de esfuerzo.La capacidad vesical se encontró aumentada en el cistocele grado 3 (p=0,003). La presencia de cistoceleno se relacionó con la hiperactividad vesical (p=0,65),al igual que el diagnóstico de incontinencia urinaria deesfuerzo (p=0,37). CONCLUSIONES: No se ha demostrado ninguna relación entre la presencia y grado de cistocele por una parte, y los síntomas funcionales del tracto urinario inferior de almacenamiento, y datos urodinámicos de hiperactividad vesical y de incontinencia de esfuerzo, por otra parte. Esto tendría importantes implicaciones terapéuticas

OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of women with lower urinary tract symptoms (bladder filling phase) presenting various rates of cystocele. METHODS: 119 female patients were included in this study; mean age was 55.8 yr. (range 15-87). All patients underwent urogynecologic physical examination (cystocele was graded 0-3) and complete urodynamic study. Urodynamic terminology and measurements comply with the ICS (InternationaL Continence Society) standards. Statistical significance was established below 0.05. Quantitative variables were compared by the Student’s t and non parametric variables by Pearson`s chi-square. RESULTS: The most frequently reported symptom was urinary incontinence when coughing (77/118, 65.3%), followed by urge incontinence (71 patients, 60.2%). The grade of cystocele was 0 in 31.1%, 1 in 25.2%, and 2 in 26.1%, and 3 in 17.6%. There was a statistically significant association between grade of cystocele and the symptom “vaginal bulge” (p=0,00002). The presence of cystocele did not show any statistical association with lower urinary tract symptoms of the filling phase. Mean cystomanometric bladder capacity was 224.8 ml. Involuntary contractions of the detrusor muscle appeared in 38 cases (21.9%), stress urinary incontinence in 19 (16%), mixed incontinence in 8 (6.7%) and absence of evidence of urinary incontinence in 58 (48.7%). Patients with urgency had a lower bladder capacity than patients without it (p = 0.02), as did patients with urge incontinence (p = 0.02). Nocturia (p = 0.05), urgency (p = 0.02) and urge incontinence (p = 0.01) were significantly associated to bladder capacity. The existence of involuntary contractions was statistically associated with urge incontinence (p = 0.01). Patients with involuntary contractions during the filling phase showed increased diurnal voiding frequency (p = 0.02), as well as patients without a stress urinary incontinence (p =0.04) and cases without a stress urinary incontinence (p = 0.04). The symptom incontinence with coughing had a significant statistical association with the urodynamic diagnosis of stress urinary incontinence (p= 0.01). Bladder capacity was augmented in grade 3 cystocele (p= 0.003). The existence of cystocele was not associated with bladder hyperactivity (p = 0.65), neither was the diagnosis of a stress urinary incontinence (p = 0.37). CONCLUSIONS: No relationship has been demonstrated between existence and degree of cystocele and functional lower urinary tract symptoms of the filling phase, on the one hand, and urodynamic evidence of bladder hyperactivity and incontinence on the other hand. This could have important therapeutic implications

Factores de descompensación miccional y cistocele / Factors for voiding dysfunction and cystocele

