Kang Jun Cho

Current Trends in the Management of Post-Prostatectomy Incontinence

One of the annoying complications of radical prostatectomy is urinary incontinence. Post-prostatectomy incontinence (PPI) causes a significant impact on the patients health-related quality of life. Although PPI is stress urinary incontinence caused by intrinsic sphincter deficiency in most cases, bladder dysfunction and vesicourethral anastomotic stenosis can induce urine leakage also. Exact clinical assessments, such as a voiding diary, incontinence questionnaire, pad test, urodynamic study, and urethrocystoscopy, are necessary to determine adequate treatment. The initial management of PPI is conservative treatment including lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder training. An early start of conservative treatment is recommended during the first year. If the conservative treatment fails, surgical treatment is recommended. Surgical treatment of stress urinary incontinence after radical prostatectomy can be divided into minimally invasive and invasive treatments. Minimally invasive treatment includes injection of urethral bulking agents, male suburethral sling, and adjustable continence balloons. Invasive treatment includes artificial urinary sphincter implantation, which is still the gold standard and the most effective treatment of PPI. However, the demand for minimally invasive treatment is increasing, and many urologists consider male suburethral slings to be an acceptable treatment for PPI. The male sling is usually recommended for patients with persistent mild or moderate incontinence. It is necessary to improve our understanding of the pathophysiologic mechanisms of PPI and to compare different procedures for the development of new and potentially better treatment options.

Efficacy and Safety of Desmopressin Add-On Therapy for Men with Persistent Nocturia on α-Blocker Monotherapy for Lower Urinary Tract Symptoms: A Randomized, Double-Blind, Placebo Controlled Study

Purpose: We investigated the efficacy and safety of desmopressin add‐on therapy for men with persistent nocturia on &agr;‐blocker for lower urinary tract symptoms in this placebo controlled study. Materials and Methods: The study included men 40 to 65 years old with lower urinary tract symptoms and persistent nocturia despite &agr;‐blocker therapy for at least 8 weeks. Patients were randomized to once daily placebo or desmopressin 0.2 mg for 8 weeks. The primary end point was to assess changes in the mean number of nocturia episodes from baseline to the final assessment. Other secondary end points and adverse events were evaluated. Results and Limitation: A total of 86 patients were randomized to treatment, including placebo in 39 and desmopressin 0.2 mg in 47. Baseline characteristics were similar in the 2 groups. The desmopressin add‐on group was significantly superior to placebo in terms of the change from baseline in the mean number of nocturia episodes (−1.13 ± 0.92 vs −0.68 ± 0.79, p = 0.034), the changes in nocturnal urine volume (p <0.001), total I‐PSS (International Prostate Symptom Score) (p = 0.041), the nocturnal polyuria index (p = 0.001) and ICIQ‐N (International Consultation on Incontinence Questionnaire‐Nocturia) (p = 0.001), and the willingness to continue (p = 0.025). The incidence of adverse events in the desmopressin add‐on group was similar to that in the placebo group. Most adverse events were mild. Conclusion: Desmopressin add‐on therapy in men 40 to 65 years old with persistent nocturia on &agr;‐blocker monotherapy for lower urinary tract symptoms is effective and well tolerated.

Preoperative Factors Affecting Postoperative Early Quality of Life During the Learning Curve of Holmium Laser Enucleation of the Prostate

Purpose The aim of this study was to investigate the preoperative factors related to early quality of life (QoL) in patients with benign prostatic hyperplasia after holmium laser enucleation of the prostate (HoLEP) during the surgeons learning curve. Methods The medical records of 82 patients with a follow-up period of at least 3 months who were treated with HoLEP during the time of a surgeons learning curve were analyzed retrospectively. We divided the patients into two groups on the basis of the QoL component of the International Prostate Symptom Score (IPSS) 3 months after HoLEP: the high QoL group (IPSS/QoL≤3) and the low QoL group (IPSS/QoL≥4). Preoperative factors in each group were compared, including prostate volume, prostate-specific antigen, history of acute urinary retention (AUR), urgency incontinence, IPSS, and urodynamic parameters. Detrusor underactivity was defined as a bladder contractility index less than 100 on urodynamic study. Results A total of 61 patients (74.3%) had a high QoL, whereas 21 (25.7%) had a low QoL. A history of AUR, detrusor pressure on maximal flow (PdetQmax), bladder outlet obstruction grade, bladder contractility index, and detrusor underactivity were associated with postoperative QoL in the univariate analysis. In the multivariate analysis, a history of AUR and PdetQmax were independent factors affecting postoperative QoL. Conclusions A history of AUR and bladder contractility affect early QoL, and preoperative urodynamic study plays an important role in the proper selection of patients during the HoLEP learning curve.

