Benign Prostatic Hyperplasia and Urodynamics

Facts:

BOO is present in 90% of men with larger prostates
(>80 ml), in those with small volumes (<40>15 ml/s only about 1/3 [3]. These data indicate that urine flow studies are not sufficient for the definitive
diagnosis of BOO (Abrams, BJUI 1995)

Obstructed patients do not always fare well with TURP (success rate: 79–93%) and conversely, unobstructed men do not always fail with success rates of 55–78% (Homma, BJUI 2001)

The EAU guidelines.

Who should have UDx prior to TURP?
(i) previous unsuccessful invasive treatment of LUTS;
(ii) elderly men (>80 years);
(iii) younger men (e.g. <50 years);
(iv) post-void residual volume >300 ml;
(v) suspicion
of neurogenic bladder dysfunction;
(vi) previous radical pelvic surgery


Previous unsuccessful invasive treatment

Nitti et al. have performed urodynamics studies in 50 consecutive patients referred because of persistent LUTS after prostatectomy. In this series, 62% of these men were urodynamically unobstructed, 22% were in the equivocal zone and only 16% were urodynamically obstructed; detrusor instability was present in 54%. Symptoms were unreliable in predicting urodynamic findings. These data clearly demonstrate that another deobstructing procedure (i.e. 2nd TURP) is unlikely solve the problem in this group of patients. Only pQs (urodynamics) can guide the appropriate treatment in these patients (Nitti, J Urol 1997)

Elderly patients

For two reasons, geriatric patients (>80 years) should undergo pQs prior prostatectomy. First of all, because morbidity of prostatectomy in this high age group is increased. Secondly, and equally important, is the fact that the ageing urinary bladder reveals a number of age related urodynamics changes in men [17,18]. Among these is a decrease of Qmax, an increase of post-void residual volume, a decline in bladder capacity and of bladder compliance. As a consequence
the percentage of patients without BOO despite a reduced Qmax of 10–15 ml/s and an interrnational Prostate Symptom Score (IPSS) exceeding 7 increases substantially in men older than 70 years and particularly above 80 years (Fig. 3) [17,18]. This observation is a strong argument for routine pQs in this high age group. The real predictive value of urodynamics on the outcome after surgery is also questionable. In a recent paper, van Venrooij (J Urol 2002) showed that in 32 unobstructed or equivocal patients, there was a 40% increase in mean effective capacity of the bladder after surgery which was correlated with the improvement
of symptoms. Furthermore, 50% of unstable bladders became stable after surgery, and this could not be predicted from urodynamics. Numerous studies show that more than 50% of
patients who would have been eliminated from surgery, according to PFS, are, in fact, improved after surgery.
This confirms that all symptoms in the presence of BPH do not correspond to obstruction, and that the latter may have different profiles on PFS. Patients with a weak detrusor should not be systematically eliminated from surgery. We should consider that the weaker the detrusor contraction is, the more important is the impact of an increase of urethral resistance. In such
patients, the relief of any degree of obstruction should improve micturition. There is an inherent limitation of PFS in detecting obstruction, when obstruction and a weak detrusor coexist, and a low detrusor pressure does not necessarily contraindicate prostatectomy. Operate on those who suffer failure with their conservative management. Some patients could benefit from minimally invasive therapies, but it has not yet been proven that urodynamics is able to differentiate
indications.


Urodynamics and success with TURP: Does obstruction make any difference to outcome.

No says Hakenberg et al: BJUI 2003

Variable
N
Age (yrs)
IPSS change
QOL



(improvements)
Pre Post
Ag Number














<15>40
46
72.5
9.5
5 1







AG# = Pdet at Qmax – 2(Qmax). >40 is obstrcucted, <20 is unobstructed, 20-40 equivocal



Outcome of TURP in pts with High Pressure Chronic Retention (Styles and Neal, J Urol 1991)
68 men with bladder outflow obstruction and chronic retention (residual urine greater than 300 ml.) Postoperatively, upper tract dilatation (present in 28 men preoperatively) resolved in all but 2 men and serum creatinine levels improved significantly. Irritative and obstructive symptom scores improved postoperatively (p less than 0.00006), although 17% of the men still had significant symptoms. Residual urine volumes decreased and flow rates improved (p less than 0.00006) 32% of the men still had a residual urine of greater than 200 ml.

