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Transurethral Incision of the Prostate: A Preoperative and Postoperative Analysis of Symptoms and Urodynamic Findings
From the Department of Urology, Kaiser Permanente Medical Center,
1l1lV',,",,riI~1'V\r""VY"i>'lln
of transurethral incision of riIAV\£~A of outlet obstruction men
A ..·,. ..
Angeles, California
CtDd~AY'riI4JI1r''''T
MATERIALS AND METHODS
All men evaluated center 1 of us (G. E. Criteria for group inclusion were cut urodynamic evidence of outflow obstruction (high detrusor pressure with low flow a digitally benign prostate estimated to be 30 gm. or less on physical examination, stable medical status and absence of neurogenic bladder dysfunction. Lastly, patients required complete urodynamic evaluations operatively and postoperatively for inclusion in the study. minimal period for re-evaluation was 6 months after transurethral incision of the prostate. Accepted for publication July 7, 1989.
After verification of antibiotics were urine and intravenous the transurethral incisions were with the patient under a of anesthetics spinal and general). Local anesthesia was administered with a resectoscope needle via Orandi's technique of transurethral injection of the bladder neck and prostate combined with transperineal injection of the prostatic capsule with lidocaine hydrochloride as described by Sinha and associates. 3,4 Final verification of the suitability for transurethral incision based on prostatic size was made with the under anesthesia and digital examination. JLJLJL .... ULlJ'VUL.
1508
KELLY, ROSKAMP AND LEACH TABLE
1. Weighted symptom score
TABLE
2. Improvement in weighted symptom scores postoperatively in
26 patients
Group Mean Value Symptom
Before Transurethral Incision
After Transurethral Incision
1.423
0.423
Stream strength: O-normal I-variable 2-weak 3-dribbling Hesitancy of initiation: O-none 3-yes Intermittency of stream: O-none 3-yes Completeness of bladder emptying: O-complete I-variable 2-incomplete 3-1 episode of retention 4-chronic retention Post-void dribbling: O-none 3-yes Urgency: O-none I-mild 2-moderate 3-severe with urge incontinence Nocturia: 0-0-1 1-2 2-3-4 3-4 or more Daytime frequency: O-every 3 hrs. or more I-every 2-3 hrs. 2-every 1-2 hrs. 3-every 1 hr. or less Total possible score 25
Total symptom score Irritative symptoms (frequency, urgency and dribbling) Obstructive symptoms (nocturia, hesitaney, intermittency, poor sense of emptying, decreased stream strength)
Delta Mean*
T Value
P Value
6.9±4.9 2.5±1.9
7.22 6.88
<0.001 <0.001
4.3±4.4
5.06
<0.001
* Mean ± standard deviation refers to absolute change from preoperative value. 1.269
0.308 TABLE
3. Analysis of preoperative and postoperative urodynamic
variables 0.808
0.115
1.115
0.346
1.154
0.385
1.385
0.500
1.231
0.308
Noninvasive: Peak flow Mean flow Invasive: Peak flow Mean flow Flow vol. Post-void residual Cystometrogram: Initial pressure First urge Strong urge Maximum capacity Maximum pressure/filling Maximum pressure/voiding
No. Pts.
