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413Influence of neurovascular bundles on the urethral pressure
413
414
I N F L U E N C E OF N E U R O V A S C U L A R BUNDLES ON THE U R E T H R A L PRESSURE
F O C A L ADMINISTRATION OF B O T U L I N U M TOXIN A IN PATIENTS WITH NEUROGENIC DETRUSOR OVERACTIVITY PRODUCES B L A D D E R FUNCTION I M P R O V E M E N T S W I T H O U T DRUG-RELATED A D V E R S E EVENTS
Schmid D.M. Strebel R., Fatzer M., John H., Hauri D. University Hospital Zurich, Urology, Zurich, Switzerland I N T R O D U C T I O N & OBJECTIVES: Aim of this prospective study was to evaluate the influence of the nervi cavernosi on the urethral pressure by means of electrostimulation and local anaesthesia for experimentally corroborating the clinical observation of better postoperative continence after seminal vesical and nerve sparing radical prostatectomy. M A T E R I A L & M E T H O D S : 10 patients, undergoing TRUS-guided prostate biopsy, were randomized for bilateral injections of the neurovascular bundles (NVB) with 5 ml ropivaeaine 7.5 mg/ml versus NaC1 0.9%. Before injection procedure, a 8 Fr microtip catheter was placed into the urethral sphincter and resting pressure was recorded during 5 min., the bladder filled with 200 ml. Then, the injections of the NVB were performed bilaterally TRUS- and Duplex-guided (landmarks: dorsolat arteries). Urethral pressure was recorded up to 15 min. after injections with an urodynamie unit. In 5 other patients undergoing nerve/seminal vesical sparing radical prostatectomy intraoperative electrostimulation (5 see. duration, 15 Hz. frequency, 20 mA strength, 800 usec pulse width, bipolar, without muscle relaxation) of the NVB and seminal vesicle tips (SVT) was performed with a bipolar needle and an electromyograph before prostate removal. Urethral pressure was simultaneously measured with a microtip catheter inserted into the membranous urethra. The pressure peaks during stimulation at NVB, SVT and control sites (wall of the pelvis) were continuously registered with an urodynamic unit.
Chartier-Kastler E. t, Schurch B.2, De S~ze M.3, Denys R4, Haab F.5, Everaert K.6, Plante R7, Perrouin-VerbeB? 'Group Hospitalier Pitir-Salprtri+re, Clinique Urologique, Paris, France, 2U1)iversityHospital Balgrist, Spinal Cord Injury Centre, Zurich, Switzerland, ~Hrpital Pellegrin, Service de Medecine Physiqueet de Readaptation,Bordeaux,France,4H6pitaIRaymondPoincarr, Servicede R66ducation Neurologique, Garches, France, 5Hrpital Tenon, Service Urologie, Paris, France, 6GhentUniversity Hospital, Departmentof Urology, Ghent, Belgium,7Hgpital Rangueil,ServiceUrologie, Toulouse, France, 8CHUNantes,RehabilitationDepartment,Nantes,France INTRODUCTION & OBJECTIVES: Neurogenic detrusor overactivity produces symptoms of illeontJuence and increases risk of vesicouretericreflux and kidney damage because of increased detrusorpressure.Effectivemanagementof neurogenicbladder is essentialto minimiseimpactof the conditionon patients' lives and risk of further damage.This randomised,double-bllnd,multi-centre, placebo-controlled study investigated the effect of botulinum toxin A (BOTOX®) on bladder managementin patientswith neurogenicdetrusoroveractivity. MATERIAL& METHODS: Patientswith neurogenicdetrusoroveractivityrequiringregularcIean intermittent self-catheterisation, failing on oral anticholinergics, were eligible for inclusion. Each subjectwas randomisedto receive a single dose of BOTOX® (200 U or 300 U) or placebo as 30 injectionsevenly distributedover the detmsormuscle.Effectson maximumcystometriccapacit) (MCC), reflex detmsor volume (RDV) and maximumdemtsor pressureduring bladder contraction (MDP)were measuredduringstudyvisitsthroughout24 weekspost-treatmentSafetyassessmentswere conductedat eachvisit and presenceof antibodiesto BOTOX~ monitoredat baselineand week 24.
RESULTS: The nervous blockade with local anaesthesia resulted in a marked pressure decrease (Ap=30 cmH20) from mean 55 to 25 cmH20. No effect was seen after injection of NaC1 solution. The nervous stimulations of NVB and SVT provoked at both sides reproducible pressure peaks (Ap-20 cmH20) from mean 25 to 45 cmH20. No pressure peaks were seen after stimulation of the control sites.