Types of Penil prosthesis

1-Soft
2-Semi-rigid
3-Bendable metallic core
4-Interlocking segments
5-Inflatable- 1,2 & 3 part

1 Soft
Subrini
SSDA, Virilis
Rarely used in UK
Peyronnie's surgery
Augments natural erection by providing core bulk

2 Semi-rigid
Cheap
Simple
Reliable: No moving parts
Hard to conceal, ‘bendability’
Limited width
Erosion

Mentor Accuform
9.5 mm, 14-23 cm
11 mm, 16-25 cm
13 mm, 18-27 cm (hard to bend)
Bendability ~ 90 degrees
RTE 0-1 cm

AMS
600 series
9.5 mm & 11.5 mm width

650 series
11 mm & 13 mm width
Tip extenders, both ends
length 12-20 cm
Bendability ~110 degrees

AMS
Dura II
Interlocking PTFE segments with steel spring
10,12 mm
13 cm + tip extenders both ends
Bendability ~150 degrees

Inflatable

Concealment
‘Natural’
Rigidity
Expensive
Infection
Mechanical failure
Manual dexterity


Inflatable – 2 piece
AMS Ambicor
Combined cylinders + reservoir
Pump
limited fluid volume

Mentor Mark II

Inflatable-3 piece

AMS 700CX, CXM, CXR
Triple layer
Expands in width
Smallest 12 cm
AMS Ultrex
Expands in length and width
Antibiotic coating (inhibiZone)
Rifampicin & Minocycline

Inflatable-3 piece

Mentor Alpha 1, Titan & narrowbase
Smallest 10cm
Expands girth++
Oval
Bioflex
Lockout valve
Hydrophilic antibiotic adsorbant surface

Bladder cancer and BCG Immunotherapy

Bacillus Calmette-Guerin
First used 1921

Morales et. Al. 1976 (successful treatment in 7 of 9 patients of recurrent Ta and T1 tumours)
Live attenuated M.Bovis. (Freeze dried vaccine)

All derived from Pasteur Institute strain.
Connaught 81 mg or 180 * 10 8 CFU
Tice 12.5 mg or 2-8 *10 8 CFU
Pasteur
Frappier
Tokyo

Indications:
Mulitiple G2 pT1
G3 pTa / pT1, CIS

I am a lower pole calculus of 2 cm. My preferred treatment is:

Percutaneous nephrolothotomy

Why?

Lower pole study group (Albala, Clayman and et al, J Urol 2001):

122 pts, lower pole stone and symptoms, under 3cm, randomised to PCNL vs SWL, stratified by stone size

CLEARANCE RATES

LOWER Pole stone PCNL ESWL
1cm 100% 63%
1-2cm 92% 23% (but 56% by Lingman)

>2cm 85% 14%






SWL: stent for size >2.5 cm
PCNL: single stage procedure, used flexible endoscopy and fragmentation with laser, uss, lithoclast
Outcome: fragmentation to fragments less than 3mm
Clearance rate 11-20mm stones 23% vs 92% for SWL vs PCNL, 14% vs 100% for stones 21-30mm

No effect found from lower pole calyx anatomical factors
(cf Elbahnasy, where infundibulopelvic angle under 90°, length over 30mm and width <5mm all associated with poor clearance rates of stones using SWL)

Cost effectiveness to be stone free
Stones 11-19mm SWL 133% more than PCNL
Stones >20mm cost of SWL 411% greater than PCNL
No statistical difference in morbidity




Lower pole study group 2:
Ureteroscopy versus PCNL
1-2.5 cm lower pole stone
31% stone free in urs versus 76% for pcnl
Stone Ureteroscopy PCNL
1-2.5 31% 76%




Ureteroscopy versus ESWL for stone < 1cm (pearl, lower pole study 3 ) no diff between urs and eswl. (35% versus 50% statistically not significant) (Pearl Jurol 2005)


Stone Ureteroscopy ESWL
<1 cm 35% 50%





stones <10mm URS vs SWL, stones 11-25mm URS vs PCNL
• Why?
o Stone free rates 11-20mm 71%, >20mm 65% with URS (Grasso, 1999)
o All stones greater than 2cm clearance rate of 91% after second look procedure in pts with renal stones who were poor PCNL candidates (Grasso, J Urol 1998)

Male urethral Trauma

The important factors that need to be considered in the management of the Ijury in the Immediate settings include:
Mechanism of injury
Has the patient voided? Haematuria? Increase in swelling after voiding? (extravasation)

Examination
Signs of shock?
Perineum – extent of haematoma. Confined to perineum/penile shaft then Buck’s fascia intact. If more extensive then suggests rupture of Bucks fascia and will be confined by Colles fascia
Blood at urethral meatus?–present in 75% of anterior urethral trauma
PR – prostate should feel normal
Is bladder distended?

Investigation
Usual trauma investigations including bloods.

Injury may be contusion or laceration of the urethra.
Urethrography – if urethra intact this is a contusion injuries and the haematoma usually resolves without complication. May wish to prescribe analgesia and antibiotics as prone to infection. Patient should be encouraged to void.

