Surgical Treatment: Outlet Reduction, Men and Women
The International Continence Society (ICS) defines detrusor underactivity (DU) as “a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within normal time span”. Cur
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Surgical Treatment: Outlet Reduction, Men and Women Bilal Chughtai, Dominique Thomas, Austin Te, and Steven A. Kaplan
Key Points
1. The most relevant preoperative test to determine the relative degree of DU and bladder outlet obstruction is a pressure flow urodynamic study, however the factors that predict outcome are not well characterized 2. For men outlet reduction, including TURP, HoLEP and PVP, has resulted in variable success in patients with DU. 3. The decision as to whether to perform surgical therapy in patients with DU should be highly individualized and include appropriate counseling as to the unpredictability of the outcome. 4. In absence of any demonstrable anatomical obstruction, there is currently no clear role for outlet reduction surgery in women with DU.
Introduction The International Continence Society (ICS) defines detrusor underactivity (DU) as “a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within normal time span” [1]. DU is thus a urodynamic diagnosis [2] which occurs in almost 48 % of older men (>65) and 13 % of older women (>65) evaluated for lower urinary tract symptoms (LUTS) [4]. DU can occur in association with chronic bladder outlet B. Chughtai • D. Thomas • A. Te Department of Urology, Weill Cornell Medicine, 425 East 61st Street, New York, NY 10065, USA e-mail: [email protected]; [email protected]; [email protected] S.A. Kaplan, M.D (*) Professor of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 C.R. Chapple et al. (eds.), Underactive Bladder, DOI 10.1007/978-3-319-43087-4_7
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obstruction, aging, myogenic or various neurogenic defects or idiopathic causes [2]. Clinically DU is characterized by voiding LUTS and reduced voiding efficiency [3]. DU is also associated with complications such as recurrent urinary tract infections and bladder stones. Urodynamics are essential in the determination of the relative contribution of bladder outlet resistance and DU to patients’ symptoms. This is particularly important when considering surgery to the bladder outlet. There has however been a lack of literature regarding the urodynamic evaluation of DU [5]. Clearly preoperative planning, extensive patient counselling are necessary before any surgical procedure in this cohort. The aim of this chapter is to provide an analysis of the role of outlet reduction surgery in both men and women with underlying DU.
Pre-operative Studies The most useful test to determine the degree of BOO and detrusor contractility is a pressure flow urodynamic study [6]. In addition important information such as bladder sensation, compliance and capacity that is relevant to preoperative planning can also be gleaned [6]. Several urodynamic measures of bladder contractility are described and are described in detail in Chap. 3 . Estimation of post-void residual (PVR) with the use
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