Urodynamics (Pressure-Flow) prior to Bladder Outlet Obstruction … · of overactive bladder...

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:

• Before invasive procedures

• To pick up dangerous bladders

When not:

• Before conservative and drug therapy

Urodynamics in Male Patients: When?

When:

• Before invasive procedures

- surgery for LUTS suggestive of BPO/BOO*

- surgery for OAB/DO

- surgery for PPI

• To pick up dangerous bladders (neurourology)

* Little evidence for UDS in men who cannot void (acute retention secondary to BPO)

Dr Rieken’s Excellent

Bibliography

Pubmed lists more than 80

papers/letters to Editor on:

• Urothelial Cancer, including NMIBC, cystectomy

• Prostate Cancer

• Prostatectomy for BPO, including green light:

with outcome measures: Qmax and PVR.

• No urodynamic papers, but

• Good review on “IPP”

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 Dec;69(6):548-555.

CONCLUSIONS:

• Analysis of IPP may be regarded as potential non-invasive

alternative to standard PFS in the assessment of BOO.

Patients with IPP>10 mm should be counseled regarding the

high chance of need for surgical treatment following acute

urinary retention

https://www.ncbi.nlm.nih.gov/pubmed/?term=Rieken M[Author]&cauthor=true&cauthor_uid=28263050https://www.ncbi.nlm.nih.gov/pubmed/28263050

DU: DiagnosisProxies for the Diagnosis of BOO/BPO

• Functional Proxies for obstruction;

- Qmax: does not distinquish between BOO and DU

- PVR: does not distinquish between BOO and DU

• 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

LUTS’ 21st Birthday: April 2015

Terminology12

1.Abrams P BMJ 1994 2.McVary KT, et al. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010. Available at: https://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf. 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.

https://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf

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 :

• BOOI (bladder outlet obstruction index)

• BCI (bladder contractility index)

• 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 Jul;84(1):14-5

.

https://www.ncbi.nlm.nih.gov/pubmed/10444116

coloured slide of BOOI

Bladder Contractility Index (BCI)

Urodynamics Prior to Prostatectomy: Why?

Before surgery for BPO:

• There are no symptoms diagnostic of BPO

• There are no signs diagnostic of BPO

• Urine flow studies are unable to distinquish BPO

from DU as the cause of low flow/raised PVR

• ONLY pressure-flow studies can diagnose BPO

• SURGERY IS DESIGNED TO RELIEVE BPO

“One, or even two Cases don’t make a

guideline or a paradigm”

Evaluation of Evidence:

Levels of Evidence are used to derive Grades of Recommendation in Guidelines

• Level 1 evidence usually involves one or more randomised controlled trials

• Level 2 evidence includes good quality prospective ‘cohort studies’.

• Level 3 evidence includes good quality retrospective ‘case-control studies’.

• Level 4 evidence includes good quality ‘case series’.

• 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 Evidence• Zhoa 2014: men with DO do worse

• Blatt 2012: men with DU do worse

• Seki 2009: men without DU do better

• Harding 2007: men without BPO do worse

• Qi 2012: men without BPO do worse

• Losco 2013: men without BPO do worse

• Dib 2008: 46% of diabetic LUTS men have no BPO

• Madersbacher 1996: 80% of LUTS men over 80 have no BPO

• Masurmori 2010: men without BPO deteriorate faster after TURP

• Welliver 2015: men in “Sham” arms or surgical BPO trials do well, that is have a significant placebo

response

Statistics notes: Absence of evidence is not evidence of absenceBMJ 1995;311:485

Douglas G Altman, J Martin Bland,

PUMP – PIPE – VALVE

• If you were a hydraulic engineer asked to sort out a PUMP – PIPE – VALVE problem (bladder-prostate-sphincter)

• Flow from pipe is reduced, what do you do, replace the pump, or the valve or both, or do you test the system?

• You test the system

• Urologists are hydraulic engineers

• Hence, an “a priori argument”, 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;

• UTI: less than 5%

• Urinary retention: less than 1%

TURP Mortality: less than 1%

• TURP syndrome: up to 5%

• Haemorrhage: up to 5% transfusion

• Stricture: 2-3%

• Evrard 2017: 176 men aged 75+, 47% had complications (20% Clavien Gd 3 or 4) with one death

Why don’t you perform Pressure-Flow Studies (PFS) to prove BPO, prior to surgery?

