Bladder outlet obstruction accelerates bladder carcinogenesis

OBJECTIVE

To examine the correlation between partial bladder outlet obstruction (PBOO) and bladder carcinogenesis.

MATERIALS AND METHODS

Female Wistar rats (6 weeks old) were divided into three groups of 10 each: group 1 was exposed to n‐butyl‐n‐butanol nitrosamine (BBN, a carcinogen) in drinking water for 8 weeks; group 2 had PBOO induced surgically after exposure to BBN for 8 weeks; group 3 had a sham operation and the rats drank normal water (control group). After 20 weeks, all of the rats were killed humanely and their bladders analysed.

RESULTS

There were no significant differences in body weight among the groups. The bladder weight of group 2 was significantly greater than either group 1 or group 3. Histopathologically, bladder smooth muscle hypertrophy was the major cause of the increased bladder weight for group 2. In group 2 there were increases in bladder wall thickness and many nipple‐shaped urothelial tumours. Basic fibroblast growth factor and hypoxia‐inducible factor‐1α expression were significantly greater in group 2 than in groups 1 and 3.

CONCLUSIONS

Exposure of the bladder to carcinogens during bladder hyperplasia and hypertrophy induced by PBOO results in a greater incidence of superficial bladder carcinoma.     

The postnatal management of boys in a national cohort of bladder outlet obstruction

Aim

The most common cause of congenital bladder outlet obstruction (BOO) is posterior urethral valves (PUV). Initial treatment requires decompression, but transurethral incision (TUI) or primary diversion is all described. There is no randomized control trial to guide management. This study aims to describe management, circumcision, and UTI rate in a national cohort of PUV boys.

多沙唑嗪对兔膀胱出口部分梗阻致膀胱顺应性减低的影响

目的 探讨多沙唑嗪对兔膀胱出口部分梗阻后膀胱顺应性改变的影响.方法 成年雄性新西兰兔40只随机分为4组,每组10只,A组为假手术对照组,B组为膀胱出口部分梗阻组,C组为膀胱出口部分梗阻后口服多沙唑嗪组,D组为假手术后给予多沙唑嗪组.各组于14周行尿动力学检测,检测完成后处死并留取膀胱标本,行膀胱称重.结果 4组膀胱标本质量分别为(3.2±0.9)、(14.1±2.3)、(5.0±2.0)、(2.9±0.5)g;B、C组均高于A、D组,B组高于C组,差异均有统计学意义(P＜0.01);A、D组间比较差异无统计学意义(P＞0.05).4组逼尿肌漏尿点压分别为(10.2±2.5)、(18.8±6.1)、(13.5±4.7)、(11.6±3.6)cm H2O(1 cm H2O=0.098 kPa),B组高于A、D组,差异有统计学意义(P＜0.01),且高于C组,差异有统计学意义(P＜0.05);A、C、D组间差异无统计学意义(P＞0.05).膀胱顺应性分别为(2.86±0.56)、(1.22±0.39)、(4.25±2.19)、(2.90±0.53)ml/cm H2O,B组与A、D组相比明显下降,差异有统计学意义(P＜0.01);C组高于A、D组,差异有统计学意义(P＜0.05);A、D组间差异无统计学意义(P＞0.05).结论膀胱出口部分梗阻后早期应用多沙唑嗪治疗能够延迟梗阻对膀胱顺应性的损害,保护膀胱储尿功能.

Abstract：

Objective To explore the effect of doxazosin on rabbit bladder compliance after partial bladder outlet obstruction. Methods A total of 40 male New Zealand white rabbits were randomized into 4 groups, with 10 rabbits in each group. Partial bladder outlet obstruction was established in groups B and C, while groups A and D underwent the same operation but without partial bladder outlet obstruction. On the day after the operation, groups C and D received oral administration of doxazosin. After 14 weeks, urodynamic examinations were carried out in all groups, and the bladder was weighted after cystectomy. Results Bladder weight was (3.2±0.9) g in group A, (14.1±2.3) g in group B, (5.0±2.0) in group C,and (2.9±0.5) g in group D. The bladder weight in groups B and C increased significantly compared to groups A and D (P＜0.01), group B increased significantly over group C (P＜0.01), and there was no significant difference between groups A and D (P＞0.05).The detrusor leak point pressure was (10.2±2.5) cm H2O in group A, (18.8±6.1) cm H2O in group B, (13.5±4.7) cm H2O in group C,and (11.6±3.6) cm H2O in group D. The detrusor leak point pressure in group B was significantly higher than group A, group D (P＜0.01) and group C (P＜0.05). There was no significant difference between group A, group C and group D (P＞0.05). The bladder compliance was (2.86±0.56) ml/cm H2O in group A, (1.22±0.39) ml/cm H2O in group B, (4.25±2.19) ml/cm H2O in group C,and (2.90±0.53) ml/cm H2O in group D. The bladder compliance was significantly decreased in group B compared to groups A and D (P＜0.01). Bladder compliance in group C was significantly higher than in groups A and D (P＜0.05), and there was no significant difference between group A and group D (P＞0.05). Conclusion Early use of doxazosin can delay the occurrence of lower bladder compliance after partial bladder outlet obstruction, thus protecting the storage function of bladder.     

