Transurethral incision of the prostate: a preoperative and postoperative analysis of symptoms and urodynamic findings

The efficacy of transurethral incision of the prostate was evaluated prospectively in 26 men with urodynamic evidence of outlet obstruction secondary to small prostate glands (estimated size less than 30 gm). All men completed preoperative and postoperative symptom questionnaires and extensive urodynamic testing with a median postoperative followup of 16.25 months. There was a significant improvement in subjective symptom analysis and objective urodynamic parameters (peak and mean uroflow rates, maximal detrusor pressure at peak flow, volume at first urge and post-void residual volume) as a result of transurethral incision of the prostate with minimal postoperative morbidity. Antegrade ejaculation was preserved in 55% of the men with normal preoperative ejaculation. Based on subjective and objective criteria, transurethral incision of the prostate is an effective treatment option for selected men with outlet obstruction.     

Transurethral incision of the bladder neck: An objective and subjective evaluation of its efficacy

This study is designed to evaluate the efficacy of treatment of bladder neck obstruction using objective (urodynamic) and subjective (assessment of satisfaction) parameters and to investigate sexual function. The results of transurethral 4 and 8 o'clock incisions of the bladder neck in 62 men (mean age 48.5 years) were reviewed with a mean follow-up of 6–12 months. Preoperative urodynamic evaluation was compared to recent postoperative urodynamic evaluation. There is marked symptomatic improvement after transurethral incision of the bladder outlet. The mean peak urine flow rate increased from 7.2 ml/s to 16.8 ml/s. Fifty-three men (85.4%) reported long-term improvement after transurethral incision of the bladder neck with an overall satisfaction rate of 71% (range 0 to 100). Five men (8%) reported new retrograde ejaculation after transurethral incision of the bladder neck. These results demonstrate that in well selected, properly diagnosed cases 4 and 8 o'clock transurethral incision of the bladder neck is an effective procedure for long-term relief of bladder outlet obstruction.     

Ejaculation and sexual function after endoscopic bladder neck incision

Endoscopic incision of the bladder neck, performed to relieve outflow obstruction, was evaluated as regards effects on ejaculation and orgasm in 61 men (mean age 48 years) by analyses of seminal fluid and a questionnaire. Relief of obstruction was confirmed by post-operative normalisation of urinary flow. In 47 cases there was unchanged antegrade ejaculation, while reduced semen volume was reported by 11 men and retrograde ejaculation by only 3. The quality of orgasm and sexual satisfaction were not permanently changed by the operation. Post-operative analysis of seminal fluid was performed in 27 patients, with normal results in 26. In 16 men who provided specimens both before and after bladder neck incision, no consistent change was found in the semen. An incision completely splitting the bladder neck but not extending distal to the verumontanum will relieve outlet obstruction. Maintenance of antegrade ejaculation can be expected in most patients undergoing this operation.     

Primary Bladder Neck Obstruction: Urodynamic Findings and Treatment Results in 36 Men

Purpose

We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction.

Materials and Methods

A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases.

Results

Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30 percent of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87 percent overall improvement in symptoms after transurethral incision.

Conclusions

Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.     

Unsuspected proximal urethral obstruction in young and middle-aged men

Proximal urethral obstruction, a common cause of prostatism in young and middle-aged men, often is misdiagnosed as prostatitis, neurogenic bladder or a psychogenic voiding disorder. Simple urodynamic studies (uroflowmetry and cystometry) do not distinguish a poor flow owing to bladder neck obstruction from that caused by poor detrusor contractility in these patients. Only the simultaneous measurement of detrusor pressure and uroflowmetry can make this distinction. A total of 23 patients with unsuspected proximal urethral obstruction underwent synchronous video-pressure-flow electromyography studies, and were treated and followed for a minimum of 1 year. Treatment by transurethral prostatic resection or bladder neck incision almost always was curative but alpha-adrenoceptor blocking agents have not been effective. All patients who underwent transurethral prostatic resection or bladder neck incision at the 5 and 7 o'clock positions have had retrograde ejaculation but both patients who underwent unilateral bladder neck incision reported antegrade ejaculation.     

