Voiding Function And Dysfunction, And Female Urology

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VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY

VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY Urinary Continence in Spinal Injury Patients Following Complete Sacral Posterior Rhizotomy R. P. MACDONAGH, D. M. C. FORSTER AND D. G. THOMAS, Spinal Injury Unit, Lodge Moor Hospital and Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom

Brit. J. Urol., 66: 618-622, 1990 Complete sacral posterior rhizotomy was carried out in 15 spinal injury patients in conjunction with implantation of sacral anterior root stimulators. All patients were incontinent preoperalively and had video-pressu:re cystometry before and at regular intervals after surgery. Detrusor hyper-reflexia was totally abolished in all but 1 patient following rhizotomy and 87% no longer require any form of incontinence appliance. Deafferentation produced adverse changes in vesicourethral function and even when rhizotomy was complete, continence could not be guaranteed. The pre-operative state of the bladder neck and distal sphincter mechanism had an important bearing on future continence and those patients with a closed bladder neck and no previous sphincterotomy had the greatest chance of becoming continent after deafferentation. The majority of patients in this series are now fully continent, representing a transformation in their quality of life; it is recommended, however, that to optimise the success of rhizotomy precise preoperative evaluation and selection of patients are essential. Editorial Comment: This group of 12 male and 3 female patients with traumatic complete suprasacral spinal cord injury underwent diathermy and division of the posterior roots of S2 to S4. In addition, deafferentation of S5 was performed if a detrusor response was obtained on stimulation. Bladder compliance was normal in all patients preoperatively but at the first urodynamic assessment 8 days after surgery 6 patients had abnormally low compliance, with opening of the bladder neck early in filling and subsequent stress incontinence. At 3 months reduced compliance persisted in only 1 patient. The state of the bladder neck on video urodynamic study before surgery was related to subsequent continence: of 4 patients who had an open bladder neck at rest 3 were incontinent after deafferentation, and of 11 patients with a closed bladder neck 10 were subsequently continent. Five patients with autonomic hyperreflexia had complete relief of symptoms. All patients operated on lost reflex bowel activity, requiring manual evacuation for bowel emptying. In addition, reflex erections were lost in all male subjects. There has been no evidence of recurrent detrusor activity in these patients (mean followup 9.2 months, range 2 to 17 months). Alan J. Wein, M.D. High Prevalence of Benign Prostatic Hypertrophy in the Community W. M. GARRAWAY, G. N. COLLINS AND R. J. LEE, Department of Public Health Sciences, Edinburgh University, Edinburgh, and Department of Urology, Stirling Royal Infirmary, Stirling, United Kingdom

Lancet, 338: 469-4 71, 1991

There is a strong suspicion among urologists that the prevalence of benign prostatic hyperplasia is higher than has been reported in clinical retrospective and necropsy studies. To find out the prevalence in one community all men aged 40-79 years registered with a group general practice were invited to complete a urinary symptom questionnaire and to undergo uroflowmetry. 705 men (77% of those eligible) participated. 214 men (84% of those invited) with signs and symptoms of prostatic dysfunction subsequently underwent transrectal ultrasonography (TRUS) for assessment of the volume (and by inference weight) of their prostates. The prevalence rate of benign prostatic hypertrophy (BPH), defined as enlargement of the prostate gland of equivalent weight >20 g in the presence of symptoms of urinary dysfunction and/or a urinary peak flow rate <15 ml/s and without evidence of malignancy, was 253 (95% CI 221-285) per 1000 men in the community, rising from 138 per 1000 men aged 40-49 years to 430 per 1000 men aged 6069 years. Thus apparently well men have a much higher frequency of BPH than was previously thought to be the case. Editorial Comment: The availability of an increasing number of nonprostatectomy options to treat voiding dysfunction secondary to benign prostatic hyperplasia will likely prompt many patients to seek treatment who would not have done so at a time when the primary choices of therapy were surgery and watchful waiting. This fact, coupled with an increasing desire on the part of many patients to rule out prostate cancer, could result in a huge increase in the number of prostate-related visits to the urologist's office and a staggering increase in the national prostate health bill, far exceeding any anticipated reduction secondary to a permanent or temporary decrease in the number of surgeries performed for benign prostatic enlargement. Alan J. Wein, M.D. Infertility in Men With Spinal Cord Injury T. A. LINSENMEYER AND I. PERKASH, Departments of Physical Medicine and Rehabilitation, and Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, and Department of Urology, Stanford University Medical Center and Spinal Cord Injury Service, Department of Veterans Affairs Medical Center, Palo Alto, California

