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Re: Functional and Anatomical Differences between Continent and Incontinent Men Post Radical Prostatectomy on Urodynamics and 3T MRI: A Pilot Study
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
1. Drake MJ: Should nocturia not be called a lower urinary tract symptom? Eur Urol 2015; 67: 289.
Suggested Reading De Guchtenaere A, Vande Walle C, Van Sintjan P et al: Desmopressin resistant nocturnal polyuria may benefit from furosemide therapy administered in the morning. J Urol 2007; 178: 2635.
Re: The Feasibility of Clean Intermittent Self-Cathetherization Teaching in an Outpatient Setting J. A. Bickhaus, E. Z. Drobnis, W. A. Critchlow, J. A. Occhino and R. T. Foster, Sr. Department of Obstetrics, Gynecology and Women’s Health, University of Missouri School of Medicine, Columbia, Missouri, and Division of Gynecologic Surgery, Department of Urogynecology, Mayo Clinic, Rochester, Minnesota Female Pelvic Med Reconstr Surg 2015; 21: 220e224. doi: 10.1097/SPV.0000000000000155
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25679356 Editorial Comment: This population consisted of women undergoing prolapse and/or urinary incontinence surgery. The time that it took to teach clean intermittent catheterization on average was 3.7 minutes. The authors state that the overwhelming majority of patients were able to retain the skill weeks after being taught at the clinic. I am sure that some enterprising individual will repeat this in a population of men. Our observations would suggest that it takes about 10 to 15 minutes to teach this to men and to observe them do 1 or 2 catheterizations. Thank you, Lapides et al.1 Alan J. Wein, MD, PhD (hon) 1. Lapides J, Diokno AC, Silber SJ et al: Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol 1972; 107: 458.
Re: Functional and Anatomical Differences between Continent and Incontinent Men Post Radical Prostatectomy on Urodynamics and 3T MRI: A Pilot Study A. P. Cameron, A. M. Suskind, C. Neer, H. Hussain, J. Montgomery, J. M. Latini and J. O. DeLancey Departments of Urology, Radiology, and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan Neurourol Urodyn 2015; 34: 527e532. doi: 10.1002/nau.22616
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24752967 Editorial Comment: This study from the University of Michigan examined parameters associated with incontinence in men who had undergone radical prostatectomy a minimum of 12 months previously. Mean urethral pressure profiles at rest were similar between continent and incontinent patients but the ability to raise the urethral pressure during pelvic muscle contraction was 2.6 times lower in the incontinent group (change of 56.3 vs 147.5 cm water). The anatomical urethral sphincter length was 35% shorter in the sagittal view and 31% shorter in the coronal view, and the bladder neck was 28.9 degrees more funneled (open) among cases on sagittal angular measurement. Subjective asymmetry or distortion of the sphincter area was noted in 85.5% of incontinence cases and 16.7% of controls. There were no differences in measurements of levator ani length or thickness, and there were no differences between robotic and open prostatectomy patients. None of these findings is particularly surprising except for the fact that the authors ascribe potential importance to a more widely open bladder neck possibly contributing to incontinence. All of these findings are useful for the surgeon who performs these procedures to remember and to adjust his/her technique accordingly. It remains to be seen whether future efforts by this group will be able to define preoperative parameters that predict a higher chance of postoperative urinary incontinence, possibly altering patient choice of therapy. There have been studies on this subject in the past but none yet has resulted in agreed on parameters. Alan J. Wein, MD, PhD (hon)
1039
1040
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
Suggested Reading Myers RP, Cahill DR, Devine RM et al: Anatomy of radical prostatectomy as defined by magnetic resonance imaging. J Urol 1998; 159: 2148. Coakley FV, Eberhardt S, Kattan MW et al: Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002; 168: 1032.