Delta Mean*
22 21
6.8 ± 9.85 3.4 ± 4.85
25 25 25 24
5.7 1.6 65.4 -129.7
25 24 23 24 26 24
1.2 85.3 58.6 22.6 -6.9 -44.3
± 6.93
P Value
0.004 0.004
± -159.6
<0.001 0.020 0.109 <0.001
± 5.6 ± 101.3 ± 133.5 ± 165.4 ± -32.1 ± -41.7
0.257 <0.001 0.047 0.509 0.282 <0.001
± 3.23 ± 196
* Mean ± standard deviation. 1.269
0.385
9.634
2.770 (p <0.001)
The Collings knife was introduced, and the ureteral orifices and verumontanum were located. An incision was made at the 4 o'clock position approximately 1 cm. distal to the left ureteral orifice, and extended distally through the bladder neck to a point just proximal to the verumontanum. The incision was deepened through the prostatic capsule until periprostatic fat was observed. Similarly, a second incision was made at the 8 0' clock position. A 24F 3-way Foley catheter was inserted with 30 cc water in the balloon. The catheter was placed on gentle traction and continuous bladder irrigation was begun. Typically, the catheter was removed 1 day postoperatively and the patient was discharged from the hospital in 1 to 2 days, when he was voiding adequately with low post-void residual urine volume. Statistical analysis. Paired t tests were used to compare values of continuous variables before and after transurethral incision of the prostate. Two-group t tests were used to compare results from groups of patients with defined characteristics. Finally, contingency table analysis was used to compare responses for binary data (yes and no). Statistical significance was considered at a p value of less than 0.05. RESULTS
Symptom profile. Table 1 lists the individual mean weighted preoperative and postoperative symptom scores. The over-all mean preoperative weighted symptom score was 9.6 (0 to 21), which decreased to 2.8 (0 to 9) postoperatively (p <0.001). When separated into constellations of obstructive and irritative symptoms this high level of significance persisted (table 2). Urodynamic analysis. Paired t test analysis was used to evaluate the effect of transurethral incision of the prostate on the urodynamic parameters studied. Table 3 lists the preoperative and postoperative group mean values for individual vari-
bles, and the respective mean difference and standard deviations of the absolute change from preoperative to postoperative values. Detrusor instability was present in 46% of the patients preoperatively (12 of 26) and in 27% postoperatively (7 of 26). No instances of de novo detrusor instability were observed. The presence of preoperative detrusor instability had no influence on the effect of transurethral incision of the prostate on detrusor pressure during filling or voiding. Operative considerations. Transurethral incision of the prostate was performed with the patient under local (9 men), spinal (9) and general (8) anesthesia. Patients typically were discharged from the hospital 2 days postoperatively and mean hospitalization lasted 3.19 days (range 2 to 5 days). Only 1 complication occurred (1 episode of clot retention). No transfusions were required and to date no patient has required reoperation for recurrent outflow obstruction. Sexual function. Of 26 patients 13 (50%) were potent and sexually active preoperatively. Potency was not affected by transurethral incision of the prostate. Twenty patients (77%) claimed to experience orgasm (with or without potency) preoperatively compared to 21 (81 %) postoperatively. Of 11 patients with antegrade ejaculation preoperatively who were sexually active postoperatively 6 (55 %) reported preservation of antegrade ejaculation at evaluation. DISCUSSION
Transurethral incision of the prostate is an accepted treatment modality for functional bladder neck obstruction. 5,6 In 1973 Orandi reported the technique of transurethral incision of the prostate for bladder outlet obstruction secondary to prostatic hypertrophy using a bilateral incision. 7 In a series of 646 patients Orandi suggested that transurethral incision may be most efficacious for smaller prostate glands. 8 Edwards and associates found transurethral incision of the prostate to be effective in a large series of men with small prostates (less than 35 gm.) using a unilateral incision.l,g Unfortunately, comparison of transurethral resection and transurethral incision has been difficult owing to flaws in study design (that is poorly
