Effects of bladder volume on transabdominal ultrasound measurements of intravesical prostatic protrusion and volume

[Diagnostic work-up of benign prostatic hyperplasia : The German S2e-guideline 2023 part 1]

BACKGROUND

Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH; in German guidelines: benign prostatic syndrome [BPS]) is the most frequent urological disease in men and can result in a considerable deterioration of quality-of-life. BPS can be associated with LUTS, benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO) or benign prostatic obstruction (BPO), respectively. The expert group on BPS of the German Society of Urology has re-evaluated the tests for the assessment of BPH and provides evidence-based recommendations.

OBJECTIVES

Presentation and evidence-based rating of tests for the assessment of patients with BPS.

MATERIALS AND METHODS

Summary and overview of chapters 5, 6, and 8 of the latest long version of the German S2e guideline on BPS.

RESULTS

The diagnostic work-up should clarify (1) whether the complaints of the patient are caused by BPS, (2) how relevant the complaints are and whether treatment is necessary, (3) whether complications of the lower or upper urinary tract already exist, and (4) which treatment will be most suitable. Baseline assessment should be done in all BPS patients and include history, measurement of LUTS and quality-of-life, urinalysis, serum prostate-specific antigen, post-void residual, ultrasound of the lower urinary tract, including measurements of prostate volume, intravesical prostatic protrusion and detrusor wall thickness, and ultrasound of the upper urinary tract. Additional tests can follow when questions remain unanswered after baseline assessment. These optional tests include bladder diaries, uroflowmetry, serum creatinine, urethrocystoscopy, other noninvasive tests for the determination of BOO/BPO such as penile cuff test, condom catheter method and near-infrared spectroscopy, and other imagining tests such as X‑ray and MRI investigations.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations on the diagnostic work-up, including the assessment of the BPS components BPE, LUTS, and BOO/BPO.

Clinical Significance of Intravesical Prostatic Protrusion Index in Patients with Clinical Diagnosis of Benign Prostatic Hyperplasia

Background: To investigate the clinical significance of the intravesical prostatic protrusion (IPP) index in benign prostatic hyperplasia (BPH) patients to clarify its diagnostic value in predicting the clinical and structural abnormalities of the prostate. Methods: In this descriptive and analytical cross-sectional study, every man older than 50 years with lower urinary tract symptoms (LUTS), predominantly voiding or obstructive, suggestive of BPH were included. The patients were evaluated to determine the following indices: International Prostate Symptom Score (IPSS) index, quality of life (QoL), prostate volume (PV) and postvoid residual urine (PVR), serum PSA level, and the maximum urinary flow rate (Qmax) obtained by uroflowmetry. Subsequently, the assessment of the IPP index was conducted by transabdominal ultrasonography. The categorization of the IPP index was done into 3 grades: grade one (below 5 mm), grade two (between 5 and 10 mm), and grade three (greater than 10 mm). Results: A significant direct correlation between the IPP and IPSS, QoL, PV, PVR, and serum PSA, as well as inversely with the Qmax, was detected before and after medical treatment. Also, the need for surgical intervention increased significantly with the IPP index. Conclusions: The IPP can be used to evaluate and predict the severity of symptoms and outcomes in patients with clinical BPH.

Correlation of intravesical prostatic protrusion with severity of lower urinary symptoms among patients with benign prostatic hyperplasia

Background

Benign prostate hyperplasia (BPH) is characterized by an increase in the number of epithelial and stromal cells in the periurethral area of the prostate. Lower urinary tract symptoms (LUTS) often develop as a manifestation of bladder outlet obstruction (BOO) due to benign prostate enlargement. When the prostate enlarges, protrusion into the bladder often occurs as a result of morphological changes of the gland. Prostatic protrusion into the bladder can be measured with ultrasound as intravesical prostatic protrusion (IPP). There are studies that have shown IPP as a reliable predictor of bladder obstruction index (BOOI) as measured by pressure flow studies. IPP is thereby reliable in assessing the severity of BOO in patients with BPH. The severity of symptoms in patients with BPH can be assessed through several scoring systems. The most widely used symptoms scoring system is the International Prostate Symptoms Score (IPSS). The aim of this study is to determine the correlation of IPP with IPSS in men with BPH at our facility.

Methods

The study was a cross-sectional observational study that was conducted at the Division of Urology, Department of Surgery, in our facility. The study was conducted on patients greater than 50 years LUTS and an enlarged prostate on digital rectal examination and/or ultrasound. All consenting patients were assessed with the International Prostate Symptoms Score (IPSS) questionnaire, following which an abdominal ultrasound was done to measure the intravesical prostatic protrusion (IPP), prostate volume (PV) and post-void residual (PVR) urine. All the patients had uroflowmetry, and the peak flow rate was determined. The data obtained were entered into a proforma. The results were analyzed using Statistical Package for Social Sciences (SPSS) software package version 20.

Results

A total of 167 patients were seen during the study period. The mean age was 63.7 ± 8.9 years, with a range of 45–90 years. The mean IPSS was 18.24 ± 6.93, with a range of 5–35. There were severe symptoms in 49.1%, while 43.1% had moderate symptoms and 7.8% had mild symptoms. The overall mean IPP was 10.3 ± 8 mm. Sixty-two patients (37.1%) had grade I IPP, 21 patients (12.6%) had grade II IPP and 84 patients (50.3%) had grade III IPP. The mean prostate volume and peak flow rate were 64 g ± 34.7 and 11.6 ml/s ± 5.4, respectively. The median PVR was 45 ml with a range of 0–400 ml. There was a significant positive correlation between the IPP and IPSS (P = 0.001). IPP also had a significant positive correlation with prostate volume and post-void residual and a significant negative correlation with the peak flow rate (P < 0.01).

Conclusion

Intravesical prostatic protrusion is a reliable predictor of severity of LUTS as measured by IPSS, and it also shows good correlation with other surrogates of bladder outlet obstruction.

A Systemic Review and Meta-analysis of Transabdominal Intravesical Prostatic Protrusion Assessment in Determining Bladder Outlet Obstruction and Unsuccessful Trial Without Catheter

CONTEXT

Urodynamic study (UDS) provides the most objective assessment of bladder outlet obstruction (BOO) but is impractical to be recommended routinely in outpatient services. Intravesical prostatic protrusion (IPP) had been described to obstruct urinary flow by creating an anatomical ball-valve effect, but there remains a lack of pooled evidence that can objectively correlate with BOO in benign prostatic hyperplasia.

OBJECTIVE

To update the current evidence on the predictive role of IPP in determining BOO and unsuccessful trial without catheter (TWOC).

EVIDENCE ACQUISITION

A comprehensive literature search was performed to identify studies that evaluated IPP in diagnosing UDS-determined BOO and TWOC. The search included the PubMed/MEDLINE, EMBASE, and Cochrane Library up to January 2021. An updated systemic review and meta-analysis was performed.