Bladder outlet obstruction after pubovaginal fascial sling

The purpose of this cross-sectional study was to evaluate patients’ satisfaction and urodynamic findings in women undergoing pubovaginal fascial sling procedure. We have evaluated, clinically and urodynamically, 45 women who underwent the rectus fascia pubovaginal sling for urodynamically proven stress urinary incontinence with at least 12 months of postoperative follow-up. After a mean follow-up of 25 months, 93.3% of patients reported being stress continent and 73.3% were satisfied with the result of the surgery. Patients with longer follow-up had a significantly lower satisfaction score (6.4 vs. 9.3, p = 0.005). Using the Blaivas–Groutz nomogram, some degree of obstruction was observed in 51.1% of women. Storage symptoms were related to obstruction (p = 0.004), longer follow-up (p = 0.022), and negative impact on quality of life. Half of the patients had some degree of obstruction, which was directly related to urge syndrome and decrease in quality of life.     

Correlation of intravesical prostatic protrusion with bladder outlet obstruction

OBJECTIVES: To determine the effect of intravesical protrusion of the prostate (IPP, graded I to III) on lower urinary tract function, by correlating it with the results of a pressure-flow study. PATIENTS AND METHODS: In a prospective study men (aged> 50 years) with lower urinary tract symptoms were initially evaluated as recommended by the International Consultation on Benign Prostatic Hyperplasia, together with the IPP and prostate volume, as measured by transabdominal ultrasonography. These variables were then correlated with the results from a pressure-flow study. RESULTS: The IPP was a statistically significant predictor (P < 0.001) of bladder outlet obstruction (BOO) compared with other variables in the initial evaluation. In all, 125 patients had significant BOO, defined as a BOO index of> 40. Of these men, 94 had grade III and 30 had grade I-II IPP. Seventy-five patients had a BOO index of < 40; 69 had grade I-II and six grade III IPP. In patients with BOO confirmed on the pressure-flow study, grade III IPP was associated with a higher BOO index than was grade I-II (P < 0.001). CONCLUSION: The IPP assessed by transabdominal ultrasonography is a better and more reliable predictor of BOO than the other variables assessed.     

Bladder outlet obstruction causes fetal enterolithiasis in anorectal malformation with rectourinary fistula

Extraluminal calcified meconium is found frequently by prenatal ultrasound in cases with bowel perforation and meconium peritonitis. Intraluminal intestinal meconium calcifications are rarely seen in prenatal sonography. Meconium calcifications result from a mixture of meconium and urine that indicates a connection between intestinal and urinary tract.We report a case of a male newborn prenatally diagnosed with intraluminal echogenic calcifications at 23 weeks of gestation, suggesting an anorectal malformation (ARM) with rectourinary fistula. At birth, the child presented with a complex ARM including high anal atresia with both perineal and rectourethral fistula. Furthermore, a bladder outlet obstruction due to a urethral stenosis was diagnosed. Vesicostomy was performed as an emergency procedure followed by colostomy during neonatal period. Posterior sagittal anorectoplasty was performed at the age of 4 months.Prenatal echogenic calcifications within bowel should raise the suspicion of ARM with rectourinary fistula and bladder outlet obstruction.     