RESULTS: 59 patients (overall mean durationof detmsor overactivity:63.1 months)were enrolled into the study. Improvementsin bladder managementwere observed in both BOTOX® groups. Significantincreases(p<0.020)in mean MCC,with mean percentchangefrombaselinerangingfrom 59.5% to 141%, and significantdecreases(p_<0.023)in MDP from baseline were seen at all posttreatmenttime points.No such changeswere observedwith placebo. 23 patientsexperiencedno RDV for at least 1 follow-upvisit, 91% of whom were in a BOTOX®4reatedgroup. For patientshavinga post-treatmentRDV, significantincreases (p<0.021) from baseline were seen at weeks 6 (300 U BOTOX®) and 24 (200 U BOTOX®).BOTOX®therapywas well tolerated: no drug-relatedadverse events were reported. No cases of autonomicdysreflexiawere seen. No patient was positive for neutralisingantibodiesat baselineor study end.
CONCLUSIONS: Our experimental results corroborate the clinical finding of a better postoperative continence after seminal vesical and nerve sparing radical prostatectomy: obviously not only the pudendal nerve but also autonomous nerves running in the NVB contribute to the resting urethral tone.
CONCLUSIONS: BOTOX® produced substantial improvements in urodynamie parameters, showing increasedability of the bladder to hold and retain urine, sustainedthroughout24 weeks. BOTOX® may be an important therapeutic option for improvingneurogenicbladder management and reducingrisk ofvesicouretericreflux,potentiallypreventingupper urinarytract deteriorationand kidney damage.
L A R G E P O S T V O I D RESIDUAL URINE VOLUMES: DOES IT A F F E C T C L I N I C A L P R O G R E S S I O N OF TREATED AND UNTREATED BPH?
INFLUENCE OF I N D W E L L I N G T R A N S U R E T H R A L CATHETERS ON PSA-LEVELS IN PATIENTS WITH BENIGN PROSTATIC
416 HYPERPLASIA
Mochtar C.A?, Kiemeney L. a, Van Riemsdijk M. 3, Lagnna M.P?, Debruyne F.a, De la Rosette j.1 ~Academic Medical Centre, University of Amsterdam, Urology, Amsterdam, The Netherlands, 2Radboud University Hospital, Urology, Nijmegen, The Netherlands, 3GlaxoSmithKline, Epidemiology, Zeist, The Netherlands I N T R O D U C T I O N & OBJECTIVES: To assess the value of large postvoid residual urine volumes (PVR) at baseline, as predictor of clinical progression during long-term follow-up of patients with symptomatic benign prostatic hyperplasia (BPH) treated initially with c~-blockers or watchful waiting (WW). M A T E R I A L & M E T H O D S : The baseline and follow-up data of a cohort of 2264 BPH patients were collected prospectively. For this study, only patients treated with a~-blockers or watchful waiting (WW) were evaluated. Inclusion criteria were serum prostate-specific antigen (PSA) <=10 ng/ml, and prostate volume (PV) <=200 ml. Patients with prostate cancer, prostatitis, previous BPH-related invasive therapy, and neurogenic bladder at baseline were excluded. Baseline IPSS scores, PSA, prostate volume, uroflowmetry, and pressure-flow parameters and follow-up data were compiled. PVR was measured through transabdominal ultrasound and calculated by a standard ellipsoid formula. Clinical progression was defined as the need for BPH-related invasive therapy. Kaplan-Meier method was used to calculate the 5-year cumulative risks of invasive therapy. The relative risk between large and small PVRs, stratified by 50, 100, and 300 ml cut-off levels, were calculated using proportional hazards analyses, RESULTS: For the analyses, 942 patients were eligible for inclusion. With increasing PVR cut-off levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45%, 44% to 64% and from 15%, 16% to 21% in the c~,-blockers and W W group, respectively. Large PVR has a significant two-fJd up to a four-fold age-adjusted increased risk of invasive therapy compared to small PVR in both treatment groups. After adjustment with additional prognostic factors these significant risk differences largely disappear, although a statistically not significant higher risk remains for the 'very' large PVR (>=300 ml) patients. CONCLUSIONS: Large PVR does not seem to affect clinical progression in c~.-blocker and WW managed patients. Only patients with 'very' large PVR may h~ve a two-fold increased risk for invasive therapy compared to patients with smaller PVR.