EVIDENCE SYNTHESIS

A total of 18 studies with 4128 patients were examined. Eleven studies with 1478 patients examined the role of IPP in UDS-determined BOO. The pooled area under the curve (AUC) was 0.83 (95% confidence interval [CI]: 0.79-0.86), and at a cut-off of >10 mm, the sensitivity (Sn) and specificity (Sp) were 0.71 (95% CI: 0.61-0.78) and 0.77 (95% CI: 0.68-0.84), respectively. The probability-modifying plot revealed positive and negative likelihood ratios of 3.34 (95% CI: 2.56-4.36) and 0.35 (95% CI: 0.26-0.45), respectively. Seven studies with 2650 patients examined IPP in predicting unsuccessful TWOC, with a pooled AUC of 0.74 (95% CI: 0.70-0.84), with Sn of 0.51 (95% CI: 0.43-0.60) and Sp of 0.79 (95% CI: 0.73-0.84) at an IPP cut-off of >10 mm. Five studies compared prostate volume (PV) and IPP and revealed a lower AUC of PV at 0.71 (95% CI: 0.67-0.75), which was an inferior parameter in diagnosing BOO (p < 0.001).

CONCLUSIONS

This systemic review provided evidence that IPP is a reliable clinical parameter that correlates strongly with underlying BOO and unsuccessful TWOC.

PATIENT SUMMARY

In this review, we comprehensively reviewed all the literature to date on evaluating the clinical utility of intravesical prostatic protrusion (IPP). We have demonstrated that IPP correlates strongly with urodynamic study (UDS)-determined bladder outlet obstruction and failure of trial without catheter (TWOC). Outpatient IPP measurement is a quick, inexpensive, and reproducible clinical parameter that can determine the severity of benign prostatic hyperplasia. The clinical role of IPP in predicting failure of TWOC selects patients who are best treated with aggressive surgical approaches rather than conservative medical therapies. More importantly, IPP can facilitate the discriminatory use of invasive UDS, reserved for patients with a strong suspicion of concomitant detrusor abnormalities.

Tradução para a língua portuguesa do artigo original em inglês “ The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction”

Introdução

No desenvolvimento da terminologia do trato urinário inferior, devido à sua crescente complexidade, a terminologia para os sintomas e a disfunção do trato urinário inferior masculino e assoalho pélvico precisa ser atualizada, utilizando abordagem específica masculina e por meio de um relatório de consenso clinicamente embasado.

Métodos

Este relatório combina a contribuição de membros do Standardisation Committee da International Continence Society em um Grupo de Trabalho com especialistas reconhecidos no campo, assistido por muitos julgadores externos. Categorias clínicas centrais apropriadas e uma subclassificação foram desenvolvidas para fornecer uma codificação numérica para cada definição. Um extenso processo de 22 rodadas de revisão interna e externa foi desenvolvido para examinar exaustivamente cada definição, com tomada de decisão por opinião coletiva (consenso).

Resultados

Um relatório de terminologia para os sintomas e a disfunção do trato urinário inferior e do assoalho pélvico foi desenvolvido, abrangendo cerca de 390 definições/descritores separados. É clinicamente embasado nos diagnósticos mais comuns definidos. A clareza e a facilidade de uso foram os principais objetivos para torná-lo interpretável por profissionais e estagiários em todos os diferentes grupos de especialidades envolvidos na disfunção do trato urinário inferior e do assoalho pélvico masculino. Imagens específicas para homens (ultrassonografia, radiologia, tomografia computadorizada e ressonância magnética) foram um adicional importante, enquanto figuras apropriadas foram incluídas para complementar e ajudar a esclarecer o texto.

Conclusões

Um relatório de terminologia com base em consenso para sintomas e disfunção do trato urinário inferior e do assoalho pélvico masculino foi produzido visando ser um auxílio significativo para a prática clínica e um estímulo para a pesquisa.

Correlation of prostatic morphological parameters and clinical progression in aging Chinese men with benign prostatic hyperplasia: Results from a cross-sectional study

OBJECTIVES

Our study aimed to investigate the correlation of prostatic morphological parameters and benign prostatic hyperplasia (BPH) clinical progression in aging Chinese men.

METHODS

In this retrospective study, a total of 1038 patients were reviewed. Prostatic morphology was measured by transrectal ultrasound (TRUS). Detailed medical history of all candidates was recorded and analyzed after being classified by specific prostatic measurements. Univariate and multivariate logistic regression analyses were used to estimate the correlation between variables.

RESULTS

The cumulative incidence of BPH clinical progression was 63.68% (661/1038) in the study population. Prostate volume (PV), transitional zone volume (TZV), transitional zone index (TZI), and intravesical prostatic protrusion (IPP) were all positively associated with BPH progression (all p < .001). Patients with a PV > 60 ml, TZV > 15 ml, TZI > 0.5, or IPP > 5 mm had a significantly higher possibility of overall BPH clinical progression (adjusted odds ratio (OR): 2.485, 1.678, 1.886, and 1.924, respectively; 95% confidence interval (CI): 1.559-3.960, 1.131-2.489, 1.379-2.579, and 1.357-2.728, correspondingly).

CONCLUSION

Prostatic morphological parameters are significantly associated with BPH clinical progression. Patients with larger prostatic morphological parameters are more easily prone to clinical progress. As a result, reasonable managements should be timely considered for those patients before clinical progression occurs.

Variation of prostatic morphology in Chinese benign prostatic hyperplasia patients of different age decades

OBJECTIVE

Our study aimed to investigate the age-related growth in prostatic morphological parameters in Chinese benign prostatic hyperplasia (BPH) patients, and to find out the regularity of how these parameters change with aging.

METHODS

Medical records of 1038 BPH patients were obtained from a retrospective database of first-visit men with BPH. Change regularity of prostatic anatomical factors with aging was analyzed.

RESULTS

Patients were classified into four groups according to different age decades. All prostatic anatomical factors assessed in this research increased with age growth (p < .0001). However, these anatomical factors sustained stably when older than 70 years. By analyzing the detailed correlation between age and prostatic morphological parameters, transitional zone index (TZI) (Pearson r = 0.358, r² = 0.128, p < .0001) and transitional zone width (TZW) (Pearson r = 0.344, r ²= 0.118, p < .0001) showed the best correlation coefficient with age. After adjusted the influence of cardiovascular disease (CVD) and diabetes mellitus (DM), the result remained still similarly.

CONCLUSION

Prostatic morphological parameters increase progressively with age growth when patients were younger than 70 years, indicating reasonable interventions to be provided to BPH patients before 70 years. In addition, TZI and TZW are two practical, easy-to-measure prostatic parameters that are significantly associated with the growth of age compared to others.