• Too costly (man not worth it, UNTRUE)

• Too morbid (man shouldn't suffer, UNTRUE)

• PFS unreliable (I don’t really understand UDS,

QUITE POSSIBLY)

• The urodynamicists cannot decide how to

diagnose BPO (USE ICS nomogram)

• I can diagnose BOO without PFS in the majority

of cases (DO YOU ALSO HAVE A GOD COMPLEX?)

• Not enough evidence (THERE IS A LOT)

Best Practice: essential elements before

surgery

• Patient wants something done

• All non-surgical options have been explored

• Diagnosis has been confirmed or diagnostic

limitations explained

• Full information on the risk:benefit ratio of

surgery

• Fully informed consent

What does a patient want to know before

surgery?

He may ask the question: “Will I do less well than the

average man?”

The answer will be “Yes”, if:

• You have no obstruction

• You have significant OAB/DO

• You have DU

• You are unlucky enough to get complications: stricture or

incontinence”

HENCE UDS ALLOW FULLY INFORMED CONSENT

Conclusions: Are PFS needed prior to

Surgery for MLUTS suggestive of BPO?

• YES, for most men with bothersome LUTS

• If the Qmax is < 10 ml/s then there is a 90% chance the man has obstruction

• If the Qmax is > 10 ml/s then there should be a full discussion with the patient (AUA guidelines)

• Are you giving fully informed consent?

• All urologists need to understand urodynamics

• Should urologists without the facilities for urodynamics do TURPs for symptoms?

Concluding Question

• “Forgive them for they know what not they do: The importance of the extent of pelvic lymph node dissection at radical prostatectomy”

(title of a Rieken publication)

• Luke 23:34: Jesus said, “Father, forgive them; for they do not know what they are doing”

• Matthew 7:12 : Matthew said “In everything, then, do to others as you would have them do to you”

• 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 15ml/s you have a 20-35% chance that you do not have BPO?

http://biblehub.com/matthew/7-12.htm

Sham controls in BPO Surgery

• J Urol. 2015 Dec;194(6):1682-7. doi: 10.1016/j.juro.2015.06.091. Epub 2015 Jul 2.

• Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized, Controlled Benign Prostatic Hyperplasia Surgery Trials.

• Welliver C1, Kottwitz M2, Feustel P3, McVary K2.

• Author information

• Abstract

• PURPOSE:

• 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.

• MATERIALS AND METHODS:

• 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.

• RESULTS:

• The initial search yielded a total of 1,998 potential studies. After reviewing abstracts and full text articles 14 randomized, controlled trials were included in some part. An average decrease from 22.3 to 16.7 (-27%) was seen in studies of the AUASS (American Urological Association symptom score) 3 months after a sham endoscopic procedure (p=0.0003) with an increase in maximum urinary flow of 1.3 ml per second (14%, p=0.001) at 3 months. Prostate injection based studies at 3 months were similar with a decrease from 21.3 to 15.7 (-26%, p

Effect of Pre-op DO on Outcome

• nt J Urol. 2014 Oct;21(10):1035-40. doi: 10.1111/iju.12482. Epub 2014 May 13.

• Predictors of short-term overactive bladder symptom improvement after transurethral resection of prostate in men with benign prostatic obstruction.

• Zhao YR1, Liu WZ, Guralnick M, Niu WJ, Wang Y, Sun G, Xu Y.


• Abstract

• OBJECTIVES:

• 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.

• METHODS:

• 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.

• RESULTS:

• Overall, there was a statistically significant improvement in mean overactive bladder symptoms score from 9.6 to 2.7 (P

Effect of Absence of BOO on Outcome

• BJU Int. 2013 Nov;112 Suppl 2:61-4. doi: 10.1111/bju.12382.

• Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction.

• Losco G1, Keedle L, King Q.


• Abstract

• OBJECTIVE:

• 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.

• PATIENTS AND METHODS:

• 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.

• RESULTS:

• 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 < 0.01). 70% predicted as not obstructed did not have a successful outcome after surgery (p < 0.01).

• CONCLUSION:

• 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

https://www.ncbi.nlm.nih.gov/pubmed/24127677https://www.ncbi.nlm.nih.gov/pubmed/?term=Losco G[Author]&cauthor=true&cauthor_uid=24127677https://www.ncbi.nlm.nih.gov/pubmed/?term=Keedle L[Author]&cauthor=true&cauthor_uid=24127677https://www.ncbi.nlm.nih.gov/pubmed/?term=King Q[Author]&cauthor=true&cauthor_uid=24127677https://www.ncbi.nlm.nih.gov/pubmed/24127677

Effect of DU on Outcome

• J Urol. 2012 Dec;188(6):2294-9. doi: 10.1016/j.juro.2012.08.010. Epub 2012 Oct 22.

• Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes?

• Blatt AH1, Brammah S, Tse V, Chan L.


• Abstract

• PURPOSE:

• 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.


• 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.

• RESULTS:

• 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.

• CONCLUSIONS:

• 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

https://www.ncbi.nlm.nih.gov/pubmed/23083643https://www.ncbi.nlm.nih.gov/pubmed/?term=Blatt AH[Author]&cauthor=true&cauthor_uid=23083643https://www.ncbi.nlm.nih.gov/pubmed/?term=Brammah S[Author]&cauthor=true&cauthor_uid=23083643https://www.ncbi.nlm.nih.gov/pubmed/?term=Tse V[Author]&cauthor=true&cauthor_uid=23083643https://www.ncbi.nlm.nih.gov/pubmed/?term=Chan L[Author]&cauthor=true&cauthor_uid=23083643https://www.ncbi.nlm.nih.gov/pubmed/23083643

Effect of PFS diagnosis of BOO on

outcome

• Chin Med J (Engl). 2012 May;125(9):1536-41.

• Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients.

• Qi J1, Yu YJ, Huang T, Xu D, Jiao Y, Kang J, Chen YQ, Zhu YK, Huang YR.


• Abstract

• BACKGROUND:

• 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.

• METHODS:

• 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. Fisher's linear discriminant analysis was applied to establish the predictive models of surgical efficacy by choosing parameters from ultrasonography or urodynamics as independent factors. Receiver's operating characteristic curve was then plotted to compare the values between the models.

• RESULTS:

• 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 > 0.05).

• CONCLUSIONS:

• 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.

https://www.ncbi.nlm.nih.gov/pubmed/22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Qi J[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Yu YJ[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Huang T[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Xu D[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Jiao Y[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Kang J[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Chen YQ[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Zhu YK[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/?term=Huang YR[Author]&cauthor=true&cauthor_uid=22800817https://www.ncbi.nlm.nih.gov/pubmed/22800817

Effect of Pre-op DO on symptomatic

Outcome

• Urology. 2010 Jun;75(6):1460-6. doi: 10.1016/j.urology.2009.09.065. Epub 2009 Dec 6.

• Influence of detrusor overactivity on storage symptoms following potassium-titanyl-phosphate photoselectivevaporization of the prostate.

• Cho MC1, Kim HS, Lee CJ, Ku JH, Kim SW, Paick JS.


• Abstract

• OBJECTIVES:

• 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).

• METHODS:

• 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).

• RESULTS:

• The IPSS and FVC showed that the storage symptoms were reduced significantly after the PVP in both groups (Por=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 13.9%, 25.9%, 47.8%, and 52.9% in the DO group, and 22.2%, 24.4%, 33.3%, and 33.3% in the non-DO group, respectively.

• CONCLUSIONS:

• 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

https://www.ncbi.nlm.nih.gov/pubmed/19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Cho MC[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Kim HS[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Lee CJ[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Ku JH[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Kim SW[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/?term=Paick JS[Author]&cauthor=true&cauthor_uid=19963247https://www.ncbi.nlm.nih.gov/pubmed/19963247

Influence of Pre-op BOO on 12 year

symptomatic outcome of TURP

• BJU Int. 2010 May;105(10):1429-33. doi: 10.1111/j.1464-410X.2009.08978.x. Epub 2009 Oct 26.

• 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.

• Masumori N1, Furuya R, Tanaka Y, Furuya S, Ogura H, Tsukamoto T.


• Abstract

• OBJECTIVE:

• 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.


• 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.

• RESULTS:

• 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.

• CONCLUSION:

• The symptomatic improvement provided by TURP lasts for >10 years, although there is a gradual deterioration with time. The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings

https://www.ncbi.nlm.nih.gov/pubmed/19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Masumori N[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Furuya R[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Tanaka Y[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Furuya S[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Ogura H[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/?term=Tsukamoto T[Author]&cauthor=true&cauthor_uid=19863522https://www.ncbi.nlm.nih.gov/pubmed/19863522

Prediction of outcome from pre-op UDS

• Neurourol Urodyn. 2009;28(3):197-201. doi: 10.1002/nau.20619.

