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PREDICTIVEVALUE OF FEMALE VOIDING (OUTFLOW OBSTRUCTION AND DETRUSOR CONTRACTION-) NOMOGRAMS IS INSUFFICIENT
685
686
ITALIAN SINGLE-CENTRE EVALUATION OF ADJUSTABLE CONTINENCE THERAPY FOR THE TREATMENT OF FEMALE STRESS URINARY INCONTINENCE: 4 YEAR FOLLOW-UP
USE OF HO:YAG LASER IN THE TREATMENT OF PATIENTS WITH RECURRENT AND INTERSTITIAL CYSTITIS
Kocjancic E., Crivellaro S., Ranzoni S., Bonvini D., Frea B.
MSMSU, Urology, Moscow, Russia
Ospedale Maggiore Della Caritayou, Clinica Urologica, Novara, Italy
INTRODUCTION & OBJECTIVES: We studied efficacy of endovesical ablation with Ho: YAG laser in patients with various forms of chronic cystitis.
INTRODUCTION & OBJECTIVES: There are a great number of reported effective minimally invasive treatments for urethral hypermobility yet many do not address the Intrinsic Sphincter Deficiency (ISD) component of Stress Urinary Incontinence. The development and increased adoption of the use of Valsalva leak point pressure (VLPP) as a diagnostic tool has resulted in clearer differentiation between hypermobility and ISD diagnosis, emphasising the need to specifically manage pure ISD in certain patients. The Adjustable Continence Therapy (ACT®) has been developed for this purpose by increasing urethral coaptation. We evaluated the procedure and assessed it’s mid-long term follow up in our centre. MATERIAL & METHODS: The ACT device consists of two balloons placed para-urethrally in the vesico vaginal space at the level of bladder neck, each being attached to an injectable port placed in the labia majora, enabling postoperative adjustment beyond 6 weeks. 42 female patients with ISD were stratified by VLPP and assessed by pad usage and Incontinence Quality of Life (I-QoL) questionnaire measures prior to implantation and at 6, 12, 24, 36 and 48 months post-op. RESULTS: IQOL increased from 31.2 at baseline (n=42) to 73 at 6 months (n=36), 70.1 at 12 months (n=30), 75.3 at 24 months (n=27), 87.5 at 36 months(n=23) and 90.7 months at 48 months(n=15). Pad Usage decreased from 5.5 at baseline(n=42) to 1.6 at 6 months (n=35), 1.2 at 12 months (n=29), 1.25 at 24 months (n=28), 0.7 at 36 months(n=24) and 0.2 at 48 months(n=15) with 30/42 (71.5%) patients completely dry, 7/42 (16.7%) significantly improved, and 5/42 (11.9%) remaining unchanged at last observed follow-up. Neither balloon volume, number of adjustments nor immediate post-operative continence were predictive factors for eventual success. However, a baseline VLPP of 30 cm H2O or greater correlated strongly with a significant improvement in 70% of patients (p=0.00176; CI 95%) based on both pad usage and reported change in QOL. Complications necessitating device removal occurred in 11/42 (26%) of patients and included migration 6/42 (14.3%) balloon failure in 4/42 (9.5%), urethral erosion in 1/42 (2.3%) and port erosion 1/42 (2.3%). All complications were easily managed by in office removal and subsequent implantation of a new balloon. CONCLUSIONS: The ACT can provide long-term continence in women diagnosed with ISD and a 70% success rate can be reliably predicted in those patients with a baseline VLPP of 30cm H2O or more.
Zaitcev A., Pushkar D., Diyakov V., Galchikov I.
