The prostatic middle lobe: clinical significance, presentation and management

The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.

Correlation between bladder wall thickness and uroflowmetry in West African patients with benign prostatic enlargement

Background

Pressure flow urodynamic study remains the gold standard for the diagnosis of bladder outlet obstruction; however, their use is limited by their relative unavailability in our environment, cost, and invasiveness. Measurement of bladder wall thickness (BWT) by transabdominal ultrasonography is a promising tool that can be used to diagnose bladder outlet obstruction in our environment where pressure-flow urodynamic study is not readily available.

Objective

The study aimed to correlate BWT with uroflowmetry and to establish a BWT cut-off in patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement.

Materials and Methods

This was a prospective one-year study of patients with LUTS due to benign prostatic enlargement. The patients were divided into obstructed and non-obstructed groups with Q- max of 10 ml/s serving as the cut-off value. Receiver Operator Curve (ROC) was used to evaluate the performance of BWT in diagnosing BOO. Statistical significance was set at P < 0.05.

Results

The mean BWT and Q-max were 4.53 ± 2.70 mm and 15.06 ± 9.43 ml/s. There was a negative correlation between BWT and Q-max (r = -0.452, P = 0.000), Q-average (r = -0.336, P = 0.000), and voided volume (r = -0.228, P = 0.046). A BWT cut-off of 5.85 mm was found to be the best threshold to differentiate obstructed from non-obstructed patients with a sensitivity and specificity of 70 and 88.2 percent respectively.

Conclusion

Bladder wall thickness showed an inverse relationship with maximum flow rate with high sensitivity and specificity. This non-invasive test can be used as a screening tool for BOO in our setting, where the pressure flow urodynamic study is not readily available.

Impact of the bladder detrusor muscular ring on lower urinary tract symptoms due to benign prostatic hyperplasia: A quantitative MRI analysis

BACKGROUND

The etiology of lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH) remains uncertain.

OBJECTIVE

The purpose of our study was to quantitatively analyze anatomic characteristics on magnetic resonance imaging (MRI) to assess novel independent factors for symptoms.

METHODS

This retrospective single-institution study evaluated treatment-naïve men who underwent prostate MRI within 3 months of international prostate symptom score (IPSS) scoring from June 2021 to February 2022. Factors measured on MRI included: size of the detrusor muscular ring (DMR) surrounding the bladder outlet, central gland (CG) mean apparent diffusion coefficient (ADC), levator hiatus (LH) volume, intrapelvic volume, intravesicular prostate protrusion (IPP) volume, CG volume, peripheral zone (PZ) volume, prostate urethra angle (PUA), and PZ background ordinal score. Multivariable logistic regression and receiver operating characteristic analysis were used to analyze factors for moderate/severe (IPSS ≥ 8) and severe LUTS/BPH (IPSS ≥ 20).

RESULTS

A total of 303 men (mean age: 66.1 [SD: 8.1]) were included: 154 demonstrated moderate or severe symptoms with 28 severe and 149 with asymptomatic/mild symptoms. Increasing age [p = 0.02; odds ratio (OR): 1.05 (1.01-1.08)], PUA [p = 0.02; OR: 1.05 (1.01-1.09)], LH volume [p = 0.04; OR: 1.02 (1.00-1.05)], and DMR size measured as diameter [p < 0.001; OR: 5.0 (3.01-8.38)] or area [p < 0.001; OR: 1.92 (1.47-2.49)] were significantly independently associated with moderate/severe symptoms, with BMI [p = 0.02; OR: 0.93 (0.88-0.99)] inversely related. For every one cm increase in DMR diameter, patients had approximately five times the odds for moderate/severe symptoms. Increasing DMR size [diameter p < 0.001; OR: 2.74 (1.76-4.27) or area p < 0.001; OR: 1.37 (1.18-1.58)] was independently associated with severe symptoms. Optimal criterion cutoff of DMR diameter for moderate/severe symptoms was 1.2 cm [sensitivity: 77.3; specificity: 71.8; AUC: 0.80 (0.75-0.84)]. Inter-reader reliability was excellent for DMR diameter [ICC = 0.92 (0.90-0.94)].

CONCLUSION

Expansion of the DMR surrounding the bladder outlet is a novel anatomic factor independently associated with moderate and severe LUTS/BPH, taking into account prostate volumes, including quantified IPP volume, which were unrelated. Detrusor ring diameter, easily and reliably measured on routine prostate MRI, may relate to detrusor dysfunction from chronic stretching of this histologically distinct smooth muscle around the bladder neck.

Foggia Prostate Cancer Risk Calculator 2.0: A Novel Risk Calculator including MRI and Bladder Outlet Obstruction Parameters to Reduce Unnecessary Biopsies

Risk calculator (RC) combining PSA with other clinical information can help to better select patients at risk of prostate cancer (PCa) for prostate biopsy. The present study aimed to develop a new Pca RC, including MRI and bladder outlet obstruction parameters (BOOP). The ability of these parameters in predicting PCa and clinically significant PCa (csPCa: ISUP GG ≥ 2) was assessed by binary logistic regression. A total of 728 patients were included from two institutions. Of these, 395 (54.3%) had negative biopsies and 161 (22.11%) and 172 (23.6%) had a diagnosis of ISUP GG1 PCa and csPCa. The two RC ultimately included age, PSA, DRE, prostate volume (pVol), post-voided residual urinary volume (PVR), and PIRADS score. Regarding BOOP, higher prostate volumes (csPCa: OR 0.98, CI 0.97,0.99) and PVR ≥ 50 mL (csPCa: OR 0.27, CI 0.15, 0.47) were protective factors for the diagnosis of any PCa and csPCa. AUCs after internal validation were 0.78 (0.75, 0.82) and 0.82 (0.79, 0.86), respectively. Finally, decision curves analysis demonstrated higher benefit compared to the first-generation calculator and MRI alone. These novel RC based on MRI and BOOP may help to better select patient for prostate biopsy after prostate MRI.

Severe urinary tract damage secondary to primary bladder neck obstruction in women

Objective

To present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI).

Methods

Retrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4–5 and/or 7–8 o’clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline.

Results

Median patient age was 56.5 years (range 40–80). All presented with urinary retention–four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0–4.0] mL/s to 15 [10–22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22–76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients.

Conclusion

PBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

Biometric and morphological features on magnetic resonance imaging of fetal bladder in lower urinary tract obstruction: new perspectives for fetal cystoscopy

OBJECTIVES

Incompatibility between currently available fetoscopes and the anatomical constraints of the distended fetal bladder, with the resulting curvature around the bladder neck, account for most technical difficulties during fetal cystoscopy in lower urinary tract obstruction (LUTO). The aim of this anatomical study was to assess by magnetic resonance imaging (MRI) the variation in three bladder angles (bladder-neck angle (BNA), vesicourethral angle (VUA) and angle between bladder dome and posterior urethra (DUA)), according to gestational age (GA), bladder volume and the presence of LUTO.