1986 Hellstrom and associates a randomized of transurethral incision versus transurethral resection of prostate for relief of bladder outflow obstructive symptoms caused small prostates. 10 Prostatic size was gauged transvesical and cases were limited to prostate glands of less than 30 gm. A total of 24 patients was studied (13 transurethral resection of the prostate and 11 transurethral incision of the prostate) with preoperative and postoperative urodynamic and symptom analysis. Of the 11 men treated with transurethral incision of the prostate 9 underwent a I-incision technique. Although detrusor pressure at maximal flow was improved to a greater degree in the transurethral resection group, maximal flow rates and subjective improvement were comparable. Remarkably, no men undergoing transurethral incision of the prostate had retrograde ejaculation, compared to 62 % of the men in the transurethral resection group. The symptom score used in our study is based upon the scoring method devised by Madsen and Iversen. l l This system, as well as preoperative and postoperative urodynamic parameters, was evaluated by Frimodt- M~ller and associates in a prospective analysis of 84 men selected for transurethral resection of the prostate based upon symptoms and cystoscopic findings. 12 At transurethral resection the median amount of resected prostate was 20 gm. 5 to 80 gm.). lln.DrOVlemleIllt in symptom scores obstructive and parameters measured ~mln].m(3.1 resistance, maximal flow rates and residual urine observed. no correlation between the of symptoms and urodynamic criteria for obstruction was noted. Furthermore, urodynamic evaluation failed to identify patients who fared less well after transurethral resection of the prostate. In our study improvement in symptoms and objective urodynamic parameters also were noted after transurethral incision of the prostate but too few cases are available for meaningful correlations of stratified symptoms scores and urodynamic variables. What seems important is the presence of corroboration between subjective and tests. t-'''TO evidence of the of transurethral incision of the prostate was observed of and profiles. Mean invasive and mean flow rates during the study from 5.1 to 10.8 (p <0.001) from 4.0 to 5.6 (p <0.020) cc per Similar enhancement of noninvasive and mean flow rates free- flow was <0.004 observation COJrro,borat;ed. the effect of tranSl1re"thral flow rates. 1,6,8-10 as measured of postvoid residuals also was incision the The mean volume before transureincision of was cc, which decreased to 113 cc after incision <0.001). Bladder was as reflected a postoperative volume at first urge (p <0.001) and a postoperative decrease in the incidence of detrusor instability from 46 to 27% (p <0.05). This decrease in detrusor after relief of obstruction is in accordance with the findings seen after either transvesical or transurethral prostatectomy.12-15 In contrast to the study by Hellstrom and associates in which transurethral incision of the prostate did not improve detrusor pressure at peak flow rate postoperatively,7 in our study detrusor pressure at peak flow rate decreased from 102.5 to 58.3 cm. water (p <0.001). Hellstrom and associates used a unilateral incision during transurethral incision of the prostate with excellent preservation of antegrade ejaculation. We used a bilateral incision, which may account for a higher rate of retrograde ejaculation. IJ.L 'JUL'-"'V'VV.A.
'-4..LV.L ..........,'-''UL.L.I.'VL
"-J.Lj;• .L.L.LJL.l.V .......L.l.V
Dh"n. .....
.L.L.LV.l.U .... '-'.I..1.
of incision rather than resection. -n.a·r+n, 1"Ylari a correlative of men with proseXlamlnl.ng 11 4'"\ri'1>T'n!:~rn·l(l and histological 20 This study demonstrated men with smaller glands, predominantly stromal hyperplasia, responded less favorably to transurethral resection of the prostate than men with glandular hyperplasia. In summary, transurethral incision of the prostate was performed easily and safely with a short hospitalization. Transurethral incision is an effective treatment alternative for outlet obstruction caused by the small prostate gland with documented subjective and objective improvement after the simple incision procedure. REFERENCES
1. Edwards, L. and Powell, C.: An objective comparison of transurethral resection and bladder neck incision in the treatment of prostatic hypertrophy. J. Urol., 128: 325, 1982. 2. Abrams, P., Blaivas, J. G., Stanton, S. L. and Andersen, J. T.: Standardization of terminology of lower urinary tract function. Neurourol. Urodynam., 403, 1988. D. and Narayan, P.: 3. Sinha, B., Haikel, G., Lange, P. H., Moon, Transurethral resection of the prostate with local anesthesia in 100 J. Urol., 719,1986. A.: Urological en~C1OS)CO]PIC cost- r~edUlCIIJlf! idea. J. Milroy, E. C. A urodynamic view clinical problems associated bladder neck dysfunction and its treatment by endoscopic incision and trans-trigonal posterior prostatectomy. Brit. J. Urol., 45: 44, 1973. 6. Christensen, M. G., Nordling, J., Andersen, J. T. and Hald, T.: Functional bladder neck obstruction. Results of endoscopic bladder neck incision in 131 consecutive patients. Brit. J. Urol., 60,1985. 7. Orandi, A.: Transurethral incision of the prostate. J. Urol., 229,1973. 8. Orandi, A.: Transurethral incision of prostate in 15 years-a chronological appraisal. Brit. 1985. 9. Edwards, L. E., Bucknall, T. E., Richardson, D. R. and Stanek, J.: Transurethral the prostate and bladder neck incision: a review of 700 cases. Brit. J. Urol., 168, 1985. 10. Hellstrom, P., Lukkarinen, O. and Kontturi, M.: Bladder neck incision or transurethral electroresection for the treatment of obstruction caused a small A ranurodynamic study. 187, 1986. 11. Madsen, O. and tive candidates. In: and S. J:)o,yaJrSKY. 1983. 12. ........... , .... .L.J .....
