Satoshi Hamano

Functional Bladder Capacity as Predictor of Response to Desmopressin and Retention Control Training in Monosymptomatic Nocturnal Enuresis

Objective: To evaluate the efficacy of intranasal desmopressin (DDAVP) and retention control training (RCT) for monosymptomatic nocturnal enuresis in childhood and to assess the predictive value of daytime functional bladder capacity for both methods.Materials and Methods: A total of 114 children with monosymptomatic nocturnal enuresis, of whom 99 (86.8%) wetted the bed every night, were treated with 1 of the 2 methods: intranasal DDAVP in 54 and RCT in 60 subjects.Results: Twenty–one of 54 patients (38.9%) and 14 of 60 patients (23.3%) in the DDAVP group and the RCT group, respectively, achieved strong improvement (p = 0.061). Forty–five of 54 (90.0%) in the DDAVP and 35 of 60 (58.3%) in the RCT group had a more than 50% decrease in wet nights (p = 0.004). In the DDAVP group, the functional bladder capacities at baseline in responders and nonresponders were 82±22% and 56±20% of the predicted bladder capacity for their age (p<0.001). In the RCT group, responders and nonresponders did not differ in functional bladder capacity at baseline.Conclusion: DDAVP treatment is more effective than RCT in decreasing the number of wet nights in childhood nocturnal enuresis, but not so effective in children with a low functional bladder capacity. Daytime functional bladder capacity is a valuable predictor of response to DDAVP, but not so to RCT.

Pyogenic Psoas Abscess: Difficulty in Early Diagnosis

Aim: To report on the clinical features, diagnosis, and treatment of psoas abscess (PA) with special attention to the presence of septic shock. Patients and Methods: This study included 17 patients (mean age 66.2, range 43–81 years) with PA. Treatment consisted of intravenous administration of antibiotics and abscess drainage, either surgical or percutaneous with ultrasound guidance. Results: The typical patients presented with fever >38°C (16/17, 94%), pain in back, flank, or abdomen (15/17, 88%), hip flexion contracture with pain extension (14/17, 82%), and mass felt in the flank (5/17, 29%). All 8 patients without septic shock (100%) had the clinical triad (fever, pain in back, flank, or abdomen, and hip flexion contracture) as compared with 4 of 9 patients with septic shock (44%) (p = 0.012). The duration of symptoms before hospitalization was significantly shorter in the patients with septic shock (median 2, range 1–5 days) than in those without septic shock (median 18.5, range 11–63 days; (p = 0.0005). The mortality rates were 33% (3 of 9) and 0% (0 of 8) in the patients with and without septic shock, respectively (p = 0.071). Conclusions: PA patients with septic shock had a tendency to have nonspecific symptoms and an occult clinical course as compared with those without septic shock. A delay in diagnosis and treatment can result in a worse clinical outcome (death or totally disabled state). Increased awareness of this condition should lead to earlier diagnosis and treatment with improved outcomes.

Evaluation of functional bladder capacity in Japanese children

Background: Functional bladder capacity is a very important factor in the diagnosis of children with voiding disorders. Because Japanese children are thought to have somewhat smaller functional bladder capacity compared with Western children, the convenient formula (so‐called Koff formula) bladder capacity (in ounces) = age (in years) + 2 is not suitable for use in Japanese children.

Clinical effect of alpha 1D/A adrenoceptor inhibitor naftopidil on benign prostatic hyperplasia: an international prostate symptom score and King's Health Questionnaire assessment.

Objectives:  To examine the effect of alpha 1D/A adrenoceptor inhibitor naftopidil on health‐related quality of life (QOL) in men with benign prostatic hyperplasia (BPH).

