URODYNAMICS IN MALE LUTS: NECESSARY OR WASTE OF TIME?

Transcription

1 URODYNAMICS IN MALE LUTS: NECESSARY OR WASTE OF TIME? Andrea Tubaro, MD, FEBU Chairman Department of Urology Sant Andrea Hospital Sapienza University of Rome, Italy

2 Disclosures Consultant, paid speaker, investigator, grant recipient Allergan Astellas AMS GSK Pfizer Pierre Fabre Shionogi Takeda

3 Urodynamics in male LUTS BPO Bother Prostate volume

4 Urodynamics in male LUTS BPO Bother DO DU Prostate volume

5 Urodynamics in male LUTS Urodynamic diagnoses Sensory dysfunction: (absent, reduced, normal, increased, non specific) Sensory urgency DO (phasic, terminal, DO incontinence) Bladder capacity Bladder compliance (C=V.Δ Pdet) DU (acontractile, underactive, normal) BOO Urethral function (normal, sphincter deficiency, urethral instability)

6 CLINICAL ISSUES

7 Assumptions in male LUTS In the management of LMUTS we assume that: We treat symptoms with medical treatment We manage BPE progression with drugs We treat obstruction with surgery The outcome of surgery is sometimes lower than expected because of: Lack of bladder outlet obstruction Disorders of bladder sensitivity Detrusor overactivity Detrusor underactivity Else?

8 Problems in PFS Difficult diagnosis of BOO if: Patient is unable to void Try removing urethral catheter once the bladder is filled and place a suprapubic line (peridural line or similar) Use VDS to monitor detrusor contractility and level of obstruction Detrusor underactivity Power factor Bladder contractility index (pdetqmax + 5Qmax) Strong: 150 Normal Weak: 100

9 The relation of BOO and DO Oelke et al. Eur Urol 2008; 54(2):

10 Can uroflow distinguish BOO from DU? Bladder outlet osbtruction versus impaired detrusor contractility: the role of uroflow. M.B. Chancellor et al. J Urol (4) BOO (31 pts) DU (14 pts) p Time to Qmax n.s. Voiding time n.s. Qmax n.s. Qave n.s. Qmax/time to Qmax n.s Time between Qmax and 95% voided volume/time to 95% voided volume Time to Qmax/voiding time n.s. Qmax/Qave n.s. n.s.

11 DO and the outcome of TURP van Venrooij GEPM et al. J Urol. 2002; 62(4); 672-6

12 BOO and the outcome of TURP Machino R, et al. Neurourol Urodyn 2002; 21(5): 444-9

13 Tanaka Y. et al. J Urol 2006; 13(11) Urodynamic baseline parameters and the outcome of TURP Excellent and good overall treatment efficacy of TURP according to the combination of preoperative urodynamic findings.

14 Urodynamic parameters of success/failure in patients with AUR undergoing TURP Risk of failure for TURP Age 80 yrs or older Retention >1500 ml No DO Maxdetp <28 cmh 2 O Djavan B, et al. BJUI 1997; 158:

15 DU and outcome of BPH surgery Monoski MA et al. Urology 2006; 68:

16 GUIDELINES

17 Urodynamics in male LUTS SUFU Guidelines The only way to accurate diagnose bladder outlet obstruction (BOO) is by PFS Urol Clin N Am 41 (2014)

18 67-y-old man with chief complaints of LUTS Symptoms: +weak stream and intermittent flow, incomplete emptying, urinary urgency Failed medical management Physical examination: Moderately enlarged prostate Diagnostics: Voided volume: 150 ml Maximum flow: 9 ml/s PVR: 130 ml Recommendation: TURP or equivalent procedure Discussion: In this scenario, this gentlemen has obstruction LUTS. His age, prostatic enlargement, and diagnostic studies strongly suggest (but do not definetively diagnose) obstruction. In this setting, proceeding to surgery is reasonable. Urodynamics is an option to evaluate for any other factors that may influence treatment or patient counselling 37-y-old man with chief complaints of LUTS Symptoms: +weak stream and intermittent flow, incomplete emptying, urinary urgency Failed medical management Physical examination: Moderately enlarged prostate Diagnostics: Voided volume: 150 ml Maximum flow: 9 ml/s PVR: 130 ml Recommendation: VUDS and cystoscopy Discussion: In this scenario, there are several factors that represent a complicated setting of male LUTS. This patient s young age and his small prostatic size are not common in the presentation of male LUTS. In this setting, a diagnosis of obstruction should be sought (and the only way to obtain a diagnosis of obstruction is PFS). A cystoscopy should be considered to rule out anatomic abnormalities. Thus, in this complex scenario, PFS is recommended. VDUS should be considered to more precisely localize the level of obstruction.