Biomarkers for lower urinary tract dysfunction

Lower urinary tract dysfunction is highly prevalent, but has relatively low persistence and compliance with therapy because of poor efficacy. Although urodynamic study is the gold standard for detailed evaluation of lower urinary tract dysfunction, urodynamic study has limitations as a biomarker, such as invasiveness and a lack of reproducibility of symptoms. Thus, many investigations about new biomarkers for lower urinary tract dysfunction have been carried out and reported. For imaging biomarkers, bladder and prostate parameters assessed by ultrasonography have been used to evaluate lower urinary tract dysfunction. For urinary biomarkers, neurotrophins, such as nerve growth factor and brain derived neurotrophics factor, prostaglandins and cytokines, have been analyzed and evaluated. Among these, nerve growth factor is considered one of the key factors in the pathophysiology of lower urinary tract dysfunction, and is researched in various ways. Serum markers have suggested that C‐reactive protein and sex hormones have a relationship with lower urinary tract dysfunction. The possibility of genetic biomarkers in lower urinary tract dysfunction has also been raised. Nevertheless, as yet these biomarkers have not shown enough evidence to reflect lower urinary tract dysfunction and require further investigation. This review will discuss promising and potential biomarkers in lower urinary tract dysfunction to date.

Effect of 5-alpha Reductase Inhibitor on Storage Symptoms in Patients with Benign Prostatic Hyperplasia

Purpose Many patients with benign prostatic hyperplasia (BPH) have storage symptoms. The aim of this study was to evaluate the effects of treatment with a 5-alpha reductase inhibitor (5ARI) on storage symptoms in patients with BPH. Methods This study was conducted in 738 patients with lower urinary tract symptoms secondary to BPH. Patients with a prostate volume of higher than 30 mL on the transrectal ultrasound were classified into two groups: group A, in which an alpha blocker was solely administered for at least 12 months, and group B, in which a combination treatment regimen of an alpha blocker plus 5ARI was used. This was followed by an analysis of the changes in parameters such as the total International Prostate Symptom Score (IPSS), voiding symptom subscore, and storage symptom subscore between the two groups. In addition, we examined whether there was a significant difference between the two groups in the degree of change in storage symptoms between before and after the pharmacological treatment. Results Of the 738 men, 331 had a prostate volume ≥30 mL, including 150 patients in group A and 181 patients in group B. Total IPSS, the voiding symptom subscore, and the storage symptom subscore were significantly lower after treatment than before treatment in both groups (P<0.05). A comparison of the degree of change between before and after treatment, however, showed no significant differences in the storage symptom subscore between the two groups (P>0.05). Conclusions Alpha blocker and 5ARI combination treatment is effective for patients with BPH including storage symptoms. However, 5ARI does not exert a significant effect on storage symptoms in BPH patients.

Predictors of urgency improvement after Holmium laser enucleation of the prostate in men with benign prostatic hyperplasia.

Purpose To investigate the change in urinary urgency and predictors of urgency improvement after holmium laser enucleation of the prostate (HoLEP) in men with benign prostatic hyperplasia (BPH). Materials and Methods We retrospectively analyzed the medical records of patients who were treated with HoLEP for BPH and had preoperative urgency measuring ≥3 on a 5-point urinary sensation scale. Those with prostate cancer diagnosed prior to or after HoLEP, a history of other prostatic and/or urethral surgery, moderate to severe postoperative complications, and neurogenic causes were excluded. Patients who had improved urgency with antimuscarinic medication after HoLEP were excluded. We divided the patients into 2 groups based on urgency symptoms 3 months after HoLEP: improved and unimproved urgency. Improved urgency was defined as a reduction of 2 or more points on the 5-point urinary sensation scale. Preoperative clinical and urodynamic factors as well as perioperative factors were compared between groups. Results In total, 139 patients were included in this study. Voiding parameters in all patients improved significantly after HoLEP. Seventy-one patients (51.1%) had improved urgency, while 68 (48.9%) did not show any improvement. A history of acute urinary retention (AUR) and postvoid residual were associated with postoperative urgency improvement in univariate analysis. In multivariate analysis, a history of AUR was an independent factor affecting urgency improvement. Conclusions A preoperative history of AUR could influence the change in urgency after HoLEP surgery in patients with BPH.

Changes in Adenosine Triphosphate and Nitric Oxide in the Urothelium of Patients with Benign Prostatic Hyperplasia and Detrusor Underactivity

