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Guidelines on BPH: an international comparison
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U S E F U L N E S S O F P R E - V O I D I N G U L T R A S O U N D B L A D D E R S C A N IN BPH P A T I E N T S I N V O L V E D IN C L I N I C A L S T U D I E S
G U I D E L I N E S O N BPH: AN I N T E R N A T I O N A L C O M P A R I S O N lrani Jacuues ~, Brown Christian 2. van der Meulen Jan 2, Emberton Mark z ~Urology, CHU La Miletrie, Poitiers, France, ZClinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
Dicuio M. t , Francesca F. 2, Damber J.E?, Dahlstrand C ?
I N T R O D U C T I O N & O B J E C T I V E S : Over the last decade, a number of organisations have developed clinical practice guidelines on BPH, in order to ensure appropriate health care. To what extent are these guidelines consistent? In order to examine this, we compared the recommended diagnostic tests and treatment recommendations of patients with BPH in different regions of the world.
~Department of Urology, Sahlgrenska University Hospital, G6teborg, Sweden, -*Department of Urology, Urologia Ospedaliera, Pisa, Italy
M A T E R I A L & METHODS: A computer-assisted literature search completed by hand-search identified BPH guidelines produced by national and supra national organisations. Eight BPH guidelines were identified: European (Germany, United Kingdom and the European Association of Urology), American (United States), Asian (Singapore and Malaysia), Australian and the International Consensus Committee. Guideline development was mostly by a thorough search of the relevant literature analysed by a panel of experts. RESULTS: The guidelines agreed on the main management areas stressing the treatment alternatives: watchful waiting, medical treatment, non-surgical invasive therapies and surgical treatment. The patient's preference in treatment decision making was also mentioned. The recommended diagnostic tests varied significantly between the guidelines. All of the 8 guidelines recommended the following 3 tests: patient history including comorbidity, assessment of patient's symptoms using e.g. IPSS and physical examination including DRE. Urinalysis, serum creatinine, postvoid residual urine measurement, uroflowmetry, voiding diary, PSA, ultrasound imaging of the urinary tract and the prostate, KUB were recommended in respectively 7, 7, 5, 4, 4, 3, 1 and 1 guidelines. The number and total cost of the recommended diagnostic tests were not proportional to the country's wealth and resources. Guidelines which involved at some stage of their development individuals from varied backgrounds*, were those whom recommended less diagnostic tests, emphasised watchful waiting for the majority of patients, and stressed patient involvement in all levels of treatment independently of the investigations results. *Academic and private-practice urologists, internists and other specialists, nurses, economists, general practitioners, consumer representatives, methodologists and health services personelle CONCLUSIONS: Despite their different origins, these guidelines have more similarities than differences with regard to the management of BPH. The differences concerning the diagnostic approach emphasises the lack of consensus about the underlying pathological processes causing the changes in urinary function in the ageing man. An important research area that could help standardise guidelines is the impact that they have on clinical outcomes.
I N T R O D U C T I O N & O B J E C T I V E S : In most BPH studies, a voided volume of 125 or 150 cc is required. Often, patients do not fulfil this volume and it is cumbersome to have repeated uroflowmetry. We wanted to correlate ultrasoundmeasured bladder volume to voided volume. M A T E R I A L & M E T H O D S : 121 BPH patients with a mean age of 69.2+_8.7 SD (range 46-88) years, a baseline prior to treatment mean IPSS of 17.0+_9.2 (range 1-35 points), a serum PSA of 4.3+_3.9 (range 0.4-20) ng/ml, a TRUS volume of 50.0_+25.4 ( 18-166) cc entered in this study performing two flow rates before treatment. Bladder volume was measured by transabdominal ultrasound when the patient felt urgency to void and after the uroflowmetry to calculate residual urine. RESULTS: There was a strong correlation between the pre-voiding measured volume (Pre-Vol) and the voided volume (Void-Vol) (r=0.801, p<0.0001 ). Linear regression analysis yielded 1st flow rate recording is Void-Vol=32.703 + (0.637*Pre-Vol) (r ^ 2=0.642; p<0.0001) and 2 "d flow rate recording is Void-Vol= 16.264+(0.704*Pre-Vol) ((2=0.73; p<0.0001 ). C O N C L U S I O N S : The use of bladder scanning before uroflowmetry recording is a useful test to reduce the number of non-evaluable Qmax data. If a voided volume of >125 ml (>150 ml) is required, a mandatory pre-voiding bladder scan value should be >200 ml (>250 ml). Hereby, the number of non-eligible Qmax recording will decrease from 21% to 5.8% (28% to 4.1%).
