Urinary symptoms, potency, and quality of life in patients with localized prostate cancer followed up with deferred treatment.

OBJECTIVES: To evaluate urinary symptoms, potency, and quality of life in a group of patients with prostate cancer followed up with deferred treatment. METHODS: A self-administered questionnaire was mailed to patients with localized prostate cancer who were followed up with deferred treatment. Data regarding clinical stage, pathologic grade, and treatment after diagnosis were obtained from patient files. RESULTS: A total of 71 consecutive patients (age 79 years or less) were included. Of the 52 patients (73%) who responded, 31% had undergone transurethral resection of the prostate, 8% underwent radiation therapy, and 44% underwent hormonal deprivation during the follow-up period. With respect to incontinence, 21% were using pads and 37% leaked urine daily; in 21% of the patients, urine dripping or leaking was a substantial problem. Before the diagnosis of their prostate cancer, 81% stated they were able to have an erection. At the time of the questionnaire, 77% stated that their ability to have erections was reduced and only 29% had had an erection after the prostate cancer was diagnosed. For 12%, impotence was a problem. With respect to quality of life, 52% of the patients rated their health as excellent or good and 61% would be happy to spend the rest of their life feeling the way they did at the time of the questionnaire. Eighty-five percent were satisfied with the treatment policy for their prostate cancer, and 96% would choose deferred treatment again if faced with the decision. CONCLUSIONS: By use of a self-administered questionnaire, a high frequency of incontinence and impotence was found in a group of patients with prostate cancer followed up with deferred treatment. Despite these problems, more than half of the patients rated their health as good and would undergo expectant management again if faced with the decision.

Atraumatic loss of a kidney in a patient with alpha1-antitrypsin deficiency.

Alpha1-Antitrypsin (alpha1AT) deficiency is characterized by a high risk of developing pulmonary emphysema and liver disease. Arteriopathy may be associated with alpha1AT deficiency. We present a patient with only one kidney and alpha1AT deficiency, but only mild pulmonary symptoms and no signs of liver disease, and atraumatic loss of the remaining kidney. Histological examination of the renal artery showed desposits of a mucoid ground substance in the arterial media, as has been demonstrated in other patients with alpha1AT deficiency. After dialysis treatment for 15 months, the patient underwent an uneventful kidney transplantation. The case draws attention to the awareness of complications of alpha1AT deficiency even in cases with only mild pulmonary manifestations of the disorder. To our knowledge, atraumatic loss of a kidney in a patient with alpha1AT deficiency has not previously been reported.

Pelvic pain following radical retropubic prostatectomy: a prospective study.

OBJECTIVES: To evaluate subacute and chronic pelvic pain after radical retropubic prostatectomy (RRP) performed for clinically localized prostate cancer. METHODS: Twenty-four consecutive patients undergoing RRP completed pain, quality-of-life, and incontinence questionnaires. They also wore pads for 24 hours to measure urine loss objectively before and after surgery. RESULTS: Three patients had pelvic pain preoperatively. Thirteen, 7, and 5 patients had pelvic pain at 1, 3, and 6 months, respectively, after RRP. At 6 months, none of the 5 patients with pelvic pain required analgesic medication. There was a strong relationship between pain and cancer worry, as well as between pain and incontinence. CONCLUSIONS: Many patients have subacute pelvic pain after RRP but improve over time. Severe chronic pain is unlikely after RRP.

A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy.

OBJECTIVES: To prospectively evaluate the level of urinary incontinence and its impact on quality of life in patients undergoing radical retropubic prostatectomy. METHODS: Patients completed a 24-hour pad test together with an incontinence and quality-of-life questionnaire before and after surgery. RESULTS: Patients were followed up for an average of 7.6 months (range 4.7 to 12.5) after radical prostatectomy. The 24-hour pad test demonstrated that 87% of patients had some incontinence at 1 month and 63% at 6 months after surgery. The median volume of urine leakage was 34 mL at the last follow-up visit; 55% of patients indicated substantial bother from incontinence at the 1-month follow-up visit and 29% at the 6-month follow-up visit. For most patients, there was a substantial discrepancy between the reported and the measured level of incontinence. Patient-reported bother regarding incontinence correlated best to the actual amount of urine loss. CONCLUSIONS: Patients become incontinent after surgery but improve over time. Seventeen percent of patients still experienced leakage of more than 150 mL daily at the last follow-up visit. The questionnaire utilized in this study identifies the presence of incontinence but was not accurate in estimating the amount of urine loss. Initially, quality of life was reduced by surgery but improved over time and nearly returned to the preoperative level.

