LITHUANIAN UNIVERSITY OF HEALTH SCIENCES LUHS LIBRARY REPOSITORY

Klinikinių ir urodinaminių požymių svarba prognozuojant gerybinės prostatos hiperplazijos chirurginio gydymo rezultatus

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dc.contributor.author Trumbeckas, Darius
dc.date.accessioned 2017-08-21T08:06:40Z
dc.date.available 2017-08-21T08:06:40Z
dc.date.issued 2006
dc.identifier.uri http://repository.lsmuni.lt/handle/1/60062
dc.description.abstract INTRODUCTION Benign prostatic hyperplasia (BPH) is the most common pathological condition of aged men which significantly impairs the quality of life status. Though pharmacotherapy with adrenoblockers and 5-alpha reductase inhibitors markedly decreased the rate of surgical interventions, BPH surgery still constitutes the main workload (around ¼ of total) of urologists in the department. The results of the observational study performed by Barry et al. show that the probability of surgical treatment of BPH during the period of 4 years for subjects with mild symptoms equals to 10%, and in case of moderate and severe symptoms - 24% and 39%, respectively. According to the data of large multicenter study performed with 7,588 men in Asia and Australia, moderate and severe symptoms are present in 29%, 40%, and 56% of men in their fifth, sixth, and seventh decade of life, respectively. Symptoms are the main driving force of BPH treatment, but their correlation with residual urine, objective findings of uroflowmetry and invasive urodynamics is only poor. The association of various parameters with the outcomes of surgical treatment is complicated and still not completely investigated. Therefore finding parameters that predict the outcome of surgical BPH treatment is important. According to the literature, unfavorable outcomes of transurethral resection are present in around 15-30% of men with symptomatic BPH. This is mostly associated with inadequate preoperative evaluation, not fully clear prognostic factors, and lack of criteria for elective surgery. Studies show that good postoperative results can be achieved in up to 90% of cases if only patients with urodynamically proved obstruction are operated on. TURP is effective in only 60% of obstruction-free patients. Obstruction can be reliably proved by urodynamic investigation, but this investigation is invasive, time- and cost-consuming, and thus is not used universally. There is no complete agreement on whether invasive urodynamics and selection of patients based on its results could help to improve postoperative outcomes of BPH surgery. Prognostic methods of obstruction need to be developed and proved to be equal or better than urodynamics in terms of postoperative outcome. Clinical and urodynamic factors of surgically treated BPH patients are investigated and compared in the first part of this work. The second part is intended to investigate the clinical factors important for the prediction of bladder outlet obstruction. The predictive model is presented. The work has been accomplished at the Clinic of Urology, Kaunas University of Medicine. THE AIM AND OBJECTIVES The aim To determine clinical and urodynamic factors important to the outcomes of surgical treatment of benign prostatic hyperplasia. Objectives 1. To evaluate the results of surgical treatment of BPH. 2. To evaluate correlations of preoperative clinical and urodynamic factors with the outcomes of surgical treatment. 3. To determine preoperative prognostic factors for favorable outcomes of surgical treatment. 4. To evaluate correlations of clinical factors with urodynamic bladder outlet obstruction/BPH and to determine prognostic factors for bladder outlet obstruction. 5. To evaluate the accuracy of the predictive model. The novelty and originality of the study There is not completely clear whether urodynamic studies could help to improve the results of surgical treatment for BPH. Recently some authors have claimed that the outcomes of TURP are the same, whether routinely selected or only urodynamically obstructed subjects are operated on. Few data show that simple clinical parameters, e.g. flow rate or transition zone index, can be as much predictive as urodynamic studies, but this is still unclear. Further investigations are needed to confirm this. Our study was intended to investigate the relationship between the clinical and urodynamic factors with respect to TURP outcomes. We have no data indicating that similar studies have been performed in Lithuania. MATERIALS AND METHODS One hundred and forty men aged over 45 years with lower urinary tract symptoms/BPH were involved in this prospective study carried out during the period of March 2003 to June 2005. Subjects either applied themselves or were referred to our hospital by another institution. Study inclusion criteria were applied. Study activities were performed after obtaining the patients’ informed consent. General and targeted investigations were performed. After the collection of medical history, the symptoms were evaluated by self-filled IPSS questionnaire, including the QoL question. PSA was evaluated. The prostate was evaluated by digital rectal examination. Free urinary flow rate was investigated by uroflowmetry (Urodyn 1000). Transabdominal bladder scan was performed for residual urine, and prostate volume was estimated using transrectal ultrasound examination (Sonoline SI-250, Siemens; Panther, B-K Medical; LOGIQ 200 Pro Series, GE Medical Systems). The total prostate and transitional zone volumes were calculated according to the ellipsoid formula: 0.52 x transverse diameter x superoinferior diameter x anterioposterior diameter. Intravesical