Can stone density on plain radiography predict the outcome of extracorporeal shockwave lithotripsy for ureteral stones?

PURPOSE: The objective was to determine whether stone density on plain radiography (kidney-ureter-bladder, KUB) could predict the outcome of extracorporeal shockwave lithotripsy (ESWL) for ureteral stones. MATERIALS AND METHODS: A total of 223 patients treated by ESWL for radio-opaque ureteral stones of 5 to 20 mm were included in this retrospective study. All patients underwent routine blood and urine analyses, plain radiography (KUB), and noncontrast computed tomography (NCCT) before ESWL. Demographic, stone, and radiological characteristics on KUB and NCCT were analyzed. The patients were categorized into two groups: lower-density (LD) group (radiodensity less than or equal to that of the 12th rib, n=163) and higher-density (HD) group (radiodensity greater than that of the 12th rib, n=60). Stone-free status was assessed by KUB every week after ESWL. A successful outcome was defined as stone free within 1 month after ESWL. RESULTS: Mean stone size in the LD group was significantly smaller than that in the HD group (7.5+/-1.4 mm compared with 9.9+/-2.9 mm, p=0.002). The overall success rates in the LD and HD groups were 82.1% and 60.0%, respectively (p=0.007). The mean duration of stone-free status and average number of SWL sessions required for success in the two groups were 21.7 compared with 39.2 days and 1.8 compared with 2.3, respectively (p<0.05). On multivariate logistic analysis, stone size and time to ESWL since colic and radiodensity of the stone on KUB were independent predictors of successful ESWL. CONCLUSIONS: Our data suggest that larger stone size, longer time to ESWL, and ureteral stones with a radiodensity greater than that of the 12th rib may be at a relatively higher risk of ESWL failure 1 month after the procedure.

Analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence

PURPOSE: The definition of posttransobturator tape procedure (post-TOT) voiding dysfunction (VD) is inconsistent in the literature. In this study, we retrospectively investigated the risk factors for post-TOT VD by applying various definitions in one cohort. MATERIALS AND METHODS: The medical records of 449 patients were evaluated postoperatively. Acute urinary retention requiring catheterization, subjective feeling of voiding difficulty during follow-up, and postoperative postvoid residual (PVR) greater than 100 mL or PVR greater than 50% of voided volume (significant PVR) were adopted for the definition of VD. With these categories, multivariate analysis was performed for risk factors of postoperative VD. RESULTS: Ten patients (2.2%) required catheterization, 47 (10.5%) experienced postoperative voiding difficulty, and 63 (14.7%) showed significant PVR. In the multivariate logistic analysis, independent risk factors for postoperative retention requiring catheterization were previous retention history (p=0.06) and preoperative history of hysterectomy. Risk factors for subjective postoperative voiding difficulty were underactive detrusor (p=0.04) and preoperative obstructive voiding symptoms (p<0.01). Previous urinary retention history (p<0.01)) was an independent risk factor for concomitant postoperative voiding difficulty and significant PVR. Spinal anesthesia (p=0.02) and previous urinary retention history (p=0.02) were independent risk factors for significant postoperative PVR. CONCLUSIONS: With the use of several definitions of VD after the midurethral sling procedure, postoperative peak flow rate and PVR were significantly different between groups. Although there were no independent risk factors consistent with various definitions of VD, preoperative obstructive voiding symptoms and objective parameters suggesting impaired detrusor tend to have predictive power for post-TOT VD.

