Ger E.P.M. van Venrooij

Recovery of storage and emptying functions of the urinary bladder after spinal anesthesia with lidocaine and with bupivacaine in men.

Background The aim of this study was to evaluate and compare the effects of spinal anesthesia with lidocaine and with bupivacaine on urinary bladder function in healthy men who were scheduled for minor orthopaedic surgical procedures. Methods Twenty men were randomly allocated to receive either bupivacaine or lidocaine. Before spinal anesthesia, filling cystometry was performed with the patient in the supine position and a pressure flow study was done with the patient in the standing position. After operation, cystometric measurements were continued until the patient could void urine spontaneously. The levels of analgesia and of motor blockade were recorded. Results The urge to void disappeared immediately after injection of the local anesthetics. There was no difference in the duration of lower extremity motor blockade between bupivacaine and lidocaine. Detrusor blockade lasted significantly longer in the bupivacaine group (means +/‐ SD, 460 +/‐ 60 min) than in the lidocaine group (235 +/‐ 30 min). Total fluid intake and urine volume accumulated during the detrusor blockade were significantly higher in the bupivacaine group than in the lidocaine group. In the bupivacaine group, the total volume of accumulated urine (875 +/‐385 ml) was also significantly higher than cystometric bladder capacity (505 +/‐ 120 ml) with the risk of over distension of the bladder. Spontaneous voiding of urine did not occur until segmental sensory analgesia had regressed to the third sacral segment. Conclusions Spinal anesthesia with lidocaine and with bupivacaine causes a clinically significant disturbance of bladder function due to interruption of the micturition reflex. The urge to void disappears quickly and bladder function remains impaired until the block has regressed to the third sacral segment in all patients. With long‐acting local anesthetics, the volume of accumulated urine may exceed the cystometric bladder capacity. With respect to recovery of urinary bladder function, the use of short‐acting local anesthetics for spinal anesthesia seems to be preferable.

Intrathecal opioids and lower urinary tract function: a urodynamic evaluation.

Background: Intrathecal administration of opioids may cause lower urinary tract dysfunction. In this study, the authors compared the effects of morphine and sufentanil administered intrathecally in a randomized double-blind fashion (two doses each) on lower urinary tract function in healthy male volunteers. Methods: Urodynamic evaluation was performed before and every hour after drug administration up to complete recovery of lower urinary tract function using pressure and flow measurements recorded from catheters in the bladder and rectum. Sense of urge and urinary flow rates were assessed every hour by filling the bladder with its cystometric capacity and asking the patient to void. Full recovery was defined as a residual volume of less than 10% of bladder capacity and a maximum flow rate within 10% of the initial value. Results: Intrathecal administration of both opioids caused dose-dependent suppression of detrusor contractility and decreased sensation of urge. Mean times to recovery of normal lower urinary tract function were 5 and 8 h after 10 or 30 μg sufentanil and 14 and 20 h after 0.1 or 0.3 mg morphine, respectively. This recovery profile can be explained by the spinal pharmacokinetics of both opioids. Conclusions: Intrathecal opioids decrease bladder function by causing dose-dependent suppression of detrusor contractility and decreased sensation of urge. Recovery of normal lower urinary tract function is significantly faster after intrathecal sufentanil than after morphine, and the recovery time is clearly dose dependent.

Non‐Radical Hysterectomy And The Function Of The Lower Urinary Tract: II: Urodynamic Quantification Of Changes In Evacuation Function

The intermediate sequelae of non‐radical abdominal and vaginal hysterectomies on the evacuation function of the lower urinary tract were studied by comparison of pre‐ and postoperative urodynamic parameters. No significant changes were observed in detrusor contractility or the contribution of abdominal straining after hysterectomy. Pressure‐flow studies revealed no development towards obstructive patterns. Uroflowmetry did not demonstrate any changes in flow rates or in flow patterns. Except in one woman, no major variations were seen in residual urine volumes. There were no differences between abdominal and vaginal hysterectomies. It is concluded that lower urinary tract evacuation function remains unaltered by total hysterectomy.

