urodynamics (pressure-flow) prior to bladder outlet ... · benign prostatic hyperplasia (bph)...
TRANSCRIPT
Urodynamics (Pressure-Flow) prior to
Bladder Outlet Obstruction Intervention
Paul Abrams
Professor of Urology
Bristol Urological Institute
Bern Urology Arena 2017
Disclosures
Paul Abrams
Consultant Pfizer Astellas Ferring Ipsen
Lecturer Astellas Pfizer Ferring Sanofi Sun
Pharma Pierre Fabre
Urodynamics in Male Patients When when not
When
bull Before invasive procedures
bull To pick up dangerous bladders
When not
bull Before conservative and drug therapy
Urodynamics in Male Patients When
When
bull Before invasive procedures
- surgery for LUTS suggestive of BPOBOO
- surgery for OABDO
- surgery for PPI
bull To pick up dangerous bladders (neurourology)
Little evidence for UDS in men who cannot void (acute retention secondary to BPO)
Dr Riekenrsquos Excellent
Bibliography
Pubmed lists more than 80
papersletters to Editor on
bull Urothelial Cancer including NMIBC cystectomy
bull Prostate Cancer
bull Prostatectomy for BPO including green light
with outcome measures Qmax and PVR
bull No urodynamic papers but
bull Good review on ldquoIPPrdquo
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Disclosures
Paul Abrams
Consultant Pfizer Astellas Ferring Ipsen
Lecturer Astellas Pfizer Ferring Sanofi Sun
Pharma Pierre Fabre
Urodynamics in Male Patients When when not
When
bull Before invasive procedures
bull To pick up dangerous bladders
When not
bull Before conservative and drug therapy
Urodynamics in Male Patients When
When
bull Before invasive procedures
- surgery for LUTS suggestive of BPOBOO
- surgery for OABDO
- surgery for PPI
bull To pick up dangerous bladders (neurourology)
Little evidence for UDS in men who cannot void (acute retention secondary to BPO)
Dr Riekenrsquos Excellent
Bibliography
Pubmed lists more than 80
papersletters to Editor on
bull Urothelial Cancer including NMIBC cystectomy
bull Prostate Cancer
bull Prostatectomy for BPO including green light
with outcome measures Qmax and PVR
bull No urodynamic papers but
bull Good review on ldquoIPPrdquo
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Urodynamics in Male Patients When when not
When
bull Before invasive procedures
bull To pick up dangerous bladders
When not
bull Before conservative and drug therapy
Urodynamics in Male Patients When
When
bull Before invasive procedures
- surgery for LUTS suggestive of BPOBOO
- surgery for OABDO
- surgery for PPI
bull To pick up dangerous bladders (neurourology)
Little evidence for UDS in men who cannot void (acute retention secondary to BPO)
Dr Riekenrsquos Excellent
Bibliography
Pubmed lists more than 80
papersletters to Editor on
bull Urothelial Cancer including NMIBC cystectomy
bull Prostate Cancer
bull Prostatectomy for BPO including green light
with outcome measures Qmax and PVR
bull No urodynamic papers but
bull Good review on ldquoIPPrdquo
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Urodynamics in Male Patients When
When
bull Before invasive procedures
- surgery for LUTS suggestive of BPOBOO
- surgery for OABDO
- surgery for PPI
bull To pick up dangerous bladders (neurourology)
Little evidence for UDS in men who cannot void (acute retention secondary to BPO)
Dr Riekenrsquos Excellent
Bibliography
Pubmed lists more than 80
papersletters to Editor on
bull Urothelial Cancer including NMIBC cystectomy
bull Prostate Cancer
bull Prostatectomy for BPO including green light
with outcome measures Qmax and PVR
bull No urodynamic papers but
bull Good review on ldquoIPPrdquo
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Dr Riekenrsquos Excellent
Bibliography
Pubmed lists more than 80
papersletters to Editor on
bull Urothelial Cancer including NMIBC cystectomy
bull Prostate Cancer
bull Prostatectomy for BPO including green light
with outcome measures Qmax and PVR
bull No urodynamic papers but
bull Good review on ldquoIPPrdquo
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Rieken M Bibliography
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement a systematic review and critical analysis of current evidence
Rieken M1 et al
Minerva Urol Nefrol 2017 Dec69(6)548-555
CONCLUSIONS
bull Analysis of IPP may be regarded as potential non-invasive
alternative to standard PFS in the assessment of BOO
Patients with IPPgt10 mm should be counseled regarding the
high chance of need for surgical treatment following acute
urinary retention
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
DU DiagnosisProxies for the Diagnosis of BOOBPO
bull Functional Proxies for obstruction
- Qmax does not distinquish between BOO and DU
- PVR does not distinquish between BOO and DU
bull Anatomical Proxies for obstruction
- Detrusor wall thickness does not distinquish between BOO and DO
- PV and TVP have a weak correlation with BPO
- IPP Grade 3 has an association with BPO
Pressure-flow studies of voiding (PFS) as in any hydrodynamic situation pressure and flow are required for the diagnosis as obstruction is defined by high pressure and low flow
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
1994 BMJ article
Paul Abrams BMJ 1994
LUTSrsquo 21st Birthday April 2015
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Terminology12
1Abrams P BMJ 1994 2McVary KT et al American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH) 2010 Available at httpswwwauanetorgcommonpdfeducationclinical-guidanceBenign-Prostatic-Hyperplasiapdf Accessed June 2016
