Urodynamic assessment for urinary incontinence treatment selection: An argument for ACTTM (adjustable continence therapy)

673 URODYNAMIC TREATMENT (ADJUSTABLE

ASSESSMENT FOR URINARY INCONTINENCE SELECTION: AN ARGUMENT FOR ACTTM CONTINENCE THERAPY)

674 TREATMENT OF DETRUSOR OVERACTIVITY OF NEUROGENIC ORIGIN BY TAMSULOSIN TREATMENT, A PILOT STUDY Carbone A., Palleschi G., Tubaro A., Parascani R.

Sadi’,

Sauter T.‘, Kocjancic E.‘, Costa P.‘, Pacetta A.‘, Chattier-Kastler E:, Wachter J.“,

Maier U.‘, Slutsky J.’

La Sapienza University, Urology, Rome, Italy

‘University of Santa Amaro, Urology, Sao Panlo, Brazil, ‘University of Benjamin Franklin, Urology, Berlin, Germany, ‘Ospedale Maggiore, Urology, Novara, Italy, ‘Hopital Gaston Doumergue, Urology, Nimes, France, ‘Gronpe Hospitalier Pitie Salp@tnere, Urology, Paris, France, “Abteihtng im Donauspital, Urology, Vienna, Austna, ‘Riverside Medtcal Center, Urology, Kankakee, United States of America

INTRODUCTION & OBJECTIVES: Patients (pts) suffering from detrnsor overacttvity (DO) often refer bothersome storage symptoms affecting their quality of life. No consensus exists as to the possible role of alphal-adrenoceptors (alphal-AR) in the pathophysiology of DO and overactive bladder. Alphal-AR are know to be expressed in the spinal cord, with the prevalence of alphald subtype. It has been hypothesized that prejunctional alphala receptors can modulate acetylcholine release by the cholinergic axons increasing detrusor contractility. From an experimental standpoint, the superior effect of intrathecal versus mtra-arterial alphal-AR blockers in spontaneous hypertensive rats, the presence of the alphal-AR on parasympathetic neurons and the alphal-AR subtypes distribution in spinal cord suggest that alphal-AR may have a role in the pathophysiology of DO. Aim of this study was to investigate the effect of tamsulosin on DO of neurogenic origin.

INTRODUCTION & OBJECTIVES: Multiple approaches for implantation of tension-free slingplasty have gained popularity for primary hypennobile patients. The concern of urologists has been the issue of selecting appropriate therapy for prnnaty and secondary procedures and according to basehne urodynamic assessment. The study aimed to investigate baseline urodynamic results as a predictor of clinical response in patients treated with ACT. Parameters considered were abdominal leak point pressure (ALPP) and maximal urethral closure pressure (MUCP). MATERIAL & METHODS: The ACT consists of two silicone balloons positioned periurethrally at the bladder neck. Each balloon is individually attached via a conduit to a port situated in the labia. Independent post-operative adjustability of each balloon is realized in an outpatient setting. In 119 patients treated, 55% (n=66) had undergone at least one antiincontinence surgery including bulking agents, slingplasty, colposuspension or hydraulic sohincter. At baseline 72% (81/l 12) had ALPP ~60 and 42% (48/l IS)had MUCP ~30 cm H20. Per clinical examination 52% (62/Jl9) were classified as Ty& II a&48% (571119) as Type III. Direct visual stress test (DVST) was used to assess clinical efftcacy at 6 and 12 months post implantation of the ACT. RESULTS: Baseline urodynamic assessment identified 72% (81/l 12) patients with ALPPc60 of whom 93% (72180) were nositive on DVST. At the 6 and 12 month follow-nos. sienificant nnmbers of these patients were dry: 63% (29146, p
MATERIAL & METHODS: Twenty-eight pts, 39 to 74 years old (mean 61.8+9.3), with DO of neurogenic origin (Multiple System Atrophy 6 pts, Parkinson disease 7 pts., MultiInfarct Encephalopathy 3 pts, Multiple Sclerosis 9 pts, post-infectious myelitis 2 pts, sponddogenic myelopathy 1 pt) were enrolled. Pts were investigated by IPSS, urinalysis, kidney and bladder ultrasound, tilling cystometty and pressure-flow study with concentric needle electromyography (in duplicate, 45 minute apart). Standard urodynamic parameters were evaluated at baseline and after 4 weeks of 0,8 mg/day tamsulosin treatment. RESULTS:

Results of tamsulosin treatment are summarized in table Pre

1

IPSS pts with IDC

I.