Purpose: We investigated changes in the levels of adenosine triphosphate and nitric oxide in the urothelium of men with detrusor underactivity and benign prostatic hyperplasia. Materials and Methods: We prospectively enrolled in study 30 men who planned to undergo surgical treatment for benign prostatic hyperplasia. The 15 patients with a bladder contractility index less than 100 were assigned to the detrusor underactivity group while the 15 with a bladder contractility index more than 100 were assigned to the no detrusor underactivity group. Bladder mucosal specimens were collected at surgical prostate resection, and adenosine triphosphate and endothelial nitric oxide synthase were analyzed in these specimens. The levels of adenosine triphosphate and endothelial nitric oxide synthase were compared between the 2 groups. The correlation of urodynamic parameters with adenosine triphosphate and endothelial nitric oxide synthase was assessed in all patients. Results: Mean ± SEM endothelial nitric oxide synthase did not significantly differ between the detrusor underactivity and no underactivity groups (3.393 ± 0.969 vs 1.941 ± 0.377 IU/ml, p = 0.247). However, the mean level of adenosine triphosphate in the detrusor underactivity group was significantly lower than in the no detrusor underactivity group (1.289 ± 0.320 vs 9.262 ± 3.285 pmol, p = 0.011). In addition, in all patients adenosine triphosphate positively correlated with the bladder contractility index (r = 0.478, p = 0.018) and with detrusor pressure on maximal flow (r = 0.411, p = 0.046). Conclusions: Adenosine triphosphate was significantly decreased in the urothelium in men with detrusor underactivity and benign prostatic hyperplasia, reflecting the change in detrusor function.

Factors Associated With Early Recovery of Stress Urinary Incontinence Following Holmium Laser Enucleation of the Prostate in Patients With Benign Prostatic Enlargement

Purpose To investigate factors associated with early recovery of stress urinary incontinence (SUI) following holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic enlargement (BPE). Methods The medical records of 393 patients who underwent HoLEP for BPE were retrospectively reviewed. Patients with SUI following HoLEP were selected and divided into 2 groups: those who experienced early recovery of SUI and those who experienced persistent SUI. Recovery of SUI within 1 month after HoLEP was defined as early, and SUI that remained present after 1 month was defined as persistent. Preoperative clinical and urodynamic factors, as well as perioperative factors, were compared between groups. Results SUI following HoLEP was detected in 86 patients. Thirty-three patients exhibited recovery of SUI within 1 month, and SUI remained present in 53 patients after 1 month. Multivariate analysis showed that the transition zone prostate volume (odds ratio [OR], 5.354; 95% confidence interval [CI], 1.911–14.999; P=0.001) and the enucleation ratio (OR, 8.253; 95% CI, 1.786–38.126; P=0.007) were significantly associated with early recovery of SUI. Conclusions Early recovery of SUI within 1 month following HoLEP was associated with transition zone prostate volume and the enucleation ratio.

Evaluation of female overactive bladder using urodynamics: relationship with female voiding dysfunction.

ABSTRACT Purpose: To investigate the role of urodynamic study (UDS) in female patients with overactive bladder (OAB) analyzing the relationship between OAB symptoms and female voiding dysfunction (FVD). Materials and Methods: We analyzed the clinical and urodynamic data of 163 women with OAB symptoms. OAB symptoms were categorized as dry and wet. FVD was described as detrusor underactivity (DUA), which was defined as a maximum flow rate (Qmax) of ≤15mL/s associated with a detrusor pressure at Qmax (PdetQmax) of ≤20cmH2O, along with bladder outlet obstruction (BOO), which was defined as a Qmax of ≤15mL/s with a PdetQmax of >20cmH2O. Clinical and urodynamic results were compared between patients with dry and wet symptoms and between those with and without FVD. Results: 78 (47.9%) had dry, and 85 (52.1%) had wet symptoms. The entire group had a relatively low Qmax (15.1±6.6mL/s) and relatively high number of BOO (42.9%, 70/163) and DUA (8.6%, 14/163). A significantly higher number of patients with wet symptoms had detrusor overactivity compared to those with dry, as detected by the UDS (p<0.05). No significant differences were found in BOO and DUA number between dry and wet groups. Further, the international prostate symptom score did not different significantly between patients with and without FVD. Conclusion: A significant number of women with OAB had voiding dysfunction. However, the OAB symptoms themselves were not useful for predicting the presence of FVD. Therefore, UDS may be necessary for accurate diagnosis in women with OAB symptoms.

Alfuzosin for the treatment of storage symptoms suggestive of overactive bladder.

Introduction: Antimuscarinics are the mainstay of overactive bladder (OAB) pharmacotherapy although other agents, such as α-adrenergic receptor antagonists, might also be effective. Alfuzosin has α1-adrenoreceptor antagonist activity and is available worldwide for the treatment of lower urinary tract symptoms resulting from benign prostate hyperplasia. Alfuzosin may relieve storage symptoms suggestive of OAB in patients with or without bladder outlet obstruction (BOO). Areas covered: This paper reviews the available literature on the use of alfuzosin in the treatment of storage symptoms suggestive of OAB. Additionally, the role of α-adrenoreceptor antagonists in the treatment of OAB is reviewed, based on pathophysiology. Expert opinion: Although alfuzosin is effective against storage symptoms, it does not improve them in all patients with OAB. It is likely that alternative types of therapy, such as antimuscrarinics, need to be co-administered to patients with residual storage symptoms after alfuzosin administration. Alfuzosin can decrease the risk of adverse events associated with antimuscarinics. The sequential use of alfuzosin and antimuscarinics appears to be an appropriate strategy for the treatment of storage symptoms suggestive of OAB related to BOO.