[Evaluation of symptoms in patients with benign prostatic hyperplasia]. / Evaluering af symptomer hos patienter med benign prostatahyperplasi.

Benign prostatic hyperplasia (BPH) is the most common cause of voiding dysfunction in elderly men. With the age related demographic changes in the western world, the epidemiological and economical burden of BPH is anticipated to increase. BPH is clinically diagnosed on a variety of more or less well defined symptomatic, macroscopical, and physiological criteria, whereas the histological diagnosis is straightforward. Yet, no symptom is specific for BPH and numerous other diseases have to be considered when a patient presents with symptoms of bladder outlet obstruction. A BPH questionnaire is useful when weighing the pros and cons for intervention. Furthermore, a symptom index represents a valuable indicator for the quality of care provided. Through the last decades a number of BPH questionnaires have been introduced. This article scrutinizes various BPH indices and provides an introduction to the prerequisites of clinical questionnaires.

[Spontaneous resolution of urodynamically proven sphincter lesion following surgery for prostatic hyperplasia]. / Spontanforløbet af urodynamisk påvist sphincterlaesion efter operation for benign prostatahyperplasi.

Assuming that post-prostatectomy incontinence frequently resolves to various extents, forty patients from a background material of 105 consecutively referred patients with this complaint were reexamined three to 106 months (median 55 months) after first examination. During the time interval between first examination and the revisit only four patients had some improvement of their incontinence. Eleven patients were evaluated urodynamically at both occasions showing no change in MUCP (maximal urethral closure pressure) or other urodynamic parameters. Consequently we could not confirm the dogma that sphincter lesion due to prostate surgery may gradually resolve. Our investigation indicates a poor continence prognosis in patients incontinent after transurethral or transvesical surgery of the prostate and that there therefore should be a more active treatment attitude. The patients should be offered an operation after evaluation of their incontinence, when a sphincter lesion is first diagnosed.

Prostatic histology in secondary transurethral resection of the prostate.

Human benign prostatic hyperplasia consists of 3 major components, stromal and glandular tissue, and glandular lumen. To our knowledge morphometric analysis of prostatic tissue from patients who have undergone a secondary transurethral resection of the prostate has never been reported. Quantification of these histological components might aid in selecting treatment for patients with recurrent urinary symptoms following transurethral resection of the prostate. Transurethral resection specimens from 13 consecutive patients who had undergone prostatectomy twice were stained by the Masson trichrome method. Quantitative morphometric analysis was performed using computer image analyzing software. The mean total area was 15.9%, 15.4% and 68.7% for glandular lumen, and glandular and stromal areas, respectively, in the initial transurethral resection specimens and 13.3%, 14.1% and 72.6%, respectively, for secondary transurethral resection of the prostate. There was no significant difference among the 3 morphometric components in the 2 prostatectomy specimens with respect to percent area, within subject variability and skewness (all p values > or = 0.38). Our study confirms previous findings that the majority of initial transurethral resection specimens are predominantly stroma. Furthermore, our study indicates that the percent distributions between initial and secondary transurethral resection of the prostate with respect to the 3 major histological components are not different, suggesting that the stromal, glandular and glandular lumen content of an initial transurethral resection specimen is representative of the recurrent prostatic tissue.

A pharmacodynamic study of desmopressin in patients with nocturnal enuresis.

The pharmacokinetics of desmopressin (1-desamino-8-D-arginine vasopressin) were investigated in 8 patients with nocturnal enuresis, of whom 4 were known to respond completely to desmopressin and 4 were nonresponders. A decrease in urine production was confirmed in responders after the administration of desmopressin while the drug did not cause antidiuresis in nonresponders. Absorption and excretion of desmopressin were identical in each group. Results indicate at least 2 pathophysiological mechanisms in nocturnal enuresis, including insufficient nocturnal production of arginine vasopressin and impaired renal sensitivity to arginine vasopressin and desmopressin. Each type results in high nocturnal urine production.

The effect of age, ethnicity and geographical location on impotence and quality of life.

