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POS-01.119: Risk factors for postprostatectomy incontinence in a country with low incidence of prostate cancer
UNMODERATED POSTER SESSIONS
compared the preoperative clinical variables, cure rate and satisfaction score between MONARC and SPARC groups. Results: Two groups were similar in their preoperative characteristics and the preoperative parameters including age, 1 hr pad test weight, Q-tip, maximal urethral closing pressure (MUCP) and valsalva leak point pressure (VLPP). The mean follow-up period was 20 months in the SPARC group and 9 months in the MONARC group. There was no significant difference between the two groups in terms of the cure rate: cure (57% vs. 65%, p⫽0.056), improvement (30% vs. 25%, p⫽0.099) for SPARC and MONARC, respectively. In addition, the patient satisfaction rate was not different significantly between two groups (3.5 vs. 3.9, p⫽0.056). Although it is not statistically significant, success rate of MONARC was higher than SPARC especially in patients with 1 hr pad test⬎30gm, Q-tip⬎30 degree, MUCP⬍40cmH2O and VLPP⬍60cmH2O. Conclusion: The MONARC procedure appears to be more efficient than SPARC procedure for the surgical treatment of stress urinary incontinence in women with more severe incontinence over a short-term follow-up. Abstract Withdrawn POS-01.118 Transobturator IVS used in failed stress urinary incontinence cases Chibelean C, Surcel C, Harza M, Gingu C, Cerempei V, Avram D, Patrascoiu S, Moldovan C, Sinescu I Center of Urological Surgery, Dialysis and Renal Transplantation, Fundeni, Clinical Institute, Bucharest, Romania Introduction: The synthetic slings seem to become the gold-standard for treatment of SUI. However, there are few reports about the treatment of recurrent SUI with such slings or more specifically with transobturator slings. Objective: This study tries to evaluate the outcomes of transobturator IVS used in recurrent cases of SUI. Materials & Methods: We evaluated retrospectively 12 patients who underwent between May 2005 and Dec. 2006 a IVS transobturator procedure for recurrent SUI. Physical examination, pad test and urodynamic studies were performed before operation. Results: Among 12 patients (mean age: 51,26⫹/-10,1) with recurrent SUI 3 had previously IVS, 3 Burch colposuspension, 2 Stamey-like needle suspension, 2 Kelly
226
operation, 2 Burch and Kelly operation. IVS was used by transobturator way in order to avoid the complication due to previous surgery (bladder perforation, urethral erosion, bleeding). The cure rate was 83,33% (10 of 12 patients) 1 patient was improved and 1 had persistent leakage. This last patient was referred to be treated with injectable (Zuidex). All patients had 1 and 3 months control. As complication we experienced obstruction symptoms in 1 patient but with PVR smaller than 100 ml. Conclusions: Transobturator sling for recurrent SUI has lower cure rate (83,33%) comparing with the procedure in SUI naı¨ve patients. However, for such patients this procedure may reduce the rate of potentially complications achieving good results. POS-01.119 Risk factors for postprostatectomy incontinence in a country with low incidence of prostate cancer Lai AY1,2, Kuo Y1, Lu S1, Lai M2, Hung SF 1 Division of Urology, Department of Surgery, Taipei City Hospital, Taipei, Taiwan; 2Graduate Institute of Preventive Medicine, School of Public Health, National Taiwan University, Taipei, Taiwan Introduction: The rate of urinary incontinence after radical prostatectomy is diffi-
cult to assess from the literature. We identified risk factors associated with urinary incontinence from one year longitudinal survey in men after radical prostatectomy for localized prostate cancer in Taiwan. Methods: The time from postoperative removal of urethral Foley catheter until urinary continence (equal to or less than one protective pad use per day) was achieved was determined by chart review in 103 men who were continent before undergoing radical prostatectomy between January 2000 and Mar 2006. Using univariate and multivariate analyses of data, we examined risk factors associated with incontinence. Results: The actuarial rate of urinary continence at 12 months was 71% for the entire patient population. Many factors were associated with the risk of incontinence in univariate Cox proportional hazards regression analysis (preoperative irritative symptoms, operation time, operative blood loss, the duration of urethral Foley catherization, transurethral resection of prostate, presence of intravesical growth of prostate). However, in a multivariate analysis the factors that were independently associated with early return of continence were operative blood loss, intravesical growth of prostate and preoperative irritative symptoms.