If laceration then needs catheter either single attempt urethrally or through the abdomen- probably best done under GA in child.
Laceration injuries may allow extravasation of urine which can extend along penile shaft, and up abdo wall, extension limited by Colles fascia. This may become infected and require draiage.

Will need further assessment of urethra with urethrogram (up and down) in 4/52.
Most common problem is stricture formation at site of injury. The majority of which do not require surgical intervention.
Those that do require surgical intervention should have delayed repair >3/12 after injury.
Options include simple debridement and anastomosis if short stricture (<1cm). Longer strictures will require grafts or flaps to bridge deficiency.

What is urethrogram?
12/14ch catheter in fossa navicularis ( in the penile opening). 2mls in balloon to occlude urethra. 20 mls of undiluted contrast injected slowly and films taken at 30 degree oblique angle.

BCG in my bladder!

BCG is a vaccine developed to combat the tuberculosis epidemic. The anti cancer potential of tuberculosis was known before the development of BCG. It had been seen in autopsy studies that people who had suffered from tuberculosis had lower incidence of having a cancer of the affected organ than the ones who did not. BCG was initially tried to treat skin cancers ( melanomas) with variable success. Later it was shown that BCG could protect against bladder cancer recurrence and progression (worsening aggressive nature). The BCG is put into the bladder and has to be retained there for 2 hours. The aim is to stimulate the immune system to reject the cancer. The standard practice is to use an induction course followed by a maintenance course. The induction course involves six cessions of BCG instillation at weekly interval followed by a telescopic examination usually about 3 months after the last dose to evaluate the response. This is followed by the maintenance schedule.
There are different maintenance schedules being used in different hospitals due to lack of consensus in this regards. There is a strong consensus that maintenance therapy following is more effective than induction therapy of BCG alone.
It is common for patients to experience burning sensation during voiding with an element of urgency to pass urine. Quite a few other side effects are possible with BCG use in bladder cancer and due to this reason it recommended for aggressive bladder cancers.

Urinary incontinence in women

The complaint of urinary incontinence in adult women can most commonly is either due to wekness of the sphinctor mechanism to keep her dry leading to leakage whenever the abdominal pressure rises like coughing sneezing jumping (Stress incontinence) or due to a bladder which contracts and pushes urine out when it should be holding it in, patient usually finds it difficult to hold whenever she gets this urge to pass urine (urgency to urinate)and cannot make it to the toilet in time (urge incontinence).
There can be quite a few other causes for urinary leakage but most common complaints fall in the above two groups.
The treatment is dictated by the type of incontinence.
With Stress Incontinence the target is to support the and strengthen the muscles that support the urethra and the pelvic organs including the bladder vagina uterus and rectum. treatment methods availible range from pelvic muscle strengthening exercises, abdominal operations to reposition prolapsing pelvic organs and vaginal operations to suuport the organs and to provide extra suppoert to urethra.
For Urge incontinence the aim to calm the bladder to damp down these uncontrolled bladder contractions. Bladder retraining tablets to controll the bladder and operations to paralyse the muscle (botox injection in bladder) or by cutting the nerve supply to bladder or by removing muscle layer partially from the bladder or by putting a piece of bowel in the bladder.

Can teblets controll my waterworks?

The urinary symptoms can simply considered to be of two types i.e. due to obstruction to the urine flow due to enlarged prostate (Hesitancy to start urine flow, weak flow and sense of incomplete emptying)and iritative symptoms due to incomplete emptying or premeture bladder contrations (frequent passing of urine, urgency to pass urine)
The drugs which have been used to controll the prostate related symptoms are of three types, the Alpha Blockers relax the bladder neck and thus reduce the resistance offered by the urethra to the urine flow, they donot effect the prostate size so with time as the prostate grows their effectiveness might go down. The Alpha reductase inhibitors can reduce the prostate volume if teken over an extended period of time. Both of these groups of drugs are focusing on the prostate, trying to reduce the resistance to urine flow by an enlarged or obstructing prostate. The Anti cholinergic medicines act on the bladder bladder, allowing it to hold a larger volume for longer period of time.

Viagra ‘The Miracle drug’

The Phosphodiesterase group of medicines (Viagra, Levitra, Cialis etc.) are a major step forward in the management of this important quality of life issue. These medicines are commonly associated with minor side-effects like, nasal stuffiness, facial flushing, heart burn. People with heart problems should have a frank discussion with their doctor before trying the medicine.
There is evidence that if the first dose doesn’t work still the subsequent dose might, so no need to despair!
It is becoming more and more recognised that a proportion of aging population has low testosterone levels, which are also contributing to the erectile dysfunction and improving the testosterone levels can improve their wellbeing and also increase chances of effectiveness of the Phosphodiesterase group (Viagra, Levitra, Cialis etc.).