OBJECTIVE: To estimate the prevalence of impotence in men over 40 years of age and correlate impotence to age, geographical location, ethnicity and quality of life. SUBJECTS AND METHODS: While attending 'The Prostate Cancer Awareness Week' in Madison, WI, USA, New Orleans, LA, USA and New York, NY, USA, 1680 men were asked to complete a questionnaire regarding impotence, age, geographical location, ethnicity and quality of life. RESULTS: Impotence was found to be significantly associated with age, was less associated with geographical location but independent of ethnicity. Men living in Madison reported a lower potency score compared with men living in New Orleans and New York. However, potency score for men living in Madison did not appear to decline as rapidly with age when compared with men living in New Orleans and New York. Impotence and quality of life were also found to be associated even when the quality of life estimates were adjusted for age, geographical location, and age by geographical location. CONCLUSION: This study indicates that impotent men have a lower quality of life than potent men and has confirmed previous findings that age is associated with impotence. Surprisingly, answers to impotence questions were also associated with geographical location.

The spontaneous course of urodynamically verified sphincter lesion after surgery for benign prostatic hyperplasia.

Assuming that post-prostatectomy incontinence frequently resolves to various extents, forty patients selected from a background material of 105 consecutively referred patients with this complaint were reanalysed 3 to 106 months (median 55 months) after first examination. During the time interval between first examination and the revisit only 4 patients had some improvement of their incontinence. Eleven patients were evaluated urodynamically at both occasions showing no change in MUCP or other urodynamic parameters. Consequently we could not confirm the dogma that sphincter lesion due to prostate surgery may gradually resolve. Our investigation indicates a poor continence prognosis in patients incontinent after transurethral or transvesical surgery of the prostate and a more active treatment attitude. The patients should be offered an operation after evaluation of their incontinence, when a sphincter lesion is first diagnosed.

Controversies about the clinical assessment of benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is a common disorder which places a considerable burden on older men and health care expenses. With advances in medical technologies and the foreseeable demographic changes in the Western world, the financial and epidemiological impact of this chronic disease is expected to increase further. The management of BPH is controversial, and this article critically reviews the clinical applicability and validity of the various measures available for assessment. Few objective modalities are indicated in the routine evaluation of BPH. There is a poor correlation between objective and subjective indicators and both measures reveal a substantial variation over time. This fluctuation is mainly attributed to the natural history of the disease. The clinical value of combining objective and subjective parameters into an analytic process seems small. Disagreements about the clinical value of BPH assessment modalities have caused inconsistent practices and consequently provision of changeable health care quality. Patients seek urological counseling and relief because of burden of illness. Quality care is provided by clinicians being perceptive to patients' preferences. Provision of quality care does not inevitably generate increasing health service expenses.

Coecal volvulus following caesarean section.

A case of coecal volvulus following caesarean section is reported. The importance of knowing the possibility of intestinal obstruction during pregnancy and puerperium is underlined.

Benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is the most common cause of bladder outlet obstruction and voiding symptoms in elderly men. The pathogenesis is not fully determined but a combination of androgens and age are needed for development of BPH. Symptoms of BPH are divided into obstructive and irritative symptoms but large interpersonal variability is found and no specific BPH symptom exists. Treatment modalities include surgery (TURP, TUIP, open prostatectomy, laser ablation, balloon dilatation, hyperthermia and thermotherapy, and urethral stents) and medical therapy. TURP is the gold standard treatment and TUIP is a safe and effective alternative to TURP in patients with smaller prostates. Laser ablation, hyperthermia and thermotherapy, and urethral stents are at the present time under investigation. Balloon dilatation is FDA-approved but not often used because of low efficacy and poor long-term results. Medical treatment includes alpha-blocker or finasteride treatment and is indicated in patients with moderate to severe symptoms of BPH without a strong indication for surgery.

Sequelae of definitive radiation therapy for prostate cancer localized to the pelvis.