Do BPH Patients Have Neurogenic Detrusor Dysfunction? A Uro-Neurological Assessment

Introduction: Most men with benign prostatic hyperplasia (BPH) are middle- aged and elderly. Neurogenic detrusor dysfunction (NDD) may also occur in these populations. We made an uro-neurological assessment in such patients in order to investigate the possibility of a concurrent NDD in patients diagnosed with BPH, and to correlate the presence of NDD with treatment outcome. Materials and Methods: 28 men, mean age 66.4 years, referred by urologists at the outpatient clinic as BPH (initial diagnosis: BPH alone, 24, BPH and NDD, 4) with regards to digital examination and lower urinary tract symptoms, underwent urodynamic study and neurological examination. MRI scans were performed to confirm the diagnosis. Results: Urodynamic study (except for 2, acontractile detrusor (AD)) showed equivocal obstruction (EO), 6; underactive detrusor (UD), 9 (voiding phase); detrusor overactivity (DO), 12; urethral relaxation, 1, and reduced sensation, 5 (filling phase). EO correlated with the presence of UD (p = 0.03). DO did not correlate with the prostate size or urodynamically-defined outlet obstruction. Reduced sensation was common in patients >65 years of age (p = 0.05). Neurological examination/imaging showed exaggerated reflexes, 1; decreased reflexes, 6; multiple cerebral infarction, 8; cervical spondylosis, 1 (in patients with DO); lumbar spondylosis, 5 (in patients with AD/UD), and the final diagnosis was made: definite BPH, 6; probable BPH, 9; BPH and NDD, 13, and NDD were common in the patients aged >65 years (p = 0.015). Transurethral prostatectomy and α-blocker were mostly successful, but the failure rate was reported in definite BPH, none, probable BPH, 29%, and BPH and NDD, 33%. Conclusions: BPH patients, particularly those >65 years of age, commonly have NDD. Multiple cerebral infarction (upper neuron disorder) and lumbar spondylosis (lower neuron disorder) might contribute to DO and UD, respectively. A uro-neurological assessment is important to select typical BPH patients for maximizing therapeutic benefit.

Experience with Ureteral Stone Management in 1,082 Patients Using Semirigid Ureteroscopes

Objectives: To assess the efficacy and complications of ureteroscopic lithotripsy (URS) using semirigid ureteroscopes. Methods: We retrospectively analyzed the records of 1,082 consecutive patients with ureteral stones who were treated with URS with or without auxiliary extracorporeal shock wave lithotripsy for stone fragments. The efficacy was estimated using the stone-free rate and efficiency quotient (EQ). Results: The stone-free rates were 79.0, 90.4 and 93.2% for upper, middle and lower ureteral stones, respectively. The EQ was 0.49 for upper, 0.79 for middle and 0.87 for lower ureteral stones. Ureteral perforation occurred in 54 cases (5.0%), of which 13 cases (1.2%) required nephrostomy (n = 11, 1.0%) or open surgery (n = 2, 0.2%). Conclusions: URS is a reasonable procedure with minor complications for stones located in the lower and middle ureter, but cannot be recommended as a first-line treatment for upper ureteral stones.

Urethral obstruction in patients with nighttime wetting: Urodynamic evaluation and outcome of surgical incision

The aim of this study was to investigate urodynamic findings and the outcome of surgical incision in patients with nighttime wetting due to urethral obstruction. A total of 239 patients with nighttime wetting (157 males and 82 females; mean age, 8.7; range, 4–18 years) was studied. One hundred and ten patients had monosymptomatic enuresis alone and 129 both nighttime wetting and daytime symptoms, that is, the majority was not simple bedwetters, but had signs of bladder overactivity. All patients were first treated with bladder training and fluid intake after dinner was restricted. The non‐responders were then treated with tricyclic antidepressants, anticholinergics, or intra‐nasal desmopressin and conditioning therapy. Ninety‐seven patients who did not respond to these conventional treatments were investigated by voiding cystourethrography, bougie à boule, and urodynamic study. Urethral obstruction was noted in 34 patients (14.2%); posterior urethral valves in three males, ring stricture of the bulbar urethra in 26 males and distal urethral stenosis in five females. Detrusor instability was noted in 30 (94%) of 32 patients. Three patients had <15 mL/s of maximum flow rate and none had post‐void residual urine. Pressure at maximum flow (PQmax) was 106.5 ± 26.3 cm H2O in pressure/flow study. After surgery, nighttime wetting was cured in 25 patients (73.5%), improved in four (11.8%). Detrusor instability disappeared in six of 16 patients studied (37.5%) and improved in 8 (50%), and PQmax decreased significantly after operation (P = 0.0034). In conclusion, most of the patients with urethral obstruction have detrusor instability and high pressure voiding, and these conditions improved after operation. Neurourol. Urodynam. 19:241–248, 2000.