Clinical and Pathological Characteristics of Hard Nodules Resistant to Morcellation During Holmium Laser Enucleation of the Prostate / 대한배뇨장애요실금학회지

PURPOSE: To identify the clinical and pathological characteristics of hard nodules resistant to morcellation (HNRM) during holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia (BPH). METHODS: Between July 2008 and October 2011, 246 patients underwent HoLEP for symptomatic BPH. The first 30 patients were excluded from the analysis due to the learning curve of the procedure. The remaining patients were divided into HNRM (n=29) and non-HNRM groups (n=187), and comparative analysis of the clinical parameters of the two groups was performed. International prostate symptom score analysis and urodynamic studies were performed preoperatively. Histological analysis was performed after hematoxylin and eosin staining and Masson trichrome staining of the HNRM specimens. RESULTS: Twenty-nine patients (13.4%) had HNRM. The patients in the HNRM group had significantly higher proportions of advanced age (> or =65 years, P=0.029), total prostate volume > or =65 mL (P or =35 mL (P or =10 ng/mL (P=0.007), and functional urethral length > or =70 mm (P=0.009); larger enucleation weight (P or =65 years and total prostate volume > or =65 mL were independent risk factors for HNRM. Pathological examination did not reveal any malignant cells, with mainly dense fibrous tissue found in the HNRM. CONCLUSIONS: HNRM can make morcellation cumbersome and time-consuming, and older patients with larger prostates have a higher incidence of HNRM. However, the histopathology of HNRM revealed mainly fibrotic tissue.

Transurethral Surgical Anatomy of the Arterial Bleeder in the Enucleated Capsular Plane of Enlarged Prostates During Holmium Laser Enucleation of the Prostate / 대한배뇨장애요실금학회지

PURPOSE: To identify the endoscopic vascular anatomy of the prostate during Holmium laser enucleation of the prostate (HoLEP), and analyze the clinical risk factors associated with significant arterial bleeding. METHODS: We identified 107 consecutive patients with benign prostatic hyperplasia who underwent HoLEP between September 2009 and August 2010, performed by a single surgeon (S.J.O.). Two independent reviewers reviewed the surgery video database and completed a prespecified form. The location of bleeding arteries was marked at the level of the bladder neck, proximal prostate, distal prostate, and verumontanum. Arterial bleeding was classified into one of three grades according to bleeding severity (grades 2 and 3 indicate significant bleeding). RESULTS: The mean prostate volume was 65.1+/-31.5 mL, and the mean prostate-specific antigen (PSA) level was 3.69+/-3.58 ng/mL. During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. The average number of bleeding arteries was 12.1+/-7.9 per procedure, and 1.93+/-1.20 per 10 mL of prostate volume. Multivariate analysis revealed that prostate volume and serum PSA were significant parameters for estimating the number of bleeding vessels. CONCLUSIONS: During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. Prostate volume was associated with the number of bleeders. A careful approach to the capsular plane of the proximal prostate facilitates early hemostasis during the HoLEP procedure, especially with larger adenomas.

Effect of Preoperative Flow Rate on Postoperative Retention and Voiding Difficulty After Transobturator Tape Operation

PURPOSE: Controversy exists over the preoperative risk factors for postoperative urinary retention after the midurethral sling procedure for stress urinary incontinence (SUI). We intended to analyze the effect of preoperative flow rate on postoperative urinary retention after the transobturator tape (TOT) operation. MATERIALS AND METHODS: A total of 322 patients who underwent TOT from June 2006 to May 2012 were included in this retrospective study. All patients were preoperatively investigated for urinary symptoms and underwent preoperative urodynamic studies including urine flow rate. Postoperative urinary retention, voiding difficulty, and uroflowmetry were checked. Urinary retention was defined as the need for additional catheterization longer than 1 day. Patients were divided by preoperative peak flow rate (Qmax) of 15 mL/s (low Qmax group and normal Qmax group). RESULTS: There were 3 cases of postoperative urinary retention (0.9%) and 52 cases of voiding difficulty (16.1%). The low Qmax group included 40 patients (12.4%) and the normal Qmax group included 282 patients (87.5%). Between the two groups, there were no significant differences in age, previous pelvic surgery history, or past medical history. The low Qmax group had higher scores for voided volume and detrusor pressure at Qmax. However, there was no significant difference in postoperative voiding difficulty between the two groups. Furthermore, three patients who experienced postoperative retention showed high flow rates preoperatively. CONCLUSIONS: Our results suggest that voiding difficulty in the group with low preoperative flow was tolerable and the treatment success rate was comparable to that in patients in the normal flow group. According to our analysis, patients with a low flow rate preoperatively can be safely treated with TOT for SUI.