Benign prostatic
hyperplasia (BPH)
Reserved for the
histological pattern
it describes
Benign prostatic
enlargement (BPE)
Used when there is
gland enlargement
and is usually a
presumptive
diagnosis based on
the size of the
prostate
Benign prostatic
obstruction (BPO)
Used when
obstruction has
been proven by
pressure flow
studies or is highly
suspected from
flow rates and if the
gland is enlarged
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Does this 74 year old man have BPO
11
W
Would you offer this man a TURP
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
12
Would you offer this man a TURP
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Does this 74 year old man have BPO
13
31
8
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Bladder Voiding Function
Three simple indices
bull BOOI (bladder outlet obstruction index)
bull BCI (bladder contractility index)
bull BVE (bladder voiding efficiency)
Abrams P Bladder outlet obstruction index bladder contractility index and bladder voiding efficiency three simple indices to define bladder voiding function BJU Int 1999 Jul84(1)14-5
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
coloured slide of BOOI
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Bladder Contractility Index (BCI)
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Urodynamics Prior to Prostatectomy Why
Before surgery for BPO
bull There are no symptoms diagnostic of BPO
bull There are no signs diagnostic of BPO
bull Urine flow studies are unable to distinquish BPO
from DU as the cause of low flowraised PVR
bull ONLY pressure-flow studies can diagnose BPO
bull SURGERY IS DESIGNED TO RELIEVE BPO
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
ldquoOne or even two Cases donrsquot make a
guideline or a paradigmrdquo
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Evaluation of Evidence
Levels of Evidence are used to derive Grades of Recommendation in Guidelines
bull Level 1 evidence usually involves one or more randomised controlled trials
bull Level 2 evidence includes good quality prospective lsquocohort studiesrsquo
bull Level 3 evidence includes good quality retrospective lsquocase-control studiesrsquo
bull Level 4 evidence includes good quality lsquocase seriesrsquo
bull Level 5 evidence includes expert opinion
Case histories are illustrative but are not evidence
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
PFS predicts outcome after
prostatectomy
Abrams and Griffiths BJ Urol 1979
Neal et al BJ Urol 1987
Speakman et al BJ Urol 1987
Jensen Neurourol Urodyn 1989
Schafer et al World J Urol 1989
Rollema and van Mastrigt J Urol 1992
Van Venrooij et al J Urol 1995
Robertson et al J Urol 1996
Jensen et al BJ Urol 1996
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
PFS predicts outcome after
prostatectomy
Jaole P et al J Urol 1998
Florates and de la Rosette Eur Urol 2000
Rodriques et al J Urol 2001
Machimo et al NUU 2002
Van Venrooij el al J Urol 2002
De Lima and Netto Int Braz J Urol 2003
Hakenburg et al BJU Int 2003
Thomas et al BJU Int 2004
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
PFS Predicts Outcome after
Prostatectomy Recent Evidencebull Zhoa 2014 men with DO do worse
bull Blatt 2012 men with DU do worse
bull Seki 2009 men without DU do better
bull Harding 2007 men without BPO do worse
bull Qi 2012 men without BPO do worse
bull Losco 2013 men without BPO do worse
bull Dib 2008 46 of diabetic LUTS men have no BPO
bull Madersbacher 1996 80 of LUTS men over 80 have no BPO
bull Masurmori 2010 men without BPO deteriorate faster after TURP
bull Welliver 2015 men in ldquoShamrdquo arms or surgical BPO trials do well that is have a significant placebo
response
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Statistics notes Absence of evidence is not evidence of absenceBMJ 1995311485
Douglas G Altman J Martin Bland
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
PUMP ndash PIPE ndash VALVE
bull If you were a hydraulic engineer asked to sort out a PUMP ndash PIPE ndash VALVE problem (bladder-prostate-sphincter)
bull Flow from pipe is reduced what do you do replace the pump or the valve or both or do you test the system
bull You test the system
bull Urologists are hydraulic engineers
bull Hence an ldquoa priori argumentrdquo in favour of UDS exists
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Urodynamics for Prostate Surgery Trial Randomised Evaluation of
Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men
A randomised controlled trial to determine the clinical and cost effectiveness of
invasive urodynamic studies for diagnosis and management of bladder outlet
obstruction in men in the National Health Service (NHS)
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Do No Harm Which is most dangerous
UDS or unnecessary TURP
Urodynamics
bull UTI less than 5
bull Urinary retention less than 1
TURP Mortality less than 1
bull TURP syndrome up to 5
bull Haemorrhage up to 5 transfusion
bull Stricture 2-3
bull Evrard 2017 176 men aged 75+ 47 had complications (20 Clavien Gd 3 or 4) with one death
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Why donrsquot you perform Pressure-Flow Studies (PFS) to prove BPO prior to surgery
bull Too costly (man not worth it UNTRUE)
bull Too morbid (man shouldnt suffer UNTRUE)