Safety, Efficacy and Impact on Patients’ Quality of Life of a Long–Term Treatment with the α1–Blocker Alfuzosin in Symptomatic Patients with BPH

Objective: The aim of this study was to assess the impact of a 12–month treatment period with alfuzosin, 2.5 mg t.i.d, on symptomatic patients with BPH (n = 355) by means of the International Prostate Symptom Score (I–PSS), the Symptom Problem Index (SPI), the BPH Impact Index (BII), and the single Quality of Life (QoL) question proposed by the WHO.Study Design: This was a naturalistic study, carried out under conditions of normal practice by 22 centres of urology.Methods: At baseline and on a quarterly basis up to 12 months of treatment, subjective and objective (uroflowmetry and residual urine volume) responses of the patients were evaluated. The appearance of adverse medical events (AMEs) was carefully monitored and recorded throughout the trial.Results: Both the BII and the Qol question improved gradually over time (60 and 54.6%, respectively, after 12 months of treatment). At any visits, the improvements were statistically significant versus the baseline (p<0.01). Alfuzosin was able to improve the BPH symptoms progressively and significantly over time: total mean score I–PSS: 3rd month = 22.7%, 6th month = 38.4%, 9th month 0.50%, 12th month = 61.6%. The improvement was more marked in patients with severe symptoms at baseline (I–PSS score 20–35, 63.6%). A progressive and marked improvement over time of the problems due to symptoms (SPI) was observed in the whole population (61.7% after 12 months of treatment). After 12 months of treatment, uroflowmetric data showed a significant increase in peak (+5.5 ml/s) flow rate, associated with a marked decrease in residual volume: –31 ml (–53.5%). Twenty–five patients (7.1%) experienced one or more AMEs (total AMEs n = 44). Globally, 14 vasodilatory events and 30 non–vasodilatory events were reported. Fifteen (4.3%) patients dropped out prematurely from the study for safety reasons. Seven serious AMEs were reported during the study period.Conclusions: This study showed that long–term treatment with alfuzosin in usual clinical practice had a continued and positive impact on the patients’ QoL.

Transurethral Ureterolithotomy in 100 Lower Ureteral Stones

A total of 100 patients with lower ureter stones received transurethral ureterolithotripsy (TUL) using a pulsed dye laser and/or a pneumatic lithotriptor. Extracorporeal shock wave lithotripsy treatment was added in 15 patients because fragments larger than 4 mm had been pushed back to the renal pelvis. The median stone size was 8 mm (range 3–22 mm). Operative time ranged between 3 and 157 min with a median of 30 min. Stone size correlated well with impaction, when impaction was defined as the inability of a guidewire to pass over the stone. Complete removal was defined as total clearance at 1 month without retreatment. The overal stone-free rate was 93%. Among the 7 not-stone-free cases, 5 cases were considered to have been treated successfully because asymptomatic residual fragments were smaller than 4 mm, 1 case required retreatment to become stone free, and 1 case with a silent residual fragment of 8 mm had been followed up for 3 months. The success rate was 98% when successful treatment was defined as total clearance or the presence of asymptomatic residual fragments of 4 mm or less without retreatment. Impaction was not a significant determining factor of stone-free rate (95.7 and 86.7%, respectively, p >0.05) and in situ stone-free rate (TUL alone; 85.7 and 76.7%, respectively, p >0.05). Two minor ureteral perforations were encountered. No patient required percutaneous nephrostomy or open surgery, or showed any late complications. TUL is a safe and successful method in managing lower ureteral stones.

Usefulness of tonsil forceps in radical retropubic prostatectomy

Abstract  The presence of positive surgical margins after radical retropubic prostatectomy (RRP) for prostate cancer leads to an increased risk of progression and reduces disease free survival. A positive surgical margin at the apex is more frequent and is associated with worse clinical prognosis compared to other locations. The urethra usually enters the prostate slightly anterior and proximal to the prostatic apex. After dividing the dorsal vessels and separating neurovascular bundles (NVB) from the prostatic urethral junction using scissors, the operator dissects around the urethra just below the apex to avoid incision into the apex and injury of the NVB and sphincter mechanism. We use tonsil forceps instead of a right‐angle clamp to make this important operative step more approachable. Its special curved shape with an angle of 105 degrees and short tip should make it much easier to isolate the urethra just below the apex from the surrounding tissue.