METHODS

From our fetal medicine database, we retrieved for review 46 MRI examinations of male fetuses between 2015 and 2019, including 17 with LUTO, examined at a mean GA of 28.1 (range, 17.3-35.0) weeks and 29 age-matched controls, examined at 29.9 (range, 21.9-35.0) weeks. We measured bladder volume, bladder-wall thickness and the three bladder angles, and used the Mann-Whitney U-test to compare values between groups. Variations according to GA and bladder volume were determined using analysis of variance (ANOVA). A reliability study was performed using the Bland-Altman method and Lin's correlation coefficient was calculated.

RESULTS

Both bladder volume and bladder-wall thickness were significantly greater in the LUTO group (P < 0.01). BNA was significantly larger in LUTO compared with control fetuses: the mean (range) was 127.1° (101.6-161.6°) vs 111.2° (88.5-157.3°) (P < 0.01). DUA averaged 117° and showed no difference between the groups (P = 0.92). No statistical comparison was performed on VUA since this was not measurable in most control fetuses. ANOVA showed no variation of any angle with bladder volume in both LUTO fetuses and control fetuses. BNA in LUTO fetuses was the only angle to vary with GA, being larger after, compared with at or before, 25 weeks (P = 0.04). The reliability study showed an acceptable bias for both intra- and interobserver reproducibility for all three angles.

CONCLUSION

The findings that BNA is increased by approximately 15° in fetuses with LUTO and DUA averages 117° could aid in development of a customized fetal cystoscope and help to overcome the current technical challenges of fetal cystoscopy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Value of Real-Time Shear Wave Elastography Versus Acoustic Radiation Force Impulse Imaging in the Diagnosis of Female Bladder Neck Obstruction

OBJECTIVE

To investigate the application value of shear wave elastography (SWE) and acoustic radiation force impulse imaging (ARFI) in the diagnosis of female bladder neck obstruction (FBNO), we compared the advantages of these 2 methods to provide a more accurate reference for clinical work.

METHODS

From April 2016 to February 2018, 27 patients who were diagnosed with FBNO by cystoscopy and/or urine dynamics testing were selected for the study, together with 24 healthy adults in a case-control study at Liaoning Province People's Hospital. We collected general information from 27 patients with FBNO, and using transperineal 2-dimensional ultrasound detection, shear wave elastography (SWE) and ARFI were used, respectively, to detect the Young's modulus and shear wave velocity (SWV) of the bladder necks. Cystoscopy results were considered to be the gold standard, and receiver operating characteristic (ROC) curves were drawn for ARFI, SWE, and the combined diagnosis of the two. The efficacy of the diagnosis was determined by comparing the areas under the ROC curves and calculating the sensitivity, specificity, and accuracy.

RESULTS

The areas under the ROC curve for the Q-box mean and max value detected by SWE for FBNO patients were 88.4% and 89.9%, respectively, and the sensitivity, specificity, and accuracy were 81.5%, 79.2%, and 80.4%, respectively. The area under the ROC curve detected by ARFI for FBNO patients was 93.7%, and the sensitivity, specificity, and accuracy were 88.9%, 79.2%, and 84.3%, respectively. The sensitivity, specificity, and accuracy of the combined detection of ARFI and SWE were 92.5%, 87.5%, and 90.2%, respectively. The best diagnostic cutoff point of the SWV or the Q-box mean and max value of SWE in FBNO obtained with the ROC curve was SWV = 2.38 m/s (sensitivity, 71.4%; specificity, 82.5%), Q-box mean = 20.2 kPa, Q-box max = 39.8 kPa (sensitivity, 67.5%; specificity, 76.2%). The average shear wave velocity of ARFI, Q-box mean, and Q-box max value of SWE in the control group were 1.89 ± 0.35 m/s, 15.3 ± 3.6 kPa, and 29.2 ± 8.7 kPa, respectively. In the FBNO group, these values were 2.81 ± 0.63) m/s, 27.2 ± 8.6 kPa, and 51.2 ± 12.3 kPa, respectively. The differences were statistically significant (P < .05).

CONCLUSION

The value of the ARFI in the diagnosis of FBNO is a little greater than that of SWE in terms of sensitivity and accuracy, and the combined detection of ARFI and SWE performs better than ARFI or SWE employed separately.

Ultrasonography of the Adult Male Urinary Tract for Urinary Functional Testing

The incidence of clinical benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is increasing due to the aging population, resulting in a significant economic and quality of life burden. Transgenic and other mouse models have been developed to recreate various aspects of this multifactorial disease; however, methods to accurately quantitate urinary dysfunction and the effectiveness of new therapeutic options are lacking. Here, we describe a method that can be used to measure bladder volume and detrusor wall thickness, urinary velocity, void volume and void duration, and urethral diameter. This would allow for the evaluation of disease progression and treatment efficacy over time. Mice were anesthetized with isoflurane, and the bladder was visualized by ultrasound. For non-contrast imaging, a 3D image was taken of the bladder to calculate volume and evaluate shape; the bladder wall thickness was measured from this image. For contrast-enhanced imaging, a catheter was placed through the dome of the bladder using a 27-gauge needle connected to a syringe by PE50 tubing. A bolus of 0.5 mL of contrast was infused into the bladder until a urination event occurred. Urethral diameter was determined at the point of the Doppler velocity sample window during the first voiding event. Velocity was measured for each subsequent event yielding a flow rate. In conclusion, high frequency ultrasound proved to be an effective method for assessing bladder and urethral measurements during urinary function in mice. This technique may be useful in the assessment of novel therapies for BPH/LUTS in an experimental setting.

Current epidemiology and antenatal presentation of posterior urethral valves: Outcome of BAPS CASS National Audit

AIM

Posterior urethral valves (PUVs) are the most common cause of congenital bladder outlet obstruction (BOO) in boys and end-stage renal failure (ESRF) in childhood. In the 1980s, 1 in 4000 boys had PUV. Presentation was 1/3 antenatal/neonatally, 1/3 postnatal, 1/3 late (>1 year). This study aimed to describe the current proportions in a contemporary cohort.

METHODS

A national audit (BAPS CASS) of referrals in the UK and Ireland of boys diagnosed with suspected or confirmed PUV in a year was conducted. National registration data provided the male birth-rate. Data were presented as number (%), analysed by Mann-Whitney U-test and Chi-square test, with P < 0.05 taken as significant. The study was approved by a national ethics committee (NRES Committee South Central Oxford A (12/SC/0416)).

RESULTS

Data were collected from 1st October 2014 to 30th September 2015 from 25/26 centres on 121 cases of suspected bladder outlet obstruction (BOO), of which 113 (93%) were because of PUV. The male birth rate during the period was 432,806/year. The calculated incidence of BOO was 1/3580 and for PUV was 1/3800 per-annum. The proportion of PUV presenting according to age was: antenatally (n = 40, 35%), infancy (n = 47, 42%), and late (n = 26, 23%). Plasma creatinine was higher in antenatally-diagnosed BOO vs. postnatal, 54 (39.5-109.5) μmol/l vs. 34(21-47) μmol/l, P = 0.0005. Hydronephrosis and ureteric dilatation were significantly greater in antenatally diagnosed BOO vs. postnatal vs. late. Renal dysplasia (cortical thinning, poor corticomedullary differentiation, or renal cysts) was significantly more likely in antenatally diagnosed BOO.

