The effects of spinal anesthesia with lidocaine and sufentanil on lower urinary tract functions.

BACKGROUND: Spinal local anesthetics interrupt the micturition reflex; bladder function remains impaired until sensory block had regressed to the S3 segment. Intrathecal opioids cause dose-dependent suppression of detrusor contractility. We studied the effects of spinal anesthesia with a combination of lidocaine and sufentanil on lower urinary tract function. METHODS: Filling cystometry was performed in 10 healthy young male patients undergoing elective lower limb orthopedic surgery. After baseline recordings, each patient received spinal anesthesia with 100 mg hyperbaric lidocaine combined with 20 microg sufentanil. In the postoperative phase, regressions of sensory and motor block were recorded and urodynamic measurements continued until the patient could void spontaneously without residual volume in the bladder. RESULTS: The mean (SD) time to recovery of urge was 240 (37) min after spinal injection, but no patient was able to void at that time. Six patients experienced urge at the previously observed maximum bladder capacity when the sensory block had regressed to the second sacral segment (S2), in four patients to S3. Despite this urge, no detrusor contraction was recorded. The patients were able to completely empty the bladder 332 (52) min after spinal injection. The average time difference between recovery of urge and return of normal bladder emptying was 90 min. CONCLUSION: Bladder contractility returns much later than recovery of sensory function in sacral dermatomes (S3) when hyperbaric lidocaine combined with sufentanil is used for spinal anesthesia.

Diagnostic and predictive value of voiding diary data versus prostate volume, maximal free urinary flow rate, and Abrams-Griffiths number in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

OBJECTIVES: To investigate the information of voiding data in relation to symptoms and well-being in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and to compare this information with that of prostate volume (Vprostate), maximal free urinary flow rate (Q(max,free)), and obstruction grade (OG). METHODS: We performed mandatory tests, recommended tests, and pressure-flow studies in 384 consecutive men with LUTS suggestive of BPH. We estimated nocturia, diuria, and mean voided volume (Vmean) from their voiding diaries. Symptoms and well-being were quantified by American Urological Association symptom index (SI), quality-of-life score (QoL), symptom problem index (SPI), and BPH impact index (BII). We investigated the influence of Vprostate, Q(max,free), OG, Vmean, nocturia, and diuria on SI, QoL, SPI, and BII. We re-evaluated 48 men 6 months after transurethral resection of the prostate (TURP). We analyzed the predictive value of preoperative Q(max,free), Vprostate, OG, Vmean, nocturia, and diuria for the improvements of SI, QoL, SPI, and BII after TURP. We studied the improvements of Q(max,free), OG, Vmean, nocturia, and diuria after TURP and the improvements of SI, QoL, SPI, and BII. RESULTS: Prostate volume, Q(max,free), and OG were only slightly associated with SI, QoL, SPI, and BII, in contrast to Vmean, nocturia, and diuria. The predictive value of all parameters on the outcome of TURP was poor. Improvements of all parameters were strongly associated with improvements of SI, QoL, SPI, and BII after TURP. CONCLUSIONS: Voiding data should have a prominent role in the initial evaluation of men with LUTS suggestive of BPH.

Long-term follow-up after laser therapy for penile carcinoma.

OBJECTIVES: Although in many cases of penile carcinoma, laser therapy has become the standard treatment, opinion still differs regarding the risks related to the relatively high rate of recurrence that accompanies this form of treatment. In this study, we reviewed the results of neodymium:yttrium-aluminum-garnet laser treatment of 44 consecutive patients with penile carcinoma in our institution from 1986 to 2003. METHODS: We created five groups, on the basis of the T stage and grade of the tumor. Of the 44 patients, 21 had Stage T1, 17 had Stage T2, and 6 had carcinoma in situ. RESULTS: Local disease recurrence (in the treated area) occurred in 48% of the treated patients, and in 20% of the patients, the first recurrence was elsewhere on the glans penis. These were subsequently treated by laser therapy or partial amputation. In 10 cases, nodal metastases were found. Eight of these cases were Stage T2. Our results suggest a stronger prognostic role for the primary T stage of the tumor than for the tumor grade, with respect to the risk of nodal metastasis. CONCLUSIONS: From the high recurrence rate in our series, we decided to perform a wider initial laser excision and to diminish the number of retreatments to less than three. We also now believe that laser therapy is best for Stage Tis and T1 tumors exclusively. Only selected patients with T2 tumors should be treated in combination with early lymph node resection.

