Urodynamic study before and after radical porstatectomy 가톨릭의대성바오로병원김현우

Transcription

1 Urodynamic study before and after radical porstatectomy 가톨릭의대성바오로병원김현우

2 Introduction Radical prostatectomy - treatment of choice for patients with localized prostate cancer. Urinary incontinence and/or Bladder dysfunction - one of the most devastating complications - a source of anxiety for patients and physicians. Urodynamic study - the only instrument that can accurately diagnose the causes of incontinence and any other dysfunction during the voiding phase.

3 Introduction Incidence of PPI : 0.8% - 87% Huge range of reported rates. different length of follow-up times different definition of urinary incontinence differences in methods evaluation incontinence Incontinence persists > 1 yr postoperatively : 2% -5% De novo detrusor overactivity : 2% - 77% Augustin H et al. Eur Urol 2002 Peyromaure M et al. BJU Int 2002 Porena M et al. Eur Urol 2007

4 Pathogenesis of PPI Bladder dysfunction Sphincteric dysfunction Anatomic stricture Bladder overactivity Detrusor instability Impaired compliance Detrusor underactivity Imparied contractility Direct injury Rhabdosphincter Neural supply Supporting structure Obstruction Overflow incontinence

5 Bladder dysfunction Involuntary detrusor contractions impaired bladder filling sensation low bladder compliance impaired detrusor contractility URODYNAMIC STUDY!!!! 1. The may only occur instrument de novo following that can accurately bladder denervation diagnose the during causes of incontinence and any other dysfunction surgery. during the voiding phase. 2. may be induced by preexisting long-term BOO or be a consequence of bladder ageing. Chao R et al, J Urol. 1995

6 When Traditional 12 months post op. Current 6-12 months if no improvement for at least 3 months of conservative treatment. Bauer et al, Eur Urol 2009;55:322-33

7 The role of UDS in patients undergoing RRP Most studies underscored the role of UDS in the assessment and management of postprostatecomy incontinence. Indeed, preoperative and postoperative symptoms seem unreliable in defining the cause of urinary incontinence. - Normal preoperative detrusor function postoperative urinary incontinence: 3% - Presence of any abnormality postoperative urinary incontinence : 39% Aboseif SR et al, Urol Int 1994

8 Urodynamic study The only way to make a precise diagnosis of the cause of incontinence - define the underlying cause of incontinence - guide the therapy 1) Filling cystometrogram 2) Storage cytometrogram + provocative maneuvers urethral pressure profile 3) Voiding pressure-flow study

9 Filling phase Correlate the urodynamic finding to the patient s symptoms - bladder sensation, pain with filling, urgency 1. Detrusor instability bladder contractions (15cmH 2 O) involuntary detrusor contraction associated with an urge 2. bladder compliance (C= V/ pdet) less than 12.5 ml/cmh 2 O : impaired During filling, if there are rises in pressure secondary to instability or impaired compliance the investigator should carefully observe if incontinence occurs.

10 Storage phase Sphincteric dysfunction Abdominal (Valsalva) leak point pressure (ALPP) Urethral pressure profilometry maximum urethral closing pressure (MUCP) functional urethral length Performed without a standardized method difficult to draw clear conclusions from the results

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12 배뇨근과활동성에의한요실금

13 수술후괄약근형실금과낮은방광유순도.

14 UDS : 3-7 days before and 2 months after RRP

15 Main cause of incontinence (after RRP) sphincter weakness Preoperative detrusor overactivity cannot be the predisposing factor of postoperative incontinence preoperative overactivity was triggered by obstruction in 40%, and it disappeared after surgery. Excellent chance of immediate postoperative continence - patients under 60 - no preoperative urodynamic abnormality - higher preoperative and postoperative MUCP - no preoperative LUTS

16 PubMed databank ( ) Review of urodynamic parameters (pre and postoperative). bladder filling sensation, detrusor overactivity, bladder compliance, cystometric capacity, detrusor overactivity, impaired detrusor contractility, bladder outlet obstruction, urinary incontinence

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18 Detrusor dysfunction rarely present as the sole diagnosis and usually coupled with intrinsic sphincter deficiency Sphincter weakness (present with) detrusor overactivity : 0% - 100% reduced bladder compliance : 18% - 58% both : 4% - 64% Lack of consistent preoperative UDS makes it difficult to assess the operation s exact role in causing urodynamics performed preoperatively and f/u detrusor dysfunction. help a precise diagnosis of the underlying dysfunction appropriate treatment and prevent the incidence and onset of postoperative urinary incontinence.

19 LRP : 63 pts, RRP : 58 pts. International J of Urol 2009

20 Open RRP bladder compliance significantly lower detrusor overactivity significantly higher LRP 1. negative impact on storage function by impairing function of the urethral sphincter and decreasing bladder compliance. 2. might be associated with less impairment of bladder function than RRP.

21 CONCLUSION UDS were performed without a standardized method difficult to draw clear conclusion for the results. Most studies underscored the role of UDS in the assessment and management of postprostatectomy incontinence. Limited number of prospective studies compared preoperative and postoperativbe detrusor and sphincter function in longterm follow-ups.

22 CONCLUSION Preoperative UDS - useful to diagnose the underlying dysfunction - to prevent the incidence of postoperative incontinence. Postoperatvie UDS - useful to indicate the correct treatment of bladder dysfunction and urinary incontinence so as to achieve the best possible outcome and avoid unnecessary surgery and its complications.