CONCLUSION

Neither the incidence (~1/4000) nor the proportion antenatally diagnosed (~1/3) of boys with PUV appears to have changed in the past 30 years. Those boys who were antenatally diagnosed have significantly higher postnatal plasma creatinine, more hydroureteronephrosis, and renal dysplasia than those diagnosed in infancy or later. It may be hypothesized that this is the reason they are detected antenatally.

LEVEL OF EVIDENCE

Prognosis study - Level I - prospective national cohort study.

Vector Flow Visualization of Urinary Flow Dynamics in a Bladder Outlet Obstruction Model

Voiding dysfunction that results from bladder outlet (BO) obstruction is known to alter significantly the dynamics of urine passage through the urinary tract. To non-invasively image this phenomenon on a time-resolved basis, we pursued the first application of a recently developed flow visualization technique called vector projectile imaging (VPI) that can track the spatiotemporal dynamics of flow vector fields at a frame rate of 10,000 fps (based on plane wave excitation and least-squares Doppler vector estimation principles). For this investigation, we designed a new anthropomorphic urethral tract phantom to reconstruct urinary flow dynamics under controlled conditions (300 mm H₂O inlet pressure and atmospheric outlet pressure). Both a normal model and a diseased model with BO obstruction were developed for experimentation. VPI cine loops were derived from these urinary flow phantoms. Results show that VPI is capable of depicting differences in the flow dynamics of normal and diseased urinary tracts. In the case with BO obstruction, VPI depicted the presence of BO flow jet and vortices in the prostatic urethra. The corresponding spatial-maximum flow velocity magnitude was estimated to be 2.43 m/s, and it is significantly faster than that for the normal model (1.52 m/s) and is in line with values derived from computational fluid dynamics simulations. Overall, this investigation demonstrates the feasibility of using vector flow visualization techniques to non-invasively examine internal flow characteristics related to voiding dysfunction in the urethral tract.

Video-urodynamic characteristics of non-neurogenic, idiopathic underactive bladder in men - A comparison of men with normal tracing and bladder outlet obstruction

Objective

Underactive bladder is frequently encountered in elderly patients. It may result from detrusor underactivity (DU) or low detrusor contractility due to a urethral sphincter inhibitory effect. This study analyzed the video-urodynamic study (VUDS) characteristics of patients with underactive bladder in a large cohort of men with lower urinary tract symptoms (LUTS).

Methods

Male patients with LUTS who had failed the initial treatment were consecutively enrolled. All patients underwent detailed urological investigations including prostate measurement, free uroflowmetry, post-void residual volume (PVR) measurement, cystoscopy and VUDS. The VUDS characteristics of the men with underactive bladder were analyzed and compared with those of men with bladder outlet obstruction and normal tracing.

Results

A total of 1329 men who underwent VUDS were included in this retrospective analysis. After VUDS, the final diagnosis was DU in 165 patients, poor relaxation of external sphincter (PRES) in 525, bladder outlet obstruction in 501, and normal tracing in 138. VUDS findings in DU patients showed a slowly increased detrusor pressure, intermittent detrusor contractions, or early decline of detrusor contraction, resulting in a low maximum flow rate (Qmax), and large PVR. In comparison with the PRES groups, DU patients were older, had reduced bladder sensation, lower detrusor pressure (Pdet), lower Qmax, larger PVR volume, and lower voiding efficiency. Patients with urodynamic PRES also had low-pressure–low-flow tracings, but their bladder sensation was similar to that with normal tracing. DU patients with very low Pdet also had low detrusor tonicity, and more medical co-morbidities than the other groups did.

Conclusion

Idiopathic underactive bladder in elderly men could be attributed to urodynamic DU and PRES. DU is associated with old age, reduced bladder sensation, low voiding efficiency, and medical co-morbidities.

Transperineal Sonography and Urodynamic Findings in Women With Lower Urinary Tract Symptoms After Sling Placement

OBJECTIVES

To evaluate dynamic 2-dimensional (2D) transperineal pelvic sonographic findings and urodynamic studies in women with lower urinary tract symptoms after midurethral sling placement.

METHODS

Transperineal pelvic sonography and urodynamic studies were reviewed from women with a midurethral sling and lower urinary tract symptoms. The shape and sonographic dynamic change of the sling from the rest position to the maximum Valsalva maneuver and back to rest were recorded. Patients were categorized into 3 groups: group I, at rest, the sling lies parallel to the urethral lumen, and during Valsalva, the sling becomes C shaped; group 2, both at rest and during Valsalva, the sling runs parallel to the urethral lumen; and group 3, at rest, the sling is C shaped, and during Valsalva, this curved shape is maintained. For analytical purposes group 3 was compared with groups 1 and 2. Multiple logistic regressions were used to evaluate the association between transperineal pelvic sonography and urodynamic studies.

RESULTS

Seventy-seven women were enrolled. The detrusor pressure at the maximum flow rate was significantly higher in group 3 than groups 1 and 2 (mean ± SD, 36 ± 16 versus 19 ± 11 mm H₂ O; P < .001). The odds of high detrusor pressure (>20 mm H₂ O) in group 3 was approximately 12 times the odds of those in groups 1 and 2. After adjusting for other variables using a multiple logistic regression analysis, a statistically significant association between group 3 and high detrusor pressure persisted (odds ratio, 29.7; 95% confidence interval, 2.949-299.6; P = .0040) persisted.

CONCLUSIONS

Transperineal dynamic 2D sonography can help predict women with high-pressure voiding after midurethral sling placement and aid in the diagnosis of bladder outlet obstruction.

Urinary Continence after Robot-Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

PURPOSE

To assess the impact of intravesical prostatic protrusion (IPP) on the outcomes of robot-assisted laparoscopic prostatectomy (RALP).

MATERIALS AND METHODS

The medical records of 1094 men who underwent RALP from January 2007 to March 2013 were analyzed using our database to identify 641 additional men without IPP (non-IPP group). We excluded 259 patients who presented insufficient data and 14 patients who did not have an MRI image. We compared the following parameters: preoperative transrectal ultrasound, prostate specific antigen (PSA), clinicopathologic characteristics, intraoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, and continence until postoperative 1 year. IPP grade was stratified by grade into three groups: Grade 1 (IPP≤5 mm), Grade 2 (5 mm<IPP≤10 mm), and Grade 3 (IPP>10 mm).

RESULTS

Of the 821 patients who underwent RALP, 557 (67.8%) experienced continence at postoperative 3 months, 681 (82.9%) at 6 months, and 757 (92.2%) at 12 months. According to IPP grade, there were significant differences in recovering full continence at postoperative 3 months, 6 months, and 12 months (p<0.001). On multivariate analysis, IPP was the most powerful predictor of postoperative continence in patients who underwent RALP (p<0.001). Using a generalized estimating equation model, IPP also was shown to be the most powerful independent variable for postoperative continence in patients who underwent RALP (p<0.001).

