Outcomes of reduction cystoplasty in men with impaired detrusor contractility.

OBJECTIVE: To report surgical outcomes in patients with impaired detrusor contractility (IDC) treated with reduction cystoplasty (RC). METHODS: This was a retrospective study of consecutive patients with IDC who underwent RC. IDC was defined as a bladder contractility index of <100 and/or a detrusor contraction of insufficient duration resulting in a postvoid residual volume (PVR) >600 mL. Bladder outlet obstruction was defined by a bladder outlet obstruction index (BOOI) >40. All patients had preoperative International Prostate Symptom Score, maximum uroflow (Qmax), PVR, bladder diary, videourodynamics, and cystoscopy. Patients with prostatic obstruction underwent synchronous open prostatectomy. Postoperative Qmax, PVR, need for clean intermittent catheterization (CIC), and Patient Global Impression of Improvement (PGII) score were obtained. Follow-up was at 3 months, 1 year, and yearly thereafter. RESULTS: Eight men met inclusion criteria (mean age, 60; range, 43-75 years). Preoperatively, 3 of 8 patients (37.5%) had moderate-sized bladder diverticula, 4 of 8 (50%) had a bladder contractility index <100, and 6 of 8 (75%) had a BOOI <40. Two patients (25%) fulfilled criteria for bladder outlet obstruction (BOOI, 67 and 72). Three (37.5%) underwent synchronous bladder diverticulectomy, and 3 (37.5%) underwent suprapubic prostatectomy. All patients were available for follow-up at 1 year. Seven of 8 (88%) had a successful outcome (PGII ≤2). One patient was unchanged (PGII, 4) and still needed CIC. CONCLUSION: All but 1 patient who met specific criteria for RC had excellent outcomes after surgery based on the PGII, PVR, Qmax, and need for CIC. RC is a viable option for properly selected patients with IDC.

Optimizing prostate cancer detection during biopsy by standardizing the amount of tissue examined per core.

OBJECTIVE: To investigate the effect on cancer detection by varying the number of cores taken for prostate biopsy according to the size of the prostate. PATIENTS AND METHODS: A retrospective review of a prospectively registered prostate biopsy database identified 3040 consecutive patients undergoing prostate biopsy at a Veterans Administration Hospital between 1994 and 2008. Of 2224 biopsies, 681 (31%) were found to have cancer and 1540 (69%) had negative biopsies. Prostate volume to biopsy core ratios (volume/number of cores) were derived and a comparative analysis was performed to determine the impact on cancer detection rates. RESULTS: The median prostate volume was significantly smaller for those patients diagnosed with prostate cancer than for those with negative biopsies (33 vs 43 cc, P= 0.01). The median number of cores was the same for both groups of patients (median 12, P= 0.66). The median transrectal ultrasonography TRUS size/core ratio was 3.5 [interquartile range (IQR) 2.5] for patients with identified cancer as compared with 4.7 (IQR = 3.9) for those with negative biopsies (P= 0.000). On multivariable logistic regression analysis TRUS size/core ratio had a significant impact on cancer detection with a relative risk ratio of 1.29 (95% confidence interval, 1.1-1.5, P= 0.001) even when controlled for age, race, prostate volume, digital rectal examination and prostate-specific antigen level. CONCLUSIONS: Prostate cancer detection can be enhanced by individualizing the number of cores performed to a real-time prostate volume sampling. The present study emphasizes that optimal cancer detection rates were observed when a ratio of 3.5 cc per tissue core was achieved. Proper prospectively designed studies must be performed to further validate these findings.

Benign prostatic hyperplasia: symptoms, symptom scores, and outcome measures.

The approach to a patient with benign prostatic hyperplasia and lower urinary tract symptoms (LUTS) begins with a detailed history. The goal is to clearly identify the patient's urinary complaints, including frequency of micturition, urgency, urge incontinence, weak stream, the need to push or strain, hesitancy, intermittency, dysuria, and hematuria. Bladder diaries and symptom questionnaires are useful as adjuncts to information that is acquired in the history. The voiding diary is an essential part of the workup. The voiding diary differs from a simple frequency-volume chart in that it incorporates not only the frequency, voided volume, urge episodes, pad usage, and fluid intake but also the data related to patient activities. It allows patients to have a more thorough self-evaluation of their LUTS.