RESUMO
INTRODUCTION: Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC). MATERIALS AND METHODS: This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software. RESULTS: There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eight TURP (transurethral resection of the prostate) studies, four GreenLight PVP (photoselective vaporization of the prostate) studies, two HoLEP (Holmium laser enucleation of the prostate) studies, one GreenLight PVP/HoLEP study, one Holmium laser incision of the prostate study, and one study did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS), lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR) of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up. CONCLUSION: In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery.
Assuntos
Terapia a Laser , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Obstrução do Colo da Bexiga Urinária , Bexiga Inativa , Masculino , Humanos , Ressecção Transuretral da Próstata/efeitos adversos , Bexiga Inativa/complicações , Bexiga Inativa/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Estudos Prospectivos , Resultado do Tratamento , Hiperplasia Prostática/complicações , Hiperplasia Prostática/cirurgia , Obstrução do Colo da Bexiga Urinária/etiologia , Obstrução do Colo da Bexiga Urinária/cirurgia , Terapia a Laser/métodosRESUMO
INTRODUCTION: Both detrusor underactivity (DU) and bladder outlet obstruction (BOO) can coexist in patients with overactive bladder. Definitions of both DU and BOO are based on pressure-flow study (PFS) data. However, invasive urodynamics study can differ from a natural micturition, in fact, discrepancies between free uroflowmetry (UFM) and PFS have been largely described. Our goal is to assess the correlation of free-flowmetry and PFS among patients with OAB and to evaluate how different definitions of DU/BOO are able to discriminate patients with different free UFMs. METHODS: A retrospective review of urodynamics performed at a single institution was conducted. Females with OAB who voided more than 150 mL in both UFM and PFS were included. Parameters from both voiding episodes were compared with nonparametric test. Two definitions of DU were applied; PIP1: Pdet@Qmax+Qmax < 30 and Gammie: Pdet@Qmax < 20 cmH2 O, Qmax < 15 mL/s, and BVE < 90% (Bladder voiding efficiency). Also, two definitions of obstruction were chosen; Defretias: Pdet@Qmax ≥25 cmH2 O and Qmax ≤ 12 mL/s and Solomon-Greenwell female BOO index ≥ 18. Patients who matched with each definition were compared to those who did not, to assess if any definitions were able to discriminate different noninvasive uroflowmetries. RESULTS: A total of 195 patients were included. Overall, mean age was 55 ± 12 years, 90.8% had mixed urinary incontinence, and 39% complained of at least one voiding symptom. Globally, Qmax and BVE correlated poorly between UFM and PFS, showing that most of the variation corresponded to a systematic error. Twenty-two individuals were found to have DU, they had a difference of 13 mL/s on both maximum flows. Fifty-four patients showed BOO, with a difference between their Qmax of 19 mL/s. Among the four definitions analyzed, only PIP1 and Defreitas were able to discriminate patients with actually a lower Qmax on the free UFM. CONCLUSIONS: Patients with overactive bladder seem to have a systematic discordance between the urine flow of the free and invasive studies. Current definitions of DU and BOO, which are based on the PFS parameters, are not consistently able to discriminate patients who actually void deficiently on the free UFM.
Assuntos
Obstrução do Colo da Bexiga Urinária , Bexiga Urinária Hiperativa , Bexiga Inativa , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Bexiga Urinária Hiperativa/diagnóstico , Bexiga Urinária Hiperativa/complicações , Obstrução do Colo da Bexiga Urinária/etiologia , Obstrução do Colo da Bexiga Urinária/complicações , Bexiga Inativa/etiologia , Bexiga Inativa/complicações , Bexiga Urinária , Micção , UrodinâmicaRESUMO
INTRODUCTION AND OBJECTIVE: Previous studies suggest that men with detrusor underactivity (DUA) have less symptomatic improvement after prostate surgery than those with normal contractility, but the available data is controversial. We aim to determine the differences in functional outcomes of patients with or without DUA who underwent photovaporization of the prostate (PVP) with GreenLight™180 W XPS. METHODS: A cohort of patients with lower urinary tract symptoms (LUTS) who underwent PVP between 2012 and 2019 was evaluated. Patients were stratified according to bladder contractility index (BCI). DUA was defined as BCI < 100. Those with normal contractility (BCI = 100-150) were included in Group 1, and those with DUA (BCI < 100) in Group 2. Primary outcomes were symptomatic improvement defined as a reduction ≥ 4 points in the international prostate symptom score (IPSS) and a reduction of at least 1 point in the quality of life (IPSS-QoL). Complications according to the Clavien-Dindo classification were also recorded. RESULTS: A total of 271 patients who underwent PVP with GreenLight™ and met the inclusion criteria were assessed. Group 1 included 158 patients, while Group 2 included 113 patients. Mean follow-up was 24 months. Patients with normal contractility had a median reduction of 11 points (18.9 ± 8.0 to 7.1 ± 7.0) while patients with DUA had a median reduction of 10 points (19.3 ± 6.9 to 8.6 ± 8.4) in IPSS score; these differences were not statistically significant (p = .20). Patients in Group 1 had a 1.92 higher chance of QoL improvement (OR, 1.92; 90% CI, 1.10-3.37), compared to those in Group 2. Failure to void after PVP was most frequently reported in DUA patients (OR, 2.36; 90% CI, 1.26-4.43). Sociodemographic characteristics, intraoperative complications, conversion rates, hospital stay, and urinary catheterization time were similar between groups. CONCLUSIONS: Patients with LUTS, regardless of their BCI, improved their symptoms after PVP according to the IPSS. However, patients with DUA were more likely not to improve their QoL after the procedure and had a higher chance of failure to void in the immediate postoperative period. An appropriate counseling process with the patient discussing possible outcomes based on these findings should be encouraged.