Arch. Phys. Med. Rehab., 72: 747-754, 1991 Infertility is a significant and frustrating problem for many men after spinal cord injury. The two major causes are poor semen quality and ejaculatory dysfunction. Factors attributed to poor semen quality include stasis of prostatic fluid, testicular hyperthermia, recurrent urinary tract infections, abnormal testicular histology, possible changes in the hypothalamic-pituitary-testicular axis, possible sperm antibodies, chronic longterm use of various medications, and type of bladder management. Further work is needed to define the impact and importance of each of these factors. Ejaculations are reported to occur in only 5% of men with spinal cord injury (SCI) who have complete upper motor lesions and 18% of those who have complete lower motor lesions. Ejaculations occur in up to 70% of men with incomplete lesions. Methods that have been used to induce an ejaculate include intrathecal neostigmine, subcutaneous physostigmine, direct aspiration of sperm from the vas deferens, vibratory stimulation, electroejaculation, and direct stimulation of the hypogastric nerve. The most commonly used

VOIDING FUNCTION AND DYSFUNCTION, AND FElV!ALE UROLOGY

methods in the United States are electroejaculation and vibratory stimulation; using these two methods, ejaculates can be obtained up to 85% and 59% of the time, respectively. Each of these methods has advantages and disadvantages. Particular care needs to be given to monitoring men undergoing these procedures who are prone to autonomic dysreflexia. The future outlook is encouraging once improved technology for obtaining semen and various methods to assist reproduction, such as in vitro fertilization, are available.

Editorial Comment: This is an excellent review of poor semen quality and ejaculatory dysfunction in paraplegic and quadriplegic men due to spinal cord injury, as well as the various interventions available for each problem and the challenges yet to be solved. Alan J. Wein, M.D. Transurethral Balloon Dilatation of the Prostatic Urethra: Effectiveness in Highly Selected Patients With Prostatism

N. F. AND

WASSERMAN, P. K. REDDY, G. ZHANG, D. A. KAPOOR P. BERG, Departments of Radiology and Urology, De-

partment of Veterans Affairs Medical Center, Minneapolis, Minnesota AJR, 157: 509-512, 1991

Transurethral balloon dilatation of the prostate has been shown to be a safe and potentially effective alternative to surgery in the treatment of benign prostatic hyperplasia, with a 66% success rate in relatively unselected patients. This study hypothesized that more careful patient selection might result in a significantly better rate of improvement. Ninety-one subjects with symptoms and signs of prostatism attributable to benign prostatic hyperplasia were studied. Group 1 comprised 42 patients with an initial mean symptom score of 16.8, residual urine of 249 ml, maximal flow rate of 7.9 ml/sec, and nomogram of maximal flow rate of -1.5. Group 2 comprised 49 less symptomatic patients with an initial mean symptom score of 14.5, residual urine of 105 ml, maximal flow rate of 10.7 ml/ sec, and nomogram of maximal flow rate of -0.80 The difference in mean age and prostate size between groups was not statistically significant, but differences in baseline symptom score, residual urine, maximal flow rate, and nomogram of maximal flow rate were significant (p < .04). Transurethral balloon dilatation of the prostate was performed under local anesthesia or IV sedation and analgesia with single- or double-balloon catheters with maximal diameters of 25-30 mm inflated to 2.54.0 atmospheres pressure for 10 min. Patients were followed up with repeat symptom scoring, uroflometry, and measurement of residual urine. After a mean follow-up of 22 months (range, 6-48 months), an improvement in symptom score was seen in 80% of group 2 patients compared with 43% in group 1. Improvement in symptom scores was statistically significant in both groups (p < .04). We conclude that transurethral balloon dilatation of the prostate is more effective in patients with more moderate symptoms and with less marked signs of obstruction than in patients with more marked prostatism.