Non-Radical Hysterectomy and the Function of the Lower Urinary Tract: I: Urodynamic quantification of changes in storage function

The intermediate sequelae of non‐radical abdominal and vaginal hysterectomies on the storage function of the lower urinary tract were studied by comparison of pre‐ and postoperative urodynamic parameters. A statistically significant reduction in maximum cystometric capacity after abdominal extrafascial and vaginal hysterectomies was found, together with a decline in bladder compliance. Both findings are attributed to a decrease in the musculoelastic properties of the detrusor muscle caused by edema and surgical injury. This reduction in capacity and compliance, however, appeared to have no clinical importance. Sensory innervation remained unaltered. In general no evidence was found that hysterectomy contributed to the development of involuntary detrusor contractions and motor urge incontinence. Urethral competence, assessed by urethral pressure profilometry and urethral leakage pressure measurement, remained unaffected. No increase in stress incontinence was seen after hysterectomy. Vaginal hysterectomy appeared to influence storage function slightly more than abdominal hysterectomy did. Postoperative lower urinary tract dysfunction is for the most part determined by the preoperative urological status.

Data from frequency-volume charts versus symptom scores and quality of life score in men with lower urinary tract symptoms due to benign prostatic hyperplasia.

Objective: The aim is to study the relations between reported data on frequency–volume charts and the American Urological Association (AUA) symptom scores and quality of life score. Methods: Males with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH), were consecutively included in the study if they met the criteria of the International Consensus Committee on BPH, they voided >150 ml during uroflowmetry, residual volume and prostate size were estimated and frequency–volume charts were completed correctly. From the frequency–volume charts, voiding habits and fluid intake in the daytime and at night were evaluated. Results: In the included 160 men no correlation was found between total urine production at night or in the daytime and symptom index or quality of life score. Nycturia was correlated with symptom index, but surprisingly not with quality of life score. Small voided volumes at night and in daytime are attended by high symptom index and high quality of life score (= low quality of life). Diuria has a high impact on symptom index and quality of life score. Men who completed frequency–volume charts during 3 or more daytime periods (68%) had a significantly higher symptom index than those who completed only 1 or 2 daytime periods (32%). Conclusions: High diuria, and small voided volumes at night and in daytime contribute significantly to high symptoms and low quality of life. Nycturia correlated with AUA symptom index but surprisingly not with quality of life score.

Laser- and electrosurgery as a treatment modality of BPH: urodynamic evaluation of seven different techniques in 280 patients

Laser treatment of the prostate as an alternative for transurethral resection of the prostate (TURP) has evolved from a complicated troublesome procedure to a single office procedure. In this study, we compared the efficacy of different electrosurgical and laser techniques. The data of seven prospective studies in 280 patients were evaluated. The patients were treated for bladder outlet obstruction due to benign prostatic hyperplasia during the period from 1992 until 1998. Five procedures were offered using Nd:YAG laser light, including ultrasound-guided free beam, a free beam technique applying either a predetermined energy dose or a visually-guided energy does, contact laser prostatectomy and a hybrid method where free beam coagulation was followed by contact laser. Two procedures were offered using electrosurgery comprising transurethral resection and transurethral electrovaporization. The clinical outcome was assessed pre-operatively and 6 months post-operatively by free flowmetry, post-void residual, and Shaeffer obstruction grade. Results after 6 months are shown in the table below.

Prostate on the menu: an overview of cooking techniques and clinical outcome

In the past years there has been a significant increase in the treatment of bladder outlet obstruction caused by benign prostatic hyperplasia. Transurethral electroresection of the abundant tissue (TURP) has since the early seventies been the golden standard. The main drawback of a TURP is the relative lack of hemostasis, due to a confined energy and heat distribution around the resection loop. As sufficient tissue needs to be removed to overcome the bladder outlet obstruction, the ideal treatment has to combine both ablative and hemostatic abilities. After 1992, endoscopic laser and non laser treatment modalities have been introduced, that competed with TURP as to clinical outcome. These treatments have in common that a high amounts of energy is delivered to the prostate to remove tissue either indirectly by coagulation necrosis or directly by vaporization. Various in-vitro and clinical studies were performed using different energy sources, such as Nd:YAG and diode laser light in combination with a large variety of delivery devices. Also TURP was included in the evaluation. The in-vitro results provided understanding of the efficiency in energy delivery, the extent of heat induced in the prostatic tissue and possible side-effects, using thermal imaging techniques. Over the last five years clinical data have been collected for various techniques with a follow-up of two years showing the contact techniques to be superior over non-contact and comparable with the outcome of the standard TURP.