Invasively estimated International Continence Society obstruction classification versus noninvasively assessed bladder outlet obstruction probability in treatment recommendation for LUTS suggestive of BPH.

OBJECTIVES: To investigate the contribution of urodynamically proven presence or absence (International Continence Society classification) of bladder outlet obstruction (BOO) to treatment recommendations for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia, and to investigate the impact of the replacement of the invasively estimated BOO classification with the noninvasively assessed BOO probability on treatment recommendations. METHODS: Mandatory tests, recommended tests, and pressure-flow studies (with BOO classification) were performed in 150 consecutive men with LUTS suggestive of BPH. Three experienced urologists proposed, independently of each other, the treatment for each patient: watchful waiting, pharmacologic treatment, or surgery. After repeat randomization of the patients and replacement of the BOO classification with the BOO probability, the procedure was repeated 1 month later. A third treatment proposal was done after repeat randomization and after replacement of the BOO probability with the BOO classification. RESULTS: The symptom score and quality-of-life score were the most decisive in the treatment recommendations, followed by the BOO probability and BOO classification. The medical history, physical status, and duration of the complaints did not significantly affect the treatment recommendations. The intraindividual agreement between the judgments that included the BOO classification and the judgments that included the BOO probability was comparable to the agreement between both judgments that included BOO classification. The interindividual agreement between the judgments that included the BOO classification was not significantly different from that of the judgments that included the BOO probability. CONCLUSIONS: The symptom score and quality-of-life score were the most decisive in the medical treatment recommendations, followed by the BOO probability and BOO classification. The noninvasively assessed BOO probability was as valuable as the invasively estimated BOO classification in the medical treatment recommendations.

Cost aspects of transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization.

OBJECTIVES: To compare the costs of transurethral resection of the prostate (TURP), contact laser prostatectomy (CLP), and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia. METHODS: We conducted a randomized controlled trial that included men with lower urinary tract symptoms who met the criteria of the International Scientific Committee on benign prostatic hyperplasia. Subjective changes were quantified using questionnaires validated by the American Urological Association. The maximal free urinary flow rate was estimated. Morbidity and mortality were registered. These parameters were measured at regular intervals for up to 1 year and once during long-term follow-up. A cost analysis together with a sensitivity analysis was performed on the basis of a follow-up of 12 months. RESULTS: A total of 50 men were randomized to TURP, 45 to laser treatment, and 46 to electrovaporization. The subjective and objective changes were very similar during the 12 months of follow-up. The costs were highest for CLP (1885 dollars), followed by TURP (1707 dollars), and were lowest for electrovaporization (1489 dollars). However, the length of hospital stay decreased during the trial more for CLP and electrovaporization than for TURP. Recalculations demonstrated almost equal costs for CLP and TURP (1697 dollars and 1643 dollars, respectively) and the lowest costs for electrovaporization (1386 dollars). CONCLUSIONS: Electrovaporization has a better cost-effectiveness than CLP and TURP in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia. CLP and TURP showed very similar cost-effectiveness ratios.

Intrathecal opioids and lower urinary tract function: a urodynamic evaluation.

BACKGROUND: Intrathecal administration of opioids may cause lower urinary tract dysfunction. In this study, the authors compared the effects of morphine and sufentanil administered intrathecally in a randomized double-blind fashion (two doses each) on lower urinary tract function in healthy male volunteers. METHODS: Urodynamic evaluation was performed before and every hour after drug administration up to complete recovery of lower urinary tract function using pressure and flow measurements recorded from catheters in the bladder and rectum. Sense of urge and urinary flow rates were assessed every hour by filling the bladder with its cystometric capacity and asking the patient to void. Full recovery was defined as a residual volume of less than 10% of bladder capacity and a maximum flow rate within 10% of the initial value. RESULTS: Intrathecal administration of both opioids caused dose-dependent suppression of detrusor contractility and decreased sensation of urge. Mean times to recovery of normal lower urinary tract function were 5 and 8 h after 10 or 30 microg sufentanil and 14 and 20 h after 0.1 or 0.3 mg morphine, respectively. This recovery profile can be explained by the spinal pharmacokinetics of both opioids. CONCLUSIONS: Intrathecal opioids decrease bladder function by causing dose-dependent suppression of detrusor contractility and decreased sensation of urge. Recovery of normal lower urinary tract function is significantly faster after intrathecal sufentanil than after morphine, and the recovery time is clearly dose dependent.