bull PFS unreliable (I donrsquot really understand UDS
QUITE POSSIBLY)
bull The urodynamicists cannot decide how to
diagnose BPO (USE ICS nomogram)
bull I can diagnose BOO without PFS in the majority
of cases (DO YOU ALSO HAVE A GOD COMPLEX)
bull Not enough evidence (THERE IS A LOT)
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Best Practice essential elements before
surgery
bull Patient wants something done
bull All non-surgical options have been explored
bull Diagnosis has been confirmed or diagnostic
limitations explained
bull Full information on the riskbenefit ratio of
surgery
bull Fully informed consent
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
What does a patient want to know before
surgery
He may ask the question ldquoWill I do less well than the
average manrdquo
The answer will be ldquoYesrdquo if
bull You have no obstruction
bull You have significant OABDO
bull You have DU
bull You are unlucky enough to get complications stricture or
incontinencerdquo
HENCE UDS ALLOW FULLY INFORMED CONSENT
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Conclusions Are PFS needed prior to
Surgery for MLUTS suggestive of BPO
bull YES for most men with bothersome LUTS
bull If the Qmax is lt 10 mls then there is a 90 chance the man has obstruction
bull If the Qmax is gt 10 mls then there should be a full discussion with the patient (AUA guidelines)
bull Are you giving fully informed consent
bull All urologists need to understand urodynamics
bull Should urologists without the facilities for urodynamics do TURPs for symptoms
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Concluding Question
bull ldquoForgive them for they know what not they do The importance of the extent of pelvic lymph node dissection at radical prostatectomyrdquo
(title of a Rieken publication)
bull Luke 2334 Jesus said ldquoFather forgive them for they do not know what they are doingrdquo
bull Matthew 712 Matthew said ldquoIn everything then do to others as you would have them do to yourdquo
bull Would you allow yourself your male relatives or friends have a prostatectomy without the diagnosis of BPO knowing that even with a Qmax of less that 15mls you have a 20-35 chance that you do not have BPO
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Sham controls in BPO Surgery
bull J Urol 2015 Dec194(6)1682-7 doi 101016jjuro201506091 Epub 2015 Jul 2
bull Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized Controlled Benign Prostatic Hyperplasia Surgery Trials
bull Welliver C1 Kottwitz M2 Feustel P3 McVary K2
bull Author information
bull Abstract
bull PURPOSE
bull Medication trials frequently involve a placebo arm to more fairly assess the efficacy of the study drug However benign prostatic hyperplasia surgery trials rarely include a sham surgery group due to the inherent risks associated with simulatingtreatment in these patients As a result the placebo response to sham surgery for benign prostatic hyperplasia is largely unknown
bull MATERIALS AND METHODS
bull We systematically reviewed the available literature to look for randomized controlled trials involving endoscopic or intraprostatic injection benign prostatic hyperplasia treatments that included a sham surgical arm from January 1990 to February 2015 Studies that included an objective symptom questionnaire and maximum urinary flow at 3 months were included Results were analyzed together with weighting based on study sample size
bull RESULTS
bull The initial search yielded a total of 1998 potential studies After reviewing abstracts and full text articles 14 randomized controlled trials were included in some part An average decrease from 223 to 167 (-27) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=00003) with an increase in maximum urinary flow of 13 ml per second (14 p=0001) at 3 months Prostate injection based studies at 3 months were similar with a decrease from 213 to 157 (-26 plt0001) Maximum urinary flow increased by 20 ml per second (23 p=0043)
bull CONCLUSIONS
bull Sham controlled endoscopic and injection benign prostatic hyperplasia interventions demonstrate a considerable and statistically significant change in symptom scores and maximum urinary flow which is comparable to the response seen in medication trials Future uncontrolled benign prostatic hyperplasia surgical trials should consider these findings when interpreting outcomes
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Effect of Pre-op DO on Outcome
bull nt J Urol 2014 Oct21(10)1035-40 doi 101111iju12482 Epub 2014 May 13
bull Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction
bull Zhao YR1 Liu WZ Guralnick M Niu WJ Wang Y Sun G Xu Y
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate the correlation of preoperative overactive bladder symptoms and urodynamic parameters to the improvement of overactive bladder symptoms after transurethral resection of the prostate
bull METHODS
bull A retrospective study was carried out in 128 patients with urodynamically proven benign prostatic obstruction that underwent transurethral resection of the prostate All patients had preoperative urgency symptoms The patients were divided into groups according to overactive bladder symptom severity and preoperative urodynamic parameters (presence and type of detrusor overactivity degree of obstruction bladder contractility) The 3-month postoperative changes in overactive bladder symptoms were then compared between the groups
