Disfunción miccional en el adulto. Un artículo docente / Voiding dysfunction in the adult. A teaching article

Voiding dysfunction is defined as an abnormally slow and/or incomplete micturition, and can be divided in bladder outlet obstruction (BOO) and detrusor underactivity (or hypocontractility). BOO is characterized by reduced urine flow rate and increased detrusor pressure, and can be of anatomical or functional origin. Detrusor underactivity encompasses a reduced urine flow rate associated to low pressure and/or poorly sustained detrusor contraction, and its etiology is multifactorial. Lower urinary tract symptoms are classified as storage, voiding and post micturition symptoms, may be objectively quantified with specific questionnaires, and don't correlate properly with voiding dysfunction. Patients' evaluation requires a directed physical examination of the abdomen, pelvis and genitals focused to detect anatomical and neurological abnormalities. Voiding dysfunction can be demonstrated non-invasively using uroflowmetry and pelvic ultrasound. Uroflowmetry allows determining urinary flow characteristics and their most important parameters are voided volume, maximum flow rate and shape of the curve. Pelvic ultrasound permits to estimate prostatic size and post void residual, suspect detrusor hypertrophy (due to BOO) and detect bladder stones. Invasive test must be reserved for special cases of confirmed voiding dysfunction: cystoscopy when there is concomitant hematuria, urethrocystography to study urethral stenosis and urodynamics to differentiate BOO from detrusor underactivity. (AU)

Indicaciones de estudio urodinámico / Indications of urodynamic study

The basic objective of urodynamics is to reproduce the patient's symptoms while evaluating the lower urinary tract directly, with objective quantification of parameters, correlating the symptoms with the findings of the test. Traditionally, it is used: a) to diagnose lower urinary tract dysfunction, quantify its severity and determine the most significant abnormality, b) to predict the consequences of lower urinary tract dysfunction on the upper urinary tract, c) to predict the results of therapeutic interventions and possible complications and d) to investigate the causes of treatment failures. In this article we will refer to the indications of urodynamics taking into account the recommendations of the main international urological societies: 1) in women with urinary incontinence, with emphasis on those who have stress urinary incontinence and who will undergo surgery, 2) in men with non-neurogenic lower urinary tract symptoms suggestive of benign prostatic hyperplasia, and 3) in patients with neurologic involvement of the lower urinary tract ("neurogenic bladder"), considering the classification of neurological disorders according to the risk over the upper urinary tract. (AU)

Perfil de presión uretral / Urethral pressure profile

The "urethral pressure profile" is a graph indicating the intraluminal pressure along the length of the urethra and the "urethral closure pressure profile" is given by the substraction of intravesical pressure (pves) from urethral pressure (pura). Both aim to represent the ability of the urethra to prevent involuntary leakage of urine on efforts or exertion. The continuous measurement of pves also allows the detection of detrusor contractions. In this article we will refer to its terminology, the necessary equipment to carry it out, the examination technique, its morphology in women and men, and the stress urethral pressure profile in women. The most important parameter is the "maximum urethral closure pressure", which is the maximum difference between pura and pves; a value ≤ 20 cm H2O participates in the urodynamic definition of intrinsic sphincter deficiency (together with an abdominal leak point pressure ≤ 60 cm H2O). However, it must be taken into account that the different techniques used for its measurement has led to inconsistent results, which makes their acceptance in clinical practice difficult. (AU)

¿Existen diferencias entre la vía transobturadora y retropúbica en la resolución de la incontinencia de orina de esfuerzo? / Are there differences between transobturator and retropubic sling in the resolution of stress urinary incontinence?