Noninvasive assessment of prostatic obstruction in elderly men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVES: To investigate what combination of easily available parameters allows the noninvasive prediction of infravesical obstruction in optimal agreement with urodynamic classification. Urodynamically, men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia are classified as nonobstructed or obstructed. METHODS: Mandatory and recommended tests were performed in 160 consecutive men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. The classification of the International Continence Society, the group-specific urethral resistance factor, and Schäfer's obstruction grade were estimated from urodynamic studies. The frequency-volume charts were analyzed. A separate group of 173 consecutive men was used for validation. RESULTS: The formula, prostate volume (in cubic centimeters) - 3 x maximal urinary free flow rate (in milliliters per second) - 0.2 x mean voided volume (in milliliters; as estimated from frequency-volume charts), was optimal in the classification compared with the urodynamic classification. Extension of this formula to more than three parameters did not result in better selection. As estimated from receiver operating characteristic curves, the accuracy of the formula appeared to be good. The method of quantifying urethral resistance minimally affected the classification that resulted from the combination. From the results, a diagram was created presenting the probability of an individual to have infravesical obstruction. The validation results were satisfactory. CONCLUSIONS: The prediction of the probability of a man with lower urinary tract symptoms suggestive of benign prostatic hyperplasia to have infravesical obstruction can be deduced from a diagram based on a formula composed of three readily available parameters: prostate volume, maximal urinary free flow rate, and mean voided volume.

Long-term follow-up after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization.

OBJECTIVES: To compare the long-term results of subjective changes, flowmetry, morbidity, and mortality after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia. METHODS: A prospective randomized controlled trial was conducted. Included in the study were men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on Benign Prostatic Hyperplasia, had a prostate volume between 20 and 65 cm(3), and a Schäfer obstruction grade of 2 or greater. The subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, quality-of-life question, and benign prostatic hyperplasia impact index. Morbidity was registered objectively and by patient questionnaire. Maximal flow was measured by free uroflowmetry. These parameters were measured at regular intervals for up to 1 year. At the end of 2002, all patients were invited for a long-term follow-up examination, including the aforementioned parameters. RESULTS: Fifty men were randomized to undergo transurethral resection of the prostate, 45 laser treatment, and 46 electrovaporization. Of the 50 men, 70% were followed up for a maximum of 7 years. The values for the International Prostate Symptom Score, Symptom Problem Index, quality-of-life score, and benign prostatic hyperplasia impact index increased slightly after a mean follow-up of 4.3 years. The maximal uroflow decreased similarly in all treatment groups to about 150% of the preoperative values. Morbidity, reoperation rates, and mortality were also similar. CONCLUSIONS: This study, with up to 7 years of follow-up, demonstrated durable subjective and objective results for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia after transurethral resection of the prostate, contact laser prostatectomy, or electrovaporization. No clinically relevant differences were found among these modalities.

Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders.

PURPOSE: Bleeding disorders or the use of anticoagulant medication are contraindications to transurethral prostate resection in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Laser prostatectomy has proved to be adequate surgical therapy with less blood loss than transurethral prostate resection. MATERIALS AND METHODS: A prospective, controlled study was done in patients at high risk (HR) with LUTS suggestive of BPH. They were treated with contact laser prostatectomy (CLP) or the combination of CLP with visual laser ablation prostatectomy (VLAP). HR was defined as bleeding disorders or anticoagulants use. As a control, men at normal risk with LUTS suggestive of BPH were treated with CLP. Patients completed validated questionnaires and underwent urodynamics at baseline and 6 months postoperatively. RESULTS: A total of 75 patients were included, namely 19 in the HR-CLP group, 11 in the HR-CLP-VLAP group and 45 in the normal risk CLP group. Obstruction relief, and symptomatic and subjective improvement were equal in all 3 groups. Effective capacity (maximum cystometric capacity minus post-void residual volume) also improved significantly in all except the HR-CLP group. Maximum urine flow improved in all groups but not significantly in the HR-CLP group. Intraoperative and postoperative complications were slightly higher in HR cases. However, blood transfusion was never necessary and there was no mortality. CONCLUSIONS: CLP and especially CLP-VLAP perform almost as well in HR cases compared with CLP in those at normal risk. These procedures are safe for men at HR with LUTS suggestive of BPH.