bull RESULTS
bull Overall there was a statistically significant improvement in mean overactive bladder symptoms score from 96 to 27 (Pthinspltthinsp0001) However patients with preoperative mild overactive bladder symptoms had significantly lower postoperative overactive bladder symptoms scores than those with moderate or severe symptoms (Pthinspltthinsp005) Patients with preoperative terminal detrusor overactivity had significantly higher overactive bladder symptoms scores compared with patients with phasic and no detrusor overactivity (Pthinspltthinsp005) and were more likely to have persistent urge incontinence Preoperative detrusor contractility and severity of obstruction did not affect postoperative overactive bladder symptom improvement
bull CONCLUSIONS
bull Most patients with benign prostatic obstruction and overactive bladder symptoms experience an improvement in their symptoms after transurethral resection of the prostate The presence of preoperative terminal detrusor overactivity might be negatively associated with this improvement The preoperative severity of overactive bladder symptoms detrusor contractility and degree of bladder outlet obstruction do not appear to have an effect
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Effect of Absence of BOO on Outcome
bull BJU Int 2013 Nov112 Suppl 261-4 doi 101111bju12382
bull Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction
bull Losco G1 Keedle L King Q
bull Author information
bull Abstract
bull OBJECTIVE
bull To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms Patients with proven urodynamic obstruction do better after surgery The current gold standard invasive pressure-flow studies imposes cost resource demand discomfort and inconvenience to patients
bull PATIENTS AND METHODS
bull Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS) Catheterised patients were excluded Two months post-operatively they completed a further IPSS score An improvement of seven or greater was defined as a clinically successful outcome Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device
bull RESULTS
bull Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years SD 9 years) Follow-up was complete for all patients Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate Mean IPSS score was 21 (range 5 to 35 SD 6) pre-operatively and 11 (range 1 to 31 SD 9) post-operatively Thirty-five patients were predicted obstructed and 27 not obstructed 94 of those predicted obstructed had a successful outcome (p lt 001) 70 predicted as not obstructed did not have a successful outcome after surgery (p lt 001)
bull CONCLUSION
bull The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome yet 30 of those shown not to be obstructed will stilldo well Whilst numbers in our study are small outcomes compare favourably with published results on invasive urodynamic methods
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Effect of DU on Outcome
bull J Urol 2012 Dec188(6)2294-9 doi 101016jjuro201208010 Epub 2012 Oct 22
bull Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes
bull Blatt AH1 Brammah S Tse V Chan L
bull Author information
bull Abstract
bull PURPOSE
bull Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction Current investigations including urodynamics may be unable to predict the response to surgical treatment We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy
bull MATERIALS AND METHODS
bull Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractiledetrusor undergoing transurethral prostatectomy and from 5 controls Specimens were examined by transmission electron microscopy Ten individual detrusor ultrastructural features were analyzed Findings were compared with preoperative and postoperative clinical parameters
bull RESULTS
bull Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size muscle cell shape collagenosis and abnormal fascicles These 4 features were significantly associated with each other defining a distinctive pattern of detrusor failure For transurethral prostatectomy failure the sensitivity specificity and positive and negative predictive values of all 4 features together were 60 91 75 and 84 respectively Three or 4 features on detrusor biopsy predicted voiding failure
bull CONCLUSIONS
bull Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Effect of PFS diagnosis of BOO on
outcome
bull Chin Med J (Engl) 2012 May125(9)1536-41
bull Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients
bull Qi J1 Yu YJ Huang T Xu D Jiao Y Kang J Chen YQ Zhu YK Huang YR
bull Author information
bull Abstract
bull BACKGROUND
bull Transurethral resection of prostate (TURP) has been widely used as a golden standard therapy of benign prostatic hyperplasia for over 40 years However not all patients achieved favorable outcome postoperatively Since the level of bladder outlet obstruction and the dysfunction of detrusor (overactive and underactive) were both found to affect surgical efficacy urodynamics was recommended as routine preoperative examination in selecting proper surgical candidates by International Continence Society in spite of its invasiveness and high cost The aim of this research was to compare the predictive value between ultrasonography and urodynamics for TURP efficacy and determine if preoperative urodynamic test could be replaced by ultrasonography