Editorial Comment: The authors conclude that optimal success with transurethral balloon dilation of the prostate is achieved by excluding patients with severe obstruction, infection, large prostates or dominant median lobe hyperplasia. They predict the best results in pa-

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tients with symptom scores (Madsen-Iversen rating system) of less than 20, prostates weighing less than 40

gm., little o:r no median lobe hyperplasia and :residual urine less than 150 mL o:r nomog:ram peak flow less than -2.0. 1 It will be interesting to see whether similar conclusions are ultimately reached regarding the effectiveness of laser prostatotomy, microwave hyperthe:rmia and other alternative invasive technologies for the treatment of voiding dysfunction secondary to benign prostatic hyperplasia. Alan J. Wein, M.D. 1. Jergensen, J. B., Jensen, K. M., Bille-Brahe, N. E. and

Morgensen, P.: Uroflowmetry in asymptomatic elderly males. Brit. J. Urol., 58: 390, 1986.

Elevated Mortality Following Transurethral Resection of the Prostate for Benign Hypertrophy! But Why?

T. F.

ANDERSEN, H. BR0NNUM-HANSEN, ROEPSTORFF, Institute of Social Medicine,

T. SEJR AND C. University of Copenhagen; Danish Institute for Clinical Epidemiology, and Department of Urology, Glostrup County Hospital, Copenhagen, Denmark

Med. Care, 28: 870-881, 1990 This paper reevaluates the recently reported excess mortality following transurethral resection of the prostate (TURP) for benign hypertrophy as compared with traditional open resection (OPEN). We studied survival through linkage of hospital discharge data with mortality data for the entire male population of Denmark (1977-85). For a maximum of 10.5 years 38,067 prostatectomy patients were followed. Adjusting for age and health status before surgery, TURP patients were subject to significantly higher levels of mortality than OPEN patients (RR= 1.19, 95% confidence interval (1.15-1.24). The extent to which this difference is attributable to the surgical intervention itself remains an open question. The two groups of patients are quite different with regard to age and preoperative health status, and available data may not be sufficient to control such differences through statistical analysis. On the other hand, the difference in mortality persisted over calender time, even during periods when the pattern of utilization for the two procedures changed significantly (constant RR = 1.19, adjusting for age and comorbidity). The most important causes of death among Danish TURP patients differ from the causes suggested on the basis of previously reported Canadian data. The current evidence is thus ambiguous with regard to hypothetical biologic mechanismes behind the excess mortality over TURP patients. Further investigations are needed to evaluate the safety and effectiveness of prostate surgery.

TURP vs Open Prostatectomy

E. V.

CATTOLICA

Urol. Corresp. Club, p. 23, April 5, 1991 No Abstract

Editorial Comment: These 2 articles provide data relative to the recent report by Roos et al of increased mortality after transurethral resection of the prostate compared with open prostatectomy, even after carefully adjusting for differences in health status between the 2 groups before surgery. 1 The first article studies survival

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VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY

by comparing the hospital records with mortality data for up to 10.5 years. Adjusting for age and health status before surgery, patients who had undergone transurethral resection of the prostate were subject to significantly higher levels of mortality than those who had undergone open prostatectomy (relative risk = 1.19). This relative risk was smaller than that reported by Roos et al (1.45 for 5-year survival among all patients and 1.60 among the healthiest). The relative risk among the healthiest individuals in the Danish study was 1.11. The increased mortality after transurethral resection of the prostate is most pronounced 2 years after the operation (relative risk = 1.32). However, analysis of the causes of death yielde_d :re~mlts that were clearly different from those reported by Roos et al, in that cardiovascular diseases and myocardial infarction were not especially important causes of death. Furthermore, pulmonary diseases, especially chronic bronchitis, and cerebrovascular disease accounted for a disproportionate number of deaths in the Danish study. The authors conclude that this experience is consistent with the hypothesis of a higher level of postoperative mortality experienced by patients undergoing transurethral resection of the prostate, as opposed to open prostatectomy. They add, however, that some unrecognized health factors might be distributed differently between the 2 groups after retrospective adjustment for in hospital comorbidity. The second study looks at results in 8,219 patients who underwent prostatectomy in northern California between 1976 and 1987. Of these patients 94.5% underwent transurethral resection of the prostate and 5.5% had open prostatectomy. Although the overall mortality rates at 8 years were lower than those reported by Roos et al, there was still a relative risk of dying of 1.6 for transurethral resection of the prostate compared to open prostatectomy. Of the deaths 4 7% were from circulatory disorders, 28% from neoplasms and 25% from other causes. The relative risk of mortality in transurethral resection of the prostate versus open prostatectomy was 1.3 for neoplasms, 1.6 for circulatory disorders and 1.6 for other causes. The cumulative probability of reoperation for transurethral resection of the prostate was 7 .6% at 8 years, which is substantially lower than that reported by Roos et al. 1 The cumulative probability of reoperation for open prostatectomy was 1.8%. The author concludes that although the mortality difference between transurethral resection of the prostate and open prostatectomy certainly exists, it remains unexplained. The data suggest further that an increased mortality rate exists not only for circulatory disorders but for neoplasms and other causes as well, adding another facet of data that must be explained by any hypothesis specific for causation. Both of these articles report a higher mortality rate after transurethral resection of the prostate compared to open prostatectomy, the cause of which is unknown. Whether this finding represents associated comorbidity not appreciated by a retrospective assignment of risk is also unknown. The various predominant causes of death in these studies, if the differences in mortality are not due to differences in comorbidity, mandate an explanation of the possible biological mechanisms whereby this could occur. Clearly, a well designed prospective study,

such as that which organized Urology is advocating, is needed. Alan J. Wein, M.D. 1. Roos, N. P., Wennberg, J. E., Malenka, D. J., Fisher, E.

S., McPherson, K., Andersen, T. F., Cohen, M. M. and Ramsey, E.: Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. New Engl. J. Med., 320: 1120, 1989.

Bladder Outlet Obstruction Treated With Transurethral Ultrasonic Aspiration: One-Year Follow-Up on 59 Patients T. R. MALLOY, V. L. CARPINIELLO, A. J. WEIN, C. PAYNE AND D. WUCHINICH, Pennsylvania Hospital, Philaaetphia, Pennsylvania

Urology, 37: 512-515, 1991 Fifty-nine males with bladder outlet obstruction were treated with transurethral ultrasonic aspiration of the prostate. Utilizing a 26.5F urethral sheath, surgery was accomplished with a lOF, 0-700-rnicron-vibration-level ultrasonic tip with an excursion rate of 39 kHz. Complete removal of the adenoma was accomplished followed by transurethral electrocautery biopsies of both lateral lobes to compare pathologic specimens. One year follow-up revealed satisfactory voiding patterns in 57 of 59 men (96%). Bladder neck contractures developed in 2 men. Pathologic comparisons showed 100 percent correlation between aspirated and TUR specimens (56 BPH, 3 adenocarcinoma). Forty-seven men were active sexually preoperatively (6 with inflatable penile prostheses). Post ultrasonic aspiration, 46 rnen had erectile function similar to preoperative levels with 1 patient suffering erectile dysfunction. Forty men (85%) had antegrade ejaculation while 7 (15%) experienced retrograde or retarded ejaculation. No patients were incontinent. Editorial Comment: This is an alternative to prostatectomy for benign prostatic hyperplasia, which uses a familiar technology and approach. To remain competitive, however, this procedure will have to withstand the same type of intense short and long-term scrutiny and comparison to less invasive technologies that are currently being directed at transurethral resection of the prostate. Alan J. Wein, M.D. Assessment of Kegel Pelvic Muscle Exercise Performance After Brief Verbal Instruction R. C. BUMP, W. G. HURT, J. A. FANTL AND J. F. WYMAN, Department of Obstetrics and Gynecology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia

Amer. J. Obst. Gynec., 165: 322-329, 1991 Forty-seven women had urethral pressure profile determinations performed at rest and during a Kegel pelvic muscle contraction, after brief standardized verbal instruction. Twenty-three (49%) had an ideal Kegel effort-a significant increase in the force of urethral closure without an appreciable Valsalva effort. Twelve subjects (25%) displayed a Kegel technique that could potentially promote incontinence. Age, parity, weight, estrogen deprivation, prior continence surgery or hysterectomy, and passive urethral function did not predict a successful effort. We concluded that simple verbal or written