European Urology Supplements 4 (2005) No. 3, pp. 106
Lipsky K ? , Sehips L?, Pummer K ? , Rehak P?, Zigeuner R. 1 1Medical University Graz, Urology, Graz, Austria, 2Medical University Graz, Biomedical Engineering and Computing, Graz, Austria I N T R O D U C T I O N & OBJECTIVES: Data regarding impact of indwelling transurethral catheters on serum PSA are controversial. The aim of our study was to evaluate this question in a large series of patients undergoing surgery for benign prostatic hyperplasia (BPH). M A T E R I A L & M E T H O D S : 1492 Consecutive patients with negative digital-
rectal examination (DRE) and histologically confirmed BPH and who underwent either transurethral resection of the prostate (TURP) or transvesical prostatectomy for obstructive voiding symptoms at our institution were retrospectively evaluated. Patients with suspicious DRE and/or prostate cancer diagnosed by surgery or biopsy were excluded. 718/1492 (48.1%) had an indwelling transurethral catheter due to urinary retention at admission. Routine PSA testing was done in each patient at the time of admission. Patients with (group I) and without (group II) catheters were evaluated with respect to age, total PSA, weight of resected tissue, and duration of catheterisation. To compensate differences in age and prostate size between both groups, which also could result in different PSA levels, a covariate analysis was performed. RESULTS: Median patients' age and weight of resected tissue in groups I and II was 72 and 70 years, and 24 grams and 16 grams, respectively. Median PSA in groups I and II was 6.9 and 3.4 ng/ml, respectively (P<0.0001, Wilcoxon-test). Duration of catheter drainage had been documented in 426 patients, median time was 17 days (range 1-1130). A statistically significant correlation between length of catheterisation and PSA levels could not be detected. Covariate analysis excluded the influence of higher age and larger prostate volumes in group I and showed a PSA relation of 1.46:1 between groups I and II. CONCLUSIONS: Overall, PSA in catheterised patients was twice as high compared to patients without catheter. After balancing the differences in age and prostate volume catheterized patients on average still had almost 50% higher PSA levels. However, due to the wide variation of PSA in catheterized patients, a calculation of the 'true' PSA level in individual patients with indwelling catheters is not possible. Thus, catheters do not change indication for biopsy.
414
I N F L U E N C E OF N E U R O V A S C U L A R BUNDLES ON THE U R E T H R A L PRESSURE
F O C A L ADMINISTRATION OF B O T U L I N U M TOXIN A IN PATIENTS WITH NEUROGENIC DETRUSOR OVERACTIVITY PRODUCES B L A D D E R FUNCTION I M P R O V E M E N T S W I T H O U T DRUG-RELATED A D V E R S E EVENTS
Schmid D.M. Strebel R., Fatzer M., John H., Hauri D. University Hospital Zurich, Urology, Zurich, Switzerland I N T R O D U C T I O N & OBJECTIVES: Aim of this prospective study was to evaluate the influence of the nervi cavernosi on the urethral pressure by means of electrostimulation and local anaesthesia for experimentally corroborating the clinical observation of better postoperative continence after seminal vesical and nerve sparing radical prostatectomy. M A T E R I A L & M E T H O D S : 10 patients, undergoing TRUS-guided prostate biopsy, were randomized for bilateral injections of the neurovascular bundles (NVB) with 5 ml ropivaeaine 7.5 mg/ml versus NaC1 0.9%. Before injection procedure, a 8 Fr microtip catheter was placed into the urethral sphincter and resting pressure was recorded during 5 min., the bladder filled with 200 ml. Then, the injections of the NVB were performed bilaterally TRUS- and Duplex-guided (landmarks: dorsolat arteries). Urethral pressure was recorded up to 15 min. after injections with an urodynamie unit. In 5 other patients undergoing nerve/seminal vesical sparing radical prostatectomy intraoperative electrostimulation (5 see. duration, 15 Hz. frequency, 20 mA strength, 800 usec pulse width, bipolar, without muscle relaxation) of the NVB and seminal vesicle tips (SVT) was performed with a bipolar needle and an electromyograph before prostate removal. Urethral pressure was simultaneously measured with a microtip catheter inserted into the membranous urethra. The pressure peaks during stimulation at NVB, SVT and control sites (wall of the pelvis) were continuously registered with an urodynamic unit.