195
196
THE VALUE OF A SINGLE UROFLOWMETRY FOR THE DIAGNOSIS O F B L A D D E R O U T F L O W O B S T R U C T I O N IN M E N W I T H L U T S
AMBULATORY U R O D Y N A M I C M O N I T O R I N G HAS A USEFUL R O L E I N M E N W I T H AN E Q U I V O C A L O R F A I L E D C O N V E N T I O N A L STUDY
Uvelius B., Brostrt~m E., Malmberg L.
Jain Sunjay ~, Johnson Timothy 2, Turner Derek
Urology, Lund University Hospital, Lund, Sweden
~Urology, Pilgrim Hospital, Boston, United Kingdom, 2Medical Physics, Pilgrim Hospital, Boston, United Kingdom
I N T R O D U C T I O N & O B J E C T I V E S : Pressure-flow studies (PFS) offer the only unambiguous way of assessing bladder outlet obstruction (BOO). There is evidence that the demonstration of BOO by PFS reduces the failure rate after TURP. PFS is an invasive method and it seems more common to use free uroflowmetry (FFM) only. A m a x i m u m free urinary flow rate (Qmax) less than l0 ml/s is commonly considered to indicate BOO. We have compared the results of FFM with the outcome of PFS in evaluation of male patients with LUTS. M A T E R I A L & M E T H O D S : Two hundred fifty-one male patients (age >50 years) with LUTS were included. The prior evaluation had excluded lower urinary tract malignancy, neurogenic bladder dysfunction and infection. The patients underwent a single FFM followed by PFS at a later occasion. No lower limit of voided volume was used. RESULTS: One hundred thirteen patients had Qmax at FFM of l0 ml/s or less. Seventy-nine (70%) of these were found to be obstructed at PFS using AbramsGriffiths Number (AGN) of 40 as cut-off value. The remaining 34 (30%) patients were either not clearly obstructed (30 patients) or unobstructed (AGN<20, 4 patients). One hundred thirty-eight patients had Qmax above l0 ml/s. Sixty-three (46%) of these were found to be obstructed at PFS. The remaining 75 (54%) patients were either not clearly obstructed (43 patients) or unobstructed (32 patients). Interestingly, in the 68 patients with Qmax 15 ml/s or more, 24 (35%) were obstructed. C O N C L U S I O N S : In clinical practice a single free uroflow value less than 10 ml/s seems to be a good indicator of BOO. For peak flow values above 10 ml/s the situation is more complex; 40% of these patients are obstructed. It seems to be mainly in this group that PFS results are valuable for the diagnosis of BOO.
INTRODUCTION & OBJECTIVES: While conventional urodynamic studies (CUS) are extremely useful in assessing outflow obstruction in men, there are inevitably those (approximately 20%) in whom the diagnosis of obstruction is equivocal (based on the Abrams-Griffiths nomogram). A number of studies also fail, mainly because of inability of the patient to void. Since 1999 in our institution it has been the policy in either of these situations to perform ambulatory urodynamic studies (AUS) in an attempt to obtain a diagnosis. The results of this approach are presented here. MATERIAL & METHODS: 46 patients were studied, all of whom were being investigated for lower urinary tract symptoms as a prelude to possible TURE Mean age was 65 years, mean IPSS 20.4 and mean Qmax 13.8 ml/s. Ambulatory studies were performed over a mean duration of 115 minutes, with the patient free to walk around and perform some everyday activities. The median number of void cycles recorded was 2 (range 1-3). Results were interpreted using the Abrams-Griffiths nomogram. RESULTS: Results are summarised in the table.
Result of ambulatory urodynamic study Obstructed Unobstructed Equivocal Failed Result of Equivocal conventional (n=31) urodynamic Failed study (n=15)
8 (26%)
11 (35%)
12 (39%)
0 (0%)
4 (27%)
6 (40%)
3 (20%)
2 (13%)
11 of the 12 obstructed patients have either undergone or are on the waiting list for TURP. The other patient declined operation and was started on finasteride. Detrusor instability was found on CUS in 22/46 patients (48%), with similar proportions in the 2 groups. 10 of these patients were found to be stable on AUS. Conversely 5 patients who were stable on CUS were considered unstable during AUM. CONCLUSIONS: In our experience AUS can confirm or exclude bladder outflow obstruction in over half of men with equivocal or failed CUS. This may be because of the more physiological nature of the test, and the ability to record several fill/void cycles. There is considerable variation in the diagnosis of detrusor instability between the 2 techniques.
