Videourodynamics
Videourodynamic studies involve the measurement of urodynamic parameters along with the simultaneous fluoroscopic imaging of the bladder and urethra. For these studies, contrast material is infused into the bladder instead of saline or water. The term videourodynamics may be used to describe a number of different techniques. In some instances, fluoroscopy is simply added to the pressure-flow study as described previously. In other cases, a triple-lumen bladder catheter is used, with the third,...
Boo W.r.t. Bladder
1. Abrams PH, Griffiths DJ. The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Br J Urol 1979 51 129-134. 2. Andersen JT. Prostatism. Clinical, radiological and urodynamic aspects. Neurourol Urodyn 1982 1 241-293. 3. Feneley MR, Dunsmuir WD, Pearce J, Kirby RS. Reproducibility of uroflow measurement experience during a double-blind, placebo-controlled study of doxazosin in benign prostatic hyperplasia. Urology 1996 47 5 658-663. 4. Golomb J, Lindner A,...
Thermosensitive Nitinol Stent
The thermosensitive nitinol stent an alloy of nickel and titanium can expand to its maximal diameter of 42 Fr at body temperatures. After expansion, the stent loses its compressibility but keeps its flexibility so that it can adjust to the course of the prostatic urethra. Nitinol is biologically inert. The nitinol stent becomes soft and pliable again if it is cooled, and it can then be pulled out like a string. A nitinol stent Memotherm was reported by Gesenberg and Sintermann to be successful...
Info Ltg
11. Xia TG, Blackburn WR, Gardner WA Jr. Fetal prostate growth and development. Pediatr Pathol 1990 10 527-537. 12. Grayhack JT, Kozlowski JM. Benign prostatic hyperplasia. In Gillenwater J, Grayhack J, Howards S, eds., Adult and Pediatric Urology, vol. 2, ed. 2, St. Louis, MO Mosby, 1991, pp. 1211-1276. 13. Franks LM. Atrophy and hyperplasia in the prostate proper. J Pathol Bacteriol 1954a 68 617-621. 14. Franks LM. Benign prostatic hyperplasia gross and microscopic anatomy. In Grayhack JT,...
References Suq
1. Kaplan SA, Golobuff ET, Olsson CA. Effect of demographic factors, urinary peak flow rates, and Boyarsky symptom scores on patient treatment choice in benign prostatic hypertrophy. Urology 1995 45 398-405. 2. Bruskewitz R. Management of symptomatic BPH in the US who is treated and how Eur. Urol. 1999 36 suppl 3 7-13. 3. Lepor H, Tang R, Kobayashi S. Localization of the alpha-lA adrenoreceptor in the human prostate. J Urol 1995 154 2096-2099. 4. Furuya S, Kumamoto Y, Yokoyama E....
Perioperative Complications
Perioperative complications primarily include bleeding, urinary tract infection, and urinary retention. These occur in approx 7 of patients, sometimes extending the hospital stay by a few days or requiring discharge with an indwelling catheter 3,21 . It is imperative that optimal hemostasis be achieved before TURP is concluded and the patient is transported from the operating room. Methods to manage mild-to-moderate persistent bleeding, such as catheter traction and continuous bladder...
Normal Growth And Development Of Human Prostate
The human prostate increases in size and develops histologic evidence of stimulated growth during three periods of life before and at birth, during puberty, and with achievement of advancing age 20 . The evidence for prostatic stimulation during gestation and at birth is based on histologic studies. During development, the prostatic tubules progress from solid cellular buds at the ends of ducts to bud acinar combinations and then to acinar tubular clusters arranged in lobules. The tubules...
Operative Results And Retreatment Rates
Prostatectomy by any route is a significant surgical undertaking that attempts to achieve a satisfactory functional and symptomatic status in a complex multifunctional system 1 . Undesirable results can occur because of inappropriate patient selection, unrecognized preexisting and imminent pathologic changes, and technical errors. Of the undesirable results, the most disturbing is inability to void. In the cooperative evaluation of TURP, 6.5 of patients were unable to void when the catheter was...
OUTCOME Efficacy
The gold standard of transurethral surgical intervention for BPH is TURP. The available literature suggests that vaporization techniques are comparable in improvement by both subjective and objective measures. To assess how effective a treatment is, it is necessary to have standardized reproducible parameters with which to measure the treatment. Surgical intervention for BPH uses both subjective and objective parameters to measure success. The subjective parameters are most commonly assessed...