Sonographic evaluation of prostatic artery embolization: Far beyond size measurements

Prostatic artery embolization (PAE) has gained acceptance as a minimally invasive, safe and effective treatment of symptomatic benign prostatic hyperplasia. Radiologic imaging is an indispensable part of post-interventional evaluation of PAE and serves both clinical and investigational purposes. In this context, ultrasonography (US) has a central and multifaceted role. Gray-scale US is routinely utilized for measurement of significant outcome parameters (prostatic volume, intra-vesical prostatic protrusion and post-void residual volume) before and after PAE. Improvement of these parameters may become more obvious one-month post-PAE, or later. Contrast-enhanced US (CEUS) with intravenous administration of a second-generation echo-enhancer can demonstrate prostatic infarcts (as enhancement defects) immediately post-PAE and monitor their resolution over time. The volume of prostatic infarcts can also be measured and compared to prostatic volume. Prostatic infarction is a definite sign of the local efficacy of PAE and a predictor of prostate shrinkage and (at least in some patients) of clinical success. CEUS can also be performed intraoperatively in the angio-suite, for on-site evaluation of the ischemic effect; a variation of this technique, with intraarterial (instead of intravenous) administration of diluted echo enhancer, can also be applied intraoperatively, to map the embolized territory and to prevent non-target embolization. Initial experience with US-elastographic techniques (shear-wave and strain elastography) has shown that they can detect and quantify the improvement of tissue elasticity post-PAE, thus providing new insights into the therapeutic mechanisms of this treatment. With utilization of high-end equipment, experience and standardized imaging protocols, US could be the primary modality for imaging evaluation of PAE.

The possible association between serum interleukin 8 and acute urinary retention in Chinese patients with benign prostatic hyperplasia

Acute urinary retention (AUR) is one of the progressive manifestations of benign prostatic hyperplasia (BPH). This cross-sectional study was conducted to analyse the possible association between serum interleukin 8 (sIL-8) and AUR in BPH patients to provide evidence of sIL-8 as a potential biomarker for the prediction of AUR. The relationship between sIL-8 levels and AUR was evaluated by logistic regressions in 245 ageing Chinese men with BPH. The discriminant validity of sIL-8 and the optimal cut-off value were determined by a receiver operating characteristic curve. The levels of sIL-8 increased significantly in BPH patients with AUR (p < 0.001). The sIL-8 concentration was positively correlated with AUR in BPH patients (OR = 1.024, 95% CI: 1.009-1.040, p = 0.002). The correlation with AUR in the group with a high sIL-8 level (≥43.05 pg/ml) was significantly enhanced (OR = 8.853, 95% CI: 2.433-32.205, p = 0.001). The sIL-8 level correlated with AUR in Chinese BPH patients independently. As a possible predictor, sIL-8 may contribute to the screening of high-risk populations for AUR to create opportunities for the early effective interventions to improve prognosis and enhance the quality of life. Prospective studies are needed to support all these results.

Comparison of Transabdominal and Transrectal Ultrasound for Sizing of the Prostate

OBJECTIVE

To compare the accuracy of prostate sizing between pelvic abdominal (PUS) and transrectal (TRUS) ultrasound in a large, diverse cohort of men at our institution. Prostate volume plays a vital role in all types of prostate disease. American Urological Association guidelines (2018) for surgical management of benign prostatic hyperplasia now include consideration of prostate volume measurement prior to surgical intervention. Ultrasound is a quick and radiation-free imaging modality.

METHODS

We performed a single-center, retrospective study of 299 patients with prostate sizing between January 1, 2012 and August 31, 2017. Prostate volume was derived from ellipsoid volume calculation using dimensions measured on ultrasound. PUS and TRUS were compared by calculating the Pearson correlation coefficient and intraclass correlation coefficient, and agreement between modalities assessed using the Bland Altman analysis. This analysis was done for the whole sample population as well as for specific groupings according to body mass index, prostate size, and time between exams.

RESULTS

A total of 236 patients had PUS followed by TRUS and met study inclusion criteria. Median age was 63, median prostate specific antigen value prior to PUS was 7.6 ng/mL, and only 20% were white. Mean volume differences between the two modalities for the data (vol_PUS - vol_TRUS) were (-0.3 ± 1.1) cm³. Bland-Altman analysis showed agreement between PUS and TRUS only for prostates ≤ 30 cm³.

CONCLUSION

For prostates less than 30 cc, we found that PUS is interchangeable with TRUS in estimating prostate volume. However, for larger prostates where size may alter surgical management, we would recommend TRUS or cross-sectional imaging.

Measurement of Prostate Volume with MRI (A Guide for the Perplexed): Biproximate Method with Analysis of Precision and Accuracy

To review the anatomic basis of prostate boundary selection on T2-weighted magnetic resonance imaging (MRI). To introduce an alternative 3D ellipsoid measuring technique that maximizes precision, report the intra- and inter-observer reliability, and to advocate it's use for research involving multiple observers. We demonstrate prostate boundary anatomy using gross pathology and MRI examples. This provides background for selecting key boundary marks when measuring prostate volume. An alternative ellipsoid volume method is then proposed using these boundaries in an attempt to improve inter-observer precision. An IRB approved retrospective study of 140 patients with elevated serum prostate specific antigen levels and/or abnormal digital rectal examinations was done with T2-weighted MRI applying a new (Biproximate) technique. Measurements were made by 2 examiners, correlated with each other for inter-observer precision and correlated with an expert observer for accuracy. Correlation statistics, linear regression analysis, and tests of means were applied using p ≤ 0.05 as the threshold for significance. Inter-observer correlation (precision) was 0.95 between observers. Correlation between these observers and the expert (accuracy) was 0.94 and 0.97 respectively. Intra-observer correlation for the expert was 0.98. Means for inter-rater reliability and accuracy were all the same (p = 0.001). We conclude that using more precise reproducible landmarks with biproximate technique, precision and accuracy of total prostate volume is found to be demonstrated.

Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes

PURPOSE

To evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP).

MATERIALS AND METHODS

This was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm³ (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10-656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes.

RESULTS

No significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R² = .5, P < .0001; IPP: P = .702; QOL: R² = .5, P = .0003; IPP: P = .108).

CONCLUSIONS

There were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.

Correlation between prostatic urethral angulation and symptomatic improvement after surgery in patients with lower urinary tract symptoms according to prostate size

PURPOSE

To investigate the effect of prostate anatomical factors on the changes in lower urinary tract symptoms (LUTS) and uroflowmetric values after surgery.

METHODS

The medical records of 448 patients who underwent transurethral resection of the prostate (TURP) from January 2006 to December 2018 were analyzed retrospectively. Changes in the International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual urine volume (PVR) at 3 months after TURP were evaluated. Prostate volume, intravesical prostatic protrusion (IPP), and prostatic urethral angulation (PUA) were measured using transrectal ultrasonography, and their effect on the changes in LUTS after TURP was analyzed using multivariable linear regression.