Is Concomitant Bladder Neck Reconstruction Necessary in Neurogenic Incontinent Patients Who Undergo Augmentation Cystoplasty?

PURPOSE: In patients with neurogenic bladder due to spinal cord injury or disease who undergo augmentation cystoplasty (AC) for not only bladder dysfunction but also sphincteric incontinence, the need for concomitant bladder neck reconstruction at the time of AC has not yet been established. The aim of this study was to evaluate whether concomitant bladder neck reconstruction is necessary when performing AC. MATERIALS AND METHODS: We retrospectively investigated 35 patients who underwent AC from January 2006 to September 2010. Medical history, preoperative and postoperative fluoroscopic urodynamic study (FUDS) parameters, and responses to an incontinence questionnaire (ICIQ Korean version) were reviewed. RESULTS: A final analysis was performed on 17 patients (9 male, 8 female) who were diagnosed with sphincteric incontinence. Continence status, the number of pads used, and the bother score were significantly improved postoperatively in this subpopulation. Preoperatively, all patients used pads, and the average daily number was 2.2 (median; range 0 to 6). Postoperatively, the number of pads used decreased significantly to 0.9 (median; range 0 to 3) pads a day (p=0.002). Urodynamic parameters including bladder capacity, compliance, involuntary detrusor contraction, and bladder neck incompetence proven by FUDS were also significantly improved. CONCLUSIONS: Our study demonstrated that both objective urodynamic parameters and subjective incontinence symptoms improved significantly after the completion of AC as a single procedure in patients with sphincteric incompetence. This implies that anti-incontinence bladder outlet surgery does not have to be performed simultaneously and can be considered later as a staged operation.

Usefulness of Early Extracorporeal Shock Wave Lithotripsy in Colic Patients with Ureteral Stones

PURPOSE: To compare efficacy and safety between early extracorporeal shock wave lithotripsy (eESWL) and deferred ESWL (dESWL) in colic patients with ureteral stones and to investigate whether eESWL can play a critical role in improving treatment outcomes. MATERIALS AND METHODS: A total of 279 patients who underwent ESWL for single radio-opaque ureteral stones of 5 to 20 mm in size were included in this retrospective study. The patients were categorized into two groups according to the time between the onset of colic and ESWL: eESWL ( or =48 hours, n=126). Success was defined as stone-free status as shown on a plain radiograph within 1 month of the first session. RESULTS: For all patients, the success rate in the eESWL group was significantly higher than that in the dESWL group. The eESWL group required significantly fewer ESWL sessions and less time to achieve stone-free status than did the dESWL group. For 241 patients with stones <10 mm, all treatment outcomes in the former group were superior to those in the latter group, but not for 38 patients with stones sized 10 to 20 mm. The superiority of eESWL over dESWL in the treatment outcomes was more pronounced for proximal ureteral stones than for mid-to-distal ureteral stones. Post-ESWL complication rates were comparable between the two groups. In the multivariate analysis, smaller stone size and a time to ESWL of <48 hours were independent predictors of success. CONCLUSIONS: Our data suggest that eESWL in colic patients with ureteral stones is an effective and safe treatment with accelerated stone clearance.

Holmium Laser Enucleation of Prostate for Benign Prostatic Hyperplasia: Seoul National University Hospital Experience / 대한배뇨장애요실금학회지