Tuna Procedure
The optimal candidate for TUNA is a patient with mild-to-moderate obstructive voiding symptoms attributable to BPH, who has no evidence of neurologic bladder dysfunction and no significant obstruction caused by median lobe hypertrophy. Cystoscopy is useful preopera-tively to rule out urethral stricture disease and bladder neck contracture and to evaluate for median lobe hypertrophy. Transrectal ultrasound is necessary for volume estimation of the prostate and to plan the needle placement. The...
Benign Prostatic Hyperplasia
Urinary obstruction resulting from benign prostatic disease was described in the earliest days of medicine. Initially formalized by Riolan in the 17th century, the relationship between BPH and urinary obstruction was further elucidated by Morgani in the mid-18th century he provided one of the earliest descriptions of BPH and its sequelae 23 . More specific recognition of the pathologic process has been credited to Virchow in the last quarter of the 19th century. Despite a greater understanding...
Androgen And Prostate Growth
The prostate gland is dependent on androgens that are produced exogenously by the testicles to facilitate normal development and to maintain normal structure and function 1 . Briefly, the testes are stimulated to produce and secrete testosterone and other steroids by an exogenous protein, luteinizing hormone, which is made in the pituitary gland. Testosterone T is converted to its reduced form, dihydrotestosterone DHT , by the enzyme 5a-reductase in the prostate. Both T and DHT bind to and...
LongTerm Complications
Long-term complications following TURP primarily include urinary tract infection, obstruction, incontinence, and erectile dysfunction, although there is debate about whether the latter is truly associated with the procedure. Interestingly, despite the use of prophylactic and perioperative antibiotics, delayed genitourinary infection is still a significant problem after TURP, accounting for nearly half of long-term complications 4 21 . This is probably not a result of persistent bacteriuria from...
BalloonExpandable Stent Titan Intraprostatic Stent
Kaplan et al. reported a multicenter study of the Titan intraprostatic stent in 68 patients 24 . This stent is made of titanium and has a tubular mesh appearance. It is expanded under direct vision in the prostatic urethra. All patients in this series were able to void spontaneously within 36 hr of stent insertion. At 18 mo, peak PFR increased from 3.9 to 14.4 mL s and PVR volumes decreased from 74.4 to 40.2 mL. Of the initial 68 patients, 5 died of underlying problems but had satisfactory...
Stricture and Bladder Neck Contracture
Complications usually, but not always, recognized with prolonged follow-up include urethral stricture, with a mean incidence of 2.6 and bladder neck contracture, with a mean incidence of 1.8 reported in the guideline review of open prostatectomy 21 . Both are reported to occur more frequently with a suprapubic than with a retropubic approach, but this may be more indicative of the period of data accumulation than of the procedures themselves 1 . Specifically, the incidence of contracture...
Complications
Although relatively safe, TUMT is associated with a number of complications, and a variety of other rare but reported complications may occur. This includes, but is not limited to, urethrorectal fistula, bladder perforation, and emphysematous prostatic abscess 25,26 . Proper monitoring by both physicians and nurses during treatment and accurate catheter placement are vital to decrease these risks. TUMT and TURP are associated with a similar complication rate, although the types of complications...
TUVP Technique
Standard resectoscope equipment is introduced into the patient's bladder, and the procedure is performed with continuous glycine irrigation. A roller electrode element is used instead of a loop element. The electrical current generator is set between 120 and 300 watts for cutting and 60 and 75 watts for coagulation. The vaporization proceeds in much the same way as described above. The roller element should not be dragged through tissue as the loop is instead it is rolled over the pros-tatic...
Anesthesia
The use of a regional or a general anesthetic is usually required for TURP. The choice of anesthesia should be tailored to the patient's needs and the surgeon's preference. Although the use of local anesthesia for TURP has been reported, this technique is infrequently used 6-8 . The use of regional anesthesia such as a subarachnoid or an epidural block offers the advantage of allowing close interaction with the patient during the procedure. Changes in mental status, particularly those that...
Urinary Obstruction After Brachytherapy
Significant LUTS following brachytherapy for prostate cancer remains a significant clinical issue. Often, these patients are younger and are selected for brachytherapy based on the desire to minimize the risks associated with radical surgery or external beam radiation. It is tempting to believe that the less invasive nature of TUIP will translate into improved outcomes and a lower complication rate in men with retention after permanent brachytherapy. Furthermore, TURP could compromise full-dose...
Infection Risk and Preoperative Antimicrobial Therapy
As stated previously, documented preoperative urinary tract infection must be eradicated with appropriate antimicrobial therapy. This is very important given the observation that bacteremia occurs postoperatively in 10-32 of patients without recognized preoperative bacteri-uria and occurs much more frequently in patients with infected urine 9,10 . Prophylactic antibiotic administration to reduce immediate and long-term infection-related risks in patients without preoperatively documented...