OBJETIVOS: Valorar las características clínicasy urodinámicas de una serie de mujeres con residuopostmiccional (micción descompensada) y diferentesgrados de cistocele asociado.MÉTODOS: Se estudiaron 119 pacientes de sexofemenino mediante evaluación clínica, urodinámica, yradiológica (cistouretrografías). Todas las pacientes fueronsometidas a historia clínica, exploración física uroginecológica(valorando el cistocele, al vasalva, degrado 0 a grado 3), exploración física neurourológicay estudio urodinámico completo. A 50 pacientes(42%), se les realizó estudio radiológico del tracto urinarioinferior (TUI). Se consideró micción descompensada(MD), la existencia de un residuo postmiccional(RP) mayor del 20% del volumen miccional. La resistenciauretral se midió mediante el URA. La tipificación dela obstrucción estructural se realizó mediante el PURR(clasificación CHESS). El estudio de la obstrucción funcionalse realizó mediante el DURR y la EMG perineal(asociada a la flujometría libre). La potencia contráctildel detrusor se valoró mediante el Wmax, W80-20 yduración de la contracción del detrusor. La terminologíaurodinámica y medidas siguieron las normas de laInternational Continence Society, ICS. La probabilidadde los diferentes análisis estadísticos se consideró significativapor debajo de 0.05, analizándose las variablescuantitativas mediante el test de la T de Student, ylas variables no paramétricas mediante la chi cuadradode Pearson.RESULTADOS: La edad media de las pacientes (119),fue de 55.84 años (rango 15-87). En relación con elRP (114 flujometrías valorables), fueron etiquetadas deMD, 25 pacientes (21.9%) y compensada (MC), 89(74.8%). Respecto a los datos clínicos, solo existierondiferencias significativas (DS) entre ambos grupos en ladificultad miccional. En los datos flujométricos, existierontan solo DS en el percentil (nomogramas deHaylen), del Qmax (35 MC vs 22, MD; p=0,02). Enla cistomanometría, se demostró hiperactividad vesicalen la MD en 16 casos (64%) frente a 31 casos (34,8%)en la MC (p=0,008), que presentó relación con incrementode la resistencia uretral (URA) p=0,01. En el estudioP/F, se demostró DS en el valor del URA (14.7 MCvs 25.3 MD; p=0,001). Existieron DS en los grados deobstrucción constrictiva (0.5 MC vs 1.1 MD; p=0,009)y compresiva (0.02 MC vs 0.4 MD; p=0,04)(clasificaciónCHESS). Estos datos no presentaron relaciónsignificativa con el grado de cistocele. No existieronDS en los análisis de contractilidad isométrica (Wmax),pero sí en la contractilidad isotónica (W80-20) y duraciónde la contracción del detrusor. Estas últimas diferenciassi presentaron relación significativa con elgrado de cistocele. Los datos de DURR y EMG perineposalno arrojaron DS entre ambos grupos. Las alteracionesde la morfología uretral radiológica fueron estadísticamentediferentes entre ambos grupos estandopresente en el 10% de la MC vs 50% de la MD(p=0,01), aunque no presentó relación estadística(p=0,64), con la obstrucción. La presencia de cistocele,así mismo, no modificó estadísticamente ninguno detodos los datos anteriores.CONCLUSIONES: La micción descompensada, acompañótanto a la obstrucción orgánica (más significativamenteconstrictiva) del tracto urinario inferior, como ala afectación contráctil del detrusor, pero, mientras queen la primera condición no se relacionó significativamentecon la presencia y grado de cistocele, en lasegunda si se demostró dicha asociación

OBJECTIVES: To evaluate the clinical and urodynamic features of a series of women with post void residual urine (disbalanced voiding ) and various degrees of associated cystocele. METHODS: 119 female patients were studied by clinical evaluation, urodynamics, and imaging tests (VCUG). All patients underwent history and genitourological examination (evaluating cystoceles from grade 0 to 3), neuro-urological examination, and complete urodynamic study. Fifty patients (42%) underwent radiological studies of the upper urinary tract. Disbalanced voiding was defined as existence of post void residual greater than 20% of the voided volume. Urethral resistance was measured by URA. Structural obstruction was characterized by PURR (CHESS classification). Functional obstruction was studied by DURR and perineal EMG (associated with flowmetry). Detrusor contractile power was evaluated by W max, W 80-20, and duration of contraction. Urodynamic terminology and measurements complied with the International Continence Society (ICS) standards. Statistical significance was established at 0.05. Statistical analysis was done by Student’s t for quantitative variables , and Pearson`s chi-square for non parametric variables. RESULTS: 119 patients were enrolled. Mean age was 55.84 yr. (range 15-87). Regarding post void residual (114 valid uroflowmetry studies), 25 patients were classified as voiding disbalance (21.9%) and 89 as balanced (74.8%). Regarding clinical data, there were only significant differences between groups in voiding difficulty. For uroflowmetry, only the percentile of the Maximal flow (Qmax) showed significant differences (35 vs. 22 for balanced/disbalanced voiding respectively, p = 0.02). Pressure/volume studies demonstrated bladder hyperactivity in 16 cases (64%) in the group of disbalanced voiding and 31 cases (34.8%) in the normal voiding group (p = 0.008), which presented associated with increased urethral resistance (URA)(p = 0.01) . In the pressure/flow study, there were significant differences in the URA (14.7 vs. 25.3, p = 0,001). There were statistically significant differences in the degree of constrictive (0.5 vs. 1.1, p = 0.009) and compressive (0.5 vs. 1.1; p = 0.04) obstruction (Chess classification). There were not significant differences in the analysis of isometric contractility (Wmax), but there were in the isotonic contractility (W80-20) and detrusor contraction duration. These latter differences presented significant association with the degree of cystocele. DURR and perineal EMG data did not show differences between groups. Radiological abnormalities of urethral morphology were statistically different between groups, presenting in 10% of the patients with normal voiding and 50% of the disbalanced voiding group, although there was not statistical association with obstruction (p = 0.64) . The existence of cystocele did not show a statistical association with these variables either. CONCLUSIONS: Disbalanced voiding appeared with organic obstruction of the lower urinary tract (constrictive most significantly), as well as detrusor abnormal contractility, but whereas the first was not significantly associated with presence and grade of cystocele, the second showed such association