Tom A. Boon

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.

PREVALENCE AND BOTHERSOMENESS OF LOWER URINARY TRACT SYMPTOMS IN BENIGN PROSTATIC HYPERPLASIA AND THEIR IMPACT ON WELL-BEING

PURPOSE We established the prevalence and bothersomeness of symptoms and their impact on well-being in a large group of strictly selected men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS Included in our study were 475 consecutive men who met the criteria of the International Consensus Committee on BPH and voided more than 150 ml. during uroflowmetry. International Prostate Symptom Scores and quality of life score were determined. We included the 7 bothersomeness questions of the Symptom Problem Index and the 4 of the BPH Impact Index of the American Urological Association Measurement Committee. These questions refer to the degree of bothersomeness caused by urinary problems and how they affect various health domains. RESULTS The symptoms with the highest prevalence based on mean scores were weak urinary stream, frequency and urgency. Urgency, nocturia and hesitancy were the most bothersome symptoms. Patients were only discouraged from performing normal daily activity when the symptom index exceeded 20. Incomplete emptying and frequency bothersomeness correlated strongly, and weak urinary stream and hesitancy bothersomeness correlated weakly with all health and quality of life domains. CONCLUSIONS Weak urinary stream, frequency and urgency were the most prevalent symptoms, while urgency, nocturia and hesitancy were the most bothersome symptoms. In contrast to weak urinary stream and hesitancy, the bothersomeness of incomplete emptying and frequency was strongly associated with well-being.

Testicular microlithiasis, a premalignant condition: prevalence, histopathologic findings, and relation to testicular tumor

OBJECTIVES To perform a retrospective analysis concerning the prevalence of testicular microlithiasis (TM). In patients with TM, the association of TM with testicular tumor, histopathologic findings, and follow-up were studied. METHODS During a 6-year period at the Central Military Hospital or the University Medical Center in Utrecht, The Netherlands, ultrasonography of the testis was performed in 1535 patients. Patient records, ultrasound images, and histopathologic specimens were reviewed. Follow-up was performed in patients with TM. RESULTS In 63 patients (4.1%), with a mean age of 35.4 years (range 19 to 74), TM was diagnosed at ultrasonography. In 29 of these patients (46%), a concomitant testicular tumor was diagnosed. A statistically significant correlation was found between TM and the presence of a testicular tumor (P <0.001; chi-square test). No significant correlation was found concerning the respective positions of the TM and the tumor in the testis, type of calcification, and histologic type of the tumor. In 34 patients, TM was found without a malignancy at diagnosis (mean age 39.2 years; range 19 to 69). Follow-up was possible in 31 patients. During the follow-up period (median 61.8 months), 1 patient developed a testicular tumor. CONCLUSIONS A correlation was found between TM and testicular tumor. Because an increasing number of studies have reported patients with TM who developed a testicular tumor, TM should be regarded as a premalignant condition, which necessitates follow-up. Urologists should consider testis biopsy in patients with TM.

Correlations of Urodynamic Changes With Changes in Symptoms and Well-being After Transurethral Resection of the Prostate

PURPOSE To establish the predictive value of urodynamics on the outcome of transurethral prostate resection for benign prostatic enlargement we correlated urodynamic changes with symptomatic improvement, decreased bother, and increased general well-being and quality of life after transurethral prostate resection. MATERIALS AND METHODS Men with lower urinary tract symptoms were selected if they met study criteria and underwent tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia, and if post-void residual urine volume and prostate size were estimated. Patients answered quality of life, symptom index, symptom problem index and benign prostatic hyperplasia impact index questions. Patients also underwent urodynamic evaluation. Men were included in analysis when transurethral prostate resection was selected as the treatment modality. Of the 132 patients included 93 were reevaluated 6 months after transurethral prostate resection. RESULTS Improvements after transurethral prostate resection were significantly associated with decreased bladder outlet obstruction (p <0.01). However, 32 cases that were unobstructed or equivocal preoperatively also benefited moderately from resection. Effective capacity, that is cystometric capacity minus post-void residual urine volume, increased by an average of 45% postoperatively. The increase in effective capacity contributed to a significant decrease in symptoms and bother, and to improved well-being. Of the men with a urodynamically proved stable bladder 90% maintained a stable bladder after prostatectomy, while in 50% with a urodynamically proved unstable bladder it became stable postoperatively. CONCLUSIONS Performing urodynamics preoperatively helps to predict the degree of symptom relief, decreased bother and increased well-being after transurethral prostate resection.

INTERNATIONAL PROSTATE SYMPTOM SCORE AND QUALITY OF LIFE ASSESSMENT VERSUS URODYNAMIC PARAMETERS IN MEN WITH BENIGN PROSTATIC HYPERPLASIA SYMPTOMS

In 207 men with symptomatic benign prostatic hyperplasia the international prostate symptom score and score on quality of life were collected. Cystometric tests with pressure-flow studies were performed in these patients with special attention to the assessment of obstruction grade. Of the men 24% appeared not to have obstruction. A significant correlation was found between size of the prostate and grade of obstruction. No correlation was found between obstruction grade, and any symptom score or quality of life score, while symptom score and quality of life correlated well. In 41 patients the outcome of laser prostatectomy was evaluated 6 months after the procedure. Mean symptom score decreased from 19.1 to 5.4 and mean quality of life score decreased from 3.7 to 1.3 in the 31 obstruction patients, compared to decreases of 19.6 to 10.1 and 3.6 to 2.6, respectively, in 10 without obstruction. The improvement in the obstruction patients was significantly better but nonobstruction patients will benefit from prostatectomy as well.