Preoperative Details
In preparation for TUMT, patients need to be counseled about the risks and benefits of therapy, alternatives to TUMT, and what to expect from therapy. Patients who have a urinary catheter in place or had recent urinary tract manipulation should be placed on appropriate antibiotic therapy. An appropriate oral analgesic such as ibuprofen, ketorolac, or morphine and an anxiolytic benzodiazepine may be administered before the procedure. The patient is brought to the therapy suite and asked to void...
Ethanol Injection
Injection of sclerosing solutions into the prostate for the treatment of benign prostatic hyperplasia BPH was reported early in the 20th century. Sclerosing solutions including phenol, glacial acetic acid, and glycerin were injected transperineally and were successful in four of nine patients reported by Broughton and Smith 1 . However, this therapy was discontinued because of perineal pain occurring within minutes and lasting up to 24 hr in five of the nine patients. Broughton and Smith found...
Uroflowmetry
Uroflowmetry is an attractive test for both clinician and patient because it is simple to perform and noninvasive. The most clinically useful measurement is the maximum urinary flow rate Qmax , which is measured in milliliters per second. Other information that may be obtained includes the flow pattern continuous or intermittent , average flow rate, shape of the flow curve, flow time, and time to maximum flow. Postvoid residual bladder volume may also be assessed with ultra-sonography after the...
Current Clinical Urology
Essential Urology A Guide to Clinical Practice, edited by Jeannette M. Potts, 2004 Management of Benign Prostatic Hypertrophy, edited by Kevin T. McVary, 2004 Laparoscopic Urologic Oncology, edited by Jeffrey A. Cadeddu, 2004 Essential Urologic Laparoscopy The Complete Clinical Guide, edited by Stephen Y. Nakada, 2003 Urologic Prostheses The Complete Practical Guide to Devices, Their Implantation, and Patient Followup, edited by Culley C. Carson, Male Sexual Function A Guide to Clinical...
Equipment
One of the advantages of this minimally invasive device is the sophisticated yet user-friendly system that has been developed. In addition to the necessary equipment to perform rigid cystoscopy, the Indigo Laser Optic System Ethicon Endosurgery, Cincinnati, OH consists of the laser generator, the quartz fiber, and wavelength-specific eye protection. The laser generator is a 20-watt, 830-nm diode laser that is about the size of a typical computer tower Fig. 1 . It is designed to be portable and...
On 4
Fig. 1. Mechanism of action of the a1 and a2 receptors in prostatic smooth muscle. Fig. 1. Mechanism of action of the a1 and a2 receptors in prostatic smooth muscle. such as phenoxybenzamine block both the a1- and a2-receptors. The a1-specific blockers such as alfuzosin, doxazosin, prazosin, tamsulosin, and terazosin block the a1 sites preferentially. The a1-receptors have been further classified into subtypes by radioligand binding studies. These include a1A-, a1B-, and a1D-receptors 13 . The...
History Of The Procedure
Applying heat to the prostate gland is not new. In 1921, McCaskey used heat in the form of ultraviolet lamps to treat prostatism, and Corbus used diathermy probes for the same purpose in 1929 1,2 . These therapies were never clinically accepted. In the 1980s, the use of heat to treat BPH regained clinical interest as alternatives to TURP and open prostatectomy were being explored. The modern use of microwaves has been credited to Yerushalmi and associates 3 . In 1982, they performed microwave...
Histologic Effects Of Finasteride Therapy
Rittmaster et al. evaluated the effects of finasteride from a histologic perspective in their 1996 study 7 . Tissue was collected from men with BPH who were 52-82 yr old at the time of prostatectomy. Patient groups included controls not taking finasteride, patients taking finasteride 5 mg d for 6-18 days, patients taking finasteride 5 mg d for 23-73 days, and patients taking finasteride 5 mg d for 3 mo-4 yr. Epithelial cell width and ductal width were measured. Apoptosis was determined by...
Proscar Longterm Efficacy And Safety Study
After the phase III studies, finasteride was further evaluated in a 4-yr, multicenter, double-blind, placebo-controlled, randomized study called PLESS or Proscar Long-Term Efficacy and Safety Study 29 . The goals of this study were to compare long-term 4-yr treatment with finasteride 5 mg vs placebo in the following parameters urinary symptoms, urinary flow rates, incidence of surgery for BPH, and acute urinary retention. There were 3040 men enrolled, with a mean age of 64 yr. To be eligible...
Bleeding
Significant perioperative bleeding has been observed, with frequencies ranging from 0.8 to 35 2 . Reoperation to control persistent hemorrhage is exceedingly rare, with frequencies ranging from 0.8 to 1.5 in most series. Bleeding requiring a transfusion without operative intervention has occurred with a much higher anticipated frequency, ranging from 1.7 to 35.5 in three large representative series 5,23,24 . It should be noted that in the study conducted by Nicoll et al., more than half of the...
Contributors
Robert E. Brannigan, md Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL J. Quentin Clemens, md, msci Section of Voiding Dysfunction and Female Urology, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL Joseph A. Costa, do Department of Urology, National Naval Medical Center Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD Christopher M. Dixon, md Division of Urology, New York...
TUVP Safety
The most common intraoperative issues are operative time, fluid absorption, and blood loss. These complications were compared with the same complications during TURP in studies by Kaplan et al. and by Enkengren and co-workers 4,13 . In the 1998 study by Kaplan et al., operative times were longer with TUVP, but there was less fluid absorption as determined by change in serum sodium levels, and blood loss was less Table 3 . Enkengren et al. reported no difference in operative time or fluid...
Finasteride Phase Iii Clinical Trials
Two separate phase III clinical trials studying symptomatic patients with palpably enlarged prostates were conducted to evaluate the safety and efficacy of finasteride in treating symptomatic BPH. These 12-mo studies of men receiving either 5 mg of finasteride or placebo daily were performed in a randomized, double-blind, placebo-controlled fashion. In the first trial, the North American Study, men who received finasteride 5 mg d n 297 patients had a decrease in prostate volume of 19 vs a 3...
Epidemiology Of Bph
A number of investigators have studied the epidemiology of BPH. Clearly, the most important demographic factor in the incidence and severity of BPH is aging. Not only does prostate size correlate closely with age, but worsening LUTS is also seen commonly as men get older. Rhodes et al. studied men using serial prostatic ultrasonography performed during a follow-up period of approx 7 yr 31 . In general, higher prostate growth rates were seen in men with larger baseline glands, and the average...
Prostatic Stents For Treatment Of Bph
During my training, I was taught that splints were used externally, for instance to stabilize fractures, whereas stents were for internal use. A recent biographic paper on Dr. Charles Stent, a dentist who invented stents around 1856 in England said that it was invented to get dental impressions, originally called Stent's mass 8 . This formulation was also used as a tissue expander for neck and knee surgery and later to hold tubes open and in facial reconstruction during the WWI. The ancestry of...
Robert E Brannigan MD and John T Grayhack MD
Development of 5a-Reductase Inhibitors Use of Finasteride in the Treatment of BPH Finasteride Phase Ill Clinical Trials Proscar Long-Term Efficacy and Safety Study Histologic Effects of Finasteride Therapy with Finasteride Therapy Finasteride Treatment and PSA Concentration Future Directions in Finasteride Therapy References
Intraoperative Complications
There are many potential intraoperative complications that can occur during TURP. These include significant bleeding at times requiring transfusion , perforation of the prostatic capsule, perforation of the bladder, injury to the rectum, and development of TUR syndrome resulting from overabsorption of hypotonic fluid and its resultant dilutional hyponatremia. The most significant improvement in TURP complications over the last 10 years has been in the number of intraoperative complications. In...
Simple Perineal Prostatectomy
Currently, adenomectomy for the treatment of BPH is rarely performed by means of the perineal route. Previously, this approach was associated with significantly lower mortality than the abdominal route. However, this latter advantage has disappeared in the modern era as the mortality from all forms of prostatectomy has decreased to exceedingly low levels 18 . Resurgence of interest in the radical perineal prostatectomy has resulted in an increasing number of urologists becoming familiar with...
Indications For Turp
Patients selected for TURP should have clinical symptoms and signs caused by bladder outlet obstruction from BPH, because this procedure is thought to work by removal of obstructing prostate tissue. Most patients 90 who undergo TURP do so because of the bothersome irritative and obstructive symptoms associated with BPH, termed prostatism, or more recently, lower urinary tract symptoms LUTS 3 . Other patients, however, are treated for increased postvoid residual urine, urinary retention, urinary...
Indications For Open Prostatectomy
There are a number of factors that should prompt the serious consideration of suprapubic transvesical prostatectomy. These include the following 1 adenomas gt 75 g 2 transition zone hyperplasia associated with a large, prominent subtrigonal component 3 presence of a physiologically relevant diverticulum 4 multiple large bladder calculi 5 confounding orthopedic problems such as severe spinal stenosis and fusion ankylosis of the hip joints 6 large scrotal hernia or massive hydrocele 7 rigid or...
Siroky Nomogram
The purpose of urodynamic testing is to reproduce the patient's symptoms in a controlled laboratory setting. A variety of measurements bladder and urethral pressures, urine flow rate, fluoroscopic imaging are made, and based on these observations and the clinical acumen of the examining physician, a diagnosis can be found that explains the patient's complaints. In men with lower urinary tract symptoms LUTS , the primary urodynamic question is whether or not there is bladder outlet obstruction....
Suprapubic Transvesical Prostatectomy
Following the induction of satisfactory general or regional anesthesia, the operating table should be gently flexed in the modified Trendelenburg position. Care must be taken to avoid injudicious flexion that might induce a sacral stretch injury. When properly performed, this simple position change facilitates exposure within the narrow male pelvis and permits more facile mobilization of the peritoneal reflection. At this point, thigh-high anti-embolism stockings should be placed along with...
TUVRP Technique
The technique for performing TUVRP of the prostate should be very familiar to the urologist. It is essentially the same as that of the standard TURP. The major difference is that the speed of resection is decreased to allow coagulation, desiccation, and vaporization to occur. A rapid motion during an individual swipe will result in resection without substantial coagulation of blood vessels, and hemostasis and visualization will suffer. Another difference of note is that a substantial increase...
Instruments
A variety of instruments are available to perform TURP. The basic requirements are a standard cystoscopy lens usually 30 , a bridge that accommodates a resection loop, and a cystoscopy sheath specifically designed for resection Fig. 3A,B . This entire setup is typically called a resectoscope. Each one of the segments of a resectoscope can be altered to fit the needs and preferences of the surgeon. A major improvement in the sheath element has been the development of the ability for continuous...
Electrosurgical Generators
Generator power plays a crucial role in vaporization. Intuitively, an insufficiently powered generator will not provide adequate power for vaporization. Although many generators may provide sufficient power wattage at low impedance levels, some of the older generators are not efficient at delivering the same power at increased resistances. In electrovaporization, prostatic tissue is desiccated after the initial swipe. The desiccated, vaporized tissue raises the tissue impedance. Thus, the next...
Temporary Bioresorbable Prostatic Stents
In the early 1980s, high-strength, self-reinforced, biodegradable polymeric composites were developed for tissue management. They were polymers of organic acids with a molecular weight of up to 1,000,000 D. The properties of these polymers depend on the basic molecules and the degree of polymerization. The degradation depends on the structure and strength of the individual materials. The use of these polymers in temporary bioresorbable prostatic stents in 11 men was reported by Isotalo and...
References Pqy
1. Broughton AC, Smith PH. The significance of perineal pain after injection of the prostate. Br J Urol 1970 42 73-75. 2. Littrup PJ, Lee F, Borlaza GS, et al. Percutaneous ablation of the canine prostate using transrectal ultrasound guidance, absolute alcohol and Nd YAG laser. Invest Radiol 1988 23 734-739. 3. Goya N, Ishikawa N, Ito F, et al. Ethanol injection therapy of the prostate for benign prostate hyperplasia preliminary report on the application of a new therapy. J Urol 1999 162...
References Orj
1. Gormley GJ, Stoner E, Bruskewitz RC, et al. The effect of finasteride in men with benign prostatic hyperplasia. N Engl J Med 1992 327 1185-1191. 2. Lepor H, Auerbach S, Puras-Baez A, et al. A randomized, placebo-controlled multicenter study of the efficacy and safety of terazosin in the treatment of benign prostatic hyperplasia. J Urol 1992 148 1467-1474. 3. Issa MM, Ritenour C, Greenberg M, Hollabaugh R Jr, Steiner M. The prostate anesthetic block for outpatient prostate surgery World J...
Sexual Function
Preservation of sexual function after transurethral surgery for LUTS includes both antegrade ejaculation and erectile function. Retrograde ejaculation after TURP is reported in 62-100 of men but in only 035 of men after TUIP 8-10,30,47,57,59,60 . The successful preservation of antegrade ejaculation after transurethral surgery is most likely related to the quantity of residual tissue. Studies have noted that preservation of antegrade ejaculation is more likely in those men treated with a single...
Trapped Prostate
Turner-Warwick introduced the term trapped prostate to describe the small obstructing prostate trapped between the bladder neck and the external sphincter 12 . Today, this poorly understood cause of LUTS in men is termed primary bladder neck obstruction, Marion's disease, 13 dysfunctional bladder neck, 14 or bladder neck dyssynergia 15,16 . Often, these men are young age 20-50 yr , with long-standing obstructive and irritative voiding symptoms, and often they have been misdiagnosed with chronic...