Comparison of outcomes of transurethral prostate resection in urodynamicallyobstructed versus selected urodynamicallyunobstructed or equivocal men.

OBJECTIVES: To compare the benefits of transurethral resection of the prostate in urodynamically obstructed versus selected urodynamically unobstructed or equivocal men with severe lower urinary tract symptoms associated with benign prostatic enlargement. METHODS: In this case series study, men with lower urinary tract symptoms were selected if they met the study criteria and underwent the tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia. They also underwent urodynamic investigations. Men were included when transurethral resection of the prostate was selected as the treatment modality. Of the 132 included subjects, 93 could be re-evaluated 6 months after surgery. RESULTS: Of the 93 re-evaluated men, 59 were obstructed and 34 were unobstructed or equivocal. Both groups were similar with respect to age, symptoms, bother, benign prostatic hyperplasia-impact index, and quality of life. The quantified reductions in symptoms and bother in the unobstructed and equivocal men were about 70% of those reductions in the obstructed men. In the equivocal men, and even in the unobstructed men, a significant reduction with 40% of the urethral resistance occurred. CONCLUSIONS: Transurethral resection of the prostate may be a good treatment alternative for unobstructed or equivocal men with severe lower urinary tract symptoms associated with prostatic enlargement, who opt for resection or who do not respond to or do not tolerate medical therapy.

A randomized controlled trial comparing transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia: analysis of subjective changes, morbidity and mortality.

PURPOSE: We analyze subjective changes, morbidity and mortality in men with lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH) after transurethral resection of the prostate, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS: A prospective, randomized controlled trial was conducted on men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on BPH, had a prostate volume between 20 and 65 ml., and had Schäfer's obstruction grade 2 or greater. Objective morbidity was recorded for up to 12 months. Subjective morbidity was measured by a questionnaire completed by patients. Subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, Quality of Life question and BPH Impact Index. These indexes and the morbidity questionnaire were measured weekly for the first 6 weeks postoperatively and then at 3, 6 and 12 months. RESULTS: Transurethral prostatic resection was analyzed in 50 men, laser treatment in 45 and electrovaporization in 46. Baseline characteristics, and changes in the symptom scores up to 12 months postoperatively were similar. Perioperative blood loss and perforation were greatest in the resection group, and retention was greatest in the laser group. During the first 6 postoperative weeks there was less pain and less hematuria after resection, and less incontinence after laser prostatectomy. CONCLUSIONS: Subjective changes are similar for transurethral prostatic resection, contact laser and electrovaporization. In the first 6 weeks after treatment there are only slight differences in pain, hematuria and incontinence among the therapies.

Data from frequency-volume charts versus maximum free flow rate, residual volume, and voiding cystometric estimated urethral obstruction grade and detrusor contractility grade in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

AIMS: To examine associations of data from frequency-volume charts with maximum free flow rate, residual volume, and voiding cystometric estimated urethral obstruction grade and detrusor contractility in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH). METHODS: The 160 men included in the study met the criteria of the International Scientific Committee on BPH, i.e., they voided more than 150 mL during uroflowmetry, their residual volume and prostate size were estimated, and they completed frequency-volume charts correctly. From the frequency-volume charts, voiding habits and fluid intake were evaluated. Pressure-flow studies were performed as well. RESULTS: Increasing residual volume was related to a decrease of maximum voided volume and to a decrease of maximum free flow rate. Cystometric capacity was little affected by residual volume. Low contractility did not result in high residual volume. A marked decrease in voided volumes with increasing obstruction grade was observed, due to a decrease of cystometric capacity and an increase of residual volume. Detrusor contractility was little associated with voided volumes. A higher voiding frequency was related to a higher fluid intake. However, increased standardized frequency (number of voidings per 1,000 mL) was associated with a substantial reduction of fluid intake. CONCLUSIONS: Infravesical obstruction is the most important factor influencing voided volumes, cystometric capacity, and residual urine volume. Frequency of voiding was not influenced significantly because patients with small voided volumes minimized their fluid intake.