Post

1

17.4* 6.4

9.1 * 5.3

28128

14128

202 * 90

287 f 109

0.01

cc (ml)

315*105

427 * 112

0.004

Qmax (ml/s) at P/F study

10.2 i 6.1

12.1 + 6.6

0.3

PdetQmax (cmH20)

44.8 i I3

42 * 17.4

0.27

None of 28 pts repotted significant tamsulosin-related

CONCLUSIONS: The results of this study are intriguing as tamsulosin treatment (0.8 mg/day) resulted in a 50% cure rate of DO in neurogenic patients. Although this IS only a pilot study wtth no placebo arm, the absence of any involuntary detrusor contraction in responders is striking. Confirmation studies and placebo-controlled trials are necessary to contirtn the results of this study. These data suggest the possible clinical relevance of different pathophysiology of DO in various neurological conditions and in different patients.

676 RESINIFERATOXIN FOR IDIOPATIC REFRACTORY TO ANTICHOLINERGICS

Riedl C.‘, Daha L.‘, Knoll M.‘, Pflueger H.’

Universidade Estadual de Campinas, Urology, Campinas, Brazil

Lainz, Urology,

Baden, Austria,

‘Hospital

Lainz, Urology, Vienna,

INTRODUCTION & OBJECTIVES: Detrusor acontractility is commonly treated with cholinergic drugs, mainly oral bethanechol. However, there are only sparse, uncontrolled and controversial data on the efftcacy of bethanechol. The aim of the present study was to demonstrate the efficacy and safety of bethanechol in the restitution of the acontractile detrusor muscle. MATERIAL & METHODS: 16 patients with urinary retention were enrolled in this double-blind, placebo-controlled, crossover, randomised, clinical study approved by the local ethics committee. Only patients with sufficient residual detrusor capacity documented by intravesical electromotive administration of bethanechol chloride (BC) were included. Each patient received BC 4 x 25 mg/day for 14 days, either preceded or followed by a 14-days placebo period. Throughout the study period patients emptied their bladders via a suprapubic tube or by intermittent self-catheterisation. The efficacy of the trial medication was assessed by measurement of detrusor pressure, residual volume and urinary flow rate. RESULTS: BC significantly reduced residual volume and increased urinary flow rate compared to placebo (~~0.02 and p
The present results demonstrate that bethanechol effectively function in case of acontractility due to a non-myogenous/ neurogenic lesion. Bethanechol is effective especially in the early phases of detrusor contractility disorders. Thus, it is essential to institute early cystometric evaluation and BC therapy in cases of complete or partial urinary retention.

0.001

side-effects during the study period.

BETHANECHOL FOR THE TREATMENT OF NEUROGENIC DETRUSOR CONTRACTILITY DISORDERS: A PROSPECTIVE, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSSOVER CLINICAL TRIAL

‘Hospital

P’ 0.018

Volume at 1st IDC (ml)

675

Austria

1

Palma P., Thiel M., Riccetto

C., Dambros

OVERACTIVE

M., Fraga R., Myaoka

BLADDER

R., Netto Jr. N

INTRODUCTION & OBJECTIVES: Resiniferatoxin is a potent vanilloid receptor agonist found in type C sensorial tibres and has low dosage desensitisation properties. Part of the mechanism involved in detrusor instability is believed to be related to these nerve tibres and therefore, the irritant symptoms resulting from this alteration may be controlled by intravesical resiniferatoxin instillation. The purpose of this study was to verify the efficacy of this new substance regarding clinical symptoms and the urodynamic alterations that may occur, MATERIAL & METHODS: This study was conducted on 30 women whose median age was 56 years (ranging from 24 to 88 years), with diagnostic of detrusor instability for over six months and a history of anticholinergic utilization for at least 40 days with no response or intolerable side effects. A 50 nM resiniferatoxin (RTX) solution was prepared just before each intravesical instillation. All the patients were questioned about urinary symptoms before the instillation of resiniferatoxin and again 30 days after. Cystometry was also performed before instillation and again 30 days later. The cystometric parameters assessed were maximum cystometric capacity, maximum amplitude of involuntary contractions and the presence of urgency or urinary leakage during these contractions RESULTS: The instillations were well tolerated for most patients and there weren’t side effects. Clinical improvement was observed in 30% of the patients with urgency and in 33 % of the patients with urge-incontinence. The mean maximum cystometric capacity before instillation was 303.9+78.9 and after instillation was 341G4.6, presenting no significant statistical difference. The mean maximum amplitude of the contractions diminished significantly from 47.86*29.64 to 38.72130.77 (p less than 0.05). CONCLUSIONS: Besides it’s safety and painless, resiniferatoxin, in this concentration, proved to be useful in the treatment of detrusor instability only in a small percentage of patients, considering the clinical improvement after intravesical instillation. Nevertheless, it brought about a significant reduction in the maximum amplitude of the involuntary contractions, Further studies with higher concentration are warranted to access the role of RTX for this subset of patients. European

Urology

Supplements

2 (2003)

No. 1, pp. 171