RESULTS

Among patients with prostate volume < 50 mL, preoperative IPSS total score (IPSS-t), voiding symptom score (IPSS-vs), and storage symptom score (IPSS-ss) were significantly better in patients with a smaller PUA (< 51°) than in those with a larger PUA (≥ 51°) (p = 0.001, < 0.001, and 0.020, respectively). Changes in IPSS-t, IPSS-vs, IPSS-ss, and PVR at 3 months after TURP were significantly correlated with PUA (p ≤ 0.001, < 0.001, 0.048, and 0.012, respectively). Multivariable linear regression revealed PUA to be independently associated with changes in IPPS-t and IPSS-vs (p = 0.025 and < 0.001, respectively) only in patients with prostate volume < 50 mL.

CONCLUSION

Prostatic urethral angulation was significantly associated with postoperative changes in LUTS only in patients with small prostate, and had no clinical significance in patients with large prostate. In patients with small prostate and large PUA, surgery should actively be considered.

Investigation of the relationship between bladder function and sarcopenia using pressure flow studies in elderly male patients

AIMS

Although detrusor underactivity is often encountered in elderly patients, the etiology remains unclear. We have hypothesized that sarcopenia was associated with impaired bladder contractility. Therefore, we have evaluated the relationship between bladder contractility and clinical parameters including sarcopenia markers in elderly male patients.

METHODS

This retrospective, single-centre study included male patients over 65 years of age who underwent a pressure flow study (PFS). We excluded patients with any previous medical histories that could affect bladder function, currently on urinary medication, and with no available data of abdominal CT scan. The psoas muscle area (PMA) (cm² /m² ) was measured as a surrogate for psoas muscle mass on computed tomography. PMA, serum CRP, and albumin are known as sarcopenia markers. Correlation and multiple regression analyses were performed to evaluate the association of bladder contractility index (BCI) with the following parameters: age, body mass index (BMI), prostate volume, bladder outlet obstruction index (BOOI), serum C-reactive protein (CRP), serum albumin, and PMA.

RESULTS

Out of 558 male patients identified in our PFS database, 119 patients were enrolled. In the correlation analysis, age, prostate volume, serum albumin, BOOI, and PMA significantly correlated with BCI. However, no significant correlation of BCI with CRP or BMI was observed. Multiple linear regression analysis showed that serum albumin, BOOI, and PMA were significantly associated with BCI.

CONCLUSIONS

We have demonstrated that serum albumin and PMA were significantly positively associated with detrusor contractility. It is possible that sarcopenia is associated with impaired detrusor contractility.

Oxidative stress in the bladder of men with LUTS undergoing open prostatectomy: a pilot study

Purpose:

This study aims to evaluate the link between preoperative parameters and oxidative stress (OS) markers in the bladder wall of men undergoing open prostatectomy.

Materials and Methods:

From July 2014 to August 2016, men aged ≥ 50 years and presenting with LUTS were prospectively enrolled. Preoperative assessment included validated questionnaires (IPSS and OAB - V8), lower urinary tract ultrasound and urodynamics. Bladder biopsies were taken during open prostatectomy for determination of OS markers. Increased OS was defined by increased concentration of malondialdehyde (MDA) and / or decreased concentration of antioxidant enzymes (superoxide dismutase and / or catalase). P<0.05 was regarded as statistically significant.

Results:

Thirty - eight consecutive patients were included. Mean age was 66.36 ± 6.44 years, mean prostate volume was 77.7 ± 20.63 cm3, and mean IPSS was 11.05 ± 8.72 points. MDA concentration was increased in men with severe bladder outlet obstruction (BOO grade V - VI according to the Schaefer's nomogram) in comparison with BOO grade III - IV (p = 0.022). Patients with severe LUTS also had higher MDA concentration when compared to those with mild LUTS (p = 0.031). There was a statistically significant association between increased post - void residual urine (cut off ≥ 50 mL) and not only higher levels of MDA, but also reduced activity of SOD and catalase (p < 0.05).

Conclusions:

This pilot study showed that severity of LUTS and BOO were associated with increased MDA concentration in the bladder wall of men undergoing open prostatectomy. Further studies are still needed to assess the role of non - invasive biomarkers of OS in predicting bladder dysfunction in men with LUTS.

[Diagnostic procedures and diagnostic strategy for lower urinary tract symptoms/benign prostatic hyperplasia : An overview]

BACKGROUND

Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) is the most common condition affecting the lower urinary tract of men. Evidence-based assessment is the basis for an ideal treatment approach.

OBJECTIVES

To provide an overview of the current status of diagnostic measures for LUTS/BPH.

MATERIALS AND METHODS

Descriptive review of the literature on the diagnosis of LUTS/BPH.

RESULTS

A medical history inquiring about LUTS/BPH symptoms and burden as well as a standardized and validated symptom questionnaire such as the International Prostate Symptom Score (IPSS) are the basis of the assessment. A physical examination including a rectal exam and the ultrasonography of the lower and upper urinary tract are also part of the basic diagnostic workup. Prostate size is ideally measured by transrectal ultrasound. Serum prostate-specific antigen measurement may help to estimate the prostate size and the risk fo progression. It can also be helpful in the detection of prostate cancer. Urine dipstick or sediment is used to exclude urinary tract infection, hematuria, or glucosuria. Voiding dysfunction can be detected by uroflowmetry. In addition to the aforementioned examinations, further tests such as frequency-voiding charts, multichannel urodynamic evaluation, measurement of detrusor wall thickness and X‑ray imaging of the upper urinary tract as well as a cystoscopy may be offered if needed.

CONCLUSIONS

Diagnostics of LUTS/BPH consist of basic exams as well as optional exams and can be used to assess the progression risk, to identify complications and to offer the ideal treatment.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction

INTRODUCTION

In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text.

CONCLUSIONS

A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Intravesical prostatic protrusion is not always the same shape: Evaluation by preoperative cystoscopy and outcome in HoLEP

AIMS

To examine how morphological differences in intravesical prostatic protrusion (IPP) predict outcome of Holmium laser enucleation of prostate (HoLEP) treatment.

METHODS

We analyzed 173 patients who had undergone HoLEP in our hospital. The protrusion shape was evaluated by outpatient preoperative flexible cystoscopy and classified into five groups: A, no protrusion; B, middle lobe only; C, unilateral lobe only; D, bilateral lobes; and E, B + C or B + D. Paired-match analysis that adjusted for preoperative International Prostate Symptom Score (IPSS) voiding/storage subscores and IPP was performed between the group with middle lobe protrusion (B + E) and the group without it (C + D).