European Urology Supplements 1 (2002) No. 1, pp. 51
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U S E F U L N E S S O F P R E - V O I D I N G U L T R A S O U N D B L A D D E R S C A N IN BPH P A T I E N T S I N V O L V E D IN C L I N I C A L S T U D I E S
G U I D E L I N E S O N BPH: AN I N T E R N A T I O N A L C O M P A R I S O N lrani Jacuues ~, Brown Christian 2. van der Meulen Jan 2, Emberton Mark z ~Urology, CHU La Miletrie, Poitiers, France, ZClinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
Dicuio M. t , Francesca F. 2, Damber J.E?, Dahlstrand C ?
I N T R O D U C T I O N & O B J E C T I V E S : Over the last decade, a number of organisations have developed clinical practice guidelines on BPH, in order to ensure appropriate health care. To what extent are these guidelines consistent? In order to examine this, we compared the recommended diagnostic tests and treatment recommendations of patients with BPH in different regions of the world.
~Department of Urology, Sahlgrenska University Hospital, G6teborg, Sweden, -*Department of Urology, Urologia Ospedaliera, Pisa, Italy
M A T E R I A L & METHODS: A computer-assisted literature search completed by hand-search identified BPH guidelines produced by national and supra national organisations. Eight BPH guidelines were identified: European (Germany, United Kingdom and the European Association of Urology), American (United States), Asian (Singapore and Malaysia), Australian and the International Consensus Committee. Guideline development was mostly by a thorough search of the relevant literature analysed by a panel of experts. RESULTS: The guidelines agreed on the main management areas stressing the treatment alternatives: watchful waiting, medical treatment, non-surgical invasive therapies and surgical treatment. The patient's preference in treatment decision making was also mentioned. The recommended diagnostic tests varied significantly between the guidelines. All of the 8 guidelines recommended the following 3 tests: patient history including comorbidity, assessment of patient's symptoms using e.g. IPSS and physical examination including DRE. Urinalysis, serum creatinine, postvoid residual urine measurement, uroflowmetry, voiding diary, PSA, ultrasound imaging of the urinary tract and the prostate, KUB were recommended in respectively 7, 7, 5, 4, 4, 3, 1 and 1 guidelines. The number and total cost of the recommended diagnostic tests were not proportional to the country's wealth and resources. Guidelines which involved at some stage of their development individuals from varied backgrounds*, were those whom recommended less diagnostic tests, emphasised watchful waiting for the majority of patients, and stressed patient involvement in all levels of treatment independently of the investigations results. *Academic and private-practice urologists, internists and other specialists, nurses, economists, general practitioners, consumer representatives, methodologists and health services personelle CONCLUSIONS: Despite their different origins, these guidelines have more similarities than differences with regard to the management of BPH. The differences concerning the diagnostic approach emphasises the lack of consensus about the underlying pathological processes causing the changes in urinary function in the ageing man. An important research area that could help standardise guidelines is the impact that they have on clinical outcomes.
I N T R O D U C T I O N & O B J E C T I V E S : In most BPH studies, a voided volume of 125 or 150 cc is required. Often, patients do not fulfil this volume and it is cumbersome to have repeated uroflowmetry. We wanted to correlate ultrasoundmeasured bladder volume to voided volume. M A T E R I A L & M E T H O D S : 121 BPH patients with a mean age of 69.2+_8.7 SD (range 46-88) years, a baseline prior to treatment mean IPSS of 17.0+_9.2 (range 1-35 points), a serum PSA of 4.3+_3.9 (range 0.4-20) ng/ml, a TRUS volume of 50.0_+25.4 ( 18-166) cc entered in this study performing two flow rates before treatment. Bladder volume was measured by transabdominal ultrasound when the patient felt urgency to void and after the uroflowmetry to calculate residual urine. RESULTS: There was a strong correlation between the pre-voiding measured volume (Pre-Vol) and the voided volume (Void-Vol) (r=0.801, p<0.0001 ). Linear regression analysis yielded 1st flow rate recording is Void-Vol=32.703 + (0.637*Pre-Vol) (r ^ 2=0.642; p<0.0001) and 2 "d flow rate recording is Void-Vol= 16.264+(0.704*Pre-Vol) ((2=0.73; p<0.0001 ). C O N C L U S I O N S : The use of bladder scanning before uroflowmetry recording is a useful test to reduce the number of non-evaluable Qmax data. If a voided volume of >125 ml (>150 ml) is required, a mandatory pre-voiding bladder scan value should be >200 ml (>250 ml). Hereby, the number of non-eligible Qmax recording will decrease from 21% to 5.8% (28% to 4.1%).
