Efficacy and tolerability of combined medication of two different antimuscarinics for treatment of adults with idiopathic overactive bladder in whom a single agent antimuscarinic therapy failed.

OBJECTIVE: Recent studies have investigated a combination of two antimuscarinics for adult neurogenic bladder managed with clean intermittent catheterization or pediatric refractory overactive bladder (OAB). We assessed the efficacy and tolerability of this strategy in adults with idiopathic OAB. METHODS: We reviewed 49 patients with idiopathic OAB who received combined antimuscarinic medication. Patients had serially received different kinds of antimuscarinics as monotherapy, but wished to take combined medication due to a lack of sufficient subjective improvement in urgency, even with dosage escalation. Efficacy was measured by changes of episodes of urgency, daytime voiding, nocturia and mean voided volume before and after the addition of the second antimuscarinic. RESULTS: The mean duration of combined medication was 9.3 months. After adding the second antimuscarinic, urgency per day decreased from 3.8 to 1.9 (p < 0.001) and daytime voiding decreased from 10.4 to 7.4 (p < 0.001). The number of nocturia episodes and the mean voided volume also improved, although there was no statistical significance. Efficacy did not differ between the 29 cases, with non-selective and non-selective drugs and 20 cases with non-selective and M3 selective drugs. Thirty-three (67.3%) patients reported to have benefited from combined medication. Maximal flow rate and post-void residual volume did not change in either of the sexes. Eleven (22.4%) patients discontinued the combination due to continued ineffectiveness and dry mouth. CONCLUSION: This retrospective study suggests that combined medication can help adults with refractory idiopathic OAB. Combined medication was tolerated in most of our patients.

Detrusor after-contraction is associated with bladder outlet obstruction.

AIMS: The aims of this study were to determine how we can differentiate detrusor after-contraction (DAC) from artifacts, and to understand the clinical implications and significance of DAC. MATERIALS AND METHODS: A retrospective analysis was performed on 2,309 patients with neurogenic or non-neurogenic voiding dysfunction. Investigators asked patients to cough when detrusor contraction occurred following cessation of urinary flow. No simultaneous change of detrusor pressure (P(det) ) could confirm that P(det) increase could be regarded as true DAC. Patients were subcategorized according to the presence of large postvoid urine volume, increase of electromyographic activity, the amount of P(det) change, and multiplicity. RESULTS: Detrusor contraction occurred after cessation of urinary flow in 245 patients (10.6%). The contractions of 57 patients (23.3%) were regarded as artifacts. DAC was identified in 188 patients (132 males, 5.7% and 56 females, 2.4%). The mean increase in P(det) from the initiation of DAC to the maximal P(det) of DAC was 22.6 ± 11.2 cmH(2) O in males, and 18.6 ± 7.9 cmH(2) O in females. DAC occurred more frequently as males became older. Detrusor pressures at maximal flow were higher in patients with DAC. Patients of both genders with bladder outlet obstruction (BOO) had an increased risk of developing DAC. Males with benign prostatic hyperplasia had an increased risk of developing DAC. CONCLUSIONS: DAC should be differentiated from artifacts using cough test and the presence of DAC was significantly correlated to the presence of BOO.

Predictor of de novo urinary incontinence following holmium laser enucleation of the prostate.

AIMS: To investigate the incidence of de novo urinary incontinence (UI) after holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia and to determine predictors of postoperative de novo UI. METHODS: A total of 204 men who underwent HoLEP and in whom 12-month follow-up data on UI were available were included in this study. The efficacy of HoLEP was assessed at 1-, 3-, 6-, and 12-month postoperatively using the International Prostate Symptom Score (IPSS) and with uroflowmetry. The presence or absence of UI was recorded at each follow-up visit. All definitions of UI corresponded to recommendations of the International Continence Society. RESULTS: The mean preoperative total prostate and transition zone volumes were 53.3 (range 20-162) g and 27.2 (range 4-107) g, respectively. The mean enucleated weight was 23.0 (range 3.0-82.3) g. The IPSS and uroflowmetry showed that all micturition parameters improved significantly starting at 1-month postoperatively. After HoLEP, 29 patients (16.2%) had de novo UI, most of which resolved within 1-6 months; 11 had stress UI, 12 had urgency UI, and the remaining 6 had mixed UI. On logistic regression analysis, bladder mucosal injury during morcellation and maximum urethral closure pressure on baseline urodynamics were the independent predictors of de novo UI after surgery. CONCLUSIONS: Our data suggest that HoLEP is effective in improving micturition, but de novo postoperative UI occurred in some patients although usually transient. Surgeons should be careful to not injure the bladder mucosa during morcellation.