RESULTS

Type A prostate shape was found in 23 patients, type B in 14, type C in 31, type D in 71, and type E in 34. Groups with middle lobe protrusion (B and E) had better changes in the total IPSS (P < 0.05) and the IPSS storage subscore (P < 0.01). Pair matching identified 37 patients each with or without middle lobe protrusion. The group with middle lobe protrusion had significantly more improved total IPSS (-17.5 ± 7.5 vs -13.5 ± 8.3, P < 0.05) and IPSS storage subscore (-6.9 ± 3.4 vs -4.8 ± 3.3, P < 0.05) than did those without middle lobe protrusion.

CONCLUSIONS

Patients with middle lobe protrusion had greater IPSS improvement after HoLEP than those having comparable-length IPP but without middle lobe protrusion. IPP is not always the same shape and should be clinically divided into at least two groups.

Implantable bladder volume sensor based on resistor ladder network composed of conductive hydrogel composite

An accurate bladder volume monitoring system is a critical component in diagnosis and treatment of urological disorders. Here, we report an implantable bladder volume sensor with a multi-level resistor ladder which estimates the bladder volume through discrete resistance values. Discretization allows the sensor output to be resilient to the long-term drift, hysteresis, and degradation of the sensor materials. Our sensor is composed of biocompatible polypyrrole/agarose hydrogel composite. Because Young's modulus of this composite is comparable to that of the bladder wall, the effect of mechanical loading of the sensor on the bladder movement is minimized which allows more accurate volume monitoring. We also demonstrate the patterning and molding capability of this material by fabrication various structures. Lastly, we successfully demonstrate the functionality of the multi-level resistor ladder sensor as a bladder volume sensor by attaching the sensor on the pig's bladder and observing the impedance change of the sensor.

Non-invasive evaluation of lower urinary tract symptoms (LUTS) in men

Lower urinary tract symptoms (LUTS) are common in males over the age of 40 years old and are likely to increase with an aging population. Currently urodynamic studies are the gold standard to determine the aetiology of voiding dysfunction and LUTS. However, due to its invasive nature, a great number of non-invasive ultrasound based investigations have been developed to assess patients with symptomatic LUTS. The clinical application of non-invasive tests could potentially stratify patients who would require more invasive investigations and allow more precise patient directed treatment. A PubMed literature review was performed and we will discuss the non-invasive investigations that have been developed thus far, focusing on bladder wall and detrusor wall thickness (BWT & DWT), ultrasound estimated bladder weight (UEBW) and intravesical prostatic protrusion (IPP).

Collagen content in the bladder of men with LUTS undergoing open prostatectomy: A pilot study

AIMS

To evaluate the collagen content in the bladder wall of men undergoing open prostate surgery.

METHODS

From July 2014 to August 2016, men aged ≥ 50 years, presenting LUTS and undergoing open prostate surgery due to benign prostatic enlargement (BPE) or prostate cancer were prospectively enrolled. Preoperative assessment included validated questionnaires (IPSS and OAB-V8), lower urinary tract ultrasound, and urodynamics. Bladder biopsies were obtained during open prostatectomy for determination of collagen content (sirius red-picric acid stain; polarized light analysis). Collagen to smooth muscle ratio (C/M) in the detrusor was measured and its relationship with preoperative parameters was investigated. The level of significance was P < 0.05.

RESULTS

Thirty-eight consecutive patients were included in this pilot study. Mean age was 66.36 ± 6.44 years and mean IPSS was 11.05 ± 8.72 points. Men diagnosed with diabetes mellitus (DM2) were found to have higher collagen content in the bladder wall when compared to non-diabetic patients (17.71 ± 6.82% vs 12.46 ± 5.2%, respectively; P = 0.024). Reduced bladder compliance was also marker for higher collagen content (P = 0.042). Bladder outlet obstruction (BOO) was not a predictor of increased collagen deposition in the bladder wall (P = 0.75). Patients with PVR ≥ 200 mL showed a higher collagen to smooth muscle ratio in the bladder wall (P = 0.036).

CONCLUSIONS

DM2 and urodynamic parameters, such as increased PVR and reduced bladder compliance, were associated with higher collagen content in the bladder wall of men with LUTS.

Can men with prostates sized 80 mL or larger be managed conservatively?

Purpose

To analyze the long-term clinical outcomes of men with large prostate sizes of 80 mL and greater who were managed conservatively.

Materials and Methods

We retrospectively analyzed men with prostate sizes of 80 mL and greater from our electronic hospital database. Clinical parameters such as age, International Prostate Symptom Score (IPSS), quality of life (QoL) scoring, serum prostate-specific antigen (PSA), uroflowmetry variables, and transabdominal ultrasound findings were evaluated. These parameters were compared at entry to our study and at the patient's latest follow-up visit.

Results

For the 50 men included in our analysis, mean age was 68 years, median PSA was 9.9 ng/mL, and median prostate volume was 94 mL. Seven men underwent upfront prostate surgery, whereas the other 43 were managed conservatively, predominantly with pharmacotherapy (98%). Only serum PSA, QoL scores, and postvoid residual urine demonstrated a significant reduction at the end of a median follow-up period of 62 months. Fourteen men (33%) were considered to have progressed clinically, with 8 experiencing retention of urine and 6 having symptomatic deterioration. Of the 35 men who were still receiving conservative treatment at the end of the follow-up period, 24 men (69%) had a peak flow rate of 10 mL/s or greater, a QoL score of 3 or less, and mild to moderate (IPSS, 0–19) symptoms.

Conclusions

Although the incidence of clinical progression in men with prostate sizes of 80 mL and greater is high, there is still a role for conservative management with pharmacotherapy.

Singapore Urological Association Clinical Guidelines for Male Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia

The first clinical guidelines for male lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) were published in 2005. An update is urgently needed in view of BPH being recognised as one of ten chronic illnesses by the Ministry of Health, Singapore. This review summarises the definition of BPH and the epidemiology of male LUTS/BPH in Singapore. BPH can be phenotyped with noninvasive transabdominal ultrasonography, according to intravesical prostatic protrusion and prostate volume, and classified according to severity (staging) for individualised treatment. At the initial evaluation, the majority of patients (59%) can be managed with fluid adjustment, exercise and diet; 32% with medications, using alpha blockers and/or 5-alpha reductase inhibitors for prostates weighing more than 30 g; and 9% with surgical intervention for more advanced disease. The 2015 guidelines comprise updated evidence that will help family medicine practitioners and specialists manage this common ailment more cost-effectively.

