Computerized artifact detection and correction of uroflow curves: towards a more consistent quantitative assessment of maximum flow

Effectiveness and safety of electroacupuncture and its cotreatment with electronic moxibustion in the treatment of patients with moderate benign prostatic hyperplasia using alpha blocker: An assessor-blinded, randomized, controlled pilot study

BACKGROUND

Benign prostatic hyperplasia (BPH) is a disease that affects the quality of life by causing lower urinary tract symptoms (LUTS) in men. Electroacupuncture (EA) and moxibustion therapy have been suggested as an adjunct therapy for improving LUTS in patients with BPH, but clinical studies evaluating the effectiveness of EA and its cotreatment with electronic moxibustion (EM) in patients who have been prescribed alpha blockers have yet to be reported. Therefore, this study aimed to evaluate the effectiveness and safety of EA and EM.

METHODS

Twenty-eight patients diagnosed with BPH were randomized to treatment group (TG, n = 14) or control group (CG, n = 14). The TG continued to use the previously prescribed alpha blocker and received the cotreatment of EA and EM 3 times a week for 6 weeks. The CG continued to use the previously prescribed alpha blocker alone for 6 weeks. The primary outcome was the mean change in the international prostate symptom score (IPSS) from baseline to week 6. The secondary outcomes were IPSS at week 3 and 12, clinical relevance, IPSS life satisfaction, EuroQol-Five dimensions, average urinary flow rate, maximum urinary flow rate, and prostate volume.

RESULTS

The IPSS decreased at all time points with a statistically significant difference between the 2 groups (3W: P = .0313; 6W: P = .0010; 12W: P = .0304). Based on the minimal clinically important difference (MCID, 3 points), there were significant differences between the TG and the CG at week 3, 6, and 12 (3W: P = .0461; 6W: P = .0123; 12W: P = .0216). Significant group × week interaction effects were found for the IPSS score (P = .0018), as determined from analyses using repeated measures analysis of variance. There were no significant differences between the 2 groups in IPSS life satisfaction, EuroQol-Five dimensions, average urinary flow rate, maximum urinary flow rate, and prostate volume.

CONCLUSION

EA and its cotreatment with EM might have a beneficial effect as an adjunct therapy in improving LUTS in patients with BPH. Large-scale randomized controlled trials are warranted to confirm the effectiveness and safety of EA and its cotreatment with EM.

Benign prostatic hyperplasia: clinical manifestations and evaluation

Benign prostatic hyperplasia (BPH) is a very common condition, related to aging and causing symptoms, called lower urinary tract symptoms. On account of its huge prevalence, it is important for clinicians who are involved in the management of patients with BPH to be aware of the very strict recommendations for BPH evaluation. In this article, we describe the different steps and procedures doctors should follow to evaluate these patients; symptoms and signs of BPH are reviewed, as well as the clinical evaluation steps and examinations available. The basic evaluation of the patients with BPH should include, according to the recommendations of the most relevant international guidelines, lower urinary tract symptoms evaluation with appropriate symptom scores, digital rectal examination, voiding charts, prostate-specific antigen and creatinine measurement, urinalysis, and imaging of the urinary tract.

Interobserver agreement for noninvasive bladder pressure flow recording with penile cuff

PURPOSE

We assessed variability in interpreting noninvasive measurements of bladder pressure and urine flow between experienced and novice users of the penile cuff.

MATERIALS AND METHODS

Urodynamicists at 6 sites were asked to use the penile cuff test as part of clinical assessment in 30 men presenting with lower urinary tract symptoms. After a short training period they measured maximum flow rate and cuff interruption pressure from penile cuff test recordings to enable categorization of bladder outlet obstruction using a nomogram. Similar measurements were then made on the same traces by 2 expert observers from the originating center. Interobserver differences were assessed.

RESULTS

Complete agreement on obstruction categorization was seen in 77% of subjects, which increased to 86% when plots positioned on category boundary lines were allocated to the favored category. The 95% confidence limits of interobserver variability in maximum flow rate and cuff interruption pressure measurements were +/- 1.7 ml per second and +/- 13 cm H(2)O, respectively, although a small number of studies yielded discrepancies between observers that were larger than expected. They arose from complex recordings but were equally likely between experts as between expert and novice. Investigation of the causes suggested in some cases how such discrepancies may be avoided in the future.

