David C. Chaikin

NONINVASIVE OUTCOME MEASURES OF URINARY INCONTINENCE AND LOWER URINARY TRACT SYMPTOMS: A MULTICENTER STUDY OF MICTURITION DIARY AND PAD TESTS

PURPOSE We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms. MATERIALS AND METHODS We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lins concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability. RESULTS Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance. CONCLUSIONS The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.

Collagen injection therapy for post-radical retropubic prostatectomy incontinence : Role of valsalva leak point pressure

PURPOSE We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

Erectile dysfunction following minimally invasive treatments for prostate cancer.

OBJECTIVES Cryosurgical ablation of the prostate (CSAP) and interstitial radiotherapy (IR) are relatively new procedures intended to be less invasive than radical prostatectomy for the treatment of prostate cancer. Despite absence of long-term or intermediate data of efficacy, many patients choose one of these therapies because they presume their potency will be maintained. We report our experience with CSAP, IR, and post-procedure erectile dysfunction. METHODS Global sexual assessments were made in 12 months after therapy in 28 CSAP patients, and at 18 months in 37 IR patients. Each patient was contacted by telephone following his procedure. The patients were asked several questions regarding their sexual function both preoperatively and postoperatively. The questionnaire was administered only to the patient. RESULTS Twenty-eight of 36 patients who underwent CSAP responded to the questionnaire (78%). Twenty patients were potent preoperatively (71%). The mean age of the potent group was 69 years (range 54 to 82). Following therapy, 2 of these patients (10%) reported potency at 12 months. Thirty-seven of 42 patients who underwent IR responded to the questionnaire (88%). Twenty-seven were potent preoperatively (73%). The mean age of the potent group was 70 years (range 56 to 83). The mean follow-up was 18 months (range 5 to 36). Following therapy, 15 patients reported potency (55%). All of the patients who reported potency felt that the quality of their erections had decreased following radiation. CONCLUSIONS Our short-term results with IR and CSAP suggest a significant adverse effect on erectile function. Our results suggest that enhanced preservation of potency should not be used as an enticement in the promotion of IR or CSAP.

Voiding dysfunction: definitions.

‘Lower urinary tract symptoms’ is a term that describes symptoms related to both the storage and emptying phases of the micturition cycle. Storage symptoms include urinary frequency urgency, urge incontinence, nocturia, dysuria and other kinds of pain emanating from the bladder or urethra. Emptying symptoms consist of hesitancy, straining to void, difficulty starting, diminished stream, a feeling of incomplete bladder emptying and urinary retention. In both sexes, the etiology of lower urinary tract symptoms is multifactorial, and symptoms are a poor indicator of underlying pathophysiology. In men, lower urinary tract symptoms are most often attributed to prostatic obstruction, but only approximately two-thirds of men with lower urinary tract symptoms meet the accepted diagnostic criteria for obstruction. Approximately half have detrusor overactivity and a smaller number have impaired detrusor contractility, sensory urgency, sphincteric incontinence, polyuria or nocturnal polyuria. In women, lower urinary tract symptoms are often considered to result from hormonal abnormalities, childbirth, aging, or previous surgery, but the multifactorial underlying pathophysiology is similar to that seen in men, except for a much lower incidence of urethral obstruction and a high incidence of sphincteric incontinence. Treatment typically begins with empiric, conservative therapies aimed at resolving detrusor instability or bladder outlet obstruction. However, although either or both of these etiologies may exist in the individual with lower urinary tract symptoms, treatment may fail as a result of another cause. We believe that treatment based on the pathophysiology of the symptoms will lead to better outcomes than treatment based on symptoms alone.

MP31-20 CORRELATION BETWEEN SYMPTOM SEVERITY AND BOTHER IN PATIENTS WITH LOWER URINARY TRACT SYMPTOMS

Value (NPV) of 85% for a diagnosis of IC/PBS, as well as a PPV of 90% and NPV of 53% for a diagnosis of OAB (Figure 1B). These results are reflective of the prevalence of significant bladder pain (35%) in OAB patients and the presence of incontinence in IC/PBS patients. CONCLUSIONS: The significant overlap of urinary tract symptoms between OAB and IC/PBS suggests common pathological elements. Future studies aimed at assessing the diagnostic value of novel classification schemes that address symptoms rather than specific diagnoses may improve patient prognosis. Regardless, these data suggest a new paradigm for how we approach BHS.

Re: Imaging Use Among Employed and Self-Employed Urologists

between multispecialty groups, which potentially allay those issues, and single specialty practices. They accuse self-employed urologists of being bad doctors, “spend(ing) less time with their patients to facilitate greater throughput,” and yet fail to bother reporting the average number of patients seen by an employed vs self-employed urologist. It may be enlightening as well to see the distribution of new vs established patient visits between employed and self-employed urologists, especially in the context of imaging orders, and yet there is no effort to include this analysis. Finally, there is a substantial disparity in imaging orders between DOs and MDs, a fact never acknowledged in the Discussion. Certainly a submission regarding the imaging use disparity between DOs and MDs would not garner the same attention. This selective use of the available data should raise suspicions that the authors chose to analyze in-depth only those points that would not draw attention away from their preconceived conclusions. These data were presented at the 2010 AUA Annual Meeting with the title, “Associations Between Urologist Financial Incentives and Imaging Use.” Changing the title does not hide the biased intent because the selective analysis supporting preconceived conclusions remains. Accusations of clinical decision making based on financial motivation and other vilification of urologists have become a staple of the lead author, a former colleague and representative of my former residency training department. That pattern and the appearance that the conclusions preceded the question should lead to pause. Perhaps the authors could use their apparent talents to illustrate something urologists are doing right?