膀胱出口梗阻指数在评估良性前列腺增生症膀胱出口梗阻中的应用

目的 探讨膀胱出口梗阻指数(BOON)在评估前列腺增生患者膀胱出口梗阻(BOO)中的意义.方法 对临床有下尿路症状,怀疑存在因前列腺增生症(BPH)导致膀胱出口梗阻的76例患者,测定前列腺体积(经直肠),最大自由尿流率(Qmax)和平均排尿量,通过公式计算BOON=前列腺体积(cm3)-3×Qmax(ml/s)-0.2×平均排尿量(ml).同时对患者进行压力.流率测定,计算AG值和Schafer梗阻级别,与BOON对照,分析利用BOON评估膀胱出口梗阻的准确性.结果 将本组患者年龄、前列腺体积、最大尿流率、残余尿量及BOON值,以AG作为因变量,同AG进行多元线性回归分析.整体回归方程中R=0.542(P=0.000),其中BOON值同AG值相关性最强(P=0.000).18例BOON值>-10,此时利用BOON判断BOO的敏感性为31%,特异性为100%,取BOON>-20时,敏感性为42.4%,特异性为88.2%;取BOON>-30时,敏感性为66.1%,特异性为82.4%;而取BOON>-40时,敏感性为77.9%,其特异性为64.7%.取BOON值-30作为分界点,在不明显降低特异性的同时,能够更敏感的判断BOO,BOON数值越大,利用BOON判断膀胱出口梗阻的特异性越高.结论 通过测定前列腺体积,最大自由尿流率(Qmax)和平均排尿量计算膀胱出口梗阻指数,取BOON>-30为分界点,是预测前列腺增生症是否存在膀胱出口梗阻的一种简易、无创方法,具有较好的特异性和敏感性.     

The treatment of female bladder outlet obstruction

Authors from the USA present a review of the treatment of BOO in the female. This topic is important, which should be of considerable help to the reader. It is covered systematically, dealing with anatomy and then therapy. There is also a meta‐analysis comparing industry‐ and non‐industry funded trials of antimuscarinic medication. This careful study shows no difference in outcomes between them, but suggests there are some shortcomings that need to be overcome.     

Refractory overactive bladder after urethrolysis for bladder outlet obstruction: management with sacral neuromodulation

Refractory overactive bladder (OAB) after urethrolysis for iatrogenic bladder outlet obstruction (BOO) is a clinical dilemma without established guidelines for management. We sought to evaluate the efficacy of sacral neuromodulation (SNM) in the management of this complex patient population. Retrospective review identified eight patients who underwent SNM secondary to refractory OAB after urethrolysis or sling take-down. SNM was performed with the Interstim® device (Medtronic, Minneapolis) using a two-stage implant technique. SNM outcomes were determined subjectively during follow-up. Validated questionnaires were completed to assess symptom bother, patient satisfaction, and quality of life. Statistical analyses were conducted using Stata® version 9.0. Six patients had a favorable response to SNM during test stimulation and underwent implantation of the implantable pulse generator (IPG). With follow-up of 15.7?±?11.1 months (6–34), all patients significantly improved, with three patients being dry and three patients having one to two urgency incontinence episodes per week. Patient-reported outcomes indicated that patients perceived themselves as very much improved (3) or much improved (3) after SNM, while those failing test stimulation perceived no change. Quality of life and symptom bother were significantly better in SNM responders vs nonresponders. SNM appears to be an effective and viable treatment option in this complex patient population. Further work is needed to determine clinical factors predictive of outcome and durability of response.     

Altered distribution of interstitial cells in the guinea pig bladder following bladder outlet obstruction

AIMS: We investigated the effects of bladder outlet obstruction (BOO) on the distribution of interstitial cells (ICs) in the guinea-pig bladder. METHODS: Bladder overactivity of BOO animals was validated with urodynamic studies. Immunohistochemical analyses for Kit and vimentin as markers for ICs were performed on both BOO and control bladders. Morphological and functional properties of detrusor smooth muscle (DSM) were examined with alpha-smooth muscle actin staining and intracellular recording, respectively. Electron microscopy was also carried out to characterize ultrastructural morphology of ICs. RESULTS: Two weeks after surgery, BOO animals showed an increased voiding frequency and a reduced voiding volume. Filling cystometry demonstrated a frequent incidence of non-voiding contractions, a reduced interval between voiding contractions and an increased voiding pressure in BOO bladders. In BOO bladders, the thickness of suburothelial and subserosal connective tissue layers was increased, whilst that of detrusor smooth muscle (DSM) layer was less affected. Population of Kit or vimentin immunoreactive ICs was increased in subserosal layers, and their distribution was altered in suburotherial layer in BOO bladders. Neither alpha-actin immunoreactivity nor spontaneous electrical activity of DSM was altered in BOO bladders. ICs were characterized by their numerous mitochondria and caveolae, and had a close contact with each other and with neighboring DSM or nerves. CONCLUSIONS: These results demonstrated the increased population of ICs in the BOO guinea-pig model for the first time, and suggest that the altered distribution of ICs may contribute to the pathophysiology of bladder overactivity.     

