Issue 3: June 2009

UIJ Volume 2 Issue 3 June 2009

Letter from the Editor - June 2009

Dear Colleagues,

This issue marks the one-year anniversary of the founding of UroToday International Journal. When the editorial team drafted our primary goal of “elevating access to relevant urology science to professionals around the world,” we had no idea that the journal would grow so quickly.

We are excited that our dream of becoming an international journal is being realized. Over the past year, we published articles from authors in 22 countries from 4 continents. These submissions reflect the world-wide distribution of our readership.

We could not achieve this success without the dedicated work of our reviewers, who continue to provide thorough and rapid feedback to our authors. We are grateful for their professional support. Because of their efforts, manuscripts received as recently as 7 weeks ago are appearing in this issue. We continue to strive for rapid turnaround of submissions so that we can share recent developments with our readers.

We have taken advantage of the fact that we are an electronic publication by adding other forms of media to the text of some articles. We hope to expand these multimedia educational tools and encourage authors to notify us if you have podcasts, video clips, Microsoft PowerPoint presentations, or audio commentary that may enhance your manuscript content. For examples, visit the audio recording of the basic science lecture in October, 2008 or the PowerPoint presentation accompanying the letter to the editor in April, 2009.

The current issue contains a wide variety of articles. Some highlights include: (1) a retrospective analysis on the effects of two dosage levels of darifenacin on 1053 patients with mild/moderate and severe urinary incontinence, written by Dr. Dmochowski and his colleagues; (2) a thorough discussion about different types of slings for correction of stress urinary incontinence, written by Dr. Farahat and his colleagues; (3) new surgical techniques for acute dilatation of the intramural ureter during ureteroscopy and for repair of distal and midpenile hypospadias, both provided by Dr. Gamal and his colleagues; (4) case reports on prostate leiomyosarcoma following radiation therapy to the prostate (Yee et al); an adenoid cystic variant of basal cell carcinoma following transurethral resection (Soloway et al); an appendicular vesical fistula (Labib and Mapulanga); a left-sided inferior vena cava in a patient with renal cell carcinoma of the right kidney (Katkoori et al); and surