Bruno Rovereto

Prognostic value of a combination of IPSS, flow rate and residual urine volume compared to pressure-flow studies in the preoperative evaluation of symptomatic BPH

OBJECTIVE Evaluate the predictive value of a combination of IPSS, uroflowmetry and ultrasound determination of residual urine volume in the determination of bladder outflow obstruction (BOO) and in predicting treatment outcome. METHODS Forty-five out of a group of 60 BPH symptomatic patients were included. Preoperative evaluation: urine culture, PSA, uroflowmetry with sonographic measurement of post-void residual urine, DRE, IPSS with quality of life questions and pressure-flow study. Selection criteria for surgery were IPSS > 16 and Qmax < 10 ml/s. Transurethral resection of the prostate was performed in these patients; the control visit was performed at 3 months. Treatment success was defined as Qmax above 15 ml/s, residual urine of less than 100 ml, a 50% reduction in IPSS and absence of urinary retention. RESULTS Urodynamic abnormalities were found in 42 patients (93.3%): 19 had detrusor instability, 5 patients showed impaired contractility, 37 patients had proven BOO, and 8 patients were unobstructed or mildly obstructed. The overall success rate was 86% when measured by the IPSS. Its preoperative value was 16.9, and dropped significantly to 4 (P = 0.005). The score improved significantly after surgery only in the obstructed group compared to the non-obstructed group (P = 0.001), however preoperative IPSS did not correlate with objective treatment results. CONCLUSIONS A high proportion of patients successfully operated (71.1%) had a combination of IPSS > 16 and Qmax < 10 ml/s, although BOO could not be accurately predicted with non-invasive methods alone. Patients with no or mild infravesical obstruction had only minimal improvement of IPSS and uroflowmetry following surgery.

Impact of Early Pelvic Floor Rehabilitation After Transurethral Resection of the Prostate

We examined the results of teaching pelvic floor muscle exercises (PME) on micturition parameters, urinary incontinence, post‐micturition dribbling, and quality of life in patients after transurethral prostatectomy (TURP). Fifty‐eight consecutive patients who were selected to undergo TURP for benign prostatic hyperplasia (BPH) were admitted into the study: 28 were randomly assigned to a control group (A), 30 formed the investigational group (B) during an initial visit conducted before surgery. In group B patients, perineal exercises were demonstrated in detail, and tested for their correct use via simultaneous rectal and abdominal examination. After the removal of the urethral catheter, these patients were instructed to perform pelvic floor muscle exercises at home and were evaluated before the exercises and at weekly intervals postoperatively. The American Urological Association Symptom Score improved significantly after TURP in both groups. The average quality of life score improved more significantly in group B after TURP, from 5.5 to 1.5 (P < 0.001). The grade of muscle contraction strength after 4 weeks of PME increased from 2.8 to 3.8 in group B (P < 0.01); it was unchanged in the group A. The number of patients with incontinence episodes and post‐micturition dribbling was significantly lower in the group B at weeks 1, 2, and 3 (P < 0.01). Our results show that pelvic floor muscle re‐education produces a quicker improvement of urinary symptoms and of quality of life in patients after TURP. Its early practice reduces urinary incontinence and post‐micturition dribbling in the first postoperative weeks. The exercises are simple and easy to perform in the clinical setting and at home, and therefore should be recommended to all cooperative patients after TURP. Neurourol. Urodynam. 20:53–59.

Insight into Urogynecologic Features of Women with Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVE The prevalence of interstitial cystitis/painful bladder syndrome (IC/PBS) among gynecologic patients attending vulvar disease or pelvic pain clinics is higher than expected. The evaluation of gynecologic characteristics in patients with IC/PBS could be important to delineate a better therapeutic strategy. METHODS We compared clinical gynecologic characteristics including localized and generalized vulvodynia and sexual activity of 47 women with a definite diagnosis of IC/PBS versus 47 negative controls. RESULTS The prevalence of both generalized or localized vulvodynia was 85.1% (40 of 47) in the patients and 6.4% (3 of 47) in the control group (p<0.0001 by Fisher exact test). The mean visual analogue score on generalized or localized vulvodynia evaluated with the cotton swab test was 6.1+/-2.6 (SD) among women with IC/PBS and 0.6+/-1.7 in the control group (p<0.0001 with Mann-Whitney U test). Pain during intercourse was described as unbearable by 15 women with IC/PBS (31.9%) and 2 controls (4.3%; p=0.001 by Fisher exact test). Sexual function was significantly impaired in women with IC as measured by the median total score of the Female Sexual Function Index in comparison with controls (13.8 vs. 28.7; p<0.0001). CONCLUSIONS Patients with a definite diagnosis of IC/PBS appear to have a high risk of vulvodynia with the associated negative implications for sexual activity. The establishment of a multidisciplinary approach with the involvement of the gynecologist appears to be a logical requisite for a correct treatment strategy for these patients.

Proposal for a Urodynamic Redefinition of Detrusor Underactivity

PURPOSE We sought a sufficiently comprehensive urodynamic definition of idiopathic detrusor underactivity in men with nonneurological conditions and no obstruction who had mainly voiding lower urinary tract symptoms. MATERIALS AND METHODS In 75 such patients and 40 age matched controls we retrospectively analyzed intrinsic detrusor contraction strength and contraction speed by estimating isovolumetric detrusor pressure and maximum possible detrusor contraction velocity. Bladder emptying efficiency was also determined. Nonparametric statistics were done as data analysis. RESULTS Detrusor underactivity, defined as lower levels of maximum possible detrusor contraction velocity and/or isovolumetric detrusor pressure than the 25th percentiles of such parameters in controls, was found in all 75 patients. Patients could be divided into group 1-22 with low maximum possible detrusor contraction velocity, low isovolumetric detrusor pressure and bladder emptying efficiency less than 67%, group 2-25 with low maximum possible detrusor contraction velocity, low isovolumetric detrusor pressure and bladder emptying efficiency 67% or greater, and group 3-28 with low maximum possible detrusor contraction velocity, normal isovolumetric detrusor pressure and bladder emptying efficiency 67% or greater. For insignificantly different urethral resistance levels there were significant decreases in maximum possible detrusor contraction velocity in group 3 vs those in controls, and in maximum possible detrusor contraction velocity and isovolumetric detrusor pressure in groups 2 and 1 vs those in group 3. CONCLUSIONS In our patients with detrusor underactivity intrinsic detrusor speed was more compromised than intrinsic strength. The definition of idiopathic detrusor underactivity of a slower and/or weaker bladder with or without poorly sustained micturition contractions proved more effective than a definition of decreased detrusor contraction strength and/or poorly sustained micturition contractions. The decreasing trend in detrusor contractility from group 3 to groups 2 and 1 suggests that our classification of idiopathic detrusor underactivity may reflect the evolution of this condition from an initial stage to obviously impaired voiding function.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: Perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project). MATERIALS AND METHODS patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status. RESULTS SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN. CONCLUSIONS Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Development of Idiopathic Detrusor Underactivity in Women: From Isolated Decrease in Contraction Velocity to Obvious Impairment of Voiding Function

OBJECTIVES To sequentially assess the evolution of urodynamic parameters in women who could be studied before and after the development of idiopathic detrusor underactivity (DUA). METHODS We assessed retrospectively 32 consecutive postmenopausal women seen during the period 1989 to 2006. They had invasive urodynamics (cystometry and pressure/flow study) performed when first referred (time 1) and then after several months (time 2). Group A, 17 women with a history of recurrent acute uncomplicated cystitis, had time 2 assessment performed a median of 24 months after time 1, following the discovery of large postvoid residual urine volumes at follow-up. As controls we took 15 age-matched women (group B), referred to exclude anxiety as the main cause for lower urinary tract symptoms, who proved normal urodynamically at time 1, were then lost at follow-up, and proved still normal urodynamically when reassessed a median of 27 months later (time 2). RESULTS At time 1, group A showed normal urodynamic findings, except for a reduced detrusor contraction velocity. During the period between times 1 and 2, antimicrobial prophylaxis caused a 17% decrease in acute cystitis recurrences. At time 2, group A showed an obvious DUA, with reduced bladder emptying efficiency, lowered detrusor contraction strength, and a further decrease in detrusor contraction velocity. CONCLUSIONS An isolated decrease in detrusor contraction velocity showed as the early phase of the process leading to obvious DUA in the patients studied. This appeared to be a pathological process rather than a natural evolution due to aging.

Partial Nephrectomy in Clinical T1b Renal Tumors: Multicenter Comparative Study of Open, Laparoscopic and Robot-assisted Approach (the RECORd Project).

OBJECTIVE To evaluate perioperative results of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomies (RAPN) and to identify predictive factors of Trifecta achievement for clinical T1b renal tumors in a multicenter prospective dataset. METHODS Data of 285 patients who had OPN (133), LPN (57), or RAPN (95) for cT1b renal tumors were extracted from the RECORd Project. High-volume centers were defined as ≥50 overall cases of partial nephrectomy per year. Trifecta was defined as simultaneous absence of perioperative complications, negative surgical margins, and ischemia time <25 minutes. RESULTS The 3 groups had comparable body mass index, preoperative hemoglobin, creatinine and estimated glomerular filtration rate, tumor clinical diameter, and growth pattern. LPN and RAPN were more frequently exclusive of high-volume centers. RAPN showed significantly lower median estimated blood loss compared with OPN and LPN. Trifecta was achieved in 62.4%, 63.2%, and 69.5% of OPN, LPN, and RAPN (P = NS) cases. Median warm ischemia time (WIT) was significantly shorter during OPN than during LPN and RAPN. RAPN had significantly shorter WIT compared with LPN. RAPN was significantly less morbid than OPN regarding intraoperative and postoperative complications. LPN (1.9%) and RAPN (2.5%) showed a lower rate of positive margins compared with OPN (6.8%) (P = NS). At multivariable analysis, exophytic tumor growth pattern, estimated blood loss, and high-volume centers were significant predictive factors for Trifecta achievement. CONCLUSION Clinically, T1b renal tumors suitable for NSS can be safely treated by LPN or RAPN in high-volume centers. RAPN allows for significantly lower WIT and estimated blood loss with higher rate of Trifecta achievement compared with LPN.

TriMatch comparison of the efficacy of FloSeal versus TachoSil versus no hemostatic agents for partial nephrectomy: Results from a large multicenter dataset

To evaluate the efficacy of hemostatic agents, TachoSil and FloSeal, during partial nephrectomy using a large multicenter dataset.

A snapshot of nephron-sparing surgery in Italy: A prospective, multicenter report on clinical and perioperative outcomes (the RECORd 1 project)

INTRODUCTION Nephron-sparing surgery (NSS) has become the standard of care for the surgical management of small and clinically localized renal cell carcinoma (RCC). The conservative management of those RCCs is increasing over time. Aim of this study was to report a snapshot of the clinical, perioperative and oncological results after NSS for RCC in Italy. MATERIAL AND METHODS We evaluated all patients who underwent conservative surgical treatment for renal tumours between January 2009 and December 2012 at 19 urological Italian Centers (RECORd project). Perioperative, radiological and histopathological data were recorded. Surgical eras (2009 vs 2012 and year periods 2009-2010 vs 2011-2012) were compared. RESULTS Globally, 983 patients were evaluated. More recently, patients undergoing NSS were found to be significantly younger (p = 0.05) than those surgically treated in the first study period, with a significantly higher rate of NSS with relative and imperative indication (p < 0.001). More recently, a higher percentage of procedures for cT1b or cT2 renal tumours was observed (p = 0.02). Utilization rate of open partial nephrectomy (OPN) constantly decreased during years, laparoscopic partial nephrectomy (LPN) remained almost constant while robot-assisted partial nephrectomy (RAPN) increased. The rate of clampless NSS constantly increased over time. The use of at least one haemostatic agent has been significantly more adopted in the most recent surgical era (p < 0.001). CONCLUSIONS The utilization rate of NSS in Italy is increasing, even in elective and more complex cases. RAPN has been progressively adopted, as well as the intraoperative utilization of haemostatic agents and the rate of clampless procedures.

Different Evolution of Voiding Function in Underactive Bladders With and Without Detrusor Overactivity

PURPOSE We assessed bladder voiding function in patients with idiopathic detrusor underactivity with and without detrusor overactivity for a different evolution in time. MATERIALS AND METHODS We retrospectively analyzed clinical and urodynamic findings in 36 consecutive middle-aged men with idiopathic detrusor underactivity who were referred during 1989 to 2003 for voiding and storage lower urinary tract symptoms. After initial testing at time 1 urodynamics were repeated due to worse lower urinary tract symptoms severity at a median of 45 months (time 2). A total of 17 patients with voiding urgency showed urodynamic detrusor overactivity at times 1 and 2 (group 1) and 19 with no urgency (group 2) never had detrusor overactivity. As controls (group 3) we used 30 age matched, urodynamically normal men. Nonparametric statistics were used for data analysis. RESULTS Compared with controls at time 1 groups 1 and 2 had lower bladder emptying efficiency and bladder contractility (contraction strength, velocity and energy reserve) with relatively higher contraction velocity and energy reserve in group 1 than in group 2. Compared with time 1 at time 2 the 2 detrusor underactivity groups showed an increased International Prostate Symptom Score (more increased in group 1), and decreased bladder contractility and emptying efficiency (less decreased in group 1). CONCLUSIONS A likely explanation for our findings is that by causing relatively more rapid (less slow) detrusor contractions detrusor overactivity partly decreased the time needed and, thus, the total energy expended by underactive bladders for mounting micturition contractions. This compensatory efficiency would account for the relatively better evolution of bladder voiding function with time.