Table 1. POS-01.119: Patient characteristics Variables Age (years) 0.913 Blood loss (mL) 0.403 Smoking 0.796 Yes No Nerve sparing 0.505 Yes No Pathological stage 0.841 pT2 pT3 or pT4 Weight of the prostate (g) 0.494 Time to urethral catheter removal (days) 0.372 Hospitalization (days) 0.768
With irritative symptoms
Without irritative symptoms
(nⴝ56) (nⴝ47) 66.4⫾5.6
P-value 66.2⫾5.8
836.6⫾1168
1024.4⫾1081.2
9 47
9 38
24 32
21 26
26 30 44.0⫾20.9
21 26 41.2⫾20.0
13.4⫾6.9
14.4⫾6.8
10.5⫾3.7
10.7⫾3.4
Values are presented as mean ⫾ SD.
UROLOGY 70 (Supplment 3A), September 2007
UNMODERATED POSTER SESSIONS
Table 2. POS-01.119: Changes in continence rate 3, 6, 9 and 12 months after RRP Numbers of patients with continence (%) irritative symptoms(ⴙ) irritative symptoms(-) Time after surgery (nⴝ56) (nⴝ47) 3 months 9 (16%) 17 (36%) 6 months 21 (38%) 27 (57%) 9 months 29 (52%) 30 (64%) 12 months 37 (66%) 36 (77%)
P-value 0.017* 0.034* 0.151 0.170
*Fisher’s Exact Test.
Table 3. POS-01.119: Univariate and multivariate analysis of risk factors for incontinence after RRP Factors for PPI
Parameter estimate
Univariate Age (continuous) BMI (continuous) Irritative symtoms Obstructive symtoms Smoking(yes or no) Operative blood loss (continuous) Intravesical growth of prostate Weight of the prostate (g) Pathological stage Previous TURP Nerve sparing (yes versus no) Time to urethral catheter removal
Multivariate 0.950 0.603 0.026 0.557 0.763 0.049 0.370 0.149 0.074 0.016 0.126 0.001
P-value 0.086 0.582 0.046 0.798 0.505 0.021 0.012 0.893 0.087 0.145 0.299 0.028
PPI : postprostatectomy incontinence. RRP : radical retropubic prostatectomy. TURP : transurethral resection of prostate.
Conclusion: These findings suggest that it would be important to inform the patients who have preoperative irritative symptoms and prominent intravesical growth of prostate that the early recovery of continence would be compromised after radical prostatectomy. POS-01.120 Transrectal linear array ultrasonography complements urodynamics and eliminates cine’ radiation exposure Perkash I, Wolfe V, Friedland G VA Palo Alto Health Care System and Stanford University, Stanford, CA, USA Objective: In the investigation of the functions of the bladder and urethra, urodynamics with radiologic cine’ need dye and there is an exposure to radiation. Instead, we incorporated ultrasonography (US) as an integral part of urodynamics to study neuromuscular dysfunctions of the bladder, about 25 years ago. Methods & Materials: Patients were usually studied in a lithotomy position. A 5 MHz linear array transducer was used with 64 t0 110 piezoelectric elements, arranged in a straight line to provide a
sagittal picture of the base of the bladder, bladder neck and almost whole urethra. Out of 449 studied, 339 were spinal cord injury (SCI) patients. Mean age was 38.4 years (range 19 to 68 years), 389 were combined transrectal sonographic and urodynamic studies and 265 were sonographic studies performed independently without the use of catheters. Results: Transrectal sonography demonstrated that 162/339 (47%) SCI had a bladder neck ledge and only 2/110 (1.8%) non SCI patients showed a posterior bladder neck ledge. The ledge, over 0.5 cm projecting from the posterior bladder neck region producing a significant bladder neck obstruction, was demonstrated in 28% of patients on intermittent catheterization. This was associated with detrusor sphincter dyssenergia (p value⬍0.0005, Mann-Whitney test). Other bladder neck abnormalities that were visualized and detected easily included bladder neck excessive sensitivity, hyperreflexic bladder, stenosis of the bladder neck, and median lobe of the prostate. Patients with severe detrusor hyperreflexia were difficult to evaluate with pressure flow studies since catheter introduction induced bladder
UROLOGY 70 (Supplment 3A), September 2007