bull METHODS
bull Two hundred and seventy-one patients took part in the retrospective analysis All the subjects had preoperative evaluation of symptoms life quality and combined examination of ultrasonography and urodynamics Surgical efficacy was measured according to the recovery of international prostate symptom score quality of life score and maximal flow rate 6 months after TURP Fishers linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors Receivers operating characteristic curve was then plotted to compare the values between the models
bull RESULTS
bull Sensitivity specificity positive and negative predictive value of models consisting of parameters from both ultrasonographyand urodynamics were favorable Corresponding models of ultrasonography and urodynamics were found to have non-significant difference in area under curve (P gt 005)
bull CONCLUSIONS
bull Preoperative ultrasonography has as strong value as urodynamics does in predicting surgical outcome of patients undergone TURP and might take the place of urodynamics in selecting surgical candidates Further prospective analysis with larger popularity and longer period of follow up should be launched to verify the result of this research
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Effect of Pre-op DO on symptomatic
Outcome
bull Urology 2010 Jun75(6)1460-6 doi 101016jurology200909065 Epub 2009 Dec 6
bull Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate
bull Cho MC1 Kim HS Lee CJ Ku JH Kim SW Paick JS
bull Author information
bull Abstract
bull OBJECTIVES
bull To investigate whether the presence of detrusor overactivity (DO) influences storage symptoms after photoselective laser vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH)
bull METHODS
bull A total of 149 patients who underwent PVP were included in this retrospective study All patients underwent a preoperative evaluation including multichannel video urodynamics The efficacy of the PVP was assessed at 1 3 6 and 12 months postoperatively using the International Prostate Symptom Score (IPSS) uroflowmetry postvoid residual urine volume and 3-day frequency-volume charts (FVC) The patients were stratified into 2 groups (DO group vs non-DO group)
bull RESULTS
bull The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Plt05) Starting from 6 months after the PVP the DO group (n=39) showed a significantly greater reduction in the subtotal storage symptom score than the non-DO group (n=110) When the improvement of storage symptoms was defined as a reduction of gtor=50 in the subtotal storage symptom scores the percentage of patients with improvement in the storage symptoms at 1 3 6 and 12 months after the PVP was 139 259 478 and 529 in the DO group and 222 244 333 and 333 in the non-DO group respectively
bull CONCLUSIONS
bull Our results show that storage and voiding symptoms significantly improved after the PVP In addition we found that men with DO might show more improvement of storage symptoms after the PVP than men without DO
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Influence of Pre-op BOO on 12 year
symptomatic outcome of TURP
bull BJU Int 2010 May105(10)1429-33 doi 101111j1464-410X200908978x Epub 2009 Oct 26
bull The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery
bull Masumori N1 Furuya R Tanaka Y Furuya S Ogura H Tsukamoto T
bull Author information
bull Abstract
bull OBJECTIVE
bull To investigate whether bladder outlet obstruction (BOO) detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction
bull PATIENTS AND METHODS
bull Of 92 patients who had TURP after a urodynamic study between 1995 and 1997 43 (47) were alive at the time of the survey in February 2008 Nine patients were excluded because of prostate cancer neurological diseases and the impossibility of symptomatic examination The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline 3 months 3 7 and 12 years after surgery for 34 patients
bull RESULTS
bull Although the improved IPSS and QoL index at 3 months gradually deteriorated with time patients at 12 years were still significantly better than those at baseline The IPSS in patients without BOO deteriorated faster than in those with it whereas neither DUA nor DO influenced the slope of change in IPSS Regardless of the preoperative urodynamic findings the QoL index remained improved for 12 years Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years
bull CONCLUSION
bull The symptomatic improvement provided by TURP lasts for gt10 years although there is a gradual deterioration with time The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Prediction of outcome from pre-op UDS
bull Neurourol Urodyn 200928(3)197-201 doi 101002nau20619
bull Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction
bull Seki N1 Yuki K Takei M Yamaguchi A Naito S
bull Author information
bull Abstract
bull AIMS
bull To identify the prognostic variables concerning the improvement of overactive bladder syndrome (OAB) related symptoms following a transurethral resection of the prostate (TURP) in patients with benign prostatic obstruction (BPO)
bull METHODS