MATERIAL & METHODS: 48 women (mean age 34.5) with chronic cystitis refractory to other treatments underwent endovesical therapy with a Ho:YAG laser. Patients were divided into 3 groups: group 1 – 19 patients (39.6%) with urothelium proliferative changes, group 2 – 7 patients (14.6%) with bladder neck pseudopolyposis, and group 3 – 22 patients (45.8%) with the Hunner’s ulcers. We used a SNT1.10 apparatus with a power of 20 W, energy of 3 J, and wave length of 2,100 nm. Cystoscopy was performed under general anaesthesia, with a 600-microne laser fibre inserted into the bladder through the cystoscope. The ablation was performed under visual control with impulses of up to 15 Hz and impulse duration of 600 milliseconds. No adverse events were observed. The bladder was drained for 24 hr. A followup evaluation was performed at 6 and 12 mo. The measures of efficacy were changes from baseline in pain and urgency (100 mm visual analog scales), 24-hr frequency and functional bladder capacity (48-hr voiding log). Symptom severity regarding pain and voiding problems was checked using the validated, self-administered IC symptom and problem index (ICSI). Bladder biopsy specimens were available from all patients at baseline. RESULTS: Urinary frequency decreased in all responders. The 24-hr voiding frequency decreased from a range of 15-22 to a range of 6-11 voids per day at 6 months follow-up. Nocturia decreased from a range of 2.0-5.5 night time voids to a range of 0-1.5 voids. Functional bladder capacity changed from 56-149 ml to 150-220 ml. A pain scale improvement was from a range of 20-96 mm at baseline to 4-30 mm and an urgency scale improvement from 49-92 mm to 3-40 mm at 6-12 months follow-up. The symptom and problem index score decreased from a range of 22-34 points to 3-16 points. Data analysis of the 1st group showed good efficacy in 14 out of 19 (73.7%) patients; in the 2nd group was considered effective in 100% of cases; and in the 3rd group good results were achieved in 18 out of 22 patients (81.8%). Symptoms recurred rapidly (mean 9.2 weeks) in 4 patients with Hunner’s ulcers. Repeat laser ablation resulted in sustained symptom improvement. CONCLUSIONS: Ho:YAG laser endovesical ablation of urothelium areas with pronounced proliferative changes and/or the presence of Hunner’s ulcers is an effective additional method in the treatment of recurrent cystitis. Laser ablation of Hunner’s ulcer appears to be excellent treatment option in this most severe form of interstitial cystitis. Ho:YAG endovesical ablation with a laser of affected areas of the bladder resulted in a significant reduction of symptoms of the disease and improvement of the quality of life of the patients by 1.5-2 times.
687
688
PREDICTIVEVALUE OF FEMALEVOIDING (OUTFLOW OBSTRUCTION AND DETRUSOR CONTRACTION-) NOMOGRAMS IS INSUFFICIENT
ELECTRICAL STIMULATION AND BEHAVIOURAL TREATMENT IN FEMALE PATIENTS WITH MILD OVERACTIVE BLADDER SYNDROME, CLINICAL RESULTS
Rosier P., De Kort L., Bosch R.
Palleschi G.1, Pastore A.1, Bova G.1, Shehi E.1, Mariani S.2, Tubaro A.2, Carbone A.1
University Medical Centre Utrecht, Department of Urology, Utrecht, The Netherlands INTRODUCTION & OBJECTIVES: Nomograms can be applied for analysis of micturition during urodynamic investigation (UDI) to classify micturition in grades from not-obstructed (NOBS) to obstructed (OBS) and from weak to normal contractility. Classification depends on plotting of flow rate (Qmax) and pressure at maximum flow (PdetQmax). The predictive value of the nomogram classes for the individuals’ efficiency of micturition in patients with prostatic enlargement is fair for the international continence society (ICS) nomogram and for Griffiths’ URA (urethral resistance) and bladder contraction parameter Wmax. However, neither the ICS nomogram or Griffiths’ analysis, nor the ‘female- specific’ Blaivas- Groutz nomogram (BGN) have ever been analysed in relation to female micturition efficiency. Efficiency of micturition is defined as percentage of bladder contents emptied and >80% is considered efficient. MATERIAL & METHODS: We analysed urodynamic (UDI) micturitions of 156 (subsequent in 2004) female patients with symptoms of lower urinary tract dysfunction, without neurological abnormalities. Griffiths’ analysis, ICS numbers (ICSN) and BGN were applied for classification of UDI-micturition, resulting classes for obstruction or contraction respectively: Griffiths-OBS; Griffiths-NOBS; ICS-OBS; ICS-NOBS; Griffiths-Weak; Griffiths- Normal etc. BGN was BGN-OBS or BGN-NOBS. RESULTS: Griffiths (Wmax)