CONCLUSION

Patients with low-grade IPP have significantly higher chances of recovering full continence. Therefore, the known IPP grade will be helpful during consultations with patients before RALP.

Application of Acoustic Radiation Force Impulse Imaging for Diagnosis of Female Bladder Neck Obstruction

OBJECTIVES

To determine the application value of combined transperineal sonography and Virtual Touch tissue quantification (Siemens Medical Solutions, Mountain View, CA) on acoustic radiation force impulse imaging as a scanning method for diagnosis of female bladder neck obstruction.

METHODS

Transperineal sonography and Virtual Touch tissue quantification were combined to depict the bladder neck and observe its sonographic characteristics in 36 patients with female bladder neck obstruction and 30 healthy adults in a case-control study. We measured the thickness and shear wave velocity (SWV) of the bladder neck's anterior and posterior lips.

RESULTS

There was a statistically significant difference in the thickness and SWV of the bladder neck between the healthy women and those with bladder neck obstruction, whose SWV was higher (P< .05). For the anterior lip, an SWV of 2.11 m/s was the best cutoff point for differentiating bladder neck obstruction from a normal bladder neck; for the posterior lip, an SWV of 2.06 m/s was the best cutoff point. The mean thicknesses of the anterior and posterior lips ± SD were 0.66 ± 0.05 and 0.68 ± 0.05 cm in the group with bladder neck obstruction versus 0.45 ± 0.07 and 0.52 ± 0.09 cm in the normal group. There was a significant difference between them (P < .05).

CONCLUSIONS

The bladder neck's anatomic structure can be observed visually by perineal sonography. Virtual Touch tissue quantification on acoustic radiation force impulse imaging can quantitatively reflect the bladder neck stiffness and change in texture. It could provide a quantitative indicator for clinical diagnosis of female bladder neck obstruction and etiology research and display important clinical values.

Diagnosing Bladder Outlet Obstruction Using Non-invasive Decorrelation-Based Ultrasound Imaging: A Feasibility Study in Healthy Male Volunteers

A feasibility study on the applicability of an ultrasound decorrelation method to urinary flow imaging was carried out in 20 healthy male volunteers, to provide a basis for a non-invasive approach to diagnose bladder outlet obstruction. Each volunteer voided five times in a flow meter in standing position. During each voiding, ultrasound radiofrequency frames were acquired transperineally at different flow rates. The results indicated that the decrease in correlation (decorrelation) of ultrasound radiofrequency signals had no unique relation with flow rate, but decreased distinctively with urinary flow velocity. In most of the healthy volunteers, the decorrelation was small because of the low flow velocity. However, because of the different flow velocities in volunteers, the variation in slope between volunteers was statistically significant. Therefore, it is probably possible to use the decorrelation method to differentiate between healthy persons and patients with obstruction.

[The volume of residual urine correlates with bladder outlet obstruction and detrusor contractility in patients with benign prostatic hyperplasia]

OBJECTIVE

To identify the correlation of the volume of residual urine (VRU) with the severity of bladder outlet obstruction (BOO) and detrusor contractility in patients with benign prostatic hyperplasia (BPH).

METHODS

A total of 152 patients with clinically diagnosed BPH underwent ultrasonography for measurement of the prostate volume and RVU, free uroflowmetry, and urodynamic examination for the severity of BOO and detrusor contractility. Using the software SPSS20. 0, we analyzed the correlation between the ultrasonographic results and urodynamic parameters and compared the two sample means by the t-test.

RESULTS

The prostate volume was correlated positively with BOO severity (r = 0.432, P < 0.01) and detrusor contractility (r = 0.343 , P < 0.01) while Qmax negatively with BOO severity (r = 0.327, P < 0.01) but not significantly with detrusor contractility (r = 0.123, P > 0.05). VRU showed a significantly negative correlation with detrusor contractility when > 150 ml (r = -0.490, P < 0.01), even more significantly when > 300 ml (r = -0.717, P < 0.01), but exhibited no significant correlation with it when ≤ 150 ml (r = 0.041, P > 0.05).

CONCLUSION

VRU can somehow predict the detrusor function. For patients with VRU > 150 ml, especially for those with VRU > 300 ml, the detrusor function should be evaluated and urodynamic examination is recommended for exact assessment of BOO severity and detrusor contractility.

Traumatic catheterisation: a near miss

A 68-year-old man presented with acute urinary retention. An indwelling catheter was inserted by a junior doctor, which immediately caused perineal pain to the patient. When asked about the catheterisation technique, the junior doctor admitted that he did not insert the catheter to the hilt prior to inflating the balloon. The patient was investigated with a pelvic CT scan and a senior doctor in the emergency department interpreted that the catheter was inserted extravesically with possible haemorrhage. However, subsequent cystoscopy revealed no urethral trauma but a small bladder and a diverticulum. It became clear that the suspected haemorrhage was actually the bladder with markedly thickened wall. What was thought to be the bladder turned out to be the diverticulum. Both pathologies were attributable to chronic bladder outlet obstruction from the occlusive prostate. The patient was discharged with a catheter in situ and planned for transurethral resection of prostate in a week's time.

Elastic modulus of the prostate: a new non-invasive feature to diagnose bladder outlet obstruction in patients with benign prostatic hyperplasia

The purpose of our study was to develop a reliable method for the non-invasive evaluation of bladder outlet obstruction (BOO) caused by benign prostate hyperplasia (BPH). In our study, the International Prostate Symptom Score was assessed in, and trans-rectal ultrasound (TRUS) and shear wave sonoelastography (SWE) were performed on, 55 patients with BPH who had undergone urodynamic evaluation (the gold standard diagnostic procedure for BOO). The results indicated that the elastic modulus of the transitional zone was the indicator most strongly correlated with BOO stage (r = 0.666, p < 0.001), and had the largest area under the receiver operating characteristic curve, 0.826 (95% confidence interval: 0.717-0.934, p = 0.001). An elastic modulus of the transitional zone ≥ 32.4 kPa or a total prostate volume ≥ 54.4 mL was diagnostic of BOO, with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy for BOO of 97.2%, 62.5%, 85.4%, 90.9% and 86.5%, respectively. The elastic modulus of the transitional zone is a promising indicator in the assessment of the severity of BOO. In addition, the combination of elastic modulus and total prostate volume was the most accurate indicator in the non-invasive diagnosis of BOO in patients with BPH.

Surgical correction of bladder neck contracture following prostate cancer treatment

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to more complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.

Disorders of bladder depletion in a young man because of a prostatic cyst: a case report

Symptomatic prostatic cysts presenting with recurrent urinary tract infections and urinary obstructive disorders in young men may be misdiagnosed as benign prostatic hyperplasia, urethral stenosis or neuropathic bladder. We report a case of a 28 year old young man with obstructive and irritative voiding disorders caused by a prostatic cyst, located in the anterior and left lateral lobe of the prostate gland. The cyst appeared to obstruct the bladder outlet by a "ball-valve" mechanism. The prostatic cyst was incised and marsupialized by transurethral resection. At post-operative follow up we observed an increase in Qmax with no residual urine and negative urine culture. The patient showed no retrograde ejaculation nor erectile dysfunction.