• Analysis of the prognostic factors for overactive bladder symptoms following surgical treatment in patients with benign prostatic obstruction.

• Seki N1, Yuki K, Takei M, Yamaguchi A, Naito S.


• Abstract

• AIMS:

• 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).

• METHODS:

• 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 >or=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.

• RESULTS:

• 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 normal/weak detrusor: 9.5, 3.4, 3.0 for score on urgency, frequency and nocturia, respectively). Both the patient's age (Odds ratio: 0.93) and the maximum flow rate (Odds ratio: 0.20) influenced the improvement in the score on nocturia.

• CONCLUSION:

• 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

https://www.ncbi.nlm.nih.gov/pubmed/18973143https://www.ncbi.nlm.nih.gov/pubmed/?term=Seki N[Author]&cauthor=true&cauthor_uid=18973143https://www.ncbi.nlm.nih.gov/pubmed/?term=Yuki K[Author]&cauthor=true&cauthor_uid=18973143https://www.ncbi.nlm.nih.gov/pubmed/?term=Takei M[Author]&cauthor=true&cauthor_uid=18973143https://www.ncbi.nlm.nih.gov/pubmed/?term=Yamaguchi A[Author]&cauthor=true&cauthor_uid=18973143https://www.ncbi.nlm.nih.gov/pubmed/?term=Naito S[Author]&cauthor=true&cauthor_uid=18973143https://www.ncbi.nlm.nih.gov/pubmed/18973143

UDS in diabetic men with LUTS

suggestive of BOO

• Urol Int. 2008;80(4):378-82. doi: 10.1159/000132695. Epub 2008 Jun 27.

• Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms.

• Dib PT1, Trigo-Rocha F, Gomes CM, Srougi M.


• Abstract

• INTRODUCTION:

• 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.

• OBJECTIVES:

• 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.


• 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 pressure/flow measurements according to the International Continence Society's standards.

• RESULTS:

• 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 > 0.05).

• CONCLUSIONS:

• 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.

https://www.ncbi.nlm.nih.gov/pubmed/18587248https://www.ncbi.nlm.nih.gov/pubmed/?term=Dib PT[Author]&cauthor=true&cauthor_uid=18587248https://www.ncbi.nlm.nih.gov/pubmed/?term=Trigo-Rocha F[Author]&cauthor=true&cauthor_uid=18587248https://www.ncbi.nlm.nih.gov/pubmed/?term=Gomes CM[Author]&cauthor=true&cauthor_uid=18587248https://www.ncbi.nlm.nih.gov/pubmed/?term=Srougi M[Author]&cauthor=true&cauthor_uid=18587248https://www.ncbi.nlm.nih.gov/pubmed/18587248

Elderly men with LUTS do not have a

high prevalence of BOO

• J Urol. 1996 Nov;156(5):1662-7.

• Age related urodynamic changes in patients with benign prostatic hyperplasia.

• Madersbacher S1, Klingler HC, Schatzl G, Stulnig T, Schmidbauer CP, Marberger M.


• Abstract

• PURPOSE:

• We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH).


• A total of 222 patients (mean age 67.3 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.

• RESULTS:

• There was no correlation between age and I-PSS (p > 0.05) but there was a statistically significant decrease in maximum flow rate (p = 0.045) and voided volume (p = 0.0013) with age. Prostate volume increased constantly from 31.3 to 64.4 ml. in patients 45 to 50 and older than 80 years, respectively (p < 0.0001). Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 0.0003) and invasive maximum flow rate (p = 0.0057) but no changes in detrusor pressure at maximum flow rate (p > 0.05), maximum detrusor pressure (p > 0.05) and linear passive urethral resistance relation (p > 0.05). The incidence of urodynamically proved bladder instability increased from 20 to 47% in men 45 to 50 and older than 80 years, respectively.

• CONCLUSIONS:

• 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

https://www.ncbi.nlm.nih.gov/pubmed/8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Madersbacher S[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Klingler HC[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Schatzl G[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Stulnig T[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Schmidbauer CP[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/?term=Marberger M[Author]&cauthor=true&cauthor_uid=8863566https://www.ncbi.nlm.nih.gov/pubmed/8863566

Outcome from TURP in men with DU

• Urology. 2008 Apr;71(4):657-61. doi: 10.1016/j.urology.2007.11.109. Epub 2008 Mar 3.

• The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index.