Griffiths (URA)
ICS
ICS
BGN
University of Rome La Sapienza, Polo Pontino, Neuro-urology, Icot, Latina, Italy, 2University of Rome La Sapienza, Urology, Sant’Andrea Hospital, Latina, Italy
1
INTRODUCTION & OBJECTIVES: Multiple sclerosis patients commonly suffer from symptoms related to overactive bladder (OAB) as frequency, urgency and urge incontinence which cause a significant impairment of quality of life. As Payne described in 2000, when OAB symptoms are mild, conservative treatment and physiotherapy are recommended. In this study our experience with electrical stimulation associated to behavioural treatment in multiple sclerosis young female patients affected by overactive bladder symptoms is reported. MATERIAL & METHODS: 54 young female patients(24 to 39 y.o.)were enrolled basing on the following criteria: voiding diary showing >8 micturition a day, with at least 4 urge episodes and 1 urge incontinence event, no significant post-voiding residue(<100mls), negative urine culture. All the patients have been submitted to electrical stimulation (3 months, three times a week for 20 minutes)associated to behavioural treatments based on: education and explanation of normal lower urinary tract function, timed voiding, timed liquid intake, bladder retraining. Symptom score was evaluated by King’s Health Questionnaire. Each 20 minutes session of electrical stimulation was performed using endovaginal probes with the following parameters: frequency 10 Hertz, impulse 200 μseconds, work time 5 seconds, rest time 5 seconds. RESULTS:
Efficient voiders OBS 4,9
NOBS
Normal
Weak
OBS
NOBS
Normal
Weak
OBS
NOBS
95.1
38.8
61.2
7.1
92.9
81.2
18.8
49.1
50.9
Inefficient voiders OBS
NOBS
Normal
Weak
OBS
NOBS
Normal
Weak
OBS
NOBS
26,7
73.3
16.7
83.3
27.3
72.7
30.3
67.7
33.3
66.7
If pressure flow analysis could predict (in)efficient micturition all italic cells in this table would approach 100% of patients. In many cells this is not the case, indicating that the analysis is unspecific in this regard, or insensitive. Also when contractility and obstruction are combined (one or both abnormal) the predictive values of positive tests are low: Griffiths 0.29; ICS 0.52 and BGN 0.74. Predictive value of negative tests: Griffiths 0.92; ICS 0.91 BGN 0.16. CONCLUSIONS: Probably, dynamic properties of the bladder outlet play a relatively large role in female (ineffective) micturition. Pressure flow analysis with Griffiths or ICS analysis is calibrated for male patients, BGN is designed for female patients. Dynamic properties are not captured by any of these methods of analysis. It is frequently impossible to provide an adequate diagnosis of female micturition because the predictive value of the current UDI analysis methods towards efficiency of micturition is too low.
Eur Urol Suppl 2006;5(2):194
Before-Treatment
After-Treatment
Micturitions/day
7 (±4)
5 (±1.2)
Urgency episodes/day
13 (±3)
8 (±0.7)
Incontinence episodes/day
3 (±2)
1 (±0.3)
2 (±0.76)
1 (±0.5)
Pads usage/day
CONCLUSIONS: The clinical results reported in the present study, besides the outcomes of KHQ evaluation which showed improvement of quality of life in treated patients, confirm data reported in Literature regarding the behavioural approach and pelvic floor rehabilitation in the treatment of patients with mild to moderate symptoms secondary to OAB. These data suggest that patients affected by Multiple Sclerosis should receive a first level urologic evaluation since neurologic diagnosis, with the aim to prevent voiding dysfunction and upper urinary tract complications, and a periodic (twice a year) neuro-urologic evaluation during the follow-up, to reserve the chance to start non-invasive treatment when clinical signs are still mild or moderate, improving the therapeutic success rate and limiting adverse event related to other therapeutic options (pharmacological) and avoiding invasive treatments.