经超声逼尿肌厚度测定在无创诊断女性膀胱出口梗阻中的应用

目的 探讨经超声逼尿肌厚度测定在女性膀胱出口梗阻诊断中的应用价值.方法 93例伴有LUTS的女性患者,行压力流率测定过程中,当膀胱容量为250 ml或最大膀胱容量的50％时,应用7.5 MHz高频线纵超声探头测定膀胱前壁逼尿肌厚度.以Qmax≤12 ml/s以及最大尿流率时逼尿肌压力≥25 cm H2O(1 cm H2O =0.098 kPa)作为诊断女性膀胱出口梗阻的标准,将患者分为梗阻及非梗阻两组,比较两组年龄、尿动力学参数及逼尿肌厚度的差异.应用相对工作特征曲线评价逼尿肌厚度测定作为诊断工具的价值. 结果 梗阻组42例,非梗阻组51例.两组年龄分别为(61.2±8.3)、(59.9±7.7)岁(P=0.44),最大膀胱灌注容量分别为(292.2±82.3)、(308.1±87.5)ml(P =0.37),组间比较差异均无统计学意义;两组最大逼尿肌压力[(43.1±11.2)、(16.2±7.1)cm H2O,P=0.00]、最大尿流率时逼尿肌压力[(34.3±8.2)、(13.1±7.8)cm H2O,P=0.00]、Qmax[(7.4±3.2)、(17.4±4.1)ml/s,P=0.00]、排尿量[(157.1±63.7)、(251.2±77.4)ml,P=0.00]、残余尿量[(117.5±71.3)、(37.7±18.1)ml,P=0.00]及逼尿肌厚度[(1.8±0.3)、(1.4±0.2)mm,P =0.00]比较差异均有统计学意义.当临界值≥1.9 mm时,特异性和阳性预测值均为100％,敏感性为38％,阴性预测值为62％.其曲线下面积为0.88±0.06. 结论 经超声逼尿肌厚度测定诊断女性膀胱出口梗阻具有无创、方便、可靠的特点.当临界值≥1.9 mm时,具有较高的特异度和阳性预测值,在一定程度上可取代压力流率测定.     

前列腺增生体积、症状积分和梗阻程度的相关性研究

目的：探讨前列腺增生体积、症状积分和膀胱出口梗阻程度的相关性。方法：对４３例住院手术的前列腺增生症患者进行国际前列腺症状评分（ＩＰＳＳ），其中经腹壁Ｂ超测前列腺体积（Ｖ）者２７例；行排尿期尿道测压确定膀胱出口梗阻者２７例，并用压力下降梯度（ＭＵＰＰ Ｇｒａｄｉｅｎｔ）代表梗阻程度。结果：ＩＰＳＳ和Ｖ呈正相关（ｎ＝２７，ｒ＝０．３９３３，Ｐ＝０．０２１），ＩＰＳＳ和ＭＵＰＰ Ｇｒａｄｉｅｎｔ呈正相关     

Early bladder outlet obstruction in fetal lambs induces renal dysplasia and the prune-belly syndrome

A model of posterior urethral valves in fetal lambs was developed in order to evaluate the effect of intrauterine urinary obstruction on the developing kidney. Complete urethral obstruction was induced in five fetal lambs at 43 to 45 days of gestation. Two control fetal lambs underwent sham operations. At full term (140 days), two of the five experimental lambs and both control lambs were available for postmortem examination. Results of gross and histological examination of the control lambs were normal. In contrast, the kidneys of the experimental lambs were markedly asymmetrical in size. Histological examination of the kidneys in experimental lambs showed cystic dilatation of the collecting ducts and occasional cystic dilatation of Bowman's spaces, features compatible with obstruction. Also noted were peripheral cortical cysts and primitive tubules lined with cuboidal epithelium and surrounded by fibromuscular collarettes, characteristic of renal dysplasia. One of the infant lambs had many characteristics of the prune-belly syndrome, including a wrinkled, markedly distended abdomen, deficient abdominal wall musculature, flared chest wall, limb deformities, and undescended testes. These results suggest that early in utero urethral obstruction (at the beginning of the second third of gestation) causes renal dysplasia. The results also support the hypothesis that the prune-belly syndrome results from abdominal distention that occurs early in gestation.     