Pathophysiology of clinical benign prostatic hyperplasia

A disease can be defined as an abnormal anatomy (pathology) and/or function (physiology) that may cause harm to the body. In clinical benign prostatic hyperplasis (BPH), the abnormal anatomy is prostate adenoma/adenomata, resulting in a varying degree of benign prostatic obstruction (BPO) that may cause harm to the bladder or kidneys. Thus clinical BPH can be defined as such and be differentiated from other less common causes of male lower urinary tract symptoms. Diagnosis of the prostate adenoma/adenomata (PA) can be made by measuring the intravesical prostatic protrusion (IPP) and prostate volume (PV) with non-invasive transabdominal ultrasound (TAUS) in the clinic. The PA can then be graded (phenotyped) according to IPP and PV. Multiple studies have shown a good correlation between IPP/PV and BPO, and therefore progression of the disease. The severity of the disease clinical BPH can be classified into stages from stage I to IV for further management. The classification is based on the effect of BPO on bladder functions, namely that of emptying, normal if post-void residual urine (PVRU) < 100 mL; and bladder storage, normal if maximum voided volume (MVV) > 100 mL. The effect of BPO on quality of life (QoL) can be assessed by the QoL index, with a score ≥3 considered bothersome. Patients with no significant obstruction and no bothersome symptoms would be stage I; those with no significant obstruction but has bothersome symptoms (QoL ≥ 3) would be stage II; those with significant obstruction (PVRU > 100 mL; or MVV < 100 mL), irrespective of symptoms would be stage III; those with complications of the disease clinical BPH such as retention of urine, bladder stones, recurrent bleeding or infections would be stage IV. After assessment, further management can then be individualised. A low grade and stage disease can generally be watched (active surveillance) while a high grade and stage disease would need more invasive management with an option for surgery. The final decision making would take into account the patient's age, co-morbidity, social economic background and his preferences/values. Proper understanding of pathophysiology of clinical BPH would lead to better selection of patients for individualised and personalised care and more cost effective management.

Clinical value of intravesical prostatic protrusion in the evaluation and management of prostatic and other lower urinary tract diseases

Intravesical prostatic protrusion (IPP) has emerged as a new prostatic morphometric parameter of significance to aid the clinicians in various aspects of managing the patients with some diseases of the lower urinary tract and the prostate. These include but may not be limited to its role in such conditions as: bladder outlet obstruction, trial without catheter, medical treatment effect, progression of lower urinary tract symptoms related to benign prostatic hypertrophy (LUTS/BPH), risk factor for bladder stone in BPH, overactive bladder, prostate carcinoma, and early urinary continence recovery after laparoscopic radical prostatectomy. In this review, I will try to summarize the different researchers' efforts on the potential practical application of this clinical tool. Technology is ever evolving to help us in the diagnosis and management of our patients. However, we as clinicians should contemplate their cost and possible suffering for the patient by wise and judicious utilization based on our clinical experience and tools. IPP seems to be one such promising clinical tool.

Combination of intravesical prostatic protrusion and resistive index is useful to predict bladder outlet obstruction in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

OBJECTIVES

To examine which parameters obtained from transrectal ultrasonography are accurate predictors of urodynamically-confirmed bladder outlet obstruction in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

METHODS

The records of 350 patients with complaints of lower urinary tract symptoms suggestive of benign prostatic hyperplasia were reviewed. Baseline parameters were international prostate symptom score, quality of life score, postvoid residual urine volume, prostate-specific antigen, and data obtained from uroflowmetry and transrectal ultrasonography. Urodynamic studies were carried out to determine bladder outlet obstruction. Receiver operator characteristic curves were generated to compare the accuracy of the different parameters, and the area under the curve of each parameter was calculated.

RESULTS

Bladder outlet obstruction index positively correlated with intravesical prostatic protrusion, total prostate volume, transition zone volume, transition zone index, resistive index and prostate-specific antigen. Further, resistive index was only a significant independent variable with intravesical prostatic protrusion. Intravesical prostatic protrusion had the highest area under the curve of 0.790 among all variables, and its cut-off value was 10 mm. The positive predictive value of intravesical prostatic protrusion was 76.2%. In addition, the positive predictive value of the combined parameters intravesical prostatic protrusion and resistive index increased to 83.8%.

CONCLUSIONS

Intravesical prostatic protrusion and resistive index are useful parameters for predicting bladder outlet obstruction in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. In clinical practice, the combination of intravesical prostatic protrusion and resistive index on ultrasound can be diagnostic of bladder outlet obstruction.

The use of imaging techniques in understanding lower urinary tract (dys)function

The ability to store urine in the bladder and to void at an appropriate time depends on several complex mechanisms in the lower urinary tract (LUT) and its neural control. Normal LUT function requires coordination of the urinary bladder, urethra, pelvic floor, efferent and afferent neurons and specific spinal cord and brain areas. These structures can be visualised using different imaging modalities, such as ultrasound, X-ray and magnetic resonance imaging. The supraspinal neural control of the LUT can be studied using functional brain imaging. During the last two decades, the many technological improvements of these imaging techniques have increased our knowledge of voiding dysfunction. Here, we review the different imaging modalities of the LUT and its neural control and discuss their importance for diagnosing and understanding voiding dysfunction.

Early outcome of transurethral enucleation and resection of the prostate versus transurethral resection of the prostate

INTRODUCTION

Recurrent prostate adenoma is a long-term complication following transurethral resection of the prostate (TURP). Transurethral enucleation and resection of the prostate (TUERP) is more appealing, since the nodular adenoma can be completely removed through endoscopy. TUERP is also hypothesised to result in a lower frequency of recurrent adenoma. This study aimed to compare the early outcomes of TUERP and TURP, and assess the feasibility and safety of TUERP.

METHODS

We compared the outcome of 81 patients who underwent TUERP with that of 85 patients who underwent TURP. International prostate symptom score, quality of life score, prostate volume, degree of intravesical prostatic protrusion, maximum flow rate, post-void residual volume and prostate-specific antigen (PSA) level were obtained pre- and postoperatively. Complications (e.g. transfusion rate, incontinence, infection and urethral stricture) were analysed.

RESULTS

Operative time was significantly longer in the TUERP group compared to the TURP group (85.3 minutes vs. 51.6 minutes). After TUERP, the maximum flow rate was significantly higher (21.1 mL/s vs. 17.1 mL/s) and PSA level was significantly lower (1.2 ng/mL vs. 1.9 ng/mL) than after TURP. The rates of infection, transfusion and urethral stricture were similar for both groups, but the TUERP group had a higher rate of temporary incontinence (13.6% vs. 4.7%).

CONCLUSION

The lower PSA level and better maximum flow rate achieved following TUERP suggest that prostate adenoma removal was more complete with TUERP. Long-term follow-up is required to establish whether TUERP results in fewer resections for recurrent adenoma.

Can intravesical prostatic protrusion predict bladder outlet obstruction even in men with good flow?

Objective

Men with benign prostate hyperplasia (BPH) with good urinary flow may still have bladder outlet obstruction (BOO). Intravesical prostatic protrusion (IPP) has been shown to be able to predict BOO. We aim to investigate the use of IPP to predict BOO in men with good urinary flow.