686
ITALIAN SINGLE-CENTRE EVALUATION OF ADJUSTABLE CONTINENCE THERAPY FOR THE TREATMENT OF FEMALE STRESS URINARY INCONTINENCE: 4 YEAR FOLLOW-UP
USE OF HO:YAG LASER IN THE TREATMENT OF PATIENTS WITH RECURRENT AND INTERSTITIAL CYSTITIS
Kocjancic E., Crivellaro S., Ranzoni S., Bonvini D., Frea B.
MSMSU, Urology, Moscow, Russia
Ospedale Maggiore Della Caritayou, Clinica Urologica, Novara, Italy
INTRODUCTION & OBJECTIVES: We studied efficacy of endovesical ablation with Ho: YAG laser in patients with various forms of chronic cystitis.
INTRODUCTION & OBJECTIVES: There are a great number of reported effective minimally invasive treatments for urethral hypermobility yet many do not address the Intrinsic Sphincter Deficiency (ISD) component of Stress Urinary Incontinence. The development and increased adoption of the use of Valsalva leak point pressure (VLPP) as a diagnostic tool has resulted in clearer differentiation between hypermobility and ISD diagnosis, emphasising the need to specifically manage pure ISD in certain patients. The Adjustable Continence Therapy (ACT®) has been developed for this purpose by increasing urethral coaptation. We evaluated the procedure and assessed it’s mid-long term follow up in our centre. MATERIAL & METHODS: The ACT device consists of two balloons placed para-urethrally in the vesico vaginal space at the level of bladder neck, each being attached to an injectable port placed in the labia majora, enabling postoperative adjustment beyond 6 weeks. 42 female patients with ISD were stratified by VLPP and assessed by pad usage and Incontinence Quality of Life (I-QoL) questionnaire measures prior to implantation and at 6, 12, 24, 36 and 48 months post-op. RESULTS: IQOL increased from 31.2 at baseline (n=42) to 73 at 6 months (n=36), 70.1 at 12 months (n=30), 75.3 at 24 months (n=27), 87.5 at 36 months(n=23) and 90.7 months at 48 months(n=15). Pad Usage decreased from 5.5 at baseline(n=42) to 1.6 at 6 months (n=35), 1.2 at 12 months (n=29), 1.25 at 24 months (n=28), 0.7 at 36 months(n=24) and 0.2 at 48 months(n=15) with 30/42 (71.5%) patients completely dry, 7/42 (16.7%) significantly improved, and 5/42 (11.9%) remaining unchanged at last observed follow-up. Neither balloon volume, number of adjustments nor immediate post-operative continence were predictive factors for eventual success. However, a baseline VLPP of 30 cm H2O or greater correlated strongly with a significant improvement in 70% of patients (p=0.00176; CI 95%) based on both pad usage and reported change in QOL. Complications necessitating device removal occurred in 11/42 (26%) of patients and included migration 6/42 (14.3%) balloon failure in 4/42 (9.5%), urethral erosion in 1/42 (2.3%) and port erosion 1/42 (2.3%). All complications were easily managed by in office removal and subsequent implantation of a new balloon. CONCLUSIONS: The ACT can provide long-term continence in women diagnosed with ISD and a 70% success rate can be reliably predicted in those patients with a baseline VLPP of 30cm H2O or more.
Zaitcev A., Pushkar D., Diyakov V., Galchikov I.