Early recovery of urinary continence after radical prostatectomy: correlation with vesico-urethral anastomosis location in the pelvic cavity measured by postoperative cystography.

OBJECTIVES: To determine the association of vesico-urethral anastomosis location (VUAL) with early recovery of urinary continence (UC) after radical prostatectomy (RP). METHODS: A retrospective analysis of 678 patients who underwent RP was carried out. Patients were divided into three groups based on the VUAL as determined by postoperative cystography: group I - VUAL above the upper margin of the symphysis pubis (SP), group II - between the upper margin and the middle of the SP, and group III - below the middle of the SP. Early recovery of UC was defined as using no pads or an occasional security pad within 3 months. Recovery rates were compared between the groups and factors predicting an early recovery of UC were investigated. RESULTS: Among all patients, 62.2% achieved an early recovery of UC. Patients in group I were younger, with a longer membranous urethra, greater percent of nerve sparing and shorter time to continence than those in groups II or III. Early recovery rates were 89.5%, 69.8% and 40.7% in group I, II and III, respectively (P < 0.001). VUAL remained an independent predictor of early recovery of UC (OR 3.2 for group I vs II and 10.8 for group I vs III [P < 0.001]) when adjusted for age, operative time, membranous urethral length and operation by surgeon with high surgical volume. CONCLUSION: VUAL represents an independent predictor of recovery of UC after RP. A higher VUAL is associated with a higher rate of early recovery of UC.

Perineural invasion is a prognostic factor for biochemical failure after radical prostatectomy.

OBJECTIVES: To identify the prognostic significance of lymphovascular invasion (LVI) and perineural invasion (PNI) in patients undergoing radical prostatectomy for prostate cancer. METHODS: Overall, 237 patients who had undergone radical prostatectomy for prostate cancer between 1995 and 2004 were analyzed for all clinical and pathological factors. The influence of these two pathological features on biochemical failure-free survival was evaluated by univariate and multivariate analysis. RESULTS: Lymphovascular and perineural invasion were identified in 41 (17.2%) and 100 (42.0%) patients, respectively. LVI and PNI were significantly associated with the preoperative prostate-specific antigen (PSA) level, a higher PSA density, a higher pathological stage, a higher Gleason score, a higher frequency of extracapsular extension, a higher frequency of seminal vesicle invasion, and a higher frequency of a positive resection margin. Positive resection margins (P = 0.001) and perineural invasion (P = 0.011) were identified as independent factors associated with biochemical failure-free survival by the multivariate analysis. CONCLUSIONS: In this series, PNI was associated with established parameters of biologically aggressive disease, and was an important prognostic factor for biochemical failure-free survival in patients undergoing radical prostatectomy. This finding supports routine evaluation of the PNI status in radical prostatectomy specimens and suggests that patients with PNI should be more closely followed after surgery.

The clinical significance of poor bladder compliance.

AIMS: There is limited data on bladder compliance associated with lower urinary tract dysfunction. The aim of this study was to investigate the decrease in bladder compliance, and the clinical relationship between patterns of increased pressure with neurological disease. MATERIALS AND METHODS: A retrospective analysis was performed in 5,027 patients with voiding dysfunction between June 2002 and April 2008. The patients with poor compliance (PC) were categorized according to the detrusor pattern of increased pressure: group A (gradual increase), group B (terminal increase), and group C (abrupt increase and plateau). RESULTS: Patients with PC were found in 170 (3.4%) cases (76 males and 94 females) with 46.5% in group A 44.7%, group B, and 8.8% group C. Bladder trabeculation was more prevalent in patients with PC than among those with normal compliance. Group A had the highest correlation with the incidence of spinal cord injury compared to the other groups. Group B had a higher correlation with a history of pelvic irradiation, radical prostatectomy, and tethered cord syndrome compared to the others. Vesicoureteral reflux was more frequently detected in group A and group C. Group C was positively correlated with the presence of detrusor overactivity and nocturnal enuresis. CONCLUSIONS: Poor compliance was correlated with the presence of neurological conditions. The gradual increase of detrusor pressure was associated with the development of spinal cord injury, and the terminal increase had an association with a history of treatment to the pelvic cavity.