The Value of Symptom Score, Quality of Life Score, Maximal Urinary Flow Rate, Residual Volume and Prostate Size for the Diagnosis of Obstructive Benign Prostatic Hyperplasia: A Urodynamic Analysis

AbstractPurpose: We investigated which linear combination of scores for symptoms, quality of life, maximum urinary flow rate, residual volume and prostate size best discriminated men with prostatism who do and do not have obstruction.Materials and Methods: Mandatory and recommended tests were performed in 196 men older than 50 years with prostatism. Schafers obstruction grade was estimated by urodynamic studies. Relative residual volume was defined as residual volume divided by cystometric capacity (times 100 percent). Correlation coefficients among the different parameters were estimated. Obstruction grade was correlated with linear weighted combinations of the parameters.Results: Of the men 79 percent appeared to have obstruction. The formula, prostate size (cm.3) -3 × maximum urinary flow rate (ml. per second) + 1/4 of relative residual volume (percent), correlated almost maximally with obstruction grade. Including quality of life score or symptom score in the expression had a negative outcome on the ...

TRANSURETHRAL MARSUPIALIZATION OF A MEDIAL PROSTATIC CYST IN PATIENTS WITH PROSTATITIS-LIKE SYMPTOMS

PURPOSE The results of transurethral marsupialization as treatment for medial prostatic cysts were assessed. MATERIALS AND METHODS Between June 1992 and August 1994 we performed transrectal ultrasound on 704 patients with symptoms of bladder outlet obstruction or lower urinary tract symptoms and a medical prostatic cyst was found in 34 (5%). Transurethral marsupialization of the cyst via incision of the prostatic floor under transrectal ultrasound guidance was performed in 18 patients. Followup was 12 to 25 months (mean 18). RESULTS Patients with a medial prostatic cyst complained of prostatitis-like symptoms (77%), scrotal pain (62%), impaired micturition (32%), small volume ejaculation (35%), painful ejaculation (24%), hemospermia (24%) and infertility (12%). After marsupialization of the cyst, symptoms resolved completely in 14 patients (78%), improved in 17 (94%) and did not improve in only 1 (6%). No complications of this procedure were noted. The 16 patients who did not undergo surgery still complain of prostatitis-like symptoms without evidence of bacterial prostatitis. CONCLUSIONS We believe that a medial prostatic cyst can cause prostatitis-like symptoms and that marsupialization of the cyst can provide symptom relief in the majority of patients.

Self-expanding stent insertion for urethral strictures : A 10-year follow-up

To evaluate the safety and efficacy of the Urolume??? endourethral self‐expandable metallic stent (American Medical Systems, MI, USA) in treating urethral strictures, based on a follow‐up of> 10 years.

COWPER'S SYRINGOCELE: SYMPTOMS, CLASSIFICATION AND TREATMENT OF AN UNAPPRECIATED PROBLEM

PURPOSE Cowpers syringocele is a rare deformity in the male urethra that is a distention of the duct of the bulbourethral (Cowpers) gland. We report on 7 cases, review the symptoms and pathophysiology, and propose a simplified classification of this uncommon lesion. MATERIALS AND METHODS We reviewed 7 cases of Cowpers syringocele diagnosed from 1997 to 1998 at our hospital. RESULTS Cowpers syringocele was diagnosed in 7 patients 25 to 51 years old with persistent post-void dribbling, frequency, urethral pain, hematuria or sudden urethral discharge. Diagnosis was made with urethrocystoscopy or retrograde urethrogram. Cowpers syringocele may be closed (a distended cyst-like swelling in the wall of the urethra) or open (an opening enabling urine reflux into the syringocele). In 2 patients asymptomatic open syringocele was diagnosed. In 1 patient symptomatic syringocele resolved spontaneously following an infection. In 4 patients open syringocele was treated with transurethral marsupialization because of persistent post-void dribbling. Postoperatively patients were completely symptom-free with a mean followup of 12 months (range 6 to 23). CONCLUSIONS Cowpers syringocele may be more common than currently realized. Urologists should rule out this possibility in young male patients with lower urinary tract symptoms and persistent post-void dribbling as it can be treated easily.

ONE 24-HOUR FREQUENCY-VOLUME CHART IN A WOMAN WITH OBJECTIVE URINARY MOTOR URGE INCONTINENCE IS SUFFICIENT

OBJECTIVES To determine whether one 24-hour frequency-volume (FV) chart in a woman with objective urinary motor urge incontinence is sufficient to gain insight into her voiding habits. METHODS Retrospectively, women 18 years old and older with urodynamically confirmed urinary motor urge incontinence without neurologic disease or other urologic pathologic findings, who correctly completed two or three 24-hour FV charts during normal daily life, were studied. For each patient, we compared the voiding parameters (mean voided volume, diuria, nocturia, minimum and maximum voided volumes, and total voided volume) and fluid intake calculated from the first FV chart with the same data calculated from all the FV charts. RESULTS Ninety-eight adult women were recruited. A marked dropout occurred, and 60 patients remained to be evaluated (mean age 54.5 +/- 15.5 years). The calculated voiding parameters agreed with those in published reports. Strong associations existed between all voiding parameters and fluid intake calculated from the first FV chart and those calculated from all FV charts (P <0.001 for all parameters). Compared with the well-known variability, the differences between the voiding parameters calculated from the first FV chart and those from all charts were small. These results agreed with studies in other patient groups (benign prostatic hyperplasia and interstitial cystitis) that analyzed the use of only one 24-hour FV chart. CONCLUSIONS The use of only one 24-hour FV chart completed during normal daily life by a woman with objective urinary motor urge incontinence is sufficient to gain insight into her voiding habits.