Usefulness of bladder-prostate ultrasound in the diagnosis of obstruction/hyperactivity in males with BPH

OBJECTIVE

To determine the utility of prostate ultrasound in the diagnosis of infravesical obstruction (IVO) and detrusor hyperactivity(DH).

METHODS

Prospective study with 39 patients consulting for LUTS. Clinical history was compiled, IPSS was determined, a digital rectal exam was performed, abdominal ultrasound was used to calculate detrusor thickness/weight, prostate volume, and middle lobe length (MLL). Urodynamic study (UD) was performed with determination of the Abrams-Griffiths number and ICS nomogram. Mean values were compared with Mann-Whitney U-test, and ROC curves were plotted determining the cutoff points for optimum sensitivity/specificity.

RESULTS

Mean age was 63.1 years (SD: 7.8), with a mean IPSS score of 14 (SD: 6). 53.8% of the patients presented IVO at UD evaluation, and 43.6% DH. The differences between free flowmetry Qmax(p=0.015) and MLL (p=0.003) between patients with and without IVO proved significant. The ROC curves yielded an AUC for middle lobe length of 0.772, with a maximum sensitivity and specificity cutoff point at 10.5 mm (sensitivity 90%, specificity 73%, PPV 76%, NPV 85%). There were no significant differences in any parameter between patients with and without DH.

CONCLUSION

Ultrasound MLL measurement in patients with LUTS offers high sensitivity/specificity in diagnosing IVO, with a cutoff point of 10.5 mm. In our study it wasn't effective in the noninvasive diagnosis of DH.

[Correlation of intravesical prostatic protrusion with clinical evaluation parameters in BPH patients]

OBJECTIVE

To investigate the correlation of the degrees of intravesical prostatic protrusion (IPP) measured by transabdominal ultrasound with the clinical evaluation parameters in BPH patients.

METHODS

We measured the length of IPP in the mid-sagittal section by transabdominal ultrasound in 275 BPH outpatients with lower urinary tract symptoms, and analyzed the correlations of the degree of IPP with the age, prostatic volume (PV), international prostatic symptom score (IPSS), maximum uroflow rate (Qmax), and postvoid residual urine volume (PVR) of the patients.

RESULTS

The degree of IPP was correlated positively with the age (r = 0.210, P < 0.01), PV (r = 0.534, P < 0.01) and PVR (r = 0.314, P < 0.01), but negatively with the Qmax (r = -0.364, P < 0.01) of the BPH patients. There was no significant correlation between the degree of IPP and IPSS (r = 0.064, P = 0.299).

CONCLUSION

The degree of IPP may be associated with the age and prostatic volume of BPH patients. Transabdominal ultrasound measurement of IPP is a useful noninvasive method to assess the presence and severity of bladder outlet obstruction in BPH patients.

In-utero stenting: development of a low-cost high-fidelity task trainer

OBJECTIVE

To develop an in-utero stent placement training model.

METHODS

The in-utero stent task trainer was constructed using a formalin-preserved gravid pig uterus. Altering the size of the uterine segment, changing the fluid level in the uterus and addition of a large Ziploc freezer bag variably filled with differing amounts of ultrasound gel can vary the procedural skill required.

RESULTS

Thoracoamniotic and vesicoamniotic shunts can be simulated using this life-like model. The cost of eight to 10 learning stations is approximately US $ 60. Fetal position, maternal size and amniotic fluid status can be altered rapidly to increase the complexity of the procedure.

CONCLUSIONS

This low-cost and realistic task trainer can provide the opportunity to practice in-utero shunt procedures in a non-clinical environment. This model should enhance learning and reinforce acquired skills.

Intravesical Prostatic Protrusion is Better Than Prostate Volume in Predicting the Outcome of Trial Without Catheter in White Men Presenting With Acute Urinary Retention: A Prospective Clinical Study

PURPOSE

Trial without catheter after a short course of an alpha-blocker in men presenting with acute urinary retention is successful in up to 50% of cases. The ability to better predict outcome could avoid a trial without catheter for some men. Intravesical prostatic protrusion and not prostate volume has been shown to predict trial without catheter outcome in an Asian cohort. We investigated the relationship between the outcome of trial without catheter and prostate volume and intravesical prostatic protrusion in white men given alpha-blockers before a trial without catheter.

MATERIALS AND METHODS

Consecutive men 50 years old or older presenting with acute urinary retention were prospectively recruited based on strict selection criteria. At presentation factors thought to precipitate acute urinary retention were treated, alpha-blocker therapy started and the patient brought back for a trial without catheter after 2 weeks. Prostate volume and intravesical prostatic protrusion were measured by standard transrectal ultrasonography.

RESULTS

Of 121 men presenting with acute urinary retention 57 fulfilled the study selection criteria. Mean (+/- SD) age, prostate volume and intravesical prostatic protrusion of recruited men were 70 +/- 9.2 years, 69.7 +/- 36.3 ml and 12.8 +/- 10.1 mm, respectively. A total of 25 men (43.9%) had a successful trial without catheter. Mean intravesical prostatic protrusion was significantly smaller in those who had a successful trial without catheter (7.2 vs 16.5 mm, 95% CI 4.5-14, p <0.001). With intravesical prostatic protrusion correlating well with prostate volume (r = 0.588), mean prostate volume was also smaller in men with a successful trial without catheter, albeit with a smaller effect size. Men with an intravesical prostatic protrusion of 10 mm or less, compared to those with a larger intravesical prostatic protrusion, were 6 times more likely to have a successful trial without catheter.

CONCLUSIONS

In this cohort presenting with acute urinary retention related to benign prostatic hyperplasia and receiving alpha-blockers before a trial without catheter, intravesical prostatic protrusion appears to strongly predict the outcome of a trial without catheter. A trial without catheter is more likely to fail in patients with intravesical prostatic protrusion larger than 10 mm.

[Residual fraction in the evaluation of bladder outlet obstruction resulting from benign prostatic hyperplasia]

OBJECTIVES

To study residual fraction (RF) in the bladder outlet obstruction (BOO) resulting from benign prostatic hyperplasia (BPH).

METHODS

Fifty adult outpatients with BPH were evaluated. With ultrasound and uroflowmetry, prevoid volume (PV) and postvoid residual volume (PRV) and peak flow rate (Qmax) were determined. Linear dependence analysis of RF and Qmax, PRV and Qmax were conducted.

RESULTS

The coefficient between RF and Qmax showed extremely negative correlation(r = -0.3859, P < 0.01). Also, PRV and Qmax showed significant negative correlation (r = -0.2831, P < 0.05).

CONCLUSIONS

The greater the RF, the more serious the BOO, the poorer potency of bladder. It is recommended that RF be used as a good supplement to PVR in the routine non-invasive evaluation of BOO caused by BPH.

Case of duplication of the urethra in an adult male, presenting with symptoms of bladder outlet obstruction

Duplication of the urethra is a rare congenital anomaly, usually found in children and adolescents. The authors present a rare case of urethral duplication, presenting in a 58-yr-old man, with symptoms of bladder outlet obstruction.