contractility but could be easily evaluated with ultrsonography without using a urodynamic catheter. The urethral abnormalities, such as urethral false passages, detrusor sphincter dyssenergia and urethral strictures detected on ultrsonography, were not easily recognized by radiologic studies alone. Therapeutic usefulness of the sonography included an easy insertion of the catheter with false passages. It also made patients visualize the outflow pathology for therapeutic considerations. Conclusions: Transrectal linear array sonography is a simple, quick and cost effective means for investigating outflow obstructive disorders of the bladder outlet and urethra and eliminates radiation exposure associated with Cine’ videocystography particularly in patients needing repeated evaluations. POS-01.121 Improving voiding efficiency in the diabetic rat by a 5-HT1A serotonin receptor agonist Gu B, Si J, Liu F, Xu Y, Andersson KE 1 Department of Urology, Shanghai 6th People’s Hospital, Shanghai Jiaotong University, Shanghai, China; 2Department. of Clinical Pharmacology, Lund University Hospital, Lund, Sweden Introduction and Objectives: Serotonin affects micturition in the normal rat through actions not only on ascending and descending spinal pathways and supraspinal centers but also on the lumbosacral spinal cord level. In a previous study we showed that the selective 5-HT1A receptor agonist, 8-OH-DPAT, reversed detrusor-sphincter dyssynergia (DSD) in the spinal cord injury (SCI) rat, thereby improving voiding efficiency. Rats with experimental diabetes mellitus (DM) have been shown to have both bladder and urethral dysfunction during reflex voiding. We therefore examined the effects of 8-OH-DPAT on micturition in DM rats. Methods: Female SD rats weighing 250275 g were used. DM was induced by an intraperitoneal injection of streptozotocin (65 mg/kg) and a cystometric study was performed 6 weeks post-injection. Intravesical pressure was monitored in urethane-anesthetized animals via a transvesical catheter. External urethral sphincter (EUS)– generated high frequency oscillations (HFOs) of intravesical pressure were assessed. The 5-HT1A antagonist WAY100635 was administered after each 8-OHDPAT dose-response curve (all drugs were administered intravenously, iv). Results: In DM rats, 8-OH-DPAT (3-1000 ug/kg, iv) induced a significant dose-de-
227
compared the preoperative clinical variables, cure rate and satisfaction score between MONARC and SPARC groups. Results: Two groups were similar in their preoperative characteristics and the preoperative parameters including age, 1 hr pad test weight, Q-tip, maximal urethral closing pressure (MUCP) and valsalva leak point pressure (VLPP). The mean follow-up period was 20 months in the SPARC group and 9 months in the MONARC group. There was no significant difference between the two groups in terms of the cure rate: cure (57% vs. 65%, p⫽0.056), improvement (30% vs. 25%, p⫽0.099) for SPARC and MONARC, respectively. In addition, the patient satisfaction rate was not different significantly between two groups (3.5 vs. 3.9, p⫽0.056). Although it is not statistically significant, success rate of MONARC was higher than SPARC especially in patients with 1 hr pad test⬎30gm, Q-tip⬎30 degree, MUCP⬍40cmH2O and VLPP⬍60cmH2O. Conclusion: The MONARC procedure appears to be more efficient than SPARC procedure for the surgical treatment of stress urinary incontinence in women with more severe incontinence over a short-term follow-up. Abstract Withdrawn POS-01.118 Transobturator IVS used in failed stress urinary incontinence cases Chibelean C, Surcel C, Harza M, Gingu C, Cerempei V, Avram D, Patrascoiu S, Moldovan C, Sinescu I Center of Urological Surgery, Dialysis and Renal Transplantation, Fundeni, Clinical Institute, Bucharest, Romania Introduction: The synthetic slings seem to become the gold-standard for treatment of SUI. However, there are few reports about the treatment of recurrent SUI with such slings or more specifically with transobturator slings. Objective: This study tries to evaluate the outcomes of transobturator IVS used in recurrent cases of SUI. Materials & Methods: We evaluated retrospectively 12 patients who underwent between May 2005 and Dec. 2006 a IVS transobturator procedure for recurrent SUI. Physical examination, pad test and urodynamic studies were performed before operation. Results: Among 12 patients (mean age: 51,26⫹/-10,1) with recurrent SUI 3 had previously IVS, 3 Burch colposuspension, 2 Stamey-like needle suspension, 2 Kelly