195
196
THE VALUE OF A SINGLE UROFLOWMETRY FOR THE DIAGNOSIS O F B L A D D E R O U T F L O W O B S T R U C T I O N IN M E N W I T H L U T S
AMBULATORY U R O D Y N A M I C M O N I T O R I N G HAS A USEFUL R O L E I N M E N W I T H AN E Q U I V O C A L O R F A I L E D C O N V E N T I O N A L STUDY
Uvelius B., Brostrt~m E., Malmberg L.
Jain Sunjay ~, Johnson Timothy 2, Turner Derek
Urology, Lund University Hospital, Lund, Sweden
~Urology, Pilgrim Hospital, Boston, United Kingdom, 2Medical Physics, Pilgrim Hospital, Boston, United Kingdom
I N T R O D U C T I O N & O B J E C T I V E S : Pressure-flow studies (PFS) offer the only unambiguous way of assessing bladder outlet obstruction (BOO). There is evidence that the demonstration of BOO by PFS reduces the failure rate after TURP. PFS is an invasive method and it seems more common to use free uroflowmetry (FFM) only. A m a x i m u m free urinary flow rate (Qmax) less than l0 ml/s is commonly considered to indicate BOO. We have compared the results of FFM with the outcome of PFS in evaluation of male patients with LUTS. M A T E R I A L & M E T H O D S : Two hundred fifty-one male patients (age >50 years) with LUTS were included. The prior evaluation had excluded lower urinary tract malignancy, neurogenic bladder dysfunction and infection. The patients underwent a single FFM followed by PFS at a later occasion. No lower limit of voided volume was used. RESULTS: One hundred thirteen patients had Qmax at FFM of l0 ml/s or less. Seventy-nine (70%) of these were found to be obstructed at PFS using AbramsGriffiths Number (AGN) of 40 as cut-off value. The remaining 34 (30%) patients were either not clearly obstructed (30 patients) or unobstructed (AGN<20, 4 patients). One hundred thirty-eight patients had Qmax above l0 ml/s. Sixty-three (46%) of these were found to be obstructed at PFS. The remaining 75 (54%) patients were either not clearly obstructed (43 patients) or unobstructed (32 patients). Interestingly, in the 68 patients with Qmax 15 ml/s or more, 24 (35%) were obstructed. C O N C L U S I O N S : In clinical practice a single free uroflow value less than 10 ml/s seems to be a good indicator of BOO. For peak flow values above 10 ml/s the situation is more complex; 40% of these patients are obstructed. It seems to be mainly in this group that PFS results are valuable for the diagnosis of BOO.
INTRODUCTION & OBJECTIVES: While conventional urodynamic studies (CUS) are extremely useful in assessing outflow obstruction in men, there are inevitably those (approximately 20%) in whom the diagnosis of obstruction is equivocal (based on the Abrams-Griffiths nomogram). A number of studies also fail, mainly because of inability of the patient to void. Since 1999 in our institution it has been the policy in either of these situations to perform ambulatory urodynamic studies (AUS) in an attempt to obtain a diagnosis. The results of this approach are presented here. MATERIAL & METHODS: 46 patients were studied, all of whom were being investigated for lower urinary tract symptoms as a prelude to possible TURE Mean age was 65 years, mean IPSS 20.4 and mean Qmax 13.8 ml/s. Ambulatory studies were performed over a mean duration of 115 minutes, with the patient free to walk around and perform some everyday activities. The median number of void cycles recorded was 2 (range 1-3). Results were interpreted using the Abrams-Griffiths nomogram. RESULTS: Results are summarised in the table.
Result of ambulatory urodynamic study Obstructed Unobstructed Equivocal Failed Result of Equivocal conventional (n=31) urodynamic Failed study (n=15)
8 (26%)
11 (35%)
12 (39%)
0 (0%)
4 (27%)
6 (40%)
3 (20%)
2 (13%)
11 of the 12 obstructed patients have either undergone or are on the waiting list for TURP. The other patient declined operation and was started on finasteride. Detrusor instability was found on CUS in 22/46 patients (48%), with similar proportions in the 2 groups. 10 of these patients were found to be stable on AUS. Conversely 5 patients who were stable on CUS were considered unstable during AUM. CONCLUSIONS: In our experience AUS can confirm or exclude bladder outflow obstruction in over half of men with equivocal or failed CUS. This may be because of the more physiological nature of the test, and the ability to record several fill/void cycles. There is considerable variation in the diagnosis of detrusor instability between the 2 techniques.
European Urology Supplements 1 (2002) No. 1, pp. 51