99mTechnetium-mercaptoacetyltriglycine scintigraphy with full bladder in patients with severe bladder dysfunction

PURPOSE

We evaluated 99mtechnetium-mercaptoacetyltriglycine scintigraphy for detecting threshold bladder volume at which upper tract obstruction occurs in patients with bladder dysfunction.

MATERIALS AND METHODS

A total of 24 patients 19 to 74 years old with severe bladder dysfunction who underwent 99mtechnetium-mercaptoacetyltriglycine scintigraphy and videocystometrogram in a 4-year period were selected for retrospective study. 99mTechnetium-mercaptoacetyltriglycine scintigraphy was done with a full bladder with a mean instilled volume of more than 850 ml saline. In patients in whom an obstructed renal outflow pattern was observed saline was drained at a rate of 100 ml every 5 minutes while dynamic imaging was performed. If results were abnormal, the study was repeated with an empty bladder. Differential function, parenchymal transit time index and outflow efficiency were calculated.

RESULTS

Of the 24 patients 15 had an obstructed outflow pattern with a full bladder, which was relieved at a bladder volume of less than 390 ml (median 300, range 250 to 600). Only 2 of these 15 patients had a normal vesical end filling pressure of less than 20 cm H2O. There was no obstruction in 9 patients, of whom 5 had increased vesical end filling pressures. Followup in patients who had normal tracer outflow on a full bladder showed no decrease in renal function, while a small decrease was seen in patients who had obstructed outflow on a full bladder.

CONCLUSION

This novel, full bladder 99mtechnetium-mercaptoacetyltriglycine scintigraphic technique provides the ability to detect bladder volumes at which obstructive outflow patterns develop in patients with severe bladder dysfunction.

Trabeculation of urinary bladder by ultrasound in patients with benign prostatic hyperplasia

The aim of our study was to assess the prognostic value of trabeculation of urinary bladder assessed by ultrasound as an non-invasive diagnostic tool to diagnose the bladder outlet obstruction and prognostic factor to urinary retention and the need for surgery. Out of 171 patients 120 were with spontaneous voiding and other 51 were presented with acute urinary retention. 87 of them underwent surgical treatment immediately and other 17 underwent surgery during follow-up period 12 months. Ultrasound investigation revealed trabeculated bladder or with diverticula in 107 men and other 64 had non-trabeculated bladders. In 120 patients with spontaneous voiding 76 had moderate urinary symptoms (10 < I-PSS < 18) and other 46 had severe symptoms (18 < I-PSS < 35). 57 patients had the residual urine volume les that 100 cc and 63 had above that amount. 50 patients had decrease peak flow below and other 70 had Qmax more than 10 ml/sec. Using chi(2) test statistical analysis urinary symptoms and residual urine did not correlate with bladder trabeculation, though the low peak urinary flow Qmax highly correlated with bladder trabeculation (p<0.005). We observed high correlation between the bladder trabeculation and urinary retention (p<0.05); immediate indication for surgical treatment (p< 0.0001) and need for surgery during the one year follow-up (p<0.00019). Bladder Trabeculation may be helpful in differentiating between the compensated and decompensated stages of bladder outlet obstruction.

Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 2: Noninvasive urodynamics and combination of measures

PURPOSE

Many methods have been suggested to diagnose bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison.

MATERIALS AND METHODS

A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods, including single measure and combinations of measures, to diagnose bladder outlet obstruction. A direct comparison of all of the different methods was made using the sensitivity, specificity, likelihood ratio, and pretest and posttest probability of diagnosing bladder outlet obstruction for each test. For many techniques these values were calculated from the data presented in the article.

RESULTS

A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods were considered in part 1 of the review. Part 2 considered noninvasive urodynamic techniques, such as uroflowmetry, the penile cuff, the condom method and Doppler urodynamics. A combination of single measures was also considered and the relative merits of these approaches were discussed.

CONCLUSIONS

A combination of noninvasive urodynamics and ultrasound derived measures provide promising methods of diagnosing bladder outlet obstruction. However, pressure flow studies still remain the gold standard for assessing bladder outlet obstruction.

Noninvasive Methods of Diagnosing Bladder Outlet Obstruction in Men. Part 1: Nonurodynamic Approach

PURPOSE

Many methods have been suggested for diagnosing bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature of the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison.

MATERIALS AND METHODS

A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods used to diagnose bladder outlet obstruction. A direct comparison of all different methods was made using the sensitivity and specificity, positive predictive value and likelihood ratio of each test. For many of the techniques these values were calculated from the data presented in the article.

RESULTS

A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods include symptoms, biochemical tests such as prostate specific antigen, ultrasound derived measurements such as post-void residual urine, bladder weight, prostate configuration and size, intravesical prostatic protrusion and the Doppler resistive index. Part 1 of the review explores and discusses the relative merits of the nonurodynamic based methods.

CONCLUSIONS

Ultrasound derived measures such as bladder wall thickness and bladder weight offer a promising possibility of diagnosing bladder outlet obstruction noninvasively. However, further reproducibility and large accuracy studies with better methodological standards are required before they can replace pressure flow studies.

Ultrasound Assessment of Detrusor Thickness in Men—Can it Predict Bladder Outlet Obstruction and Replace Pressure Flow Study?

PURPOSE

We estimated the diagnostic accuracy of ultrasound detrusor thickness measurement for BOO and investigated whether this method can replace PFS for the diagnosis of BOO in some patients with lower urinary tract symptoms.

MATERIALS AND METHODS

Detrusor thickness was measured by linear ultrasound (7.5 MHz) at a filling volume of greater than 50% of cystometric capacity in 102 men undergoing PFS for LUTS. All patients with prior treatment for bladder outlet obstruction and those with underlying neurological disorders were excluded from analysis. Detrusor thickness was correlated with PFS data. Obstruction was defined according to the Abrams-Griffiths nomogram.

RESULTS

Detrusor thickness was significantly higher (p <0.0001) in obstructed (61 cases, median detrusor thickness 2.7 mm, IQR 2.4 to 3.3) compared to unobstructed (18 cases, median detrusor thickness 1.7 mm, IQR 1.5 to 2) as well as equivocal (23 cases, median detrusor thickness 1.8 mm, IQR 1.5 to 2.2) cases. A weak to medium Spearman correlation was found between detrusor thickness and PFS parameters. For a diagnosis of BOO, detrusor thickness of 2.9 mm or greater had a positive predictive value of 100%, a negative predictive value of 54%, specificity of 100% and sensitivity of 43%. ROC analysis revealed that detrusor thickness had a high predictive value for BOO with an AUC of 0.88 (95% CI 0.81-0.94).

CONCLUSIONS

In men with LUTS without prior treatment and/or neurological disorders, ultrasonographically assessed detrusor thickness 2.9 mm or greater has a high predictive value for BOO and can replace PFS for the diagnosis of BOO. However, this cutoff value needs to be validated in a larger study population.