13. 14. 15. 16. 17. 18. 19. 20.
v'-"'u,
evaluation tranSlue1thr,al versus randomized study. Scand. J. Urol. Nephrol., 27, 1984. Detrusor hyperreflexia and residAndersen, J. T.: Prostatism. ual urine. Clinical and urodynamic aspects and the influence of surgery on the prostate. Scand. J. Urol. Nephrol., 16: 25, 1982. Price, D. A., Ramsden, P. D. and Stobbart, D.: The unstable bladder and prostatectomy. Brit. J. Urol., 52: 529, 1980. Moisey, C. U., Stephenson, T. P. and Evans, C.: A subjective and urodynamic assessment of unilateral bladder neck incision for bladder neck obstruction. Brit. J. Urol., 54: 114, 1982. Delaere, K. P. J., Debruyne, F. M. J. and Moonen, W. A.: Extended bladder neck incision for outflow obstruction in male patients. Brit. J. Urol., 55: 225, 1983. Mobb, G. E. and Moisey, C. U.: Long-term follow-up of unilateral bladder neck incision. Brit. J. Urol., 62: 160,1988. Hedlund, H. and Ek, A.: Ejaculation and sexual function after endoscopic bladder neck incision. Brit. J. Urol., 57: 164, 1985. D~rflinger, T., England, D. M., Madsen, P. O. and Bruskewitz, R. C.: Urodynamic and histological correlates of benign prostatic hyperplasia. J. Urol., 140: 1487, 1988.
1l1lV',,",,riI~1'V\r""VY"i>'lln
of transurethral incision of riIAV\£~A of outlet obstruction men
A ..·,. ..
Angeles, California
CtDd~AY'riI4JI1r''''T
MATERIALS AND METHODS
All men evaluated center 1 of us (G. E. Criteria for group inclusion were cut urodynamic evidence of outflow obstruction (high detrusor pressure with low flow a digitally benign prostate estimated to be 30 gm. or less on physical examination, stable medical status and absence of neurogenic bladder dysfunction. Lastly, patients required complete urodynamic evaluations operatively and postoperatively for inclusion in the study. minimal period for re-evaluation was 6 months after transurethral incision of the prostate. Accepted for publication July 7, 1989.
After verification of antibiotics were urine and intravenous the transurethral incisions were with the patient under a of anesthetics spinal and general). Local anesthesia was administered with a resectoscope needle via Orandi's technique of transurethral injection of the bladder neck and prostate combined with transperineal injection of the prostatic capsule with lidocaine hydrochloride as described by Sinha and associates. 3,4 Final verification of the suitability for transurethral incision based on prostatic size was made with the under anesthesia and digital examination. JLJLJL .... ULlJ'VUL.