Male infirtility

Irrespective of gender the dream of having one's own children is shared by many. The first test test usually requested by GP for male fertility evaluation is Semen Analysis ( examination under microscope of material ejaculated from the penis). The aim is to basically see whether the semen has sperms (besides some other features to ascertain the health of the semen).
If there are no sperms in the semen then either testis are not producing any sperms or the conduction mechanism i.e. the tube from testicles to the urethra is blocked.
The 'testicular biopsy' is commonly used operation to differentiate between the two. If facilities are availible then cryopreservation can be performed at the same time.
In case of obstruction being the cause of absence of sperms, srgical procedure to bipass the operation or direct retrieval of sperms from the testis through a variety of techniques is possible.
In patients with testicular biopsy failing to show any sperms, multiple biopsies might identify an island of sperm genesis.

kidney stones, the boulder in water

Kidney stones are a common urological problem encountered. the kidney stones can lead to a rather interesting course of complete silence with sudden symptoms usually severe excruciating pain (thought to be more severe than child berth!), nausea and vomiting. The kidney stones can pass spontaneously from kidney into the bladder leading resolution of pain but there is an inverse relation between the stone size and it's chance of being passed spontaneously.
the stone formation in the kidneys is a complex process and in simplest terms it can be due to increased concentration of constituents to an extent where they start sedimenting thus laying the foundation of stone formation or the constituent cannot be dissolved in the urine due to any reason and settles down. some stones can be seen on x-ray while other can't.
ways to treat the stones can be divided to non oprative and operative means.

Waterworks and the enlarged prostate

As the hair turn grey the water works can also become an issue. many a people consider prostate enlargement to be the cause. Prostate gland sits at the opening of the bladder and encircles the urethra. the prostatic enlargement can lead to compression of urethra thus compelling the bladder to work harder to push the urine through the tube ( urethra). with time due to slowly increasing obstruction the bladder becomes thicker with increase in its muscle bulk but there is a limit to the extent of force the muscles can generate and then there is the stage of progressive failure of bladder to empty completely and ultimately the bladder can fail completely perform the function of emptying itself (urinary retention needing a catheter in the bladder.
The treatment of urinary symptoms is directed at sorting the patient complaints to prevent a negative impact on one's quality of life. Not every patient with prostate enlargement will have urinary problems and vice versa.
The treatment of urinary symptoms due prostate can vary from just reassurance to tablets or even an Operation.

Erectile dysfunction: the surgical solution

Erectile dysfunction is a major male quality of life issue. the surgical solution of erectile dysfunction is either semi-rigid or inflatable penile prosthesis. It has to be appriciated that the prosthesis which ever type it may be, only provides mechanical means to have penetrative intercourse. the sensations might not be the same as it used to be with spontaneous or sexually stimulated erection. there is usually some loss of length. better understanding of the device that is to be implanted with reasonable expections of the outcome improve the overall satisfaction with this intervention

Bladder Cancer

the management of bladder cancer can be considered a real success story with so much finances being invested in the early detection efforts (hemeturia clinics) within the NHS, but are we really treating the disease the properway? though our main effort is to conserve the organs (i.e. the kidney and the bladder) but the approach being persued to controll the disease i.e. telescopic removal of the tumour through the urethra is less than ideal. we are actually many a times removing the tumour in piecemeal fashion raising the possibility of tumour cells being ejected into the bladder and then implanting at other sites in the bladder causing recurrence of disease at some other site in the bladder which can be considered as a failed operation in terms of acieving a cure though I must confess that tumour development can be a field change i.e. the lining of the bladder becoming unstable and producing tumours at various sites simultaniously or sequentially. a standard procedure capable of completely excising the tumours with a clear margin i.e. removing intact tumour is yet to be develped.

Prostate Cancer

The trend towards preventive medicine has led to an emphasis on screening programs. The prostate cancer screening is still a controversial issue with no strong evidence to point to any advantage in persuing this course but the GPs are routinely performing the PSA screening (blood test) in men above fifty years of age. if the PSA is raised then the person goes through the anxiety and tension involved in the process of further investigation. if the prostate biopsy is negative, that by no means is the end of the process and the person has to remain on the razor edge going through the regular PSA evaluation. Newer developments like PCA3 test (urine test) doesnot help for it only gives an indication of probability of cancer i.e. the result interpretation soesnot give a black and white answer whether to do a biopsy or not. various nomograms which again try to use various resk factors to predict the probability of having prostate cancer, this once again only generates a figure the clinician and the patient being left with the responcibility to decide whether to do a biopsy or not knowing that what ever these clinical exams blood test urine test or nomograms might indicate, there will always be a small but significant possibility of missing a patient with significant cancer