bull A retrospective review was conducted in 298 patients with BPO who had undergone TURP All patients had completed the preoperative evaluations including OAB related symptoms and full urodynamics as well as symptomatic assessment postoperatively OAB related symptoms were defined by the International Prostate Symptom Score questionnaires (questions 2 4 and 7 stand for frequency urgency and nocturia) They were divided into three categories based on an individual score gtor=3 for on urgency frequency and nocturia in the preoperative state The association between the baseline variables and the improvement in each symptom score was analyzed
bull RESULTS
bull A multivariate analysis suggested that the baseline degree of detrusor contractility was consistently associated with the improvement in each OAB symptom (The odds ratio in normalweak detrusor 95 34 30 for score on urgency frequency and nocturia respectively) Both the patients age (Odds ratio 093) and the maximum flow rate (Odds ratio 020) influenced the improvement in the score on nocturia
bull CONCLUSION
bull The observation of a positive and consistent correlation between the baseline degree of detrusor contractility and the improvement in OAB related symptoms suggests that good detrusor contractility is essential for the symptomatic benefits after the surgical relief of bladder outlet obstruction Aging males with good urinary flow rates appear to experience a reduced improvement of nocturia symptoms after undergoing TURP
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
UDS in diabetic men with LUTS
suggestive of BOO
bull Urol Int 200880(4)378-82 doi 101159000132695 Epub 2008 Jun 27
bull Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms
bull Dib PT1 Trigo-Rocha F Gomes CM Srougi M
bull Author information
bull Abstract
bull INTRODUCTION
bull Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement Diabetes mellitus is also more prevalent in this group LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both
bull OBJECTIVES
bull The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients
bull PATIENTS AND METHODS
bull 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS) ultrasonography and urodynamics BOO diagnosis was based on pressureflow measurements according to the International Continence Societys standards
bull RESULTS
bull Of the 50 patients in the study 23 (46) had BOO There was no correlation between the IPSS uroflowmetry post-voiding residual urine or prostate volume and the presence of BOO (p gt 005)
bull CONCLUSIONS
bull There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS Non-invasive tests did not allow the identification of these subjects Only urodynamic evaluation is able to determine symptom etiology
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Elderly men with LUTS do not have a
high prevalence of BOO
bull J Urol 1996 Nov156(5)1662-7
bull Age related urodynamic changes in patients with benign prostatic hyperplasia
bull Madersbacher S1 Klingler HC Schatzl G Stulnig T Schmidbauer CP Marberger M
bull Author information
bull Abstract
bull PURPOSE
bull We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH)
bull MATERIALS AND METHODS
bull A total of 222 patients (mean age 673 years range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS) prostate volume noninvasiveuroflowmetry residual volume and a pressure-flow study To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml per second or less and an I-PSS of 7 or more were eligible
bull RESULTS
bull There was no correlation between age and I-PSS (p gt 005) but there was a statistically significant decrease in maximum flow rate (p = 0045) and voided volume (p = 00013) with age Prostate volume increased constantly from 313 to 644 ml in patients 45 to 50 and older than 80 years respectively (p lt 00001) Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 00003) and invasive maximum flow rate (p = 00057) but no changes in detrusor pressure at maximum flow rate (p gt 005) maximum detrusor pressure (p gt 005) and linear passive urethral resistance relation (p gt 005) The incidence of urodynamically proved bladder instability increased from 20 to 47 in men 45 to 50 and older than 80 years respectively
bull CONCLUSIONS
bull The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function Because 60 of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml per second all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Outcome from TURP in men with DU
bull Urology 2008 Apr71(4)657-61 doi 101016jurology200711109 Epub 2008 Mar 3
bull The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index
bull Han DH1 Jeong YS Choo MS Lee KS
bull Author information
bull Abstract
bull OBJECTIVES
bull We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment
bull METHODS
bull Among the patients who underwent TUR-P for lower urinary tract symptoms at our institution we reviewed the records of consecutive 71 patients who had preoperative urodynamic evaluations According to the bladder outlet obstruction index and the bladder contractility index the patients were divided into 2 groups group A (25 patients) with unobstructed and weak bladder contractility and group B (46 patients) with obstructed andor normal bladder contractility We investigated the differences of International Prostate Symptom Score (IPSS) quality of life (QoL) maximum flow rate (Q(max)) postvoidresiduals (PVR) and the patient subjective satisfaction between the 2 groups after the TUR-P
bull RESULTS