A randomized controlled trial comparing transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia: urodynamic effects.

PURPOSE: We compared urodynamic and uroflowmetry improvements in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) after transurethral prostate resection, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in men with lower urinary tract symptoms suggestive of BPH who met the criteria of the International Scientific Committee on BPH, had a prostate volume of between 20 and 65 ml., and a Schäfer obstruction grade of 2 or greater. Before and 6 months after treatment urodynamics and free uroflowmetry were performed. RESULTS: A total of 50, 45 and 46 men were randomized to transurethral prostate resection, laser treatment and electrovaporization, respectively. Baseline characteristics were similar in the 3 groups. Detrusor contractility did not change in any of the treatment groups. The average maximum free flow rate increased by a factor of 2.4 after transurethral prostate resection, 2.5 after laser prostatectomy and 2.4 after electrovaporization. The Schäfer obstruction grade decreased by a factor of 0.3 in all groups. Obstruction (Schäfer grade greater than 2) was not noted after transurethral prostate resection or electrovaporization but it was evident in 2 patients after laser prostatectomy. Effective capacity increased by a factor of 1.5 or more. The incidence of detrusor instability was decreased by half in all groups. The incidence of significant post-void residual urine volume decreased in all groups. CONCLUSIONS: There were no significant differences in the improvement in urodynamic and uroflowmetry parameters 6 months after treatment when comparing transurethral prostate resection, contact laser prostatectomy and electrovaporization in men with lower urinary tract symptoms suggestive of BPH.

Correlations of urodynamic changes with changes in symptoms and well-being after transurethral resection of the prostate.

PURPOSE: To establish the predictive value of urodynamics on the outcome of transurethral prostate resection for benign prostatic enlargement we correlated urodynamic changes with symptomatic improvement, decreased bother, and increased general well-being and quality of life after transurethral prostate resection. MATERIALS AND METHODS: Men with lower urinary tract symptoms were selected if they met study criteria and underwent tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia, and if post-void residual urine volume and prostate size were estimated. Patients answered quality of life, symptom index, symptom problem index and benign prostatic hyperplasia impact index questions. Patients also underwent urodynamic evaluation. Men were included in analysis when transurethral prostate resection was selected as the treatment modality. Of the 132 patients included 93 were reevaluated 6 months after transurethral prostate resection. RESULTS: Improvements after transurethral prostate resection were significantly associated with decreased bladder outlet obstruction (p <0.01). However, 32 cases that were unobstructed or equivocal preoperatively also benefited moderately from resection. Effective capacity, that is cystometric capacity minus post-void residual urine volume, increased by an average of 45% postoperatively. The increase in effective capacity contributed to a significant decrease in symptoms and bother, and to improved well-being. Of the men with a urodynamically proved stable bladder 90% maintained a stable bladder after prostatectomy, while in 50% with a urodynamically proved unstable bladder it became stable postoperatively. CONCLUSIONS: Performing urodynamics preoperatively helps to predict the degree of symptom relief, decreased bother and increased well-being after transurethral prostate resection.

Data from frequency-volume charts versus filling cystometric estimated capacities and prevalence of instability in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

The aim was to examine associations of filling cystometric estimated compliance, capacities, and prevalence of bladder instability with data from frequency-volume charts in a well-defined group of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Men with LUTS suggestive of BPH were included if they met the criteria of the International Consensus Committee on BPH, i.e., they voided more than 150 mL during uroflowmetry, their residual volume and prostate size were estimated, and they completed frequency-volume charts correctly. From the frequency-volume charts, voiding habits, and fluid intake in the daytime and at night were evaluated. Filling cystometric studies were performed in these men as well. Decreased compliance was an exceptional finding. Cystometric capacity and especially effective capacity (cystometric capacity minus residual volume) corresponded significantly with the maximum voided volume on the frequency-volume charts. Effective capacity was almost twice as high as the average voided volume. Minimum voided volume on frequency-volume charts was not related to filling cystometric data. The presence of instability in the supine or sitting position or in both positions was not significantly associated with smaller voided volumes, higher nocturia, or diuria. Filling cystometric capacities were strongly associated with maximal and mean voided volumes derived from frequency-volume charts. The presence of detrusor instability during filling cystometry did not significantly affect voided volumes, diuria, or nocturia