Methods

One hundred and fourteen consecutive men (>50 years old) presenting with lower urinary tract symptoms suggestive of BPH were recruited in 2001 and 2002. They were evaluated with serum prostate specific antigen (PSA), uroflowmetry and transabdominal ultrasound measurement of IPP and prostate volume (PV). Pressure-flow urodynamic studies were performed on all men and BOO was defined by BOO index > 40. Men with Q_max ≥ 12.0 mL/s were considered to have good flow.

Results

Among the 114 men, 61 patients had good urinary flow. Their median age, PV and Q_max were 66 years, 32.9 mm³ and 14.5 mL/s respectively. 14/61 (23.0%) patients had BOO and their distribution of IPP were as follows: Grade 1 – 0/20 (0%) obstructed, Grade 2 – 6/22 (27.3%) and Grade 3 – 8/19 (42.1%). Sensitivity of Grade 2/3 IPP for BOO was 100% while specificity of Grade 3 IPP was 76.6%. The area-under-curve (AUC) for IPP was greater than that for PV (0.757 vs. 0.696).

Conclusion

Even in men with good flow, high grades of IPP were more likely to have BOO and hence, may be a useful adjunct to predict BOO.

The role of intravesical prostatic protrusion (IPP) in the evaluation and treatment of bladder outlet obstruction (BOO)

AIMS

Intravesical prostatic protrusion (IPP) may be an underutilized modality for the assessment of bladder outlet obstruction (BOO). Pressure flow studies or urodynamics have long been the gold standard for the evaluation of lower urinary tract symptoms (LUTS) in men but are invasive, time-consuming and costly. Potentially, IPP may be a useful adjunct prior to performing urodynamics.

METHODS

Measurement of IPP is taken in the sagittal view, using the transabdominal ultrasound. It is the vertical height from the tip of the protrusion to the base of the prostate. This technique was previously described. We reviewed previous publications that studied the accuracy, positive predictive value and clinical use of IPP. In addition, we noted the comments regarding the challenges of using this technique.

RESULTS

IPP has been shown to have a positive predictive value of 72% for BOO. It has been calculated to have an area under curve (AUC) value of 0.71 and 0.84 in some stuies. Clinically, it may be used to predict the outcome of a trial without catheter following acute retention of urine. Patients with higher IPP grade were noted to have a higher risk of clinical progression. Studies have also shown that men with higher IPP are poorer responders to medical treatment such as α-blockers.

CONCLUSIONS

Compared to other modalities, the advantage of IPP in assessing BOO may be its easy applicability and non-invasive nature. Therefore, there is a consideration for a larger role of IPP in bedside assessment and management of BOO in daily practice. Neurourol. Urodynam. 35:535-537, 2016. © 2015 Wiley Periodicals, Inc.

Relationships between Prostatic Volume and Intravesical Prostatic Protrusion on Transabdominal Ultrasound and Benign Prostatic Obstruction in Patients with Lower Urinary Tract Symptoms

Introduction: The objective of this study is to determine the relationships between prostatic volume (PV) and intravesical prostatic protrusion (IPP) with benign prostatic obstruction (BPO). Materials and Methods: A total of 408 males (aged 50 years and above) who presented with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) were recruited. All had International Prostate Symptoms Score (IPSS), quality of life (QOL) index, urofl owmetry (Qmax) and postvoid residual urine (PVR) measured by transabdominal ultrasonography (TAUS). The PV and the degree of IPP were also measured by TAUS in the transverse and sagittal planes respectively. The PV is classifi ed as Grade a, (20 ml or less), Grade b, (more than 20 ml to 40 ml) and Grade c, (more than 40 ml), while the IPP is graded as Grade 1 (5 mm or less), Grade 2 (more than 5 mm to 10 mm) and Grade 3 (more than 10 mm). Results: There was a fair positive correlation between the PV and IPP (Spearman, rs = 0.62, P <0.001) with important clinical exceptions. There was negative correlation between the PV and Qmax (rs = -0.20, P = 0.022), IPP and Qmax (rs = -0.30, P <0.001). PV and IPP were good predictors of BPO. However, IPP was slightly better (rs of -0.30 vs -0.20) than PV. Conclusion: PV is related to IPP with important clinical exceptions. IPP is a better predictor of BPO than PV. Key words: Benign prostatic hyperplasia, Prostate volume

Prostatic urethral angle might be a predictor of treatment efficacy of α-blockers in men with lower urinary tract symptoms

Purpose

We investigated the association of the prostatic urethral angle (PUA) with peak urinary flow rate (Q_max) and the severity of lower urinary tract symptoms (LUTS) on the aging male. We also evaluated the effect of the PUA on the treatment efficacy of tamsulosin on men with LUTS.

Materials and methods

The records were obtained from a prospective database for first-visit male patients with LUTS in the outpatient department of our institution. These patients underwent a detailed physical examination and taking of medical history. A transrectal ultrasound was performed on these patients. The prostate size, length of intravesical prostatic protrusion (IPP), PUA, and International Prostate Symptom Score (IPSS) of the patients were evaluated. Uroflowmetry and a bladder scan for residual urine were also performed on every patient. Tamsulosin 0.2 mg per day was prescribed. The IPSS and uroflowmetry were reevaluated after they had received treatment for 3 months.

Results

A total of 178 patients were included, and 149 of them completed this cohort study. The mean PUA was 48.32°±13.74°. The mean prostate volume was 39.19±20.87 mL, and the mean IPP was 5.67±7.85 mm. On multivariate linear regression analysis, the PUA was independently associated with the IPSS (P<0.001), Q_max (P=0.004), post-treatment IPSS change (P=0.032), and post-treatment Q_max change (P<0.001). However, the prostate volume and IPP were not associated with these clinical items.

Conclusion

The PUA is significantly associated with Q_max and IPSS in men with LUTS. The PUA is also inversely correlated with changes in Q_max and IPSS after tamsulosin treatment. Namely, the PUA might be a predictor for the treatment efficacy of α-blockers in aging men with LUTS.

Diagnosis of prostate adenoma and the relationship between the site of prostate adenoma and bladder outlet obstruction

INTRODUCTION

The objective of this study was to evaluate the accuracy of using intravesical prostatic protrusion (IPP) as a parameter for the diagnosis of prostate adenoma (PA), as well as to determine the relationship between the site of PA and bladder outlet obstruction. IPP was determined with the use of transabdominal ultrasonography (TAUS).

METHODS

A total of 77 consecutive adult men aged 30-85 years with haematuria or undergoing checkup for bladder tumour were enrolled. International Prostate Symptom Score (IPSS), and the results of uroflowmetry, TAUS and cystourethroscopy were assessed. All cases of IPP were classified into grades 0 (no IPP), 1 (1-5 mm), 2 (6-10 mm) or 3 (> 10 mm). PA diagnosis was confirmed using flexible cystourethroscopy. The sites of PA were classified as U0 (no adenoma), U1 (lateral lobes), U2 (middle lobe) or U3 (lateral and middle lobes).