19 SUFU Guidelines The use of PFS in men as a routine diagnostic test before elective surgery for BPE remains a long-standing controversy; The diagnosis of concomitant DO or poor compliance may change patient counselling; Perform PFS in complex cases when the diagnosis of BOO is uncertain; PFS remains the only way to diagnose BOO. Urol Clin N Am 41 (2014)

20 Urodynamics in male LUTS Clinicians may perform PVR in patients with LUTS (Clinical Principle); Uroflow may be used by clinicians in the initial and ongoing evaluation of LUTS that suggest an abnormality of voiding/emptying (Recommendation: Evidence: strength: Grade C); Clinicians may perform multichannel filling cystometry when it is important to determine whether DO is present (Expert Opinion); Clinicians should perform PFS when it is important to determine if BOO is present in men with LUTS (Standard; Evidence Strength: Grade B); Clinicians may perform VUDS in properly selected patients, particularly in those with PBNO (Expert Opinion). AUA/SUFU Adult Urodynamics Guidelines (2014)

21

22 Urodynamics in male LUTS PFS should be performed only in individual patients for specific indications prior to surgery or when evaluation of the underlying pathophysiology of LUTS is warranted. PFS should be performed in men who have had previous unsuccessful (invasive) treatment for LUTS. When considering surgery, PFS may be used for patients who cannot void > 150 ml. When considering surgery in men with bothersome, predominantly voiding LUTS, PFS may be performed in men with a PVR > 300 ml When considering surgery in men with bothersome, predominantly voiding LUTS, PFS may be performed in men aged > 80 years When considering surgery in men with bothersome, predominantly voiding LUTS, PFS should be performed in men aged < 50 years LE GR 3 C 3 C 3 C 3 C 3 C 3 B EAU Guidelines on Non-Neurogenic LUTS

23 Urodynamics in male LUTS Videourodynamics The inclusion of intermittent synchronous radiograph imaging and filling of the bladder with contrast-medium for cystometry and PFS is termed videourodynamics. The test provides additional anatomical information. During filling, imaging is usually undertaken in the postero-anterior axis and shows bladder configuration (bladder trabeculation and diverticula), vesico-ureteral reflux and pelvic floor activity. During voiding, a 45º lateral projection is used and can show the exact location of obstruction. Videourodynamics is recommended where there is uncertainty regarding mechanisms of voiding LUTS. EAU Guidelines on Non-Neurogenic LUTS

24 Urodynamics in male LUTS Non-invasive pressure-flow testing The penile cuff method, in which flow is interrupted to estimate isovolumetric bladder pressure, shows promise, with good test/retest repeatability and interobserver agreement, and a nomogram has been derived. A method in which flow is not interrupted is also under investigation. The external condom method agrees with invasive PFS in a high proportion. Resistive index and prostatic urethral angle have also been proposed, but are in the early stages of developing an evidence base. Ultrasound measurements of bladder or detrusor wall thickness, bladder weight, and intravesical prostatic protrusion have already been discussed in the imaging subchapter. EAU Guidelines on Non-Neurogenic LUTS

25 DISCUSSION

26 Urodynamics in male LUTS In order to recommend a diagnostic test we need evidence The outcome of the test should influence treatment TURP for BOO only The outcome of the test should have predictive value as to the treatment outcome What is the relation between the grade of BOO and outcome? What is the relation between the diagnosis/severity of DO and outcome? What is the evidence between the diagnosis of DU and outcome?

27 Urodynamics in male LUTS Knowledge based medicine Any test that helps understanding what is the pathophysiology of patient s symptoms and signs of BPH severity is recommended; P/F study provides information as to BOO, DO and DU.

28 Urodynamics in male LUTS Pros BOO patients do better DO patients do worse DU patients do worse Knowledge based medicine Cons Invasive Complications Costs No difference in outcome between obstructed and unobstructed patients

29 Urodynamics in male LUTS Options for P/F study Do it in all patients scheduled for surgery Organisation Manpower Costs for NHS Do it in selected patients, when Symptoms do not match with signs Difficult patients Possible legal issues

30 Urodynamics in male LUTS Risks of P/F study UTI rates: <15% 1 95% of pts would do P/F study again in indicated 2 Pain and embarrassment as expected in 93% of pts 3 Average pain score for males: 3.1 out of Wolf JS et al. J Urol. 2008; 179(4): Scarpero HM et al. J Urol. 2005; 173(2): Ku JH, et al. J Urol 2004; 171(6):

31 Urodynamics in male LUTS Consider P/F study when: Elderly patients with difficult history taking, prior surgeries or instrumentation; Younger patients Urinary retention Patient unable to complete uroflowmetry Symptoms that does not correlate with non-invasive findings; Any suspicion of neurogenic components of voiding dysfunction Confounding conditions (severe diabetes, previous radical pelvic surgery, pervious spine surgery) MLUTS and UI Failed prior prostate surgery

32 Conclusions After so many years no clear-cut data are available as to benefit of doing P/F study in men with LUTS; The use of urodynamics in male LUTS depends also on local organisation and manpower; Urodynamics helps in counselling patients; Consider that many patients are not standard ones; Consider urodynamics in complicated cases; No evidence for videourodynamics; In an ideal world it would be great to have PFS in all patients scheduled for surgery.

33 THANKS!