PROPÓSITO: Comparar la eficacia y complicaciones de la vía retropúbica (TVT o RP) y la vía transobturadora (TVT-O) en el tratamiento quirúrgico de la incontinencia de orina de esfuerzo (IOE). MÉTODOS: Estudio retrospectivo de pacientes con diagnóstico de IOE operadas entre Julio 2004 y Julio 2014 en el Hospital Clínico de la Universidad de Chile. Se evaluaron los datos demográficos, antecedentes médicos, síntomas y examen físico tanto preoperatorio como post operatorio y seguimiento post quirúrgico. RESULTADOS: De un total de 715, se analizaron los datos de 383 pacientes operada durante la fecha. 59,7% (n= 229) fueron sometidas a TVT-O y 40,3% (n=154) a TVT. Un 4,8% (n=11) de las pacientes en que se realizó cinta transobturadora tenían antecedente de cirugía previa de incontinencia versus un 14,29% (n=22) de las pacientes en que se realizó cinta retropúbica (P 0,006). Los datos post operatorios fueron ajustados según el dato anterior. En el seguimiento post operatorio se presentaron diferencias significativas en la disfunción del vaciamiento vesical [OR 0,28, (95%IC 0,10-0,74), p = 0,011]; y en el dolor inguinal post operatorio [OR 0,19 (95%IC 0,06-0,56), p = 0,003); siendo ambos más frecuentes en el grupo transobturador. No hubo diferencias significativas en el éxito subjetivo de la resolución de la IOE así como en otro tipo de complicaciones postoperatorias. CONCLUSIONES: Si bien ambas técnicas presentan tasas similares de éxito subjetivo en la resolución de la IOE, en nuestra experiencia, la vía transobturadora presenta mayor riesgo de disfunción del vaciamiento vesical y dolor inguinal postoperatorio.

PURPOSE: To compare the efficacy and complications of the retropubic sling (TVT or RP) and the transobturator sling (TVT-O or TOT) for the surgical treatment of stress urinary incontinence (SUI). METHODS: Retrospective study including patients diagnosed with SUI who had surgery between July 2004 and July 2014 at the Clinical Hospital of the University of Chile. Demographics, medical history, symptoms and physical examination (preoperative, postoperative and post-surgical follow-up) were evaluated. RESULTS: From a total of 715 operated during this period, the data from 383 patients was analyzed. 59.7% (n = 229) were submitted to TVT-O and 40.3% (n = 154) to TVT. 4.8% (n = 11) of patients in the transobturator sling group had previously had an incontinence surgery versus 14.29% (n = 22) of patients that had a retropubic sling (P 0.006). The postoperative data was adjusted according to this data. At the postoperative follow-up there were significant differences in bladder emptying dysfunction [OR 0.28 (95% CI 0.10 to 0.74), p = 0.011]; and postoperative groin pain [OR 0.19 (95% CI 0.06 to 0.56), p = 0.003); both being more frequent in the transobturator group. There were no significant differences in subjective success of the resolution of the SUI as well as other postoperative complications. CONCLUSIONS: Although both techniques have similar rates of subjective success in solving the SUI, in our experience, the transobturator approach has increased risk of bladder emptying dysfunction and postoperative groin pain.

Evaluación clínica del paciente con síntomas del tracto urinario inferior / Clinical evaluation of the patient with lower urinary tract symptoms

Lower urinary tract symptoms are divided into three groups, storage, voiding and post micturition symptoms. Their level of agreement with urodynamic investigation is poor. Clinicalhistory should be complemented by the application of validated symptom questionnaires and the recording of urinary events. Here we refer to: a) the International Consultation onIncontinence Questionnaire, Short Form (ICIQ-SF), b) the Urogenital Distress Inventory - Short Form (UDI-6) and Incontinence Impact Questionnaire – Short Form (IIQ-7), c) the urinary incontinence Severity Index and d) the American Urological Association Symptom Index. The recordings of urinary events can be done in three main forms: a) micturition time chart, b)frequency volume chart, and c) bladder diary. The International Consultation on Incontinence Questionnaire bladder diary (ICIQ bladder diary) is the only one validated. Physical exam should include abdominal and genital examination, covering pelvic organ prolapse quantification in women, prostate evaluation in men, pelvic floor muscle function evaluation in both genders, and a neurologic examination focused on evaluation of the sacral nerves. It is useful to supplementthe physical examination with the evaluation of the mobility of the bladder neck and proximal urethra through the Q-tip test, and with the quantification of urine leakage through the pad test.