bull Mean follow-up period after TUR-P was 19 months (range 12 to 55 months) After the TUR-P the IPSSQoL and PVR were significantly improved in group A and all parameters in group B Patients in group B showed a more significant improvement with regard to the IPSS and they were more satisfied after the TUR-P than group A
bull CONCLUSIONS
bull There were significant improvements in IPSSQoL and PVR after TUR-P in patients with weak bladder contractility and more than 60 were satisfied with the results of the surgery TUR-P is considered an optional procedure for the treatment of men with weak bladder contractility who are unresponsive to medical treatment
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Diagnosis of BOO improves outcome
from TURP
bull Eur Urol 2007 Jul52(1)186-92 Epub 2006 Nov 13
bull Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements
bull Harding C1 Robson W Drinnan M Sajeel M Ramsden P Griffiths C Pickard R
bull Author information
bull Abstract
bull OBJECTIVES
bull To determine whether categorisation of bladder outlet obstruction (BOO) using measurements of bladder pressure and urine flow obtained by a novel noninvasive medical device (the penile cuff test) improves prediction of outcome from endoscopic prostatectomy (TURP)
bull METHODS
bull A consecutive cohort of 208 men undergoing TURP following standard assessment in our institution was recruited and 179 (86) completed the protocol Each subject underwent a penile cuff test prior to surgery outcome was assessed by change in IPSS at 4 mo The proportion of men with good outcome (gt50 reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements
bull RESULTS
bull The cuff test was completed by 93 of men with 2 experiencing an adverse event Men categorised as having BOO by the test (37 of total) had an 87 chance of a good outcome from TURP (plt001) whilst of those deemed not obstructed (19 of total) 56 experienced good outcome (plt001) For the remaining men not categorised in these two groups 77 had good outcome which was identical to the result of the cohort as a whole (77 p=NS)
bull CONCLUSIONS
bull Urodynamic categorisation using measurements obtained by the noninvasive penile cuff test improves prediction of outcome for men with LUTS undergoing TURP This finding together with the ease and acceptability of the test suggest its suitability for office-based clinical use to assist men and their physicians in the selection for surgical treatment for relief of LUTS
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Prof HIPPOCRATES
HERSCHORN
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
My Proposition is that
There is an a priori argument that
ldquoUrodynamics are essential before surgery for
Lower Urinary Tract Dysfunctionrdquo
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Lower Urinary Tract structure and
function
The LUT consists of
bull A reservoir that should store and empty rapidly
to completion using its pump capabilities
bull A pipe that allows rapid and complete emptying
bull A valve that is closed during storage
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Engineering
bull Form follows function
bull Pump function is studied by pressure
measurement
bull Pipe function is assessed by flow measurement
bull Valve function is assessed by looking for
leakage
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Surgery for LUTD
bull Surgery for Stress Urinary Incontinence and
Benign Prostatic Obstruction are common
procedures
bull Patients considering these procedures assume
they will be cured of their symptoms for life
bull They do not consider the possibility that they
might be having unnecessary surgery
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
a priori argumentGalen Strawson (b 1952 British analytic
philosopher)
Wrote that an a priori argument is one in which
bull ldquoYou can see that it is true just lying on your couchrdquo
bull ldquoYou dont have to get up off your couch and go
outside and examine the way things are in the
physical worldrdquo
bull ldquoYou dont have to do any scienceldquo
Galen (b 129 saw himself as both a physician and a
philosopher and wrote a treatise entitled ldquoThat the Best
Physician is also a Philosopherrdquo)
Of course we must do science
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Research Evidence
bull Grade A recommendations require Level 1 evidence
bull At present we only have Level 3 evidence for UDS before BPO surgery and Level 23 evidence for UDS prior to SUI surgery
bull We hope to obtain funding for RCTs in both areas from the UK government
bull However our patients do not want to delay their operations for 5 years until we have the results
bull 2nd a priori argument
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Stress Incontinence Surgery
Benefits
bull Satisfaction 90
bull Cure of SUI 66
Poor Outcomes (risks) related to
bull Surgical complications
bull Patient has no SUI (unnecessary operation)
bull Detrusor overactivity during storage (OAB)
bull Intrinsic sphincter deficiency (persistent SUI)
bull Detrusor underactivity during voiding (increased PVR need for ISC)
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Pure stress leakage symptomatology is it safe
to discount ldquodetrusor instabilityrdquo
METHODS
bull Self-completion of a urinary diary in the preceding week before urodynamicassessment and a detailed urological history before undergoing cystometryby all women in the study period
