732 A NEW WAY OF MEASURING BLADDER SENSATIONS DURING CYSTOMETRY

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The natural history of lower urinary tract symptoms in females over 6.5 years: analysis of a health screening project 1

2

1

1

Lower urinary tract dysfunction after radical hysterectomy

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Yamanishi T.1, Mizuno T.1, Nakanishi K.1, Kanbara T.1, Kamai T.1, Yoshida K.I.1, Awa Y.2

Heidler S. , Deveza C. , Temml C. , Ponholzer A. , Marszalek M. , Bluhm A. , Madersbacher S.1 1



1

Donauspital, Dept. Urology and Andrology, Vienna, Austria, 2City of Vienna, Department of Preventive Health, Vienna, Austria 1

Introduction & Objectives: Little is known regarding the natural history of lower urinary tract symptoms (LUTS) in women. To analyse this issue we set up a prospective study of women participating in a health investigation in the area of Vienna and who were contacted after 6.5yrs. Material & Methods: Women participating in a health screening survey in the area of Vienna in 1998/1999 underwent a detailed health investigation and completed the Bristol Female LUTS questionnaire. In 2005 all women who where still living in the area of Vienna, were contacted by mail to complete the Bristol LUTS questionnaire. For the current study only women without urinary incontinence at baseline and follow-up were eligible. Results: A total of 223 women (mean age: 50.3yrs, range: 21-79yrs) entered this 6.5yrs longitudinal study. At baseline, 35.9% reported on LUTS, this percentage increased to 47.1% 6.5yrs later. The mean annual incidence of de novo storage LUTS was 4.1%/year (20-39yrs: 4.7%; 40-59yrs: 4.6%; 60+yrs: 2.5%). The respective value for voiding LUTS was 2.7% with no clear age dependency. The two symptoms that deteriorated most frequently within 6.5 years were “frequency” and “the feeling of incomplete emptying”. “Urgency” had the highest tendency to improve. A quality of life impairment due to LUTS was reported by 21% at baseline and by 41% 6.5yrs later.

Dokkyo Medical University, Urology, Tochigi, Japan, 2Chiba University, Urology, Chiba, Japan 1

Introduction & Objectives: Lower urinary tract dysfunction (LUTD) has been reported to occur after radical hysterectomy, temporary or permanently. The cause of LUTD may be mainly from the injury of pelvic nerve that results in acontractile detrusor and low compliance bladder. The aim of the present study is to investigate the LUTD after radical hysterectomy by video-urodynamic study. Material & Methods: A total of 80 female patients with a mean age of 53.9±12.4 (6182) years, who underwent radical hysterectomy were studied. All patients had no lower urinary tract symptoms before the surgery. Lower urinary tract symptoms including storage symptoms (urinary frequency, nocturia, urgency, urgency incontinence and stress incontinence) and voiding symptoms (difficulty in urination and urinary retention) were assessed and video-urodynamic studies were performed after the surgery in all patients. Results: After the surgery, 64 patients (80%) had lower urinary tract symptoms: urinary frequency in 5 (6%), urgency in 2 (3%), urgency incontinence in 0, stress or mixed incontinence in 9 (11%), voiding difficulty in 15 (19%) and both urinary incontinence and voiding difficulty in 33 (41%). Urinary retention was noted in 2 patients. Uroflowmetry could be performed in 45 patients and decrease in urinary flow was observed in 15 patients (33%). Postvoid residual was less than 50ml in 42 of 64 patients studied (66%), 50-100ml in 7 (11%) and more than 100ml in 15 (23%). In urethral pressure profile (n=20), maximum urethral closure pressure was <20 cmH2O in no patient, 20-40 in 5(15%) and >40 in 15(75%). Abdominal leak point pressure (n=4) was less than 60cmH2O in 1 patient and >more than 6 cmH2O in 3. In cystometry, bladder sensation was decreased in 22 patients, but almost all patients had non-specific bladder sensation. In filling phase, low compliance detrusor was noted in 40 (53%) and detrusor overactivity in 2 (3%). In voiding phase, underactive detrusor was noted in 2 (3%) and acontractile detrusor in 51 (64%). Urethral function demonstrated intrinsic sphincter deficiency in 6 patients (25%) and non-relaxing urethra in 20 (31%).

Conclusions: This longitudinal study on the natural history of LUTS in women without urinary incontinence provides estimates for incidence and remission rates over 6.5 years. In parallel to men, LUTS in women are rather a dynamic than a necessarily progressive disorder.

Conclusions: Although severe voiding difficulty including urinary retention and severe urinary incontinence are rare, radical hysterectomy may cause various LUTD postoperatively. Vesicourethral reflux and/or upper urinary tract deterioration may occur in patients with low compliance bladder and those who void with straining.