226
operation, 2 Burch and Kelly operation. IVS was used by transobturator way in order to avoid the complication due to previous surgery (bladder perforation, urethral erosion, bleeding). The cure rate was 83,33% (10 of 12 patients) 1 patient was improved and 1 had persistent leakage. This last patient was referred to be treated with injectable (Zuidex). All patients had 1 and 3 months control. As complication we experienced obstruction symptoms in 1 patient but with PVR smaller than 100 ml. Conclusions: Transobturator sling for recurrent SUI has lower cure rate (83,33%) comparing with the procedure in SUI naı¨ve patients. However, for such patients this procedure may reduce the rate of potentially complications achieving good results. POS-01.119 Risk factors for postprostatectomy incontinence in a country with low incidence of prostate cancer Lai AY1,2, Kuo Y1, Lu S1, Lai M2, Hung SF 1 Division of Urology, Department of Surgery, Taipei City Hospital, Taipei, Taiwan; 2Graduate Institute of Preventive Medicine, School of Public Health, National Taiwan University, Taipei, Taiwan Introduction: The rate of urinary incontinence after radical prostatectomy is diffi-
cult to assess from the literature. We identified risk factors associated with urinary incontinence from one year longitudinal survey in men after radical prostatectomy for localized prostate cancer in Taiwan. Methods: The time from postoperative removal of urethral Foley catheter until urinary continence (equal to or less than one protective pad use per day) was achieved was determined by chart review in 103 men who were continent before undergoing radical prostatectomy between January 2000 and Mar 2006. Using univariate and multivariate analyses of data, we examined risk factors associated with incontinence. Results: The actuarial rate of urinary continence at 12 months was 71% for the entire patient population. Many factors were associated with the risk of incontinence in univariate Cox proportional hazards regression analysis (preoperative irritative symptoms, operation time, operative blood loss, the duration of urethral Foley catherization, transurethral resection of prostate, presence of intravesical growth of prostate). However, in a multivariate analysis the factors that were independently associated with early return of continence were operative blood loss, intravesical growth of prostate and preoperative irritative symptoms.
Table 1. POS-01.119: Patient characteristics Variables Age (years) 0.913 Blood loss (mL) 0.403 Smoking 0.796 Yes No Nerve sparing 0.505 Yes No Pathological stage 0.841 pT2 pT3 or pT4 Weight of the prostate (g) 0.494 Time to urethral catheter removal (days) 0.372 Hospitalization (days) 0.768
With irritative symptoms
Without irritative symptoms
(nⴝ56) (nⴝ47) 66.4⫾5.6
P-value 66.2⫾5.8
836.6⫾1168
1024.4⫾1081.2
9 47
9 38
24 32
21 26
26 30 44.0⫾20.9
21 26 41.2⫾20.0
13.4⫾6.9
14.4⫾6.8
10.5⫾3.7
10.7⫾3.4
Values are presented as mean ⫾ SD.
UROLOGY 70 (Supplment 3A), September 2007
UNMODERATED POSTER SESSIONS
Table 2. POS-01.119: Changes in continence rate 3, 6, 9 and 12 months after RRP Numbers of patients with continence (%) irritative symptoms(ⴙ) irritative symptoms(-) Time after surgery (nⴝ56) (nⴝ47) 3 months 9 (16%) 17 (36%) 6 months 21 (38%) 27 (57%) 9 months 29 (52%) 30 (64%) 12 months 37 (66%) 36 (77%)
P-value 0.017* 0.034* 0.151 0.170
*Fisher’s Exact Test.
Table 3. POS-01.119: Univariate and multivariate analysis of risk factors for incontinence after RRP Factors for PPI
Parameter estimate
Univariate Age (continuous) BMI (continuous) Irritative symtoms Obstructive symtoms Smoking(yes or no) Operative blood loss (continuous) Intravesical growth of prostate Weight of the prostate (g) Pathological stage Previous TURP Nerve sparing (yes versus no) Time to urethral catheter removal
Multivariate 0.950 0.603 0.026 0.557 0.763 0.049 0.370 0.149 0.074 0.016 0.126 0.001
P-value 0.086 0.582 0.046 0.798 0.505 0.021 0.012 0.893 0.087 0.145 0.299 0.028
PPI : postprostatectomy incontinence. RRP : radical retropubic prostatectomy. TURP : transurethral resection of prostate.