Re: The Overactive Bladder Progression to Underactive Bladder Hypothesis M. B. Chancellor Department of Urology, Beaumont Hospital, Royal Oak, Michigan Int Urol Nephrol, suppl., 2014; 46: S23eS27. doi: 10.1007/s11255-014-0778-y
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25238891 Editorial Comment: The underactive bladder (UAB) is an increasingly popular topic for discussion but remains basically an enigma. Although everyone thinks they can recognize it, it remains impossible to define by objective criteria, such as urodynamic study, in a way that would be agreeable to all in both men and women. Currently the International Continence Society definition is that of a contraction of reduced strength and/or duration resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a usual time span. The problem is that no one can define reduced strength, reduced duration, prolonged bladder emptying or usual time span. UAB may exist during voiding/emptying in conjunction with an overactive bladder with detrusor overactivity during filling/storage. Thus, the relationship between the 2 entities is confusing as to how they could coexist in a single individual, although the pathophysiology of both can be in general similar (neural injuries or conditions; nonneural diseases affecting smooth muscle, urothelium, interstitial cells or connective tissues; bladder outlet obstruction, and, conceivably, ischemia). The hypothesis that overactive bladder is a precursor to UAB is interesting, and with respect to certain of the possible pathophysiologies is plausible, ie overactivity followed by underactivity secondary to a problem with blood supply of the lower urinary tract. To me, at least, the putative progression resulting from other categories of pathophysiology is more vague. Unfortunately there is really no treatment for underactive bladder. One can try to compensate for decreasing outlet resistance but at present there is really no pharmacological agent that will increase the ability of the bladder to exhibit a normal coordinated contraction of adequate magnitude. There remains a considerable amount of work to be done with respect to this entity, and I suspect that this will occupy many pages of the journals we all read for years to come. These subjects include the epidemiology of the condition and acceptable symptomatic diagnosis, objective criteria for diagnosis, a study of an outline of various pathophysiologies, and algorithms for evaluation and management. For the latter, except for simple behavioral compensations and decreasing outlet resistance, there are essentially none. Finally, there will most likely be at least some instances where we will be able, on the basis of knowledge accrued, to prevent or arrest progression of this entity. When the knowledge base becomes as great as that for overactive bladder, then I suspect we will move on to something else. Alan J. Wein, MD, PhD (hon)
Re: Autologous Pubovaginal Sling for the Treatment of Concomitant Female Urethral Diverticula and Stress Urinary Incontinence E. Enemchukwu, C. Lai, W. S. Reynolds, M. Kaufman and R. Dmochowski Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee Urology 2015; 85: 1300e1303. doi: 10.1016/j.urology.2015.02.022
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26099875 Editorial Comment: This contribution describes the experience with 38 women who underwent simultaneous urethral diverticulectomy and rectus sheath pubovaginal sling. All had demonstrable
1. Drake MJ: Should nocturia not be called a lower urinary tract symptom? Eur Urol 2015; 67: 289.
Suggested Reading De Guchtenaere A, Vande Walle C, Van Sintjan P et al: Desmopressin resistant nocturnal polyuria may benefit from furosemide therapy administered in the morning. J Urol 2007; 178: 2635.
Re: The Feasibility of Clean Intermittent Self-Cathetherization Teaching in an Outpatient Setting J. A. Bickhaus, E. Z. Drobnis, W. A. Critchlow, J. A. Occhino and R. T. Foster, Sr. Department of Obstetrics, Gynecology and Women’s Health, University of Missouri School of Medicine, Columbia, Missouri, and Division of Gynecologic Surgery, Department of Urogynecology, Mayo Clinic, Rochester, Minnesota Female Pelvic Med Reconstr Surg 2015; 21: 220e224. doi: 10.1097/SPV.0000000000000155
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25679356 Editorial Comment: This population consisted of women undergoing prolapse and/or urinary incontinence surgery. The time that it took to teach clean intermittent catheterization on average was 3.7 minutes. The authors state that the overwhelming majority of patients were able to retain the skill weeks after being taught at the clinic. I am sure that some enterprising individual will repeat this in a population of men. Our observations would suggest that it takes about 10 to 15 minutes to teach this to men and to observe them do 1 or 2 catheterizations. Thank you, Lapides et al.1 Alan J. Wein, MD, PhD (hon) 1. Lapides J, Diokno AC, Silber SJ et al: Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol 1972; 107: 458.
Re: Functional and Anatomical Differences between Continent and Incontinent Men Post Radical Prostatectomy on Urodynamics and 3T MRI: A Pilot Study A. P. Cameron, A. M. Suskind, C. Neer, H. Hussain, J. Montgomery, J. M. Latini and J. O. DeLancey Departments of Urology, Radiology, and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan Neurourol Urodyn 2015; 34: 527e532. doi: 10.1002/nau.22616
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24752967 Editorial Comment: This study from the University of Michigan examined parameters associated with incontinence in men who had undergone radical prostatectomy a minimum of 12 months previously. Mean urethral pressure profiles at rest were similar between continent and incontinent patients but the ability to raise the urethral pressure during pelvic muscle contraction was 2.6 times lower in the incontinent group (change of 56.3 vs 147.5 cm water). The anatomical urethral sphincter length was 35% shorter in the sagittal view and 31% shorter in the coronal view, and the bladder neck was 28.9 degrees more funneled (open) among cases on sagittal angular measurement. Subjective asymmetry or distortion of the sphincter area was noted in 85.5% of incontinence cases and 16.7% of controls. There were no differences in measurements of levator ani length or thickness, and there were no differences between robotic and open prostatectomy patients. None of these findings is particularly surprising except for the fact that the authors ascribe potential importance to a more widely open bladder neck possibly contributing to incontinence. All of these findings are useful for the surgeon who performs these procedures to remember and to adjust his/her technique accordingly. It remains to be seen whether future efforts by this group will be able to define preoperative parameters that predict a higher chance of postoperative urinary incontinence, possibly altering patient choice of therapy. There have been studies on this subject in the past but none yet has resulted in agreed on parameters. Alan J. Wein, MD, PhD (hon)
1039
1040
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
Suggested Reading Myers RP, Cahill DR, Devine RM et al: Anatomy of radical prostatectomy as defined by magnetic resonance imaging. J Urol 1998; 159: 2148. Coakley FV, Eberhardt S, Kattan MW et al: Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002; 168: 1032.
Re: The Overactive Bladder Progression to Underactive Bladder Hypothesis M. B. Chancellor Department of Urology, Beaumont Hospital, Royal Oak, Michigan Int Urol Nephrol, suppl., 2014; 46: S23eS27. doi: 10.1007/s11255-014-0778-y
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25238891 Editorial Comment: The underactive bladder (UAB) is an increasingly popular topic for discussion but remains basically an enigma. Although everyone thinks they can recognize it, it remains impossible to define by objective criteria, such as urodynamic study, in a way that would be agreeable to all in both men and women. Currently the International Continence Society definition is that of a contraction of reduced strength and/or duration resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a usual time span. The problem is that no one can define reduced strength, reduced duration, prolonged bladder emptying or usual time span. UAB may exist during voiding/emptying in conjunction with an overactive bladder with detrusor overactivity during filling/storage. Thus, the relationship between the 2 entities is confusing as to how they could coexist in a single individual, although the pathophysiology of both can be in general similar (neural injuries or conditions; nonneural diseases affecting smooth muscle, urothelium, interstitial cells or connective tissues; bladder outlet obstruction, and, conceivably, ischemia). The hypothesis that overactive bladder is a precursor to UAB is interesting, and with respect to certain of the possible pathophysiologies is plausible, ie overactivity followed by underactivity secondary to a problem with blood supply of the lower urinary tract. To me, at least, the putative progression resulting from other categories of pathophysiology is more vague. Unfortunately there is really no treatment for underactive bladder. One can try to compensate for decreasing outlet resistance but at present there is really no pharmacological agent that will increase the ability of the bladder to exhibit a normal coordinated contraction of adequate magnitude. There remains a considerable amount of work to be done with respect to this entity, and I suspect that this will occupy many pages of the journals we all read for years to come. These subjects include the epidemiology of the condition and acceptable symptomatic diagnosis, objective criteria for diagnosis, a study of an outline of various pathophysiologies, and algorithms for evaluation and management. For the latter, except for simple behavioral compensations and decreasing outlet resistance, there are essentially none. Finally, there will most likely be at least some instances where we will be able, on the basis of knowledge accrued, to prevent or arrest progression of this entity. When the knowledge base becomes as great as that for overactive bladder, then I suspect we will move on to something else. Alan J. Wein, MD, PhD (hon)
Re: Autologous Pubovaginal Sling for the Treatment of Concomitant Female Urethral Diverticula and Stress Urinary Incontinence E. Enemchukwu, C. Lai, W. S. Reynolds, M. Kaufman and R. Dmochowski Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee Urology 2015; 85: 1300e1303. doi: 10.1016/j.urology.2015.02.022
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26099875 Editorial Comment: This contribution describes the experience with 38 women who underwent simultaneous urethral diverticulectomy and rectus sheath pubovaginal sling. All had demonstrable