RESULTS

Of the 77 patients, 11 (14.3%) had no IPP. PA was confirmed using cystourethroscopy for all patients with IPP and for 7 of the 11 patients without IPP. Of the 37 patients with prostate volume < 20 g, 29 (78.4%) had IPP. Sensitivity, specificity, as well as positive and negative predictive values for diagnosing PA using only IPP were 90.4%, 100.0%, 100.0% and 36.4%, respectively. Higher sensitivity (95.9%) and negative predictive value (50.0%) were obtained when PA was used together with peak urinary flow rate (Qmax) < 20.0 mL/s. The mean Qmax of patients classified as U1 (n = 39) was 16.0 mL/s, while the mean Qmax in those classified as U2 (n = 12) and U3 (n = 22) was 11.9 mL/s and 8.9 mL/s, respectively.

CONCLUSION

All patients with IPP had PA, and PA in the middle lobe was more obstructive than those in lateral lobes. Patients without IPP may still have PA.

Pelvic ultrasound evaluation for benign prostatic hyperplasia: prediction of obstruction

Global improvements in water quality, management of infectious diseases, and other medical therapeutics have resulted in a growing population of healthy aging men. One obligate anatomic consequence of aging for these men is the development of benign prostatic hyperplasia (BPH) with secondary bladder outlet obstruction. Although the voiding symptoms associated with the change in bladder health over time predominantly impact the quality of a man's daily experience, there are also significant medical consequences of BPH that require intervention. It is a challenge to distinguish men who are at risk for these medical consequences from the much larger population of older men with voiding symptoms (lower urinary tract symptoms, LUTS). A variety of national guidelines have been developed to establish a diagnostic paradigm for meeting this challenge, but all suffer from inadequate sensitivity for the early identification of men at risk for permanent bladder injury. It is likely that the application of a thorough pelvic ultrasound designed to identify the pertinent anatomic aspects of both the bladder and prostate will improve the sensitivity of these diagnostic paradigms, with subsequent improvement in the outcomes for men with BPH/LUTS.

A new model consists of intravesical prostatic protrusion, prostate volume and serum prostatic-specific antigen in the evaluation of prostate cancer

The Prostate-specific antigen (PSA) level is largely used to diagnose prostate cancer (PCa) in last decades. However, its specificity is low in patients with a PSA level ranging from 4.0 to 10.0 ng/ml. This study aims to define the correlation between intravesical prostatic protrusion (IPP) and PSA and to establish a new model to predict PCa. A total of 339 patients order than 45 years examined between October 2010 and June 2012 were enrolled. Eligible patients were recommended for transrectal ultrasonography (TRUS)-guided prostate biopsies after measuring total prostate volume (TPV), tranzisional zone volume (TZV) and IPP. The levels of total PSA (tPSA), free PSA (fPSA) were analyzed by using Hybritech calibrated Access tPSA and fPSA assays. A new mathematical model, named IPP removed PCa predicting score (IRPPS), consists of tPSA, TZV and IPP was established. The predictive accuracy of IRPPS, PSA density (PSAD), %PSA and tPSA were compared using receiver-operator characteristic (ROC) analysis. Eighty-six patients had PSA levels of 4.0-10.0 ng/ml. Twenty of them were diagnosed as PCa. Using ROC curves, the areas under the curve for IRPPS, PSAD and %PSA and tPSA were 0.786, 0.768 and 0.664 and 0.585, respectively. We suggested IPP grade had a significant relationship with serum tPSA levels. The predictive accuracy of IRPPS was higher than the other 3 indictors.

Digital rectal examination standardization for inexperienced hands: teaching medical students

Objectives. To standardize digital rectal examination (DRE) and set how it correlates with the comprehensive evaluation of lower urinary tract symptoms (LUTS). Methods. After scaled standardization of DRE based on fingertips graphical schema: 10 cubic centimeters-cc for each fingertip prostate surface area on DRE, four randomly selected senior medical students examined 48 male patients presenting with LUTS in an outpatient clinical setting, totaling 12 DRE each. Standardized DRE, international prostate symptom score (IPSS), serum PSA, transabdominal ultrasound (US), urodynamic evaluation, and postvoid residue were compared. Results. The mean and median PVs were US-45 and 34.7 cc (5.5 to 155) and DRE-39 and 37.5 cc (15 to 80). Comparing DRE and US by simple linear regression: US PV = 11.93 + 0.85 × (DRE PV); P = 0.0009. Among patients classified as nonobstructed, inconclusive, and obstructed, the US PVs were 29.8, 43.2, and 53.6 cc (P = 0.033), and DRE PVs were 20, 35, and 60 cc (P = 0.026), respectively. Conclusion. This is the first attempt to DRE standardization focusing on teaching-learning process, establishing a linear correlation of DRE and US PVs with only 12 examinations by inexperienced hands, satisfactorily validated in an outpatient clinical setting.

Quantification of median lobe protrusion and its impact on the base surgical margin status during robot-assisted laparoscopic prostatectomy

PURPOSE

Protrusion of the median lobe (PML) is thought to add technical difficulty during robot-assisted laparoscopic prostatectomy (RALP). Thus, we quantified PML using preoperative magnetic resonance imaging (MRI) and evaluated its impact on base surgical margin (BSM) status during RALP.

METHODS

The clinical data of consecutive patients who underwent RALP were retrieved from a prospectively registered database. Of the 655 eligible men, 9 patients were excluded because they did not undergo MRI. PML was measured in a T2-weighted mid-sagittal scan. We performed univariate and multiple logistic regression analyses.

RESULTS

The mean PML was 8.3 ± 3.6 mm. The rate of positive surgical margins was 17.3 % (73/423) in pathologic stage T2 and 34.6 % (226/646) in all cases. The BSMs were positive in 10.1 % (66/646) of cases. A logistic regression analysis revealed that PML was significantly correlated with BSM positivity in all cases (odds ratio [OR] 1.080, p = 0.026). In particular, they had a stronger correlation with pathologic stage T3 or higher (OR 1.1143, p = 0.004). PML was an independent predictor of BSM positivity (OR 1.113, p = 0.046) in pathologic stage T3 or higher, as were preoperative prostate-specific antigen, prostate size, and pathologic stage. Cases with 10 mm or higher PML had significantly more BSM positivity than cases with <10 mm PML (35.9 vs. 20.1 %, p = 0.012).

CONCLUSIONS

Protrusion of the median lobe measured using preoperative MRI was significantly correlated with positive BSMs during RALP. Surgeons should pay more attention to patients with 10 mm or higher PML and advanced stages.