Estandarización y control de calidad en los estudios urodinámicos / Standardization and quality control in urodynamic studies

The main purpose of urodynamic studies is to reproduce the patient's symptoms and correlate them with the findings in the examination, so that we can answer the specific question that motivated it. Its success depends on a careful tuning of equipment and strict quality control over each of the procedures. In this article we refer to standards and best practices for measurement and quality control of uroflowmetry, filling cystometry and voiding cystometry (pressure-flow study), following the nomenclature and suggestions of the International Continence Society (ICS). This organization recommends a careful and continuous observation of the signals as they are obtained and an ongoing assessment of the credibility of them, so as to avoid artifacts which must be corrected immediately, as it is always difficult and often impossible to correct them retrospectively. Only in this way can we achieve our goal (AU)

Evaluación urodinámica de la incontinencia urinaria después de prostatectomía radical: [revisión] / Urodinamic evaluation after radical prostatectomy

El estudio de la incontinencia urinaria después de prostatectomía radical (IUPR) debe basarse en el reporte del propio paciente en una evaluación realizada por una tercera persona y debe incluir el tiempo transcurrido después de la cirugía. Los estudios poblacionales suelen reportar frecuencias mayores que aquellas de centros de referencia. El estudio urodinámico de la IUPR incluye la evaluación de: A) la disfunción esfinteriana a través de las mediciones de la presión de punto de escape con Valsalva y del perfil de presión uretral; B) la disfunción vesical a través de la cistometría de llene, cuyo objetivo es demostrar la existencia de detrusor hiperactivo o acomodación vesical disminuida; y C) la incontinencia de orina por rebosamiento (ya sea por obstrucción o alteración de la contracción del detrusor) a través del análisis del estudio flujo – presión de la micción. Se analizan estudios de pacientes con IUPR con urodinamia realizada al menos 6 meses después de la cirugía, cuyas diferentes metodologías deben considerarse en la interpretación de los resultados. La incontinencia urinaria de esfuerzo está presente en entre 60 por ciento y 100 por ciento de los pacientes analizados (8 por ciento a 71 por ciento como hallazgo exclusivo). La frecuencia de detrusor hiperactivo varía entre 19 por ciento y 92 por ciento de los casos (0,7 por ciento a 40 por ciento como alteración única); pocos estudios informan su presencia como causa efectiva de incontinencia urinaria, lo que ocurre en entre 7,2 por ciento y 27 por ciento de los casos. La acomodación disminuida se describe enun amplio rango de entre 1,7 por ciento y 56 por ciento de los pacientes. Pocos estudios informan disminución de la contractilidad del detrusor la cual varía en entre 29 por ciento y 33 por ciento de los casos, y obstrucción a la salida dela vejiga la que puede existir en hasta 21 por ciento de los pacientes.

The assessment of urinary incontinence after radical prostatectomy (UIRP) must be based on the patient’s own report on an evaluation by a third person and also include the time elapsed after surgery. The population studies often report higher frequencies than those of reference centers. The UIRP urodynamic study includes evaluation of A) the sphincter dysfunction through measurement of the Valsalva leak point pressure and urethral pressure profile, B) the bladder dysfunction by filling cystometry, which aims to demonstrate the existence of detrusor overactivity or impaired compliance and C) the overflow incontinence (either by obstruction or impaired detrusor contraction) through analysis of the pressure – flow study of urination. We analyze a selection of studies of patients with UIRP in which the urodynamic study was conducted at least 6 months after surgery, which use different methodologies that should be considered in the interpretation of the results. Stress urinary incontinence is present in between 60 percent and 100 percent of tested patients (8 percent to 71 percent as an exclusive finding). The frequency of detrusor overactivity varies between 19 percent and 92 percent of the cases (0.7 percent to 40 percent as a single alteration); few studies report its presence as an effective cause of urinary incontinence, which occurs in between 7,2 percent and 27 percent of the cases. The decreased compliance is described in a wide range of between 1,7 percent and 56 percent of the patients. Few studies report decreased detrusor contractility which varies between 29 percent and 33 percent of the cases, and bladder outlet obstruction which can exist in up to21 percent of the patients.