protrusion of prostate was indicated if it exceeded 1 cm. Invasive urodynamic investigation was carried out afterwards. Cystometry with pressure/flow (P/Q) study was performed (Duet®Logic, Medtronic), and obstruction grade as well as bladder contractility were evaluated. Patients were selected for elective surgical treatment by routinely used indications and irrespectively of the result of the urodynamic investigation. Transurethral resections (TURP) were performed using the standard technique, with resection started at the basis of prostate till verumontanum. All surgical procedures were performed under spinal anesthesia using 24-26 CH resectoscopes of Storz type, monopolar loops, and 90-110 W electric power. Resected tissues were weighted and investigated by pathologist. Postoperative investigations were performed 6 months after the treatment in the same way as preoperatively. Seventy-four prostate cancer-free subjects and subjects without strictures of urethra were treated in the final analysis of this case control study (the study group). The comparative group (retrospective analysis of prospectively collected data) consisted of 69 subjects with symptomatic BPH. These subjects were operated on by TURP and participated in previous prospective study where urodynamics was not applied. Enrollment and investigation of subjects was performed using the same criteria as in the recent study. Data from 130 urodynamically investigated patients with lower urinary tract symptoms due to BPH were used for the prediction of bladder outlet obstruction. Study inclusion criteria: 1. Age ≥ 45 years; 2. IPSS > 7; 3. Benign prostatic enlargement; 4. Written informed consent. Exclusion criteria: 1. Previous surgery on urinary bladder, prostate or urethra; 2. Cystitis, urinary bladder stones, carcinoma of urinary bladder, urethral stricture; 3. Clinically significant renal or hepatic failure; 4. Prostate cancer or PSA > 10 (unless excluded by prostate biopsy); 5. Small amounts of voided urine on uroflowmetry (< 100 ml); 6. Presence of acute urinary retention; 7. Presence of suprapubic drainage of urinary bladder; 8. Recently performed prostatic biopsy (less than 4 weeks ago) and cystoscopy (less than 2 weeks ago); 9. Obvious neurogenic bladder dysfunction; 10. Bad compliance with the requirements of the study protocol. Invasive urodynamic investigation Free flow rate was measured using uroflowmeter Urodyn 1000 before invasive investigation. Invasive urodynamic investigations were performed using urodynamic system Duet®Logic, Medtronic. For the measurement of vesical pressure, two-channel transurethral catheters of 7 F (2.3 mm) were used. For the measurement of abdominal pressure, rectal infusion catheters of 10 F (3.3 mm) were used. The bladder was filled with 37ºC saline at a constant rate of 30 ml/s. Cystometry and P/Q study were performed in upright position. The analysis of P/Q study was done after manual correction of artifacts. For the evaluation of the P/Q study, ICS as well as Schafer (linPURR) nomograms were used. Abrams-Griffiths number was calculated automatically and controlled by manual calculation. All studies were performed according to ICS recommendations and Good Urodynamic Practice Guidelines. The category of obstruction was evaluated according to the AG number and plot analysis (ICS and Schafer nomograms). AG number is calculated according to the following formula: AG = pdetQmax – 2 Qmax. Contractility was evaluated using Shafer nomogram and by calculating the detrusor power (contractility) coefficient (DECO): DECO = pdetQmax + 5Qmax / 100. Obstruction categories: · Obstructed (OBS): AG number > 40 or the zone “obstructed” in the ICS nomogram or III-VI grade of obstruction according to Schafer nomogram; · Equivocal (EQ)*: AG number 20-40 or the zone “equivocal” in the ICS nomogram or II grade of obstruction according to Schafer nomogram; · Non-obstructed (NOBS): AG number < 20 or the zone “unobstructed” in the ICS nomogram or 0-I grade of obstruction according to Schafer nomogram. *Equivocal was treated as non-obstructed in the final analysis. This approach is based on the data of literature and absence of significant differences between urodynamic parameters of NOBS and EQ categories as shown in our study. Detrusor contractility was classified as: · Weak: categories vw , w-, w+ according to Schafer or DECO < 1. · Normal/strong: categories n-, n+ and st according to Shafer or DECO ≥ 1. The presence of spontaneous detrusor contractions exceeding 15 cmH2O during the filling phase was considered as unvoluntary (unstable) detrusor contractions (UDC). Postoperative evaluation of treatment efficacy Postoperative results were evaluated on the basis of the 4th International Consultation on BPH. Efficacy cri
dc.description.abstract Predictive value of clinical and urodynamic factors on the outcome of surgical treatment of benign prostatic hyperplasia
dc.language.iso lit
dc.subject Obstrukcijos prognozavimas
dc.subject Gerybinė prostatos hiperplazija
dc.subject Obstrukcija
dc.subject Benign prostatic hyperplasia
dc.subject Transuretrinė prostatos rezekcija
dc.subject Transurethral resection
dc.subject Bladder outlet obstruction
dc.subject Urodinaminis tyrimas
dc.subject Prostatic
dc.subject Hyperplasia| surgery
dc.subject Prognosis.
dc.title Klinikinių ir urodinaminių požymių svarba prognozuojant gerybinės prostatos hiperplazijos chirurginio gydymo rezultatus
dc.title.alternative Predictive value of clinical and urodynamic factors on the outcome of surgical treatment of benign prostatic hyperplasia
dc.type Daktaro disertacija


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