CONCLUSIONS

The excellent level of agreement in measurement and categorization after a short training period suggests that introducing the penile cuff test as part of assessment in men with lower urinary tract symptoms would be straightforward.

Brachytherapy in localized prostatic cancer: 100 years of radium

Contemporary series of brachytherapy in localized prostate cancer show promising early results attributable to improved patient selection and technical refinements in treatment modalities. These innovations consist essentially of precise three-dimensional radioactive dose-distribution planning and source placement, thus solving the problem of possible under-dosage encountered in open brachytherapy.

Reliability and Agreement of Urodynamics Interpretations in a Female Pelvic Medicine Center

OBJECTIVE

To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function.

METHODS

Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (kappa) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians.

RESULTS

For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted kappa's were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each kappa were between 0.023 and 0.043.

CONCLUSION

In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses.

Evaluation of the Clinical Benefit of Permixon and Tamsulosin in Severe BPH Patients—PERMAL Study Subset Analysis

OBJECTIVE

To compare the efficacy of the lipido-sterolic extract of Serenoa repens, Permixon, to that of the alpha-blocker, tamsulosin, in the treatment of severe low urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH).

METHODS

In a 12-month, double-blind, randomized study that showed equivalent efficacy of Permixon 320 mg/day and tamsulosin 0.4 mg/day ("PERMAL study"), 685 BPH patients with IPSS > or =10 had been analyzed for efficacy. Of these, the 124 patients with severe LUTS (IPSS >19) at randomization were retained for this subset analysis. After a 4-week run-in period, 59 and 65 patients had been randomized to tamsulosin and Permixon groups, respectively. Both treatment groups were compared regarding the evolution from baseline of total IPSS and its irritative and obstructive subscores, LUTS-related QoL, prostate volume, Q(max) and MSF-4 (sexual activity questionnaire) at different time points over 1 year. An analysis of variance of changes from baseline to end point was performed for all the parameters. The over-time evolutions of total, irritative and obstructive IPSS were further compared using a variance analysis for repeated measurements.

RESULTS

At 12 months, total IPSS decreased by 7.8 with Permixon and 5.8 with tamsulosin (p=0.051); the irritative symptoms improved significantly more (p=0.049) with Permixon (-2.9 versus -1.9 with tamsulosin). The superiority of Permixon in reducing irritative symptoms appeared as soon as month 3 and was maintained up to month 12 (p=0.03).

CONCLUSION

Permixon 320 mg/day was shown to be slightly superior to tamsulosin 0.4 mg/day in reducing LUTS in severe BPH patients after 3 months and up to 12 months of treatment.

Computerised assessment of maximum urinary flow: an efficient, consistent and valid approach

OBJECTIVES

To evaluate the relative accuracy of a computerised method to quantitatively assess maximum urinary flow.

METHODS

A total of 1147 uroflows were evaluated by the computerised method and by three experts from different European countries. The sample consisted of uroflows from the respective visits by a 20% sample of randomly chosen patients (n = 223) with lower urinary tract symptoms with participation in two clinical trials in which the efficacy and safety of Permixon was evaluated. The proportions of automated maximum flow values included in the 10% extended range of experts (and their 95% confidence intervals) were assessed, as well as the concordance coefficients between experts and the computerised method and the paired Student's t-test for the average differences between experts and computer.

RESULTS

The rate of agreement between experts and computer varied between about 95 and 100% over factor levels for visit, type of machine and country. Concordance coefficients indicated good agreement between experts and the automated method. When looking at average differences between experts and the computer, the smallest differences were observed between experts 2, 3 and the computer (differences not statistically significant). Statistically significant average differences were observed between expert 1 and the other experts as well as between expert 1 and the computer.

CONCLUSIONS

The computerised assessment decreases the fraction of variability of maximum urinary flow caused by artifacts as well as intra- and inter-expert variation. The computerised assessment of maximum urinary flow is an efficient, consistent and valid approach to quantitatively assess maximum urinary flow in clinical trials.

The use of voiding studies (flowmetry and urodynamics) in the assessment and follow-up of patients

The role of urinary flow measurement and pressure-flow studies in the diagnostic work-up of men presenting with lower urinary tract symptoms suggestive of benign prostatic obstruction is still an unresolved issue. In this paper, evidence from the peer-reviewed literature of the last 12 months is critically reviewed in the light of the recent recommendations of the 4th International Consultation on benign prostatic hyperplasia.