Infección urinaria recurrente en la mujer / Recurrent urinary tract infection in women

Recurrent urinary tract infections (R-UTI) are common among women even though they generally have a normal urinary tract. Women with R-UTI have an increased susceptibility to vaginal colonization with uropathogens due to a greater propensity for them to adhere to their epithelial cells. Risk factors include frequent sexual intercourse, spermicide use, first UTI at an early age and maternal history of UTI. Prevention of recurrences can be done with low-dose continuous antimicrobial prophylaxis or with post-coital antimicrobial prophylaxis, a method that may be more efficient and acceptable. Estrogen replacement therapy using a vaginal administration in postmenopausal women is also effective in preventing R-UTI. The vaginal vaccine only diminishes percentage of women with Escherichia coli UTI. The oral vaccine reduces R-UTI with inferior results than antimicrobial prophylaxis; Cranberry intake shows some evidence in favor, although further trials are needed. Finally R-UTI can also be effectively managed with self-start antimicrobial therapy.

La infección urinaria recurrente (ITU-R) es común en mujeres que generalmente no presentan alteraciones del tracto urinario, pero que tienen una mayor predisposición a la colonización vaginal por uropa-tógenos que se adhieren más ávidamente a sus células epiteliales. Las relaciones sexuales frecuentes, el uso de espermicidas, el antecedente de ITU a corta edad y la historia materna de ITU son factores de riesgo. La prevención de la recurrencia puede hacerse con profilaxis antimicrobiana continua a dosis baja o post-coital. La terapia de reemplazo estrogénico en la mujer post-menopáusica es efectiva en prevenir ITU-R, recomendándose su uso vía vaginal. La vacuna vaginal sólo disminuye el porcentaje de pacientes con ITU por Escherichia coli; la vacuna oral disminuye las ITU-R aunque con resultados inferiores a la profilaxis antimicrobiana. La ingesta de arándano rojo muestra alguna evidencia a favor, aunque insuficiente. Finalmente, la ITU-R también puede manejarse con terapia antimicrobiana iniciada por la paciente.

Comparación de complicaciones por sangrado en resección transuretral de próstata con y sin participación de residentes / Comparison of complications for bleeding in transurethral resection of prostate with and without participation of residents

Introduction: transurethral resection of the prostate (TURP) is still the gold standard treatment of prostatic obstruction. The objective of the present study is to compare the bleeding complications of TURP with and without the participation of residents. Material and methods: The data was obtained from a prospective protocol that included 200 patients submitted to TURP. Eleven patients were excluded from the study (5,5 percent). No patient was lost from follow-up. Results: Were viewed 189 surgeries, 46 with resident participation (24,3 percent). The operations performed by residents were more prolonged, and required more days with bladder drainage. The following bleeding complications were observed: 1) Bladder catheter washing to solve obstruction by clots: 11,6 percent, 2) Endoscopic revision in severe hematuria: 2,6 percent, 3) Readmission to the hospital in complete urinary retention secondary to clots: 2,1 percent and 4) Blood transfusion: 2,1 percent. The transfusion rate was significantly higher in resident surgeries (6,5 percent versus 0,7 percent, p=0,045), without differences in the other bleeding complications. Conclusion: The rate of bleeding complications is comparable to that recently published. Applying strict criterion for blood transfusion, no difference was observed between the groups. At our institution, the process of teaching and learning TURP does not increase significantly the risk of bleeding complications.

Estudio flujo-presión de la micción en el hombre / Fluid pressure study of the micturition in men

Pressure-flow study of voiding is, at present, the best method of analysing voiding function quantitatively. It is an invasive second line study by which the relationship between pressure in the bladder and urine flow is measured during bladder emptying. The main use of it is the evaluation of older men with lower urinary tract symptoms. It allows to differentiate between patients with low urinary flow resulting from poor bladder contractility (low detrusor pressure) and those whose low urinary flow is secondary to true bladder outlet obstruction (high detrusor pressure),as well as combined alterations. In this article we describe the International Continence Society (ICS) nomenclature, the bladder detrusor and urethral functions during voiding, as well as some principles of voiding mechanics. We also discuss the analysis of the results in men with bladder outlet obstruction using the Abrams-Griffiths nomogram, the Schãfer nomogram and the ICS nomogram, including the evaluation of bladder contractility.

