经尿道前列腺电切术后尿失禁原因的尿流动力学分析

目的 :探讨尿流动力学检查在诊断经尿道前列腺电切术 (TURP)后尿失禁中的作用。　方法 :37例TURP术后尿失禁患者接受了尿流动力学检查 ,包括膀胱压力容积测定 (CMG)、压力 流率分析、静态尿道压力描计(RUPP)及应力性漏点压 (SLPP)测定 ,必要时结合膀胱尿道造影。　结果 :16例患者诊断为运动急迫性尿失禁 ,2例诊断为感觉急迫性尿失禁 ,17例诊断为压力性尿失禁 ,2例诊断为充溢性尿失禁。　结论 :通过尿流动力学能够准确判断TURP术后尿失禁类型 ,从而为选择正确的治疗方法提供客观依据     

前列腺增生症术后行前列腺癌根治术的临床观察

目的：总结前列腺增生症术后行耻骨后前列腺癌根治手术的体会。方法：对11例经尿道前列腺电切、2例经耻骨上前列腺切除术后病理检查证实为前列腺癌的患者行耻骨后前列腺癌根治术，患者平均年龄65岁，TNM分期为T1a-b 4例，T1c 8例，T2b 1例。结果：13例平均随访2年，全部无瘤存活，1例发生尿道狭窄，1例发生轻度尿失禁，最大尿流率15～32ml／min，3例恢复性功能。结论：前列腺增生症术后前列腺尖部有一定程度粘连，在耻骨后前列腺癌根治术中，通过仔细解剖，采用保护耻骨前列腺韧带和膜部括约肌的方法，同样可获得满意的尿控效果。     

InVance球部悬吊术治疗男性前列腺术后尿失禁（附5例报告）

目的探讨InVance球部悬吊术治疗男性尿失禁的安全性及有效性。方法2003年3月～2008年1月,应用InVance球部悬吊术治疗5例前列腺手术后尿失禁（经尿道前列腺电切术后4例,前列腺癌根治术后1例）。年龄62～76岁,平均67岁。尿失禁病程2～6年,平均4年。保守治疗无效。术前尿动力学检查平均漏尿点压力25.5cmH2O（20～32.5cmH2O）。截石位,会阴正中皮肤纵行切开3～5cm,显露尿道球部浅面球海绵体肌及双侧耻骨下支。采用InVance器械,电钻将带有1号不吸收合成线的钛螺钉分别在两侧的耻骨联合与耻骨下支连接部和其下约2cm处打钉6个。将聚丙烯筛网材料吊带裁剪成约3cm×4cm,将一侧耻骨下支上的三条合成线穿过吊网两角分别结扎固定,术中增加腹压后（下腹部加压等）咳嗽试验调节吊带的松紧度,或将逆行尿道漏尿点压调整为60cmH2O,留置导尿管。结果手术时间50～85min,平均60min。出血20～50ml,平均30ml。5天拔除气囊导尿管,均能自行排尿。5例随访6～24个月,平均12.6月,4例经尿道前列腺电切术后者尿失禁治愈,1例前列腺癌根治术后者尿失禁改善;尿动力学检查平均漏尿点压力65cmH2O（55～70cmHO）。结论InVance球部悬吊术是一种可治疗前列腺术后轻中度尿失禁的方法。     

巨大良性前列腺增生1例报告并文献复习

目的:探讨巨大良性前列腺增生的临床特点、诊断和手术方法。方法:回顾分析1例巨大良性前列腺增生患者的临床资料,并复习国内外文献进行分析及讨论。结果:患者77岁,临床表现主要为夜尿增多、肉眼血尿。最大尿流率10ml/s,PSA37μg/L,CT显示前列腺大小为11cm×10cm×8cm。行耻骨后前列腺切除术,术后前列腺重量450g,病理结果示"良性前列腺增生"。术后21d康复出院,无明显并发症。国内文献报道,重量在200g以上有83例;国外文献报道,重量在500g以上有14例。国内报道的83例均通过手术治疗,大多数学者采用耻骨上经膀胱前列腺切除术,部分学者采用耻骨后前列腺切除术或经尿道前列腺切除术,术后效果良好。国外报道14例中11例采用耻骨上前列腺切除术,2例采用耻骨后前列腺切除术,1例采用两种方法。结论:巨大良性前列腺增生临床少见,定义尚未统一。根据临床表现和经直肠B超、前列腺CT等辅助检查可作出诊断。治疗应行前列腺切除术,手术方式有经尿道前列腺切除术、耻骨上经膀胱前列腺切除术或耻骨后前列腺切除术,以及腹腔镜前列腺切除术,具体术式应根据患者的实际情况及术者的手术经验而定。     

治疗男性压力性尿失禁的悬吊术:前瞻性研究

作者报告了一项悬吊术治疗男性压力性尿失禁的前瞻性研究。共 2 1例患者施行了该手术 ,包括 18例根治性前列腺切除术后 ,2例经尿道前列腺切除术后及 1例脊膜膨出继发括约肌受损患者。年龄 32～ 80岁 ,平均 6 7岁。均经限制入量、药物治疗和盆底肌锻炼无效。6例经胶原注射、2例行人工括约肌治疗失败。 3例前列腺癌患者曾接受外放射治疗。尿动力学显示膀胱顺应性良好 ,无膀胱出口梗阻。术前平均漏尿点压力为 (2 6± 2 )ｃｍＨ2 Ｏ(1ｃｍＨ2 Ｏ =0 .0 98ｋＰａ)。手术方法 :尿道插入 14Ｆ尿管 ,会阴作 3.5ｃｍ切口 ,暴露尿道球部和双侧耻骨下支…     

尿动力学检查在女性压力性尿失禁诊治中的应用

目的探讨尿动力学检查在女性压力性尿失禁（SUI）诊治中的应用价值。方法对38例SUI的患者进行尿动力学检查，并根据漏尿点压测定（ALPP）对29例真性压力性尿失禁（GSUI）进行分型，对其中21例患者行经闭孔无张力阴道吊带（TVT-O）术，并对TVT-O术后10例治愈者手术前后的尿动力学指标进行分析。结果38例SUI患者经尿动力学分析，诊断GSUI29例，对其中ALPP分型为Ⅱ型、Ⅱ／Ⅲ型及Ⅲ型的21例患者行TVT-O术，18例治愈，2例好转，1例无效。对术后10例治愈者进行尿动力学测定，结果最大尿道关闭压（MUCP）较术前明显升高（P〈0．05）。结论尿动力学检查在尿失禁的病因鉴别诊断上有重要意义。ALPP对GSUI的诊断、分型、手术方式的选择有参考价值。TVT-O术具有简单、微创、安全、疗效可靠的优点，其机制可能与增加最大尿道闭合压有关。     

Madigan前列腺切除术（附68例报告）

目的 回顾总结Madigan前列腺切除术治疗前列腺增生症的临床经验。方法 经耻骨后切开前列腺包膜，钝性和锐性相结合切除前列腺，完整保留尿道。结果 术后6l例排尿通畅有力；3例短暂性尿失禁；4例症状改善不明显。另有3例出现渐进性排尿困难。结论 前列腺增生的程度不是能否选择此术式的主要依据，对中叶突入膀胱明显(3cm以上)者应慎重选择，有条件的情况下术前应通过尿动力学检查筛选患者。     

女性排尿功能障碍尿动力学检查60例分析

目的探讨女性排尿功能障碍的尿动力学特点和临床意义。方法60例女性患者,年龄19~66岁,平均49岁。其中排尿困难者17例,尿失禁者28例,尿路刺激症状者15例。均行完全性膀胱测压(Micture)检测。结果17例排尿困难者中,1例最大尿流率时逼尿肌压力(Pdet.Qmax)为0,16例为10~135cmH2O,A/G图显示梗阻者11例,A/G值>40者10例。28例尿失禁中,压力性尿失禁18例,Ⅰ型1例,Ⅱ型3例,Ⅱ/Ⅲ型8例,Ⅲ型6例。急迫性尿失禁4例,混合性尿失禁1例,反射性尿失禁3例,充溢性尿失禁2例。15例尿路刺激症状中,逼尿肌不稳定收缩6例。尿动力检查正常者2例。结论尿动力学检查对女性排尿功能障碍疾病的诊断和治疗具有重要意义。     

下尿路排尿功能障碍患者的影像尿动力学评估

目的:研究影像尿动力学检查在下尿路排尿功能障碍患者诊断和治疗中的价值。方法:应用影像尿动力学仪检查64例下尿路排尿功能障碍患者的排尿功能情况。结果:神经原性膀胱(Neurogenic bladder,NB)28例(43.75%),女性压力性尿失禁(Stress urinary incontinence,SUI)15例(23.43%),BPH 12例(18.75%),前列腺切除术(TURP)后排尿障碍4例(6.25%),女性排尿困难5例(7.82%)。发现膀胱输尿管反流5例,膀胱小梁或憩室25例,逼尿肌尿道括约肌协同失调8例,尿道远端狭窄1例。结论:影像尿动力学检查通过同时评估膀胱尿道的功能和形态,为复杂性下尿路排尿功能障碍性疾病的临床诊断和治疗提供可靠的依据。     

耻骨上前列腺切除术后排尿困难的原因分析

目的 探讨耻骨上前列腺切除术后排尿困难的原因，为预防提供依据。方法 对16例耻骨上前列腺切除术后排尿困难的临床资料进行分析。结果 后尿道狭窄9例，前尿道狭窄3例，腺体残留2例，不稳定膀胱1例，腺体增生复发1例。结论 尿道狭窄为耻骨上前列腺切除术后排尿困难的主要原因．采用提高手术技巧、预防尿路感染、术前尿动力学的筛选是预防这类并发症的有效措施。     

Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature

OBJECTIVES: To summarise the evidence for the role of urodynamic tests in the diagnosis and classification of urinary incontinence. METHODS: Reference lists in relevant papers were reviewed and MEDLINE searches conducted. RESULTS: The mean sensitivity (specificity) of clinical history versus urodynamic tests was 0.82 (0.57) for stress incontinence, 0.69 (0.60) for urge incontinence/overactive bladder, and 0.51 (0.66) for patients with mixed incontinence. The proportion of women with a clinical diagnosis of urinary incontinence but with normal findings from urodynamic tests ranged from 3 to 8%. Overall sensitivity of urodynamic tests was about 85-90% in the diagnosis of urodynamic stress incontinence, but generally lower following diagnosis of urge and mixed incontinence. No relationship emerged between urodynamic test results and response to medical treatment. CONCLUSIONS: This literature review shows that the sensitivity of clinical history versus urodynamic tests was 0.82, 0.69 and 0.51 respectively for stress, urge and mixed urinary incontinence. It also suggests that urodynamic diagnosis does not predict response to treatment. These data add to the ongoing 'urodynamics or no urodynamics' debate in the evaluation of urinary incontinence and show that urodynamic testing may not be helpful for patients receiving initial non-invasive therapy. These data are in line with the conclusions of the 1st and 2nd International Consultations on incontinence.     

Development of de novo urge incontinence in women post sling: the role of preoperative urodynamics in assessing the risk

AIMS: The study was undertaken to investigate if there are specific identifiable risk factors on the preoperative history or urodynamics testing associated with an increased risk for the development of symptoms of de novo urge urinary incontinence after a minimally invasive sling procedure. METHODS: Two hundred eighty-one women who had undergone minimally invasive sling surgery for stress urinary incontinence between January 2000 and December 2003 were identified. The records of 92 patients were included in this review. RESULTS: Twenty-five patients (27%) reported urge urinary incontinence on postoperative questioning. Clinical and urodynamic parameters were correlated with the development of de novo urge urinary incontinence. Preoperative history parameters were not predictive of the increased risk of de novo urge urinary incontinence, with the exception of increased preoperative daytime frequency (OR 3.3 (1.2, 9.1)). Of 16 women whose detrusor pressure during the filling phase of cystometry exceeded 15 cm H(2)O, de novo urge urinary incontinence developed in 9 (56%) vs. 16 (21%) of 76 women, whose detrusor pressure was < or = 15 cm H(2)O (OR 4.6 (1.4, 15.0)). CONCLUSIONS: Directed patient history is only minimally helpful in the identification of women at increased risk for the development of de novo urge urinary incontinence, with the exception of the complaint of increased daytime frequency. Women with elevated detrusor pressure during the filling phase of cystometry were more likely to develop urge urinary incontinence postoperatively. Therefore, we suggest that preoperative urodynamic evaluation, and specifically detrusor pressure > 15 cm H(2)O may help identify patients at increased risk of developing de novo urge urinary incontinence following the minimally invasive sling procedure.     

THE ETIOLOGY OF POST-RADICAL PROSTATECTOMY INCONTINENCE AND CORRELATION OF SYMPTOMS WITH URODYNAMIC FINDINGS

Purpose

We evaluated men with post-radical prostatectomy incontinence to determine the incidence of intrinsic sphincter deficiency and bladder dysfunction, and the contribution of each to incontinence. In addition, we determined if subjective symptoms of stress urinary incontinence and urge incontinence correlated with urodynamic findings of intrinsic sphincter deficiency and bladder dysfunction, respectively.

Materials and Methods

A total of 60 consecutive patients (mean age 64.8 years) were prospectively evaluated with multichannel video urodynamics. All patients were evaluated at least 6 months postoperatively and had achieved a stable level of continence. Patients characterized incontinence as stress or urge related, and stress urinary incontinence was graded from 0 to 3. Intrinsic sphincter deficiency was defined as incontinence associated with increased intra-abdominal pressure and was further assessed by Valsalva's leak point pressure. Bladder dysfunction included urodynamic findings of detrusor instability or decreased compliance.

Results

Intrinsic sphincter deficiency was demonstrated in 54 patients (90%). Some component of bladder dysfunction was seen in 27 patients (45%), including detrusor instability in 24 and decreased compliance in 3, but incontinence was actually a result of bladder dysfunction in only 16 (27%). Incontinence was due to intrinsic sphincter deficiency alone in 40 patients (67%), intrinsic sphincter deficiency and bladder dysfunction in 14 (23%), and bladder dysfunction alone in only 2 (3%). Incontinence was not demonstrated on video urodynamics in 4 patients (7%). Of the 57 men who complained of stress urinary incontinence 54 demonstrated intrinsic sphincter deficiency for a positive predictive value of 95%. The 3 patients without stress urinary incontinence did not demonstrate intrinsic sphincter deficiency for a negative predictive value of 100%. Positive and negative predictive values for urge incontinence were 44 and 81%, respectively.

Conclusions

Incontinence after radical prostatectomy is associated with intrinsic sphincter deficiency in the overwhelming majority of patients. Bladder dysfunction rarely is an isolated cause. When present on urodynamic tests bladder dysfunction may not always be a significant contributor to incontinence. The symptom of stress urinary incontinence (or its absence) accurately predicts the finding (or absence) of intrinsic sphincter deficiency on urodynamics. Urge incontinence is not as reliable in predicting incontinence due to bladder dysfunction.     

Is HCl duloxetine effective in the management of urinary stress incontinence after radical prostatectomy?

INTRODUCTION: Up to 70% of patients who undergo radical prostatectomy complain about urine leakage, but persistent stress incontinence 1 year after surgery affects <5% of them. HCl duloxetine is a dual serotonin and norepinephrine reuptake inhibitor that relieves the symptoms of stress urinary incontinence. The purpose of this study was to evaluate the efficacy of HCl duloxetine in the management of urinary incontinence after radical prostatectomy and its impact in urodynamic parameters such as maximal urethral closure pressure (MUCP), abdominal leak point pressure (ALPP) and retrograde leak point pressure (RLPP). MATERIAL AND METHODS: The study included 18 men with stress urinary incontinence 12 months after radical prostatectomy. All underwent a pad test to quantify the degree of urine loss and a urodynamic evaluation before and after a three month treatment with HCl duloxetine. The intrinsic sphincter was evaluated by ALPP and RLPP and the striated sphincter by MUCP. RESULTS: At the pretreatment evaluation the mean ALPP was 52.1 cm H(2)O, the mean MUCP was 52.5 cm H(2)O and the mean RLPP was 43.1 cm H(2)O. After 3 months of HCl duloxetine treatment the mean ALPP was 59.1 cm H(2)O, the mean MUCP was 67.3 cm H(2)O and the mean RLPP was 45.1 cm H(2)O. There was a statistically significant correlation among RLPP, MUCP and ALPP before treatment. After HCl duloxetine treatment there was significant correlation between RLPP and ALPP. CONCLUSION: The use of HCl duloxetine results in mild increase of MUCP and in significant reduction of urine loss. Its action on the extrinsic sphincter does not provide a complete treatment option for postprostatectomy incontinence.     

Stress incontinence and cystoceles

We studied prospectively 62 women with cystoceles by video-urodynamics before and after operative repair. Of 29 women with grades 1 and 2 cystoceles 8 had residual urine, 14 had urge incontinence and 24 had symptoms of stress urinary incontinence. Of these women 23 had urodynamic evidence of stress incontinence, as did 3 of 5 without stress incontinence symptoms. Of 33 women with large cystoceles 22 had symptoms of stress urinary incontinence but 10 more had urodynamic evidence of stress urinary incontinence. Of these 33 women 18 had significant residual urine and 24 had urge incontinence. Operative repair resolved stress incontinence in 51 of 54 women, urge incontinence in 33 of 38 and residual urine in 24 of 26. Cystoceles recurred in 3 patients, and enteroceles developed in 3 and recurred in 2. These findings indicate that cystoceles may cause voiding dysfunction and lack of symptoms of stress incontinence is unreliable in patients with cystoceles. In addition, cystoceles are associated with other symptoms, most of which actually resolve after operative repair.     

Prospective multicenter clinical trial of Uretex Sup for surgical treatment of stress urinary incontinence

AIM: To evaluate in a prospective multicenter study the efficacy and safety of the suburethral support Uretex (Sofradim, Trevoux, France) delivered by a suprapubic approach in the treatment of female stress urinary incontinence. METHODS: Between March 2002 and March 2003, 57 patients were treated for stress urinary incontinence with Uretex. Preoperative evaluation included urodynamic examination and questionnaires (symptoms and quality of life, Contilife). Forty patients had pure stress urinary incontinence and 17 mixed urinary incontinence. No associated procedure was performed. The objective cure rate was evaluated by clinical examination and pad-test, and the subjective cure rate was assessed through questionnaires at 1, 3 and 12 months. RESULTS: The mean follow-up was 13 months (range 11-24 months). During follow up, chronic urinary retention requiring a tape section occurred in one patient, and in another patient a delay of vaginal healing was followed by a sling exposure and resection at 4 months. No infection or urethral erosion was reported. The objective cure rate was 96.2%, and the subjective cure rate was 79.2%; four patients reported low leakage on stress and nine patients complained of urge incontinence (four de novo and five persistent). CONCLUSION: The suprapubic Uretex Sup procedure is a safe and effective treatment for women with stress urinary incontinence.     

Assessment of the intrinsic urethral sphincter component function in postprostatectomy urinary incontinence

Postprostatectomy incontinence remains a disabling condition. Sphincter injury, detrusor instability, and decreased bladder compliance have been previously reported as major factors. The aim of this study was to evaluate the urethral sphincter intrinsic component, which may provide passive continence. A urodynamic evaluation was performed in 20 patients undergoing a radical retropubic prostatectomy in the preoperative period and 3 months after surgery. Patients with disabled urinary incontinence underwent a new urodynamic evaluation 6 months later. The urethral pressure profile was measured just before, then 10, 20, and 30 minutes after the injection of 0.5 mg/kg moxisylyte chlorhydrate, an alpha adrenergic blocker. Three different pressure components were defined in urethral sphincter capacity: baseline, adrenergic, and voluntary. A postoperative intrinsic urethral sphincter pressure component was found in 17 patients and its value was under 6 cm H(2)O in five cases of severe incontinence. No significant difference was observed for these patients on urethral profile components 6 months later. In contrast, in cases of significant intrinsic component value, no incontinence was observed in most patients. Passive continence after radical prostatectomy should be a matter of concern and may also explain paradoxical incontinence, despite high voluntary urethral pressure obtained after reeducation. A follow-up evaluation of the intrinsic sphincter component is suggested, by using an alpha receptor blockage test during urodynamic studies in the management of patients with postprostatectomy incontinence.     

Pubovaginal sling and pelvic prolapse repair in women with occult stress urinary incontinence: effect on postoperative emptying and voiding symptoms

Objectives. To determine the perioperative morbidity of performing a concurrent pubovaginal sling with prolapse repair in women with occult (or potential) stress incontinence, particularly on voiding dysfunction and emptying.Methods. We reviewed the charts of 38 women with grade 3-4 pelvic prolapse and occult stress incontinence. All patients underwent video urodynamic testing with the prolapse unreduced and again with the prolapse reduced with a pessary or packing. The abdominal leak point pressure was determined. Appropriate surgical repair of all components of the prolapse was performed concurrently with pubovaginal sling placement. The outcomes were measured with respect to the time to spontaneous voiding, permanent urinary retention, development of stress incontinence or de novo urge incontinence, resolution of urge incontinence, and perioperative complications.Results. The mean age was 72 years, and the mean follow-up was 15 months (range 6 to 39). The mean time required before spontaneous voiding resumed without the need for catheterization was 11.8 days (range 2 to 46). No patient developed permanent urinary retention. Two (9.5%) of 21 women without preoperative urge incontinence developed de novo urge incontinence. However, existing urge incontinence resolved in 45%. One woman developed a suprapubic wound infection, which resolved with conservative management. Stress incontinence occurred in 2 women (7%) at 4 and 19 months postoperatively. Clinically significant prolapse (uterine) developed in 1 patient 2 years after surgery.Conclusions. Simultaneous pubovaginal sling placement for women with occult stress incontinence undergoing repair of a large pelvic prolapse is effective in preventing postoperative stress incontinence and has little negative effect on postoperative bladder emptying. It should be considered in all women with occult stress incontinence undergoing prolapse repair.     

Pathophysiologie von Drang-, Belastungs- und Mischinkontinenz

According to the new ICS classification, urinary incontinence is subdivided by symptomatic, clinical, and urodynamic criteria. Understanding the pathophysiological interactions is important to find the correct diagnosis. Disturbances in bladder storage include urge incontinence due to neurogenic or non-neurogenic (idiopathic) detrusor hyperactivity as well as stress urinary incontinence caused by an insufficient urethral closure mechanism due to reduced pressure transmission (active-passive), hypotonic urethra, hyporeactivity of sphincter musculature, or involuntary relaxation of the urethra. Stress and urge incontinence can occur in combination and then be defined as mixed incontinence.