bull Women reporting stress incontinence in the absence of bladder filling symptoms with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once had the results of their filling cystometry analysed
RESULTS
bull Of 5193 women 555 had symptoms of pure stress incontinence and a normal urinary diary Incontinence was confirmed objectively in 81 with 9 having incontinence secondary to detrusor instability 5 had detrusorinstability as the sole cause of their incontinence with 4 having a mixed picture of detrusor instability incontinence and urethral sphincter weakness
CONCLUSION
bull Genuine stress incontinence cannot be diagnosed reliably from a urological history even when rigorous selection criteria are used in combination with a normal urinary diary Without cystometry incontinence secondary to detrusor instability will be missed
James M Jackson S Shepherd A Abrams P Br J Obstet Gynaecol 1999 Dec106(12)1255-8
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Is the bladder a reliable witness for
predicting detrusor overactivity
bull The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004
bull Patients were selected based on OAB symptoms
RESULTS
bull There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women
bull 69 of men and 44 of women with urgency (OAB dry) had DO
bull 90 of men and 58 of women with urgency and urgency urinary incontinence (OAB wet) had DO
bull Stress urinary incontinence seems to have accounted for the decreased rates in women since 87 of women with urgency urinary incontinence also had the symptom of stress urinary incontinence
CONCLUSIONS
The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO more so in the OAB wet than in OAB dry patients
H Hashim and P Abrams J Urol 175 191-195 2006 [J Urol 2006]
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary
incontinence put some women at risk of a bad outcome
from stress incontinence surgery
NICE 2006 UDS are not needed if clearly defined clinical diagnosis of pure SUI
PATIENTS AND METHODS
bull 6276 women with UI were identified aged 18-80 years who had UDS over a 17-year period (1 January 1990 to 31 December 2006)
bull Strict selection criteria were used to identify patients with pure SUI
RESULTS
bull Only 52 women had pure SUI
bull 25 had other urodynamic diagnoses other than that could affect the outcome of continence surgery
CONCLUSION
bull These findings indicate that only a small group of women fulfil the NICE criteria of pure SUI These strict criteria do not ensure that all women with potentially important urodynamic findings are evaluated accordingly
bull Agur W Housami F Drake M Abrams P BJU Int 2009 Mar103(5)635-9
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Conclusions Urodynamics in Stress
Urinary Incontinence
bull Defines the condition - USI
bull Demonstrates detrusor overactivity (DO)
bull Measures urethral function
bull Assesses detrusor contractility
UDS enable fully informed consent
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Surgery for LUTS due to Prostatic
Obstruction (BPO)
Benefits
bull Marked reduction in symptoms improved QoL
Poor Outcomes
bull Surgical complications
bull Does not have BPO (unnecessary operation)
bull Detrusor overactivity during storage (persistent
OAB)
bull Detrusor underactivity during voiding (increased
PVR need for ISC)
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
bull Hippocrates
ldquoThe physician must have two special objects in
view with regard to disease namely to do good
or to do no harmrdquo
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
Conclusions
bull wwwtvt-messed-up-meshorguk
this is happening right now people are suffering
complications from having synthetic
polypropylene mesh implanted into their bodiesldquo
bull Patients are looking more closely at accuracy of
diagnosis and any poor outcomes
bull Until we have Level 1 evidence do what is safe
follow the a priori argument and do UDS before
LUTD surgery
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4
bull Prog Urol 2017 Apr27(5)312-318 doi 101016jpurol201702005 Epub 2017 Apr 1
bull [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over]
bull [Article in French]
bull Evrard PL1 Mongiat-Artus P2 Desgrandchamps F2
bull Author information
bull Abstract
bull INTRODUCTION
bull Monopolar transurethral resection of the prostate is one of standard surgical treatment of benign prostatic hyperplasia The objective of this study was to evaluate early postoperative complications in patients aged 75 years old and more using a standardized classification
bull MATERIAL AND METHODS
bull We included all patients aged at least 75 on the day of surgery between 1 January 2008 and 31 December 2013 The reporting of complications was carried from the Clavien-Dindo classification
bull RESULTS
bull One hundred and seventy-six patients were included in this study A total of 472 of patients experienced at least one complication The majority of patients (795) had complications grade 1 or 2 according to Clavien-Dindo classification One patient died postoperatively at day 27 Most complications were urological (55) A high Charlson score and low plasma hemoglobin levels have been identified as a risk factor for complications
bull CONCLUSION
bull Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients higher than in the general population
bull LEVEL OF EVIDENCE
bull 4