OBJECTIVES: To evaluate sequelae and estimate quality of life utilizing a survey instrument in 133 consecutive patients who have undergone definitive radiation therapy for localized prostate cancer. METHODS: All patients reported on have been followed for 14 to 60 months (median, 31 months) after radiation therapy and only patients with definitive prostate radiation therapy are included. Of the patients still alive at time of follow-up, 115 were mailed the questionnaire. Data regarding tumor grade and stage as well as treatment were extracted from patient files. RESULTS: Of the 91% of patients who returned the questionnaire, 11% used a pad and 13% leaked more than a few drops of urine daily. Of all the respondents, 9% stated that incontinence was a problem, and 31% found urinary leaking significantly worsened after radiation therapy compared with before their diagnosis of prostate cancer. With respect to sexual function, 77% recalled being able to have full or partial erections prior to radiation therapy. At some time after radiation therapy, 22% of previously potent respondents were able to have a full erection and 41% were able to have a partial erection. Twenty-nine percent of all patients who were able to establish an erection prior to radiation therapy reported that impotence was a problem at the time of follow-up. Forty-nine percent of patients had abdominal pain, diarrhea, or abdominal cramping during or after radiation therapy and 31% of all patients still had some intestinal symptoms at the time of follow-up. Eighteen percent of all patients were significantly bothered by one or more of these bowel problems. Overall, 31% of all patients reported a persistent degree of physical discomfort that they believed was secondary to their prostate cancer or the effect of treatment. Eighty-one percent were satisfied with radiation therapy and 97% of the patients said they would have radiation therapy again if faced with the decision. CONCLUSIONS: Utilizing a sensitive questionnaire on patients who had definitive radiation therapy for prostate cancer, we found the incidence of patients bothered by incontinence to be surprisingly frequent and higher than previously reported. The frequency of impotence is similar to previous studies. However, when our incontinence and impotence data were compared to Medicare patients who had undergone radical prostatectomy, the frequencies after radiation therapy were significantly lower. Despite the rates of sequelae, the patients were generally satisfied with the decision to undergo radiation therapy and with the medical treatment received.

Total transurethral resection versus minimal transurethral resection of the prostate--a 10-year follow-up study of urinary symptoms, uroflowmetry and residual volume.

OBJECTIVE: To assess the long-term results of total transurethral resection (T-TURP) and minimal transurethral resection of the prostate (M-TURP) in patients with obstructive symptoms caused by benign prostatic hyperplasia. PATIENTS AND METHODS: Between September 1979 and September 1980, 167 patients were studied: 83 were randomized to T-TURP and 84 to M-TURP. The patients were examined pre-operatively and 6 and 12 months post-operatively. Ten years post-operatively they were invited to attend for further examination, including uroflowmetry, determination of residual volume and evaluation of subjective symptoms. RESULTS: At the 10-year follow-up 39 patients were found to have died and 47 were lost to follow-up. Twelve patients had undergone repeat TURP and seven had been treated for urethral stricture. Thus 33 T-TURP and 29 M-TURP patients underwent detailed examination. Significant relief in obstructive and irritative symptoms was seen in both groups. The improvement in maximum flow rate remained stable throughout the follow-up period, with no significant differences between the two groups. Post-void residual urine decreased throughout follow-up, with minor differences between the groups. CONCLUSION: M-TURP is recommended as an alternative to T-TURP.

Sequelae of radical prostatectomy.

OBJECTIVE: To evaluate the sequelae of radical prostatectomy, using a survey instrument. PATIENTS AND METHODS: Ninety-three consecutively treated patients who had undergone radical prostatectomy and who had been followed-up for between 12 and 48 months (mean 22.5) were sent a questionnaire by post. Of these, 86 (92%) completed and returned the questionnaire. The mean age of the patients at time of surgery was 64 years (range 49-75) and at time of follow-up was 66 years (range 50-77). RESULTS: Of the 86 patients who responded, 47% used a pad and 59% leaked urine daily. Thirty per cent dripped more than a few drops of urine daily and 34% found their incontinence bothersome. Eighty-four per cent of patients recalled that they had erectile potency before surgery. At follow-up, 9% were able to have a full erection and 38% were able to have a partial erection. Fifty-one per cent reported a substantial problem with reduced or absent erection. Twenty per cent had undergone treatment for bladder neck contracture and more than half of these had had more than one intervention. In all, 24% of the patients reported some persisting degree of physical unpleasantness which they believed to be secondary to their prostate cancer or the effects of treatment. Despite this, 74% were satisfied with their surgery and 88% said they would undergo surgery again. CONCLUSIONS: Using this survey instrument, we found adverse sequelae of radical prostatectomy to be surprisingly high. However, patients were generally satisfied with their decision to undergo surgery.