Uroflujometría: estudio del flujo de la orina. Revisión bibliográfica / Uroflowmetry: study of the urine flow. Bibliographical revision

La uroflujometría es un estudio no invasivo del tracto urinario inferior que entrega información objetiva del flujo urinario, resultado final de la micción. Cuando es normal, permite descartar razonablemente obstrucción urinaria baja y alteración de la contractilidad vesical. Los parámetros mas utilizados en este examen son el volumen orinado, el flujo máximo, el flujo promedio y el patrón de la curva de flujo. Los valores normales dependen del volumen orinado, del sexo y la edad del paciente. Para su interpretación se han utilizado diferentes nomogramas, dentro de los cuales destacamos el de Liverpool. Finalmente, el patrón de la curva de flujo puede orientar hacia una patología determinada sin ser fidedigno.

Uroflowmetry is a noninvasive lower urinary tract study that provides objective information of the urine flow, final result of urination. If it is normal bladder outlet obstruction and impaired bladder contractility can reasonably be discarded. Most used parameters in this examination are voided volume, maximum flow rate, average flow rate and flow-curve pattern. Normal values depend on patient’s voided volume, sex and age. Different nomograms have been used for their interpretation, within them we highlight Liverpool’s. Finally, the flow curve pattern can guide to an underlying disease but isn’t reliable.

Fístulas vesicovaginales / Vesicovaginal fistulas

Objetivo: mostrar nuestra experiencia en el manejo de las fístulas vesicovaginales (FVV), analizando etiología, diagnóstico, tratamiento quirúrgico y complicaciones postoperatorias. Material y método: estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de FVV entre enero de 1987 y diciembre de 2000. Serie constituida por 35 pacientes, edad promedio 47 años, 22,8 por ciento de cirugía reparadora previa en otro centro. Resultado: el diagnóstico fue hecho por pérdida de orina vaginal y prueba de azul de metileno vesical positiva. La cistoscopia fue concluyente en el 94,3 por ciento requiriendo uretrocistografía los casos restantes. No hubo asociación con fístulas ureterovaginales. fueron secundarias a cirugía ginecobstétrica (82,9 por ciento) y radioterapia por cáncer cervicouterino (17,1 por ciento). Se intervinieron 34 pacientes, dividiéndose en: a) FVV secundarias a cirugía ginecobstétrica: 28 reparaciones transvesicales, con 4 recidivas y 1 reparación supravesical que no recidivó. b) FVV secundaria a radioterapia por cáncer cervicouterino: 3 derivaciones urinarias (2 neovejigas continentes y 1 conducto iliar) y 2 reparaciones supravesicales, las cuales recidivaron. No hubo mortalidad operatoria en la serie. Conclusiones: todas las FVV fueron secundarias a procedimientos ginecobstétricos. Preferimos la técnica supravesical con éxito superior al 85 por ciento. La mayor dificultad está dada por las FVV secundarias a radioterapia

Adenomectomía suprapúbica transvesical, revisión de 10 años: servicio de urología Hospital Clínico Universidad de Chile / Trans-bladder suprapubic adenomectomy, 10 years review: urological service at Hospital Clínico Universidad de Chile

En la actualidad la técnica de prostatectomía suprapúbica transvesical resuelve aproximadamente el 10 por ciento de los pacientes con indicación quirúrgica por Hiperplasia Prostática Benigna (HPB). Se realizó un estudio descriptivo retrospectivo revisando esta técnica en el lapso de 10 años. Se obtuvieron 415 casos, correspondientes al 8,6 por ciento de los procedimientos quirúrgicos por HPB. Con una edad promedio de 70,2 años, con un peso estimado de próstata por ecotomografía pelviana de 108,1 gr, antígeno prostático específico de 7,4 ng/ml. Tiempo quirúrgico promedio de 79,7 minutos. Uso de sonda post-op 7 días. Por anatomía patológica se comprobó un 3,8 por ciento de cáncer incidental

Utilidad del antígeno prostático / Utility of the prostatic antigen

El antígeno prostático específico (APE) es el marcador tumoral de mayor utilidad en el diagnóstico y seguimiento del cáncer prostático. La elevación del APE plasmático puede ser consecuencia de procesos benignos y malignos. Recientemente se ha incorporado la determinación de la fracción libre plasmática del APE para aumentar su especificidad en el diagnóstico precoz del cáncer prostático. Analizamos la experiencia internacional con APE libre y los resultados de su aplicación en el Hospital Clínico de la Universidad de Chile