• Han DH1, Jeong YS, Choo MS, Lee KS.


• Abstract

• OBJECTIVES:

• We evaluated the effect of transurethral resection of the prostate (TUR-P) in men with weak bladder contractility who were unresponsive to medical treatment.

• METHODS:

• 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 and/or 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.

• RESULTS:

• Mean follow-up period after TUR-P was 19 months (range 12 to 55 months). After the TUR-P, the IPSS/QoL, 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.

• CONCLUSIONS:

• There were significant improvements in IPSS/QoL 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

https://www.ncbi.nlm.nih.gov/pubmed/18313105https://www.ncbi.nlm.nih.gov/pubmed/?term=Han DH[Author]&cauthor=true&cauthor_uid=18313105https://www.ncbi.nlm.nih.gov/pubmed/?term=Jeong YS[Author]&cauthor=true&cauthor_uid=18313105https://www.ncbi.nlm.nih.gov/pubmed/?term=Choo MS[Author]&cauthor=true&cauthor_uid=18313105https://www.ncbi.nlm.nih.gov/pubmed/?term=Lee KS[Author]&cauthor=true&cauthor_uid=18313105https://www.ncbi.nlm.nih.gov/pubmed/18313105

Diagnosis of BOO improves outcome

from TURP

• Eur Urol. 2007 Jul;52(1):186-92. Epub 2006 Nov 13.

• Predicting the outcome of prostatectomy using noninvasive bladder pressure and urine flow measurements.

• Harding C1, Robson W, Drinnan M, Sajeel M, Ramsden P, Griffiths C, Pickard R.


• Abstract

• OBJECTIVES:

• 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).

• METHODS:

• 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 (>50% reduction in IPSS) was compared according to categorisation by noninvasive bladder pressure and urine flow measurements.

• RESULTS:

• 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 (p

a priori argumentGalen Strawson (b. 1952 British analytic

philosopher)

Wrote that an a priori argument is one in which:

• “You can see that it is true just lying on your couch.”

• “You don't have to get up off your couch and go

outside and examine the way things are in the

physical world.”

• “You don't have to do any science.“

Galen (b. 129 saw himself as both a physician and a

philosopher and wrote a treatise entitled “That the Best

Physician is also a Philosopher”.)

http://en.wikipedia.org/wiki/Galen_Strawsonhttp://en.wikipedia.org/wiki/Truth

Prof. HIPPOCRATES

HERSCHORN?

My Proposition is that:

There is an a priori argument that:

“Urodynamics are essential before surgery for

Lower Urinary Tract Dysfunction”

Lower Urinary Tract: structure and

function

The LUT consists of:

• A reservoir that should store and empty rapidly

to completion, using its pump capabilities

• A pipe that allows rapid and complete emptying

• A valve that is closed during storage

Engineering

• Form follows function

• Pump function is studied by pressure

measurement

• Pipe function is assessed by flow measurement

• Valve function is assessed by looking for

leakage

Surgery for LUTD

• Surgery for Stress Urinary Incontinence and

Benign Prostatic Obstruction are common

procedures

• Patients considering these procedures assume

they will be cured of their symptoms for life

• 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:

• “You can see that it is true just lying on your couch.”

• “You don't have to get up off your couch and go

outside and examine the way things are in the

physical world.”

• “You don't have to do any science.“

Galen (b. 129 saw himself as both a physician and a

philosopher and wrote a treatise entitled “That the Best

Physician is also a Philosopher”.)

Of course we must do science!

http://en.wikipedia.org/wiki/Galen_Strawsonhttp://en.wikipedia.org/wiki/Truth

Research Evidence

• Grade A recommendations require Level 1 evidence

• At present we only have Level 3 evidence for UDS before BPO surgery and Level 2/3 evidence for UDS prior to SUI surgery

• We hope to obtain funding for RCTs in both areas from the UK government

• However our patients do not want to delay their operations for 5 years until we have the results

• 2nd a priori argument

Stress Incontinence Surgery

Benefits:

• Satisfaction 90%

• Cure of SUI 66%

Poor Outcomes (risks) related to:

• Surgical complications

• Patient has no SUI (unnecessary operation)

• Detrusor overactivity during storage (OAB)

• Intrinsic sphincter deficiency (persistent SUI)

• Detrusor underactivity during voiding (increased PVR, need for ISC)

Pure stress leakage symptomatology: is it safe

to discount “detrusor instability”?

METHODS:

• 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.