1508
KELLY, ROSKAMP AND LEACH TABLE
1. Weighted symptom score
TABLE
2. Improvement in weighted symptom scores postoperatively in
26 patients
Group Mean Value Symptom
Before Transurethral Incision
After Transurethral Incision
1.423
0.423
Stream strength: O-normal I-variable 2-weak 3-dribbling Hesitancy of initiation: O-none 3-yes Intermittency of stream: O-none 3-yes Completeness of bladder emptying: O-complete I-variable 2-incomplete 3-1 episode of retention 4-chronic retention Post-void dribbling: O-none 3-yes Urgency: O-none I-mild 2-moderate 3-severe with urge incontinence Nocturia: 0-0-1 1-2 2-3-4 3-4 or more Daytime frequency: O-every 3 hrs. or more I-every 2-3 hrs. 2-every 1-2 hrs. 3-every 1 hr. or less Total possible score 25
Total symptom score Irritative symptoms (frequency, urgency and dribbling) Obstructive symptoms (nocturia, hesitaney, intermittency, poor sense of emptying, decreased stream strength)
Delta Mean*
T Value
P Value
6.9±4.9 2.5±1.9
7.22 6.88
<0.001 <0.001
4.3±4.4
5.06
<0.001
* Mean ± standard deviation refers to absolute change from preoperative value. 1.269
0.308 TABLE
3. Analysis of preoperative and postoperative urodynamic
variables 0.808
0.115
1.115
0.346
1.154
0.385
1.385
0.500
1.231
0.308
Noninvasive: Peak flow Mean flow Invasive: Peak flow Mean flow Flow vol. Post-void residual Cystometrogram: Initial pressure First urge Strong urge Maximum capacity Maximum pressure/filling Maximum pressure/voiding
No. Pts.
Delta Mean*
22 21
6.8 ± 9.85 3.4 ± 4.85
25 25 25 24
5.7 1.6 65.4 -129.7
25 24 23 24 26 24
1.2 85.3 58.6 22.6 -6.9 -44.3
± 6.93
P Value
0.004 0.004
± -159.6
<0.001 0.020 0.109 <0.001
± 5.6 ± 101.3 ± 133.5 ± 165.4 ± -32.1 ± -41.7
0.257 <0.001 0.047 0.509 0.282 <0.001
± 3.23 ± 196
* Mean ± standard deviation. 1.269
0.385
9.634
2.770 (p <0.001)
The Collings knife was introduced, and the ureteral orifices and verumontanum were located. An incision was made at the 4 o'clock position approximately 1 cm. distal to the left ureteral orifice, and extended distally through the bladder neck to a point just proximal to the verumontanum. The incision was deepened through the prostatic capsule until periprostatic fat was observed. Similarly, a second incision was made at the 8 0' clock position. A 24F 3-way Foley catheter was inserted with 30 cc water in the balloon. The catheter was placed on gentle traction and continuous bladder irrigation was begun. Typically, the catheter was removed 1 day postoperatively and the patient was discharged from the hospital in 1 to 2 days, when he was voiding adequately with low post-void residual urine volume. Statistical analysis. Paired t tests were used to compare values of continuous variables before and after transurethral incision of the prostate. Two-group t tests were used to compare results from groups of patients with defined characteristics. Finally, contingency table analysis was used to compare responses for binary data (yes and no). Statistical significance was considered at a p value of less than 0.05. RESULTS
Symptom profile. Table 1 lists the individual mean weighted preoperative and postoperative symptom scores. The over-all mean preoperative weighted symptom score was 9.6 (0 to 21), which decreased to 2.8 (0 to 9) postoperatively (p <0.001). When separated into constellations of obstructive and irritative symptoms this high level of significance persisted (table 2). Urodynamic analysis. Paired t test analysis was used to evaluate the effect of transurethral incision of the prostate on the urodynamic parameters studied. Table 3 lists the preoperative and postoperative group mean values for individual vari-
bles, and the respective mean difference and standard deviations of the absolute change from preoperative to postoperative values. Detrusor instability was present in 46% of the patients preoperatively (12 of 26) and in 27% postoperatively (7 of 26). No instances of de novo detrusor instability were observed. The presence of preoperative detrusor instability had no influence on the effect of transurethral incision of the prostate on detrusor pressure during filling or voiding. Operative considerations. Transurethral incision of the prostate was performed with the patient under local (9 men), spinal (9) and general (8) anesthesia. Patients typically were discharged from the hospital 2 days postoperatively and mean hospitalization lasted 3.19 days (range 2 to 5 days). Only 1 complication occurred (1 episode of clot retention). No transfusions were required and to date no patient has required reoperation for recurrent outflow obstruction. Sexual function. Of 26 patients 13 (50%) were potent and sexually active preoperatively. Potency was not affected by transurethral incision of the prostate. Twenty patients (77%) claimed to experience orgasm (with or without potency) preoperatively compared to 21 (81 %) postoperatively. Of 11 patients with antegrade ejaculation preoperatively who were sexually active postoperatively 6 (55 %) reported preservation of antegrade ejaculation at evaluation. DISCUSSION
Transurethral incision of the prostate is an accepted treatment modality for functional bladder neck obstruction. 5,6 In 1973 Orandi reported the technique of transurethral incision of the prostate for bladder outlet obstruction secondary to prostatic hypertrophy using a bilateral incision. 7 In a series of 646 patients Orandi suggested that transurethral incision may be most efficacious for smaller prostate glands. 8 Edwards and associates found transurethral incision of the prostate to be effective in a large series of men with small prostates (less than 35 gm.) using a unilateral incision.l,g Unfortunately, comparison of transurethral resection and transurethral incision has been difficult owing to flaws in study design (that is poorly
1986 Hellstrom and associates a randomized of transurethral incision versus transurethral resection of prostate for relief of bladder outflow obstructive symptoms caused small prostates. 10 Prostatic size was gauged transvesical and cases were limited to prostate glands of less than 30 gm. A total of 24 patients was studied (13 transurethral resection of the prostate and 11 transurethral incision of the prostate) with preoperative and postoperative urodynamic and symptom analysis. Of the 11 men treated with transurethral incision of the prostate 9 underwent a I-incision technique. Although detrusor pressure at maximal flow was improved to a greater degree in the transurethral resection group, maximal flow rates and subjective improvement were comparable. Remarkably, no men undergoing transurethral incision of the prostate had retrograde ejaculation, compared to 62 % of the men in the transurethral resection group. The symptom score used in our study is based upon the scoring method devised by Madsen and Iversen. l l This system, as well as preoperative and postoperative urodynamic parameters, was evaluated by Frimodt- M~ller and associates in a prospective analysis of 84 men selected for transurethral resection of the prostate based upon symptoms and cystoscopic findings. 12 At transurethral resection the median amount of resected prostate was 20 gm. 5 to 80 gm.). lln.DrOVlemleIllt in symptom scores obstructive and parameters measured ~mln].m(3.1 resistance, maximal flow rates and residual urine observed. no correlation between the of symptoms and urodynamic criteria for obstruction was noted. Furthermore, urodynamic evaluation failed to identify patients who fared less well after transurethral resection of the prostate. In our study improvement in symptoms and objective urodynamic parameters also were noted after transurethral incision of the prostate but too few cases are available for meaningful correlations of stratified symptoms scores and urodynamic variables. What seems important is the presence of corroboration between subjective and tests. t-'''TO evidence of the of transurethral incision of the prostate was observed of and profiles. Mean invasive and mean flow rates during the study from 5.1 to 10.8 (p <0.001) from 4.0 to 5.6 (p <0.020) cc per Similar enhancement of noninvasive and mean flow rates free- flow was <0.004 observation COJrro,borat;ed. the effect of tranSl1re"thral flow rates. 1,6,8-10 as measured of postvoid residuals also was incision the The mean volume before transureincision of was cc, which decreased to 113 cc after incision <0.001). Bladder was as reflected a postoperative volume at first urge (p <0.001) and a postoperative decrease in the incidence of detrusor instability from 46 to 27% (p <0.05). This decrease in detrusor after relief of obstruction is in accordance with the findings seen after either transvesical or transurethral prostatectomy.12-15 In contrast to the study by Hellstrom and associates in which transurethral incision of the prostate did not improve detrusor pressure at peak flow rate postoperatively,7 in our study detrusor pressure at peak flow rate decreased from 102.5 to 58.3 cm. water (p <0.001). Hellstrom and associates used a unilateral incision during transurethral incision of the prostate with excellent preservation of antegrade ejaculation. We used a bilateral incision, which may account for a higher rate of retrograde ejaculation. IJ.L 'JUL'-"'V'VV.A.