功能性膀胱出口梗阻的诊断与治疗

目的　探讨功能性膀胱出口梗阻的诊断和治疗方法。　方法　 1995年 10月至 2 0 0 2年10月 ,因排尿困难就诊的男性患者 39例 ,经尿动力学检查、排尿期膀胱尿道造影及尿道扩张器探查尿道等确诊为功能性膀胱出口梗阻。国际前列腺症状评分 (IPSS)平均 2 2 .5分 ,最大尿流率平均 10 .2ml/s,剩余尿量平均 12 4ml。所有患者应用经尿道内括约肌切开术及α 受体阻滞剂治疗。　结果　平均手术时间 15min ;平均出血 5 0ml;术后平均住院 3.5d。所有患者疗效满意 ,排尿症状明显改善。术后 1年随访平均IPSS 10 .1分 ,平均最大尿流率 2 2 .1ml/s,剩余尿量平均 4 9ml,与治疗前比较差异均有显著性意义 (P <0 .0 5 )。　结论　联合应用尿动力学检查、排尿期膀胱尿道造影及尿道扩张器探查尿道等方法可准确诊断功能性膀胱出口梗阻。经尿道内括约肌切开术及α 受体阻滞剂是有效的治疗方法。     

Effects of prazosin in men with symptoms of bladder neck obstruction and a non-hyperplastic prostate

In a double blind cross-over study, the selective alpha 1-adrenoceptor blocker prazosin was given to eleven men with a non-hyperplastic prostate and with symptoms of bladder neck obstruction. During prazosin treatment maximum and average flow rates increased and residual urine was reduced. Prazosin did not change any pressure variables recorded. All patients had antegrade ejaculation and no side effects were reported. It is concluded that in selected patients with bladder outlet obstruction, prazosin may be a therapeutic alternative to bladder neck incision.     

Bladder outlet obstruction treated withtransurethral ultrasonic aspiration one-year follow-up on 59 patients

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 10F, 0-700-micron-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 men 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.     

Neodymium: YAG Laser Coagulation Prostatectomy: 3 Years of Experience with 227 Patients

Purpose

For 3 years we prospectively followed a cumulative cohort of men who underwent neodymium:YAG laser coagulation prostatectomy to relieve bladder outlet obstruction to determine the safety, efficacy and durability of this procedure.

Materials and Methods

A total of 227 men with symptomatic bladder outlet obstruction was treated with the Urolase* side-firing laser fiber between October 15, 1991 and October 15, 1994. Voiding outcomes, including peak urinary flow rates, residual urine volumes and American Urological Association symptom scores, were measured with time, and immediate and long-term complications were assessed.*C. R. Bard, Inc., Covington, Georgia.

Results

Median patient followup was 26 months (maximum 42). Significant improvement occurred in all measured voiding parameters, including 133 percent in peak flow rates and 61 percent in symptom scores 1 year postoperatively. Overall 87 percent of patients noticed improved quality of life as a result of surgery. Minimum postoperative followup was 6 months in all cases. Complications included prostatitis in 2.6 percent of patients, urethral stricture in 1.8 percent, bladder neck contracture in 4.4 percent and reoperation for residual prostate tissue in 5.3 percent.

Conclusions

Neodymium:YAG laser coagulation of the prostate represents an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Voiding outcomes are durable through 3 years.     

Combination of symptom score, flow rate and prostate volume for predicting bladder outflow obstruction in men with lower urinary tract symptoms

PURPOSE: The severity of lower urinary tract symptoms associated with benign prostatic enlargement correlates poorly with bladder outlet obstruction. Since urodynamic studies are presumed to be relatively complex, invasive and not cost-effective, they are not routinely performed by physicians treating men with lower urinary tract symptoms. As a result, a large number of patients are treated for bladder outlet obstruction when in fact obstruction may not be present. Since other noninvasive methods have not been effective for predicting bladder outlet obstruction, we investigated whether a combination of prostate volume, uroflowmetry and the American Urological Association (AUA) symptom index would be reliable for predicting this condition. MATERIALS AND METHODS: We prospectively evaluated 204 men with a mean age plus or minus standard deviation of 66.7 +/- 7.5 years who presented with lower urinary tract symptoms. Each patient completed an AUA symptom index questionnaire and underwent uroflowmetry, post-void residual urine volume measurement, pressure flow study and transrectal ultrasound of the prostate to estimate prostatic volume. We constructed receiver operating characteristics curves using various threshold values for maximum urine flow and prostate volume. Threshold values for maximum urine flow and prostate volume were used alone and combined with the AUA symptom index for predicting bladder outlet obstruction. We selected a cutoff value for maximum urine flow of 10 or less ml. per second and prostate volume of 40 gm. or greater, and used these values with an AUA symptom index of greater than 20 to predict bladder outlet obstruction in the group overall. RESULTS: Differences in the mean symptom index score in men with and without bladder outlet obstruction were not statistically significant. There was no obstruction in 19%, 28.9% and 35% of those with severe, moderate and mild symptoms, respectively. The selected cutoff values of maximum urine flow, prostate volume and symptom score combined correctly predicted obstruction in all 39 patients. Therefore, our combination of cutoff values proved to be highly accurate for predicting bladder outlet obstruction. Sensitivity, specificity, and positive and negative predictive values were 26%, 100%, 100% and 32%, respectively. CONCLUSIONS: Our study showed that combining the AUA symptom index, maximum urine flow and prostate volume reliably predicted bladder outlet obstruction in a small subset of patients only. Although bladder outlet obstruction was correctly predicted by our threshold values of AUA symptom index, maximum urine flow and prostate volume in only 39 men (26%) with obstruction, these patients represent a substantial group in any large urological practice treating male lower urinary tract symptoms.     

HOLMIUM LASER VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: A RANDOMIZED PROSPECTIVE TRIAL WITH 1-YEAR FOLLOWUP

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.     

The evolution of detrusor overactivity after watchful waiting,medical therapy and surgery in patients with bladder outlet obstruction

PURPOSE: We analyzed the evolution of detrusor overactivity in patients with bladder outlet obstruction treated with either medical or surgical therapy or watchful waiting. MATERIALS AND METHODS: Of 255 patients with symptomatic benign prostatic enlargement who completed the International Prostate Symptom Score and underwent full urodynamic investigation 161 presented with bladder outlet obstruction. Of the 161 men 101 were reevaluated with a second clinical evaluation and urodynamics 1 to 5 years (mean 2) after watchful waiting in 20, medical treatment (alfuzosin 20 and finasteride 16) in 36 and surgery (transurethral incision of the prostate 13 and prostatectomy 32) in 45. For statistical analysis Wilcoxon matched paired data and Kruskal Wallis tests were used as appropriate. RESULTS: Overall detrusor overactivity was present in 53 patients (52%) at baseline and 41 (40%) at followup. Detrusor overactivity was present in 9 patients (45%) at baseline and 11 (55%) at followup in the watchful waiting group (p = 0.17); 7 (35%) at baseline and 6 (30%) at followup in the alfuzosin group (p = 0.37); 10 (62.5%) at baseline and 10 at followup in the finasteride group (p = 1); 6 (46%) at baseline and 4 (30%) at followup in the transurethral prostate incision group (p = 0.48); and 21 (68%) at baseline and 10 (31%) at followup in the prostatectomy group (p = 0.02). CONCLUSIONS: Detrusor overactivity is highly prevalent (52%) in patients with bladder outlet obstruction, and appears to persist for long periods when obstruction is left untreated or treated only with medical therapy. However, surgical treatment of bladder outlet obstruction, prostatectomy in particular, significantly reduces the incidence of detrusor overactivity and lessens the chance of its de novo appearance for up to 5 years.     

Correlations of urodynamic changes with changes in symptoms and well-being after transurethral resection of the prostate

PURPOSE: To establish the predictive value of urodynamics on the outcome of transurethral prostate resection for benign prostatic enlargement we correlated urodynamic changes with symptomatic improvement, decreased bother, and increased general well-being and quality of life after transurethral prostate resection. MATERIALS AND METHODS: Men with lower urinary tract symptoms were selected if they met study criteria and underwent tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia, and if post-void residual urine volume and prostate size were estimated. Patients answered quality of life, symptom index, symptom problem index and benign prostatic hyperplasia impact index questions. Patients also underwent urodynamic evaluation. Men were included in analysis when transurethral prostate resection was selected as the treatment modality. Of the 132 patients included 93 were reevaluated 6 months after transurethral prostate resection. RESULTS: Improvements after transurethral prostate resection were significantly associated with decreased bladder outlet obstruction (p <0.01). However, 32 cases that were unobstructed or equivocal preoperatively also benefited moderately from resection. Effective capacity, that is cystometric capacity minus post-void residual urine volume, increased by an average of 45% postoperatively. The increase in effective capacity contributed to a significant decrease in symptoms and bother, and to improved well-being. Of the men with a urodynamically proved stable bladder 90% maintained a stable bladder after prostatectomy, while in 50% with a urodynamically proved unstable bladder it became stable postoperatively. CONCLUSIONS: Performing urodynamics preoperatively helps to predict the degree of symptom relief, decreased bother and increased well-being after transurethral prostate resection.     

经尿道电切术治疗女性膀胱颈梗阻12例

目的探讨经尿道电切治疗女性膀胱颈梗阻的疗效。方法对12例女性膀胱梗阻患者行径尿道膀胱颈电切术治疗,年龄51±13岁,病程3个月-5年,尿流率3.8±11.4ml／s,残余尿200-800ml术后随诊6个月以上。结果手术均获成功,手术时间15-50min,平均25min,术中出血〈20ml。12例患者排尿症状评分,最大尿流率平均18ml／s,残余尿均〈50ml。最大尿流率、残余尿量等均较术前显著改善,随访无尿失禁、尿瘘发生。结论经尿道电切术治疗女性膀胱颈梗阻疗效显著,并发症少。     

Unilateral bladder neck incision: endoscopic treatment of bladder neck obstruction. Results in 100 patients

Endoscopic diathermy unilateral incision of the bladder neck was carried out in 100 consecutive male patients. This procedure was performed for bladder neck obstruction and small benign prostate. The operative details of this technique are given. Follow-up after 2 months revealed excellent symptomatic and urodynamic results. Morbidity was low. Results remain stable after 13 +/- 9 months. One patient needed a transurethral resection of the prostate. Retrograde ejaculation occurred in 5% of the patients. Unilateral bladder neck incision is a simple procedure safe, and easy to learn, with a low risk of retrograde ejaculation. It is the operation of choice for small benign prostate, bladder neck obstruction and young patients.     

Transurethral incision of the prostate and bladder neck.

Transurethral incision of the prostate (TUIP) is compared to transurethral resection of the prostate (TURP) by reviewing nonrandomized, matched, and randomized studies. These studies indicate that incision of the prostate and bladder neck relieves outflow urinary obstruction, as does TURP. The incision is relatively easier to learn and perform, and requires shorter operative time compared to TURP. The incidence of retrograde ejaculation is lower after incision than after TURP--16% versus 63%, on average. Transurethral incision of the prostate has a potential for reduced costs due to reduced operative time, shortened hospital stay, and the potential for local anesthesia.     

Endoscopic treatment of bladder outlet obstruction in men after pancreas transplantation.

PURPOSE: Diabetic cystopathy comprises a spectrum of voiding dysfunction. The usual clinical manifestations are impaired bladder sensation and detrusor contractility. Diabetic cystopathy is present in as many as 43 to 85% of patients undergoing pancreas transplantation. We evaluated endoscopic management of bladder outlet obstruction for adjuvant treatment of urological complications after pancreas transplantation. MATERIALS AND METHODS: We evaluated 10 men with recurrent urological complications, including bladder leak, urinary tract infection, the dysuria/urethritis syndrome and reflux nephropathy, after pancreas transplantation. Evaluation consisted of peak flow rate, post-void residual and written questionnaires in all cases, and preoperative urodynamics in 2. All patients had signs and symptoms of bladder outlet obstruction at post-transplant presentation and underwent bladder neck incision, direct visual internal urethrotomy, limited transurethral resection of the bladder neck or transurethral resection of the prostate. Hospital costs, including operating room, laboratory, pharmacy, hospital room occupancy, anesthesia and radiology fees, were obtained from the University of Washington. RESULTS: Mean peak flow rate plus or minus standard deviation increased from 10.1+/-3.2 to 21.0+/-5.1 cc per second and post-void residual decreased from 259.2+/-38.6 to 43.6+/-36.8 cc after endoscopic intervention. Of the patients 4 presented early (mean 4.3 months) after transplantation with bladder leak or reflux nephropathy, while late presentation (mean 43 months) was associated with recurrent urinary tract infection, the urethritis/dysuria syndrome and more obstructive symptoms. Complications resolved in all cases after surgery and enteric conversion, which costs 5-fold more than endoscopic intervention, was avoided. CONCLUSIONS: Recurrent urological complications warrant early evaluation for occult bladder dysfunction. Endoscopic procedures to relieve outlet obstruction are beneficial in alleviating recurrent urological complications in men after pancreas transplantation. This cost-effective and low morbidity procedure may obviate the need for enteric conversion in some male transplant recipients.     

Treatment of primary bladder neck obstruction in women with transurethral resection of the bladder neck

PURPOSE: We describe the presentation, clinical characteristics, treatment and followup of a series of women with primary bladder neck obstruction (PBNO). MATERIALS AND METHODS: A patient data base was searched for women who underwent transurethral resection for bladder outlet obstruction diagnosed by videourodynamic study (VUDS) according to the Blaivas-Groutz nomogram for female bladder outlet obstruction between 1993 and 2002. A total of 37 women with obstruction were identified. Patients with neurogenic, traumatic, anatomical or iatrogenic causes of obstruction were excluded. Seven patients remained who had been diagnosed with PBNO, of whom all underwent transurethral bladder neck resection. Office records were reviewed for history, presentation, surgical treatment and clinical outcome. RESULTS: Seven patients were diagnosed with PBNO. Age was 39 to 81 years. Six of 7 patients presented with symptoms of obstruction, including a weak or intermittent stream and urinary hesitancy. These 6 patients had unremarkable physical examination findings with normal perianal sensation, anal sphincter tone and lower extremity reflexes. One patient presented with abdominal swelling, which on physical examination was found to be a markedly distended bladder containing more than 1000 cc urine. All patients had overt urethral obstruction on VUDS. In 6 of 7 patients obstruction was clearly at the vesical neck and in 1 the obstruction site was equivocal. Three patients were treated or had previously been treated pharmacologically with alpha-blockers. All patients were subsequently treated with intermittent self-catheterization. All patients then underwent transurethral bladder neck resection at the vesical neck and proximal urethra. Surgical specimens weighed 1 to 5 gm and showed urethral fragments or fibromuscular tissue without specific pathological findings. Followup was 1 to 10 years (median 3) and it included physical examination, uroflowmetry, post-void residual urine measurement and videourodynamic study. Six patients considered themselves cured of lower urinary tract symptoms and 1 was improved. In 1 patient the obstruction site was not clear. One patient had mild stress incontinence under rare circumstances not severe enough to require protective pads. The average change in flow was 6 +/- 10 vs 30 +/- 17 ml per second (p <0.03). The average change in voided volume was 194 +/- 170 vs 416 +/- 206 ml per second (p <0.06). Average change in post-void residual urine was 680 +/- 445 vs 173 +/- 366 ml (p <0.05). CONCLUSIONS: PBNO is an exceedingly rare condition, which is easily treatable when properly diagnosed by VUDS. The presentation of patients in urinary retention in middle age suggests that PBNO may be more common in less apparent forms than has previously been recognized.     

女性功能性膀胱出口梗阻的诊断与治疗

目的探讨女性功能性膀胱出口梗阻的诊断与治疗方法。方法28例因排尿困难就诊的女性患者,经尿流动力学检查,排尿期膀胱造影及膀胱镜检查等确诊为功能性膀胱出口梗阻。平均最大尿流率11.3ml/s,平均剩余尿量180ml。所有患者接受经尿道内括约肌切开术和α鄄受体阻滞剂治疗。结果平均手术时间15min;术后平均住院4d,所有患者排尿顺畅,症状明显改善。术后10月随访,平均最大尿流率25.7ml/s,平均剩余尿量30ml,与治疗前相比差异显著(P<0.05)。结论联合应用尿流动力学检查,排尿期膀胱尿道造影及膀胱镜检查可准确诊断功能性膀胱出口梗阻。经尿道内括约肌切开术及α鄄受体阻滞剂治疗是较理想的治疗方法之一。     

Transurethral incision of prostate compared with transurethral resection of prostate in 132 matching cases

In a prospective project during a 2-year period 132 patients with bladder outlet obstruction who were candidates for transurethral incision of the prostate were managed alternately by transurethral incision and transurethral resection of the prostate. Both operations were compared in matched patients. The results and complications favored transurethral incision, although there was no statistical significance except for the high incidence of bladder neck contracture after transurethral resection (p equals 0.028).