PURPOSE: The objective of this study was to report the experience acquired at the Seoul National University Hospital with Holmium Laser Enucleation of Prostate (HoLEP), combined with mechanical morcellation for symptomatic benign prostatic hyperplasia (BPH). METHODS: A retrospective review was performed on the clinical data of 309 consecutive patients who underwent HoLEP at our institution between July 2008 and June 2010. All patients were evaluated preoperatively for prostate volume by transrectal ultrasound, maximum urinary flow rate (Qmax), International Prostate Symptoms Score (IPSS) and quality of life (QoL) score. Peri- and postoperative parameters were evaluated and patients were followed-up at 1-, 3-, 6-, and 12- months with the aforementioned investigations. RESULTS: The patients' mean age was 68.3 (+/-6.5) years and mean prostate volume was 55.6 (+/-23.6) mL. Mean enucleation time was 56.2 (+/-25.1) minutes, mean morcellation time was 11.3 (+/-9.5) minutes, and the mean resected weight of the prostate was 20.8 (+/-16.9) g. The mean catheter indwelling period was 1.9 (+/-1.7) days and mean hospital stay was 2.9 (+/-1.5) days. Significant improvement was noted in Qmax, IPSS, and QoL at the 1-year follow-up compared with baseline (P<0.01). At 1 month 17.2% of patients complained of irritative urinary symptoms, which were typically self-limiting within 3 months. Transient stress incontinence was reported in 15.2% of patients. No patient experienced persistent obstructive symptoms that required reoperation. CONCLUSIONS: Our study showed that HoLEP is a safe and effective therapeutic modality for BPH.

The Learning Curve for Holmium Laser Enucleation of the Prostate: A Single-Center Experience

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is known to have a steep learning curve and, as a result, its clinical usage has limitations. The purpose of this study was to analyze the learning curve and early complications following the HoLEP procedure. MATERIALS AND METHODS: A retrospective analysis was performed on 161 patients who had undergone the HoLEP procedure for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) from July 2008 to September 2009. The procedure was done by two surgeons. Perioperatively, enucleated tissue weight, enucleation time, morcellation time, enucleation ratio (enucleation weight/transitional zone volume), and enucleation efficiency (enucleated weight/enucleation time) were analyzed, and early complications were assessed. RESULTS: Mean enucleation time, morcellation time, and enucleation ratio were 61.3 min (range, 10-180 min), 12.3 min (range, 2-60 min), and 0.66 (range, 0.07-2.51), respectively. In terms of efficiency, enucleation efficiency was 0.32 g/min (range, 0.02-1.25 g/min) and morcellation efficiency was 1.73 g/min (range, 0.1-7.7 g/min). Concerning the learning curve, enucleation efficiency was stationary after 30 cases (p<0.001), morcellation efficiency reached a learning curve at 20 cases (p=0.032), and enucleation ratio had no learning curve in this study. There were several cases of surgery-related complications, including bladder mucosal injury by the morcellator (13%), capsular injury during enucleation (7%), and conversion to a conventional resectoscopy procedure (15%), which showed a reduction in incidence with time. CONCLUSIONS: The learning curve of HoLEP is steep; however, it can be overcome gradually. Further study is necessary with respect to long-term postoperative follow-up.

The Prevalence of Benign Prostatic Hyperplasia in Elderly Men in Korea: A Community-Based Study

PURPOSE: The incidence of benign prostatic hyperplasia (BPH) is increasing in Korea. However, there are few reports about the prevalence of BPH in elderly men in Korea. We report the prevalence of BPH in elderly men through a community-based study. MATERIALS AND METHODS: We collected data from the Korean Longitudinal Study on Health and Aging (KLoSHA), which was designed as a population-based, prospective study in populations aged>65 years living in Seongnam, Korea. We selected 301 male participants by random sampling. The selected participants were interviewed with the International Prostate Symptom Score (IPSS) questionnaire and were evaluated by physical examination, blood tests, and transrectal ultrasound. The number of analyzed subjects was 236. The definition of BPH was a combination of moderate (8-19) to severe (>19) IPSS and prostate enlargement (>30 g on transrectal ultrasound). RESULTS: The prevalence of BPH was 40% overall and 36% in men in their late 60s (65-69 years), 43% in men in their 70s (70-79 years), and 53% in men over 80 (> or =80 years). BPH prevalence increased according to age but showed no statistically significant differences among the groups (p>0.05). CONCLUSIONS: The overall prevalence of BPH in this study was 40%, which was higher than in other previous epidemiologic studies in Korea. This study suggests an increasing tendency of BPH prevalence in Korea.