'-4..LV.L ..........,'-''UL.L.I.'VL
"-J.Lj;• .L.L.LJL.l.V .......L.l.V
Dh"n. .....
.L.L.LV.l.U .... '-'.I..1.
of incision rather than resection. -n.a·r+n, 1"Ylari a correlative of men with proseXlamlnl.ng 11 4'"\ri'1>T'n!:~rn·l(l and histological 20 This study demonstrated men with smaller glands, predominantly stromal hyperplasia, responded less favorably to transurethral resection of the prostate than men with glandular hyperplasia. In summary, transurethral incision of the prostate was performed easily and safely with a short hospitalization. Transurethral incision is an effective treatment alternative for outlet obstruction caused by the small prostate gland with documented subjective and objective improvement after the simple incision procedure. REFERENCES
1. Edwards, L. and Powell, C.: An objective comparison of transurethral resection and bladder neck incision in the treatment of prostatic hypertrophy. J. Urol., 128: 325, 1982. 2. Abrams, P., Blaivas, J. G., Stanton, S. L. and Andersen, J. T.: Standardization of terminology of lower urinary tract function. Neurourol. Urodynam., 403, 1988. D. and Narayan, P.: 3. Sinha, B., Haikel, G., Lange, P. H., Moon, Transurethral resection of the prostate with local anesthesia in 100 J. Urol., 719,1986. A.: Urological en~C1OS)CO]PIC cost- r~edUlCIIJlf! idea. J. Milroy, E. C. A urodynamic view clinical problems associated bladder neck dysfunction and its treatment by endoscopic incision and trans-trigonal posterior prostatectomy. Brit. J. Urol., 45: 44, 1973. 6. Christensen, M. G., Nordling, J., Andersen, J. T. and Hald, T.: Functional bladder neck obstruction. Results of endoscopic bladder neck incision in 131 consecutive patients. Brit. J. Urol., 60,1985. 7. Orandi, A.: Transurethral incision of the prostate. J. Urol., 229,1973. 8. Orandi, A.: Transurethral incision of prostate in 15 years-a chronological appraisal. Brit. 1985. 9. Edwards, L. E., Bucknall, T. E., Richardson, D. R. and Stanek, J.: Transurethral the prostate and bladder neck incision: a review of 700 cases. Brit. J. Urol., 168, 1985. 10. Hellstrom, P., Lukkarinen, O. and Kontturi, M.: Bladder neck incision or transurethral electroresection for the treatment of obstruction caused a small A ranurodynamic study. 187, 1986. 11. Madsen, O. and tive candidates. In: and S. J:)o,yaJrSKY. 1983. 12. ........... , .... .L.J .....
13. 14. 15. 16. 17. 18. 19. 20.
v'-"'u,
evaluation tranSlue1thr,al versus randomized study. Scand. J. Urol. Nephrol., 27, 1984. Detrusor hyperreflexia and residAndersen, J. T.: Prostatism. ual urine. Clinical and urodynamic aspects and the influence of surgery on the prostate. Scand. J. Urol. Nephrol., 16: 25, 1982. Price, D. A., Ramsden, P. D. and Stobbart, D.: The unstable bladder and prostatectomy. Brit. J. Urol., 52: 529, 1980. Moisey, C. U., Stephenson, T. P. and Evans, C.: A subjective and urodynamic assessment of unilateral bladder neck incision for bladder neck obstruction. Brit. J. Urol., 54: 114, 1982. Delaere, K. P. J., Debruyne, F. M. J. and Moonen, W. A.: Extended bladder neck incision for outflow obstruction in male patients. Brit. J. Urol., 55: 225, 1983. Mobb, G. E. and Moisey, C. U.: Long-term follow-up of unilateral bladder neck incision. Brit. J. Urol., 62: 160,1988. Hedlund, H. and Ek, A.: Ejaculation and sexual function after endoscopic bladder neck incision. Brit. J. Urol., 57: 164, 1985. D~rflinger, T., England, D. M., Madsen, P. O. and Bruskewitz, R. C.: Urodynamic and histological correlates of benign prostatic hyperplasia. J. Urol., 140: 1487, 1988.