Conclusion: These findings suggest that it would be important to inform the patients who have preoperative irritative symptoms and prominent intravesical growth of prostate that the early recovery of continence would be compromised after radical prostatectomy. POS-01.120 Transrectal linear array ultrasonography complements urodynamics and eliminates cine’ radiation exposure Perkash I, Wolfe V, Friedland G VA Palo Alto Health Care System and Stanford University, Stanford, CA, USA Objective: In the investigation of the functions of the bladder and urethra, urodynamics with radiologic cine’ need dye and there is an exposure to radiation. Instead, we incorporated ultrasonography (US) as an integral part of urodynamics to study neuromuscular dysfunctions of the bladder, about 25 years ago. Methods & Materials: Patients were usually studied in a lithotomy position. A 5 MHz linear array transducer was used with 64 t0 110 piezoelectric elements, arranged in a straight line to provide a
sagittal picture of the base of the bladder, bladder neck and almost whole urethra. Out of 449 studied, 339 were spinal cord injury (SCI) patients. Mean age was 38.4 years (range 19 to 68 years), 389 were combined transrectal sonographic and urodynamic studies and 265 were sonographic studies performed independently without the use of catheters. Results: Transrectal sonography demonstrated that 162/339 (47%) SCI had a bladder neck ledge and only 2/110 (1.8%) non SCI patients showed a posterior bladder neck ledge. The ledge, over 0.5 cm projecting from the posterior bladder neck region producing a significant bladder neck obstruction, was demonstrated in 28% of patients on intermittent catheterization. This was associated with detrusor sphincter dyssenergia (p value⬍0.0005, Mann-Whitney test). Other bladder neck abnormalities that were visualized and detected easily included bladder neck excessive sensitivity, hyperreflexic bladder, stenosis of the bladder neck, and median lobe of the prostate. Patients with severe detrusor hyperreflexia were difficult to evaluate with pressure flow studies since catheter introduction induced bladder
UROLOGY 70 (Supplment 3A), September 2007
contractility but could be easily evaluated with ultrsonography without using a urodynamic catheter. The urethral abnormalities, such as urethral false passages, detrusor sphincter dyssenergia and urethral strictures detected on ultrsonography, were not easily recognized by radiologic studies alone. Therapeutic usefulness of the sonography included an easy insertion of the catheter with false passages. It also made patients visualize the outflow pathology for therapeutic considerations. Conclusions: Transrectal linear array sonography is a simple, quick and cost effective means for investigating outflow obstructive disorders of the bladder outlet and urethra and eliminates radiation exposure associated with Cine’ videocystography particularly in patients needing repeated evaluations. POS-01.121 Improving voiding efficiency in the diabetic rat by a 5-HT1A serotonin receptor agonist Gu B, Si J, Liu F, Xu Y, Andersson KE 1 Department of Urology, Shanghai 6th People’s Hospital, Shanghai Jiaotong University, Shanghai, China; 2Department. of Clinical Pharmacology, Lund University Hospital, Lund, Sweden Introduction and Objectives: Serotonin affects micturition in the normal rat through actions not only on ascending and descending spinal pathways and supraspinal centers but also on the lumbosacral spinal cord level. In a previous study we showed that the selective 5-HT1A receptor agonist, 8-OH-DPAT, reversed detrusor-sphincter dyssynergia (DSD) in the spinal cord injury (SCI) rat, thereby improving voiding efficiency. Rats with experimental diabetes mellitus (DM) have been shown to have both bladder and urethral dysfunction during reflex voiding. We therefore examined the effects of 8-OH-DPAT on micturition in DM rats. Methods: Female SD rats weighing 250275 g were used. DM was induced by an intraperitoneal injection of streptozotocin (65 mg/kg) and a cystometric study was performed 6 weeks post-injection. Intravesical pressure was monitored in urethane-anesthetized animals via a transvesical catheter. External urethral sphincter (EUS)– generated high frequency oscillations (HFOs) of intravesical pressure were assessed. The 5-HT1A antagonist WAY100635 was administered after each 8-OHDPAT dose-response curve (all drugs were administered intravenously, iv). Results: In DM rats, 8-OH-DPAT (3-1000 ug/kg, iv) induced a significant dose-de-
227