• 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:

• 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:

• 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 Dec;106(12):1255-8.

http://www.ncbi.nlm.nih.gov/pubmed?term=James M[Author]&cauthor=true&cauthor_uid=10609718http://www.ncbi.nlm.nih.gov/pubmed?term=Jackson S[Author]&cauthor=true&cauthor_uid=10609718http://www.ncbi.nlm.nih.gov/pubmed?term=Shepherd A[Author]&cauthor=true&cauthor_uid=10609718http://www.ncbi.nlm.nih.gov/pubmed?term=Abrams P[Author]&cauthor=true&cauthor_uid=10609718

Is the bladder a reliable witness for

predicting detrusor overactivity?

• 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.

• Patients were selected based on OAB symptoms

RESULTS:

• There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women.

• 69% of men and 44% of women with urgency (OAB dry) had DO,

• 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO.

• 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]

http://www.ncbi.nlm.nih.gov/pubmed/16890743

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:

• 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).

• Strict selection criteria were used to identify patients with pure SUI.

RESULTS:

• Only 5.2% women had pure SUI

• 25% had other urodynamic diagnoses other than that could affect the outcome of continence surgery.

CONCLUSION:

• 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.

• Agur W, Housami F, Drake M, Abrams P. BJU Int. 2009 Mar;103(5):635-9.

http://www.ncbi.nlm.nih.gov/pubmed?term=Agur W[Author]&cauthor=true&cauthor_uid=19021606http://www.ncbi.nlm.nih.gov/pubmed?term=Housami F[Author]&cauthor=true&cauthor_uid=19021606http://www.ncbi.nlm.nih.gov/pubmed?term=Drake M[Author]&cauthor=true&cauthor_uid=19021606http://www.ncbi.nlm.nih.gov/pubmed?term=Abrams P[Author]&cauthor=true&cauthor_uid=19021606

Conclusions: Urodynamics in Stress

Urinary Incontinence

• Defines the condition - USI

• Demonstrates detrusor overactivity (DO)

• Measures urethral function

• Assesses detrusor contractility

UDS enable fully informed consent.

Surgery for LUTS due to Prostatic

Obstruction (BPO)

Benefits:

• Marked reduction in symptoms, improved QoL

Poor Outcomes:

• Surgical complications

• Does not have BPO (unnecessary operation)

• Detrusor overactivity during storage (persistent

OAB)

• Detrusor underactivity during voiding (increased

PVR, need for ISC)

• Hippocrates

“The physician must have two special objects in

view with regard to disease, namely, to do good

or to do no harm.”

Conclusions

• www.tvt-messed-up-mesh.org.uk/

"this is happening right now, people are suffering

complications from having synthetic

polypropylene mesh implanted into their bodies.“

• Patients are looking more closely at accuracy of

diagnosis and any poor outcomes

• Until we have Level 1 evidence do what is safe:

follow the a priori argument and do UDS before

LUTD surgery

http://www.tvt-messed-up-mesh.org.uk/

• Prog Urol. 2017 Apr;27(5):312-318. doi: 10.1016/j.purol.2017.02.005. Epub 2017 Apr 1.

• [Morbi-mortality of transurethral resection of the prostate in patients aged 75 and over].

• [Article in French]

• Evrard PL1, Mongiat-Artus P2, Desgrandchamps F2.


• Abstract

• INTRODUCTION:

• 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.

• MATERIAL AND METHODS:

• 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.

• RESULTS:

• One hundred and seventy-six patients were included in this study. A total of 47.2% of patients experienced at least one complication. The majority of patients (79.5%) 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.

• CONCLUSION:

• Monopolar transurethral resection of the prostate is followed by significant morbidity in older patients, higher than in the general population.

• LEVEL OF EVIDENCE:

• 4.
https://www.ncbi.nlm.nih.gov/pubmed/28377079https://www.ncbi.nlm.nih.gov/pubmed/?term=Evrard PL[Author]&cauthor=true&cauthor_uid=28377079https://www.ncbi.nlm.nih.gov/pubmed/?term=Mongiat-Artus P[Author]&cauthor=true&cauthor_uid=28377079https://www.ncbi.nlm.nih.gov/pubmed/?term=Desgrandchamps F[Author]&cauthor=true&cauthor_uid=28377079https://www.ncbi.nlm.nih.gov/pubmed/28377079

Urodynamics (Pressure-Flow) prior to Bladder Outlet Obstruction … · of overactive bladder...

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