雄性兔膀胱出口部分梗阻所致逼尿肌功能障碍的研究

目的探讨膀胱出口部分梗阻所致逼尿肌功能改变.方法取新西兰雄性白兔14只,梗阻组和对照组各7只.梗阻组行手术人为造成膀胱出口部分梗阻,饲养5周后解剖膀胱,测定膀胱重量、容量;检测逼尿肌功能;对膀胱逼尿肌细胞超微结构进行观察.结果梗阻组膀胱重量为(12.129±1.627)g,对照组膀胱重量为(3.762±1.067)g(P＜0.05);梗阻组膀胱容量为(64.000±6.272)m1,对照组膀胱容量为(94.432±12.850)ml(P＜0.05);单位重量膀胱逼尿肌对各种刺激反应性均明显下降(P＜0.05或P＜0.01);梗阻膀胱逼尿肌细胞中粗面内质网明显扩张,线粒体水肿.结论通过手术可人为建立膀胱出口部分梗阻动物模型;膀胱出口部分梗阻将导致逼尿肌功能障碍;逼尿肌功能变化与其形态学变化相关.     

Ultrasound diagnosis of bladder outlet obstruction in rabbits

One of the primary characteristics of partial outlet obstruction secondary to BPH is an increase in bladder mass commonly referred to as bladder hypertrophy. This condition has been simulated in rabbits by the partial ligation of the catheterized urethra. Ultrasonography has been utilized in both adult and pediatric urology to visualize the bladder and diagnose specific bladder disorders. The aim of the present study is to determine if ultrasonography can visualize bladder wall hypertrophy induced by obstruction. Partial outlet obstructions were created in NZW rabbits using standard methodologies, and then 5 to 7 days later, sonography was performed. The films were read by both the principal investigator and blinded investigators instructed to determine bladder wall thickness and from this predict the bladder weight. Then results were correlated with cystometrograms (CMGs) and whole bladder weights. Both the principal investigator and the blinded investigators were consistently able to distinguish obstructed from control bladders based solely on sonographic depictions of relative bladder wall thickness. In addition, the investigators were able to distinguish between low (control), medium, and high bladder weights based on sonography. The accuracy of predicting the bladder weights increased when cystosonograms were correlated with CMC studies. Thus, the degree of bladder hypertrophy can be accurately estimated by the combination of cmg and ultrasonography. © 1994 Wiley-Liss, Inc.     

女性膀胱流出道梗阻的影像尿动力学检查特点分析

目的 探讨女性膀胱出口梗阻(BOO)患者影像尿动力学检查特点及意义.方法 女性BOO患者42例,根据梗阻部位分为膀胱颈梗阻(7例)、中段尿道梗阻(13例)、远端尿道梗阻(15例)、尿道外口梗阻(3例)、盆腔器官重度脱垂(4例)5组.患者术前均行影像尿动力学检查,比较5组病例Qmax、最大膀胱容量、Pdet atQmax、残余尿、逼尿肌无抑制收缩、双侧肾积水等指标.结果 42例患者中以尿频、尿急等储尿症状为主者17例(40.5%),以排尿困难等为主者4例(9.5%),混合症状者21例(50.0%).42例Qmax(10.9±5.6)ml/s、最大膀胱容量(253±140.7)ml、Pdet atQmax(53.3±25.7)cm H2O、残余尿量(76.2±70.3)ml,逼尿肌无抑制收缩者21例(50.0%);5组患者比较:最大膀胱容量差异无统计学意义;膀胱颈梗阻组Pdet atQmax最高、残余尿量最多、Qmax最低、肾积水比例最高,与其他各组比较差异有统计学意义(P<0.05);逼尿肌无抑制收缩在外括约肌部梗阻患者中10例(76.9%),与其他各组比较差异有统计学意义(P<0.05).结论 影像尿动力学检查能有效评估女性BOO下尿路功能,提示梗阻部位并指导临床治疗.女性BOO患者中膀胱颈梗阻程度是影响上尿路损害的主要因素.