MATERIAL & METHODS: 48 women (mean age 34.5) with chronic cystitis refractory to other treatments underwent endovesical therapy with a Ho:YAG laser. Patients were divided into 3 groups: group 1 – 19 patients (39.6%) with urothelium proliferative changes, group 2 – 7 patients (14.6%) with bladder neck pseudopolyposis, and group 3 – 22 patients (45.8%) with the Hunner’s ulcers. We used a SNT1.10 apparatus with a power of 20 W, energy of 3 J, and wave length of 2,100 nm. Cystoscopy was performed under general anaesthesia, with a 600-microne laser fibre inserted into the bladder through the cystoscope. The ablation was performed under visual control with impulses of up to 15 Hz and impulse duration of 600 milliseconds. No adverse events were observed. The bladder was drained for 24 hr. A followup evaluation was performed at 6 and 12 mo. The measures of efficacy were changes from baseline in pain and urgency (100 mm visual analog scales), 24-hr frequency and functional bladder capacity (48-hr voiding log). Symptom severity regarding pain and voiding problems was checked using the validated, self-administered IC symptom and problem index (ICSI). Bladder biopsy specimens were available from all patients at baseline. RESULTS: Urinary frequency decreased in all responders. The 24-hr voiding frequency decreased from a range of 15-22 to a range of 6-11 voids per day at 6 months follow-up. Nocturia decreased from a range of 2.0-5.5 night time voids to a range of 0-1.5 voids. Functional bladder capacity changed from 56-149 ml to 150-220 ml. A pain scale improvement was from a range of 20-96 mm at baseline to 4-30 mm and an urgency scale improvement from 49-92 mm to 3-40 mm at 6-12 months follow-up. The symptom and problem index score decreased from a range of 22-34 points to 3-16 points. Data analysis of the 1st group showed good efficacy in 14 out of 19 (73.7%) patients; in the 2nd group was considered effective in 100% of cases; and in the 3rd group good results were achieved in 18 out of 22 patients (81.8%). Symptoms recurred rapidly (mean 9.2 weeks) in 4 patients with Hunner’s ulcers. Repeat laser ablation resulted in sustained symptom improvement. CONCLUSIONS: Ho:YAG laser endovesical ablation of urothelium areas with pronounced proliferative changes and/or the presence of Hunner’s ulcers is an effective additional method in the treatment of recurrent cystitis. Laser ablation of Hunner’s ulcer appears to be excellent treatment option in this most severe form of interstitial cystitis. Ho:YAG endovesical ablation with a laser of affected areas of the bladder resulted in a significant reduction of symptoms of the disease and improvement of the quality of life of the patients by 1.5-2 times.
687
688
PREDICTIVEVALUE OF FEMALEVOIDING (OUTFLOW OBSTRUCTION AND DETRUSOR CONTRACTION-) NOMOGRAMS IS INSUFFICIENT
ELECTRICAL STIMULATION AND BEHAVIOURAL TREATMENT IN FEMALE PATIENTS WITH MILD OVERACTIVE BLADDER SYNDROME, CLINICAL RESULTS
Rosier P., De Kort L., Bosch R.
Palleschi G.1, Pastore A.1, Bova G.1, Shehi E.1, Mariani S.2, Tubaro A.2, Carbone A.1
University Medical Centre Utrecht, Department of Urology, Utrecht, The Netherlands INTRODUCTION & OBJECTIVES: Nomograms can be applied for analysis of micturition during urodynamic investigation (UDI) to classify micturition in grades from not-obstructed (NOBS) to obstructed (OBS) and from weak to normal contractility. Classification depends on plotting of flow rate (Qmax) and pressure at maximum flow (PdetQmax). The predictive value of the nomogram classes for the individuals’ efficiency of micturition in patients with prostatic enlargement is fair for the international continence society (ICS) nomogram and for Griffiths’ URA (urethral resistance) and bladder contraction parameter Wmax. However, neither the ICS nomogram or Griffiths’ analysis, nor the ‘female- specific’ Blaivas- Groutz nomogram (BGN) have ever been analysed in relation to female micturition efficiency. Efficiency of micturition is defined as percentage of bladder contents emptied and >80% is considered efficient. MATERIAL & METHODS: We analysed urodynamic (UDI) micturitions of 156 (subsequent in 2004) female patients with symptoms of lower urinary tract dysfunction, without neurological abnormalities. Griffiths’ analysis, ICS numbers (ICSN) and BGN were applied for classification of UDI-micturition, resulting classes for obstruction or contraction respectively: Griffiths-OBS; Griffiths-NOBS; ICS-OBS; ICS-NOBS; Griffiths-Weak; Griffiths- Normal etc. BGN was BGN-OBS or BGN-NOBS. RESULTS: Griffiths (Wmax)