Two- and three-dimensional ultrasonographic findings in urethral stenosis with bladder wall trabeculation: case report

Female bladder outlet obstruction is uncommon. We report a case of bladder outlet obstruction secondary to urethral stenosis leading to bladder wall trabeculation. The patient presented at our clinic because of lower urinary tract symptoms including nocturia, urgency, bed wetting, hesitancy, straining to void, and incomplete emptying. Urodynamic study revealed a low maximum free uroflow rate, high residual urine volume, and low compliance on filling phase cystometry. Introital ultrasonography with two- and three-dimensional (2D and 3D) scanning displayed a constriction in the echolucent part of the lower-mid urethra with hyperechogenicity and a lattice-like appearance of the bladder wall. Cystourethroscopy confirmed urethral stenosis and bladder wall trabeculation. The voiding symptoms subsided after the urethral stenosis was relieved by urethral dilatation, but, despite some improvement, the irritative symptoms persisted. Introital ultrasonography with 2D and 3D scanning may help to clarify the cause of female bladder outlet obstruction.

Comparison of Nitinol Urethral Stent Infections with Indwelling Catheter-Associated Urinary-Tract Infections

BACKGROUND AND PURPOSE

To determine the efficacy of intraurethral metal stents in preventing or eradicating urinary-tract infections (UTI) during the management of bladder outlet obstruction (BOO) by comparing the frequency and nature of the infections with indwelling-catheter-associated UTI.

PATIENTS AND METHODS

The SAS relative-risk test was used to compare the risks of UTI in 76 patients with temporary urethral stents, 60 patients with BOO who had never been catheterized nor stented, and 34 patients with a permanent indwelling urethral catheter (PIUC). Infection was assessed 1 month after placement of the devices. Scanning electron microscopy (SEM) of the proximal and distal pieces of the stents removed from five patients with and five patients without UTI was carried out in a search for predisposing changes on the surfaces.

RESULTS

After insertion of the catheter, UTI developed in 79.4% of the patients who originally had sterile urine. However, after insertion of the stent, UTI developed in only 40.9% of the patients with sterile urine. In 21 (44.6%) of the catheterized patients who had infected urine, UTI was eradicated after stent insertion. The SEM analysis of the stents showed that a thick organic layer had formed only on the infected devices but with no sign of erosion.

CONCLUSION

Urinary infection is a significant problem in patients with PIUC but is significantly less frequent and less severe in patients with urethral stents. This advantage of stents over the conventional urethral catheter, in addition to their obvious convenience for the patient, make them good alternatives to reduce the risk of UTI.

Ultrasound measurement of detrusor wall thickness in healthy adults

AIMS

Measurements of detrusor wall thickness (DWT) are used to diagnose bladder outlet obstruction (BOO). No values of DWT exist in healthy adults so far. These values, however, are necessary to judge DWT in patients with suspected BOO correctly. The aim of this study was to determine DWT in healthy adults and to investigate if bladder filling, gender, age, or body-mass index (BMI) influences DWT.

MATERIALS AND METHODS

In 55 healthy adult volunteers between 15 and 40 years of age, DWT was measured at the anterior bladder wall with a 7.5 MHz ultrasound probe and with a full bladder. In nine of those volunteers, an urodynamic investigation was performed additionally during which DWT was measured in steps of 50 ml until 300 ml and in steps of 100 ml until the maximum bladder volume.

RESULTS

DWT decreases rapidly during the first 250 ml of bladder filling but, thereafter, remains almost stable until maximal bladder capacity. No statistical difference was found between DWT at 250 ml and DWT at a higher bladder filling. Men had a greater DWT compared to women (1.4 vs. 1.2 mm, P < 0.001). The age and BMI did not have a significant impact on DWT.

CONCLUSIONS

DWT remains stable at a bladder filling of 250 ml. At this state of bladder filling, DWT between different groups are comparable. Men have to be evaluated separately from women.

Vesicoamniotic shunting using a double-basket catheter appears effective in treating fetal bladder outlet obstruction

BACKGROUND

To estimate the effect of vesicoamniotic shunting using a double-basket catheter on treating fetal bladder outlet obstruction.

METHODS

A retrospective study involving 8 prenatally diagnosed bladder outlet obstruction cases that underwent vesicoamniotic shunt placement using a double-basket catheter from 1998 to 2004. Patients were followed-up for prenatal and neonatal outcome analyses.

RESULTS

Vesicoamniotic shunting was performed in 8 fetuses aged between 13.7 and 25.4 weeks' gestation (mean+/-SD, 19.7+/-3.5 weeks). Final diagnoses included 5 posterior urethral valves, 1 cloacal anomaly, 1 urethral stenosis, and 1 unknown. There were no maternal complications associated with the procedures. One woman diagnosed as having a fetus with posterior urethral valves decided to terminate her pregnancy and one fetus died in uterus spontaneously. Six women delivered live babies, and one baby required postnatal ventilatory support. Postnatal follow-up ranged from 3 to 60 months. Of the 6 newborns, 4 survived with normal renal function, 1 had renal insufficiency, and 1 died of renal failure at 3 months of age.

CONCLUSIONS

Vesicoamniotic shunt placement using a double-basket catheter may be effective in improving perinatal and neonatal outcomes through long-term decompression of the fetal urinary tract in carefully selected cases.

AMNIOTIC FLUID INDEX AND FETAL BLADDER OUTLET OBSTRUCTION. DO WE REALLY NEED MORE?

PURPOSE

With the constant advances in technology and expertise of prenatal diagnosis, necessity of early counseling in cases of bilateral obstructive uropathy has become of paramount importance. To better evaluate fetal renal function new biochemical (serum and urine) fetal markers have been introduced in the literature. However, they are only available at select centers and always requiring an invasive approach. Furthermore, paucity of normal controls sometimes makes interpretation of results difficult. Owing to this growing interest towards biochemical evaluation of fetal renal function, assessment of amniotic fluid, which is mostly expression of fetal urination, has progressively fallen into disrepute, and studies comparing the amount of amniotic fluid with renal function are scant.

MATERIALS AND METHODS

In a 3-year period 28 cases of bilateral obstructive uropathy were seen prenatally at the Artemisia Medical Center. All cases were initially reviewed at 17 to 20 weeks of gestation when a distended fetal bladder with thickened wall and enlarged kidneys were visualized. At the same time ultrasonographic assessment of amniotic fluid was performed by calculating the amniotic fluid index. An amniotic fluid index less than the 25th percentile was considered below average and an index less below the 5th percentile was considered oligohydramnios, whereas an index between 50th and 75th percentiles was considered normal. All cases were subsequently evaluated for renal function up to age 1 year. Impaired renal function was defined as a serum creatinine greater than 1.2 mg/dl before age 1 year.

RESULTS

Of the 28 cases 18 had an index of oligohydramnios (group 1) and 10 had a normal index (group 2). No significant variations were observed in amniotic fluid index at repeated consultations throughout pregnancy. Two cases in group 1 and 1 case in group 2 were lost to followup while in the other group 1 cases intrauterine death occurred. Bilateral obstructive uropathy was confirmed in all instances after birth as valves in 18 cases and urethral atresia in 3. Of the 12 surviving group 1 cases there were 3 neonatal deaths from severe lung hypoplasia, and in the remaining 9 cases mean serum creatinine at each evaluation before age 1 year was 1.3 +/- 0.2 mg/dl. All patients in group 2 survived with a mean serum creatinine at each evaluation of 0.6 +/- 0.1 mg/dl (p <0.05).