Vesicovaginal fistula repair – 20 year experience

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Herschorn S., Chung D. University of Toronto, Urology, Toronto, Canada Introduction & Objectives: The commonest cause of vesicovaginal fistulas (VVFs) in North America is abdominal hysterectomy. Controversy still exists regarding the optimal timing of repair and surgical approach, which can be either transvaginal or transabdominal. The role of interpositional flaps is also controversial. We aimed to review our fistula patients with regard to etiology, perioperative parameters, and outome. Material & Methods: Between January 1986 and June 2006, 47 fistulas were repaired. Charts were retrospectively reviewed for etiology, location, presentation, surgical approach, perioperative complications, previous repair, complications, litigation rate, and cure rate. The abdominal approach involved entering the plane between the bladder and vagina. The bladder was not bi-valved. Multiple layer closure was performed with omental interposition. The transvaginal approach involved a multi-layer closure with flap interposition as required. Suprapubic catheters were left indwelling for 4-6 weeks. The outcome was determined by cystogram and symptoms. Results: Mean patient age was 43.11. Forty-four patients (95.6%) had undergone previous pelvic surgery. Etiology of the fistula was hysterectomy in 32 patients (69.6%), C-section in 7 (15.2%), forceps delivery in 2 (4.3%), and catheter erosion in 2 (4.3%). Mean fistula size was 8.79 mm. Mean time from fistula occurrence to repair was 6.9 mo. (range 2-22). Fistula location was posterior to the trigone in 30 patients (65.2%), trigone in 11 (23.9%), and bladder neck in 6 (13.0%). All patients presented with continuous incontinence. Of 47 VVFs 38 were complicated (80.85%). 25 patients(54.3%) had had a previous failed repair. 26 (55.3%) of the VVF repairs were performed with an abdominal approach and 19 (40.4%) with a transvaginal technique. Two repairs were performed with both transvaginal and abdominal approaches. Some patients who had had previous failed abdominal repairs were able to be closed with a transvaginal approach. Tissue flaps were used in all of the abdominal and combined repairs and 4 (21.0%) of the vaginal repairs. Mean hospital stay was 5.72 days. Mean follow-up was 20.15 months (range 0.17-132.93). All fistulas were successfully repaired. At follow-up 7 (15.2%) experienced urge incontinence, 6 (13.0%) stress incontinence, 5 (10.9%) urgency, 3 (6.5%) frequency, and 1 (2.2%) chronic pain. 23.4% of patients initiated litigation against a previous physician. Conclusions: Both approaches are highly successful. Management techniques include multi-layer closure, flap interposition as required, and suprapubic drainage. There does not appear to be a mandatory wait time between time of injury and repair, provided the tissues appear healthy. The litigation rate from VVF is very high suggesting a profoundly negative impact on quality of life.

732

A new way of measuring bladder sensations during cystometry O’Donoghue J.1, Tsang W.1, Moore J.1, Reynard J.1, Noble J.1, Brading A.2

Churchill Hospital, Urology, Oxford, United Kingdom, 2Oxford University, Pharmacology, Oxford, United Kingdom 1

Introduction & Objectives: The Standardization Sub-committee of the ICS define OAB as urgency with or without incontinence, usually with frequency and nocturia in the absence of infection or other obvious pathology. Sensory evaluation during cystometric studies is subjective because of external and physiological factors. Hence, this makes interpretation of bladder sensations difficult so we need better ways of discriminating between urgency and the normal urge to void. The aim of this study is to develop in real time an objective measure of bladder sensation during urodynamics. Material & Methods: Patients with OAB were catheterised and urodynamics carried out in the usual way. A hand held pneumatic device referred to as an urgemeter was used to express bladder sensation during filling cystometry without verbal communication with the clinician. Patients squeezed the device when they developed bladder sensation and this resulted in a continuous trace alongside other cystometric data. Results: A total of 13 patients with OAB had urodynamics with assessment of bladder sensation. The device gave reliable and repeatable measures of bladder sensation in real time. These sensations have been quantified and a temporal relationship between the detrusor trace and urgemeter trace has been established. Urge and urgency are clearly distinguishable. Validation of the device was achieved by emptying and filling the bladder and the patient was unaware of the direction of filling. Table 1. Validation of Urgemeter Device Patient 1 2 3 4 5 6 7 8 9 10 11 12 13

fbs Mean urge(SD) 65.3(38.4) 7.7(1.7) 6.8(0.4) 8.5(6.2) 8.4(6.5) 1.3(0.5) 28.6(32.1) 6.8(2.8) 18.7(8.6) 7.7(3.7) 33.6(13.8) 10.1(2.85) 49.5(24.1)

fdv Mean urge(SD) 3.7(0.5) 13.7(14.3) 51.1(11.3) 29.7(5.7) 38.4(10.1) 4.0(1.9) 57.7(24.8) 26.3(2.1) 53.6(3.8) 12.6(3.7 38.3(2.4) 9.2(10.9) 57(9.54)

sdv Mean urge(SD) 22.6(8.8) 44.1(16.0) 46.2(17.4) 24(8.4) 43.4(6.1) 16.4(6.6) 97.9(37.9) 52.7(6.3) 58.6(5.3) 41.7(22.1) 36.4(5.3) 55.4(55.05) 54(27.3)

fbs & fdv (P value)* 0.012 0.017 0.005 0.005 0.006 0.008 0.086 0.005 0.005 0.011 0.386 0.184 0.575

fdv & sdv (P value)* 0.007 0.074 0.798 0.333 0.172 0.005 0.053 0.005 0.05 0.013 0.238 0.017 0.646

fbs & sdv (P value)* 0.013 0.007 0.007 0.008 0.005 0.005 0.005 0.005 0.005 0.007 0.646 0.028 0.646

*Comparison of bladder sensations (urge units) at defined bladder volumes (Wilcoxon matched pairs test) In most of the patients, a positive relationship exists between increasing bladder volume and urge sensation as detected with the urgemeter. Occasionally patients experienced difficulty in using the device and this probably accounted for the aberrant results. Conclusions: Most patients find the device easy to use and its use did not prove to be disruptive. Sensation at each bladder volume was not affected by direction of flow and was significantly different for each bladder volume tested using the Wilcoxon matched pairs test The validation study proved that the patients’ perceptions of bladder fullness were not simply a direct response to the length of time of filling.

Eur Urol Suppl 2007;6(2):205