Griffiths (URA)
ICS
ICS
BGN
University of Rome La Sapienza, Polo Pontino, Neuro-urology, Icot, Latina, Italy, 2University of Rome La Sapienza, Urology, Sant’Andrea Hospital, Latina, Italy
1
INTRODUCTION & OBJECTIVES: Multiple sclerosis patients commonly suffer from symptoms related to overactive bladder (OAB) as frequency, urgency and urge incontinence which cause a significant impairment of quality of life. As Payne described in 2000, when OAB symptoms are mild, conservative treatment and physiotherapy are recommended. In this study our experience with electrical stimulation associated to behavioural treatment in multiple sclerosis young female patients affected by overactive bladder symptoms is reported. MATERIAL & METHODS: 54 young female patients(24 to 39 y.o.)were enrolled basing on the following criteria: voiding diary showing >8 micturition a day, with at least 4 urge episodes and 1 urge incontinence event, no significant post-voiding residue(<100mls), negative urine culture. All the patients have been submitted to electrical stimulation (3 months, three times a week for 20 minutes)associated to behavioural treatments based on: education and explanation of normal lower urinary tract function, timed voiding, timed liquid intake, bladder retraining. Symptom score was evaluated by King’s Health Questionnaire. Each 20 minutes session of electrical stimulation was performed using endovaginal probes with the following parameters: frequency 10 Hertz, impulse 200 μseconds, work time 5 seconds, rest time 5 seconds. RESULTS:
Efficient voiders OBS 4,9
NOBS
Normal
Weak
OBS
NOBS
Normal
Weak
OBS
NOBS
95.1
38.8
61.2
7.1
92.9
81.2
18.8
49.1
50.9
Inefficient voiders OBS
NOBS
Normal
Weak
OBS
NOBS
Normal
Weak
OBS
NOBS
26,7
73.3
16.7
83.3
27.3
72.7
30.3
67.7
33.3
66.7
If pressure flow analysis could predict (in)efficient micturition all italic cells in this table would approach 100% of patients. In many cells this is not the case, indicating that the analysis is unspecific in this regard, or insensitive. Also when contractility and obstruction are combined (one or both abnormal) the predictive values of positive tests are low: Griffiths 0.29; ICS 0.52 and BGN 0.74. Predictive value of negative tests: Griffiths 0.92; ICS 0.91 BGN 0.16. CONCLUSIONS: Probably, dynamic properties of the bladder outlet play a relatively large role in female (ineffective) micturition. Pressure flow analysis with Griffiths or ICS analysis is calibrated for male patients, BGN is designed for female patients. Dynamic properties are not captured by any of these methods of analysis. It is frequently impossible to provide an adequate diagnosis of female micturition because the predictive value of the current UDI analysis methods towards efficiency of micturition is too low.
Eur Urol Suppl 2006;5(2):194
Before-Treatment
After-Treatment
Micturitions/day
7 (±4)
5 (±1.2)
Urgency episodes/day
13 (±3)
8 (±0.7)
Incontinence episodes/day
3 (±2)
1 (±0.3)
2 (±0.76)
1 (±0.5)
Pads usage/day
CONCLUSIONS: The clinical results reported in the present study, besides the outcomes of KHQ evaluation which showed improvement of quality of life in treated patients, confirm data reported in Literature regarding the behavioural approach and pelvic floor rehabilitation in the treatment of patients with mild to moderate symptoms secondary to OAB. These data suggest that patients affected by Multiple Sclerosis should receive a first level urologic evaluation since neurologic diagnosis, with the aim to prevent voiding dysfunction and upper urinary tract complications, and a periodic (twice a year) neuro-urologic evaluation during the follow-up, to reserve the chance to start non-invasive treatment when clinical signs are still mild or moderate, improving the therapeutic success rate and limiting adverse event related to other therapeutic options (pharmacological) and avoiding invasive treatments.