CONCLUSIONS

Despite widespread use of prenatal biochemistry, evaluation of amniotic fluid by the amniotic fluid index remains a reproducible and inexpensive method to predict renal function in cases of bilateral obstructive uropathy of any origin. It retains its validity not only in severe, but also in milder reductions. Conversely, intact amniotic fluid mostly invariably predicts normal renal function at long-term evaluation. For a better understanding of the disease such information is to be promptly conveyed to the prospective parents at each prenatal consultation.

Purple urine bag syndrome

The purple urine bag syndrome (PUBS) is a rare condition associated with chronic urinary catheterization. It is characterized by the purple discoloration of the urine, collecting bag, and tubing. A number of factors are involved, but not always present, in its development including female sex, urinary tract infection, constipation, indicanuria, and alkaline urine. Despite multiple theories that involve the complex tryptophan metabolism to the tubing dye, the cause remains elusive. The syndrome resolves usually after treatment of urinary tract infection or changing of the collecting bag. We present a case of a patient with purple urine bag syndrome and a pertinent literature review.

Measuring resistance index in patients with BPH and lower urinary tract symptoms

PURPOSE

To assess the correlation between resistance index (RI) measured in different zones of the prostate and other more commonly used parameters of benign prostatic hyperplasia (BPH).

METHODS

Twenty-six male patients who underwent a detailed evaluation for lower urinary tract symptoms suggestive of BPH were examined with transrectal (TRUS) color Doppler sonography (CDS). The correlation between RI in various prostate zones, and various urinary flow rates, and the International Prostate Symptom Score (IPSS), and prostatic volume measured by TRUS was determined.

RESULTS

No significant difference in RI was observed between right and left transition (TZ) and peripheral zones (PZ) in the prostate (P > 0.05). There was a significant correlation between mean RI and maximum urinary flow rate (Qmax) and mean RI in both zones (r = -0.48 for TZ and r = -0.39, P < 0.05 for PZ). Individual measurements in left and right TZ RI were also correlated with Qmax. There was a correlation between prostatic volume and both the right (P < 0.05, r = 0.56) and the left (P < 0.05, r = 0.58) TZ RI, respectively.

CONCLUSION

Our results demonstrate the potential value of RI measurement in the evaluation of patients with lower urinary tract symptoms suggestive of BPH.

Change in parameters before and after alpha-1-blocker therapy for men with lower urinary tract symptoms using color doppler ultrasound urodynamics: possible application for prediction of clinical outcome

INTRODUCTION

We previously developed a noninvasive video urodynamic study using color Doppler ultrasonography. We sought the best flow velocity-related parameter which would allow prediction of an improvement in lower urinary tract symptoms (LUTS) after alpha 1-blocker treatment.

METHODS

Twenty-two men with benign prostatic hyperplasia who were treated with a nonselective alpha 1-blocker (urapidil) were included. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) before and after alpha 1-blocker treatment. We measured the flow velocities using a transperineal ultrasound technique in the distal prostatic urethra just proximal to the external urethral sphincter (V1) and in the sphincteric urethra (V2), and used them to obtain the velocity ratio (VR=V1/V2). The corresponding functional cross-sectional areas of the urethra at these two sites (A1 and A2) were calculated as Q(max)/V. All these parameters obtained by the velocity-flow urodynamics were compared before treatment and after 4 weeks.

RESULTS

After treatment, V1 and VR were decreased, and A1 was increased. V2 correlated best with the change in IPSS before and after alpha 1-blocker therapy, with Spearman's rho of 0.584. All men with V2 exceeding 50 cm/s did not show an improvement in the LUTS.

CONCLUSIONS

The maximum flow velocity at the sphincteric urethra (V2) can predict the subjective outcome of alpha 1-blocker treatment. The velocity-flow parameters changed after alpha 1-blocker treatment. We confirmed that the transperineal ultrasound urodynamic study is not only noninvasive but also informative.

Resistance index in benign prostatic hyperplasia using power doppler imaging and clinical outcomes after transurethral vaporization of the prostate

BACKGROUND

Using power Doppler ultrasonography (PDUS), we investigate the change of resistance index (RI) before and after transurethral vaporization of the prostate (TUVP) in benign prostatic hyperplasia (BPH) patients.

METHODS

In all, 49 patients underwent transrectal PDUS before receiving TUVP, three were excluded because of cancer and three could not be followed up. The remaining 43 were enrolled in the present study. Patients were assessed before and 1, 3 and 6 months after surgery, giving a mean duration of follow-up of 9.1 months. International prostate symptom scores (IPSS), quality of life (QOL) scores, postvoiding residual urine volumes (PVR) and maximum urinary flow rates (Qmax) were evaluated and total prostatic volume (TPV) and RI were measured using PDUS.

RESULTS

Resistance index ranged from 0.64 to 0.91. The postoperative parameters except for RI, such as TPV, PVR, IPSS and QOL scores improved significantly at the follow-up assessment after surgery. The elevated RI decreased significantly 1, 3 and 6 months after the treatment. Resistance index significantly decreased after TUVP and IPSS and other urodymamics parameters improved.

CONCLUSIONS

The present study suggested that RI could evaluate the severity of BPH and the degree of intraprostatic pressure or bladder outlet obstruction.

Accuracy of two noninvasive methods of diagnosing bladder outlet obstruction using ultrasonography: Intravesical prostatic protrusion and velocity-flow video urodynamics

OBJECTIVES

We assessed the accuracy of two noninvasive, ultrasound methods of diagnosing bladder outlet obstruction (BOO). The potential for the combined methods to enhance the accuracy of diagnosis was also assessed.

METHODS

We evaluated 30 male outpatients using two recently developed diagnostic methods, transabdominal ultrasound grading of intravesical prostatic protrusion (IPP) and Doppler ultrasound urodynamics (Doppler UDS), as well as conventional pressure flow studies according to the research protocol. IPP has been reported to be a useful anatomic parameter for the assessment of BOO. Doppler UDS uses transperineal ultrasonography to measure the velocity flow of urine at the prostatic and sphincteric urethras. We recruited 168 outpatients; however, of the 57 patients who fulfilled all the research criteria, only 30 were able to undergo conventional pressure flow study analysis. The results of all three diagnostic methods were analyzed statistically for reliability and relationship in the 30 patients with a BOO index from the conventional pressure flow study.

RESULTS

IPP grading correlated well with the BOO index (Spearman's rho 0.624), as did the Doppler UDS parameter (Spearman's rho 0.736). The combination of IPP grading and Doppler UDS showed good sensitivity and specificity.

CONCLUSIONS

We confirmed the accuracy of the two novel methods. The combination of the two methods may be a novel standard in the diagnosis of BOO in male patients.