Chartier-Kastler E. t, Schurch B.2, De S~ze M.3, Denys R4, Haab F.5, Everaert K.6, Plante R7, Perrouin-VerbeB? 'Group Hospitalier Pitir-Salprtri+re, Clinique Urologique, Paris, France, 2U1)iversityHospital Balgrist, Spinal Cord Injury Centre, Zurich, Switzerland, ~Hrpital Pellegrin, Service de Medecine Physiqueet de Readaptation,Bordeaux,France,4H6pitaIRaymondPoincarr, Servicede R66ducation Neurologique, Garches, France, 5Hrpital Tenon, Service Urologie, Paris, France, 6GhentUniversity Hospital, Departmentof Urology, Ghent, Belgium,7Hgpital Rangueil,ServiceUrologie, Toulouse, France, 8CHUNantes,RehabilitationDepartment,Nantes,France INTRODUCTION & OBJECTIVES: Neurogenic detrusor overactivity produces symptoms of illeontJuence and increases risk of vesicouretericreflux and kidney damage because of increased detrusorpressure.Effectivemanagementof neurogenicbladder is essentialto minimiseimpactof the conditionon patients' lives and risk of further damage.This randomised,double-bllnd,multi-centre, placebo-controlled study investigated the effect of botulinum toxin A (BOTOX®) on bladder managementin patientswith neurogenicdetrusoroveractivity. MATERIAL& METHODS: Patientswith neurogenicdetrusoroveractivityrequiringregularcIean intermittent self-catheterisation, failing on oral anticholinergics, were eligible for inclusion. Each subjectwas randomisedto receive a single dose of BOTOX® (200 U or 300 U) or placebo as 30 injectionsevenly distributedover the detmsormuscle.Effectson maximumcystometriccapacit) (MCC), reflex detmsor volume (RDV) and maximumdemtsor pressureduring bladder contraction (MDP)were measuredduringstudyvisitsthroughout24 weekspost-treatmentSafetyassessmentswere conductedat eachvisit and presenceof antibodiesto BOTOX~ monitoredat baselineand week 24.
RESULTS: The nervous blockade with local anaesthesia resulted in a marked pressure decrease (Ap=30 cmH20) from mean 55 to 25 cmH20. No effect was seen after injection of NaC1 solution. The nervous stimulations of NVB and SVT provoked at both sides reproducible pressure peaks (Ap-20 cmH20) from mean 25 to 45 cmH20. No pressure peaks were seen after stimulation of the control sites.
RESULTS: 59 patients (overall mean durationof detmsor overactivity:63.1 months)were enrolled into the study. Improvementsin bladder managementwere observed in both BOTOX® groups. Significantincreases(p<0.020)in mean MCC,with mean percentchangefrombaselinerangingfrom 59.5% to 141%, and significantdecreases(p_<0.023)in MDP from baseline were seen at all posttreatmenttime points.No such changeswere observedwith placebo. 23 patientsexperiencedno RDV for at least 1 follow-upvisit, 91% of whom were in a BOTOX®4reatedgroup. For patientshavinga post-treatmentRDV, significantincreases (p<0.021) from baseline were seen at weeks 6 (300 U BOTOX®) and 24 (200 U BOTOX®).BOTOX®therapywas well tolerated: no drug-relatedadverse events were reported. No cases of autonomicdysreflexiawere seen. No patient was positive for neutralisingantibodiesat baselineor study end.
CONCLUSIONS: Our experimental results corroborate the clinical finding of a better postoperative continence after seminal vesical and nerve sparing radical prostatectomy: obviously not only the pudendal nerve but also autonomous nerves running in the NVB contribute to the resting urethral tone.
CONCLUSIONS: BOTOX® produced substantial improvements in urodynamie parameters, showing increasedability of the bladder to hold and retain urine, sustainedthroughout24 weeks. BOTOX® may be an important therapeutic option for improvingneurogenicbladder management and reducingrisk ofvesicouretericreflux,potentiallypreventingupper urinarytract deteriorationand kidney damage.
L A R G E P O S T V O I D RESIDUAL URINE VOLUMES: DOES IT A F F E C T C L I N I C A L P R O G R E S S I O N OF TREATED AND UNTREATED BPH?
INFLUENCE OF I N D W E L L I N G T R A N S U R E T H R A L CATHETERS ON PSA-LEVELS IN PATIENTS WITH BENIGN PROSTATIC
416 HYPERPLASIA
Mochtar C.A?, Kiemeney L. a, Van Riemsdijk M. 3, Lagnna M.P?, Debruyne F.a, De la Rosette j.1 ~Academic Medical Centre, University of Amsterdam, Urology, Amsterdam, The Netherlands, 2Radboud University Hospital, Urology, Nijmegen, The Netherlands, 3GlaxoSmithKline, Epidemiology, Zeist, The Netherlands I N T R O D U C T I O N & OBJECTIVES: To assess the value of large postvoid residual urine volumes (PVR) at baseline, as predictor of clinical progression during long-term follow-up of patients with symptomatic benign prostatic hyperplasia (BPH) treated initially with c~-blockers or watchful waiting (WW). M A T E R I A L & M E T H O D S : The baseline and follow-up data of a cohort of 2264 BPH patients were collected prospectively. For this study, only patients treated with a~-blockers or watchful waiting (WW) were evaluated. Inclusion criteria were serum prostate-specific antigen (PSA) <=10 ng/ml, and prostate volume (PV) <=200 ml. Patients with prostate cancer, prostatitis, previous BPH-related invasive therapy, and neurogenic bladder at baseline were excluded. Baseline IPSS scores, PSA, prostate volume, uroflowmetry, and pressure-flow parameters and follow-up data were compiled. PVR was measured through transabdominal ultrasound and calculated by a standard ellipsoid formula. Clinical progression was defined as the need for BPH-related invasive therapy. Kaplan-Meier method was used to calculate the 5-year cumulative risks of invasive therapy. The relative risk between large and small PVRs, stratified by 50, 100, and 300 ml cut-off levels, were calculated using proportional hazards analyses, RESULTS: For the analyses, 942 patients were eligible for inclusion. With increasing PVR cut-off levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45%, 44% to 64% and from 15%, 16% to 21% in the c~,-blockers and W W group, respectively. Large PVR has a significant two-fJd up to a four-fold age-adjusted increased risk of invasive therapy compared to small PVR in both treatment groups. After adjustment with additional prognostic factors these significant risk differences largely disappear, although a statistically not significant higher risk remains for the 'very' large PVR (>=300 ml) patients. CONCLUSIONS: Large PVR does not seem to affect clinical progression in c~.-blocker and WW managed patients. Only patients with 'very' large PVR may h~ve a two-fold increased risk for invasive therapy compared to patients with smaller PVR.
European Urology Supplements 4 (2005) No. 3, pp. 106
Lipsky K ? , Sehips L?, Pummer K ? , Rehak P?, Zigeuner R. 1 1Medical University Graz, Urology, Graz, Austria, 2Medical University Graz, Biomedical Engineering and Computing, Graz, Austria I N T R O D U C T I O N & OBJECTIVES: Data regarding impact of indwelling transurethral catheters on serum PSA are controversial. The aim of our study was to evaluate this question in a large series of patients undergoing surgery for benign prostatic hyperplasia (BPH). M A T E R I A L & M E T H O D S : 1492 Consecutive patients with negative digital-
rectal examination (DRE) and histologically confirmed BPH and who underwent either transurethral resection of the prostate (TURP) or transvesical prostatectomy for obstructive voiding symptoms at our institution were retrospectively evaluated. Patients with suspicious DRE and/or prostate cancer diagnosed by surgery or biopsy were excluded. 718/1492 (48.1%) had an indwelling transurethral catheter due to urinary retention at admission. Routine PSA testing was done in each patient at the time of admission. Patients with (group I) and without (group II) catheters were evaluated with respect to age, total PSA, weight of resected tissue, and duration of catheterisation. To compensate differences in age and prostate size between both groups, which also could result in different PSA levels, a covariate analysis was performed. RESULTS: Median patients' age and weight of resected tissue in groups I and II was 72 and 70 years, and 24 grams and 16 grams, respectively. Median PSA in groups I and II was 6.9 and 3.4 ng/ml, respectively (P<0.0001, Wilcoxon-test). Duration of catheter drainage had been documented in 426 patients, median time was 17 days (range 1-1130). A statistically significant correlation between length of catheterisation and PSA levels could not be detected. Covariate analysis excluded the influence of higher age and larger prostate volumes in group I and showed a PSA relation of 1.46:1 between groups I and II. CONCLUSIONS: Overall, PSA in catheterised patients was twice as high compared to patients without catheter. After balancing the differences in age and prostate volume catheterized patients on average still had almost 50% higher PSA levels. However, due to the wide variation of PSA in catheterized patients, a calculation of the 'true' PSA level in individual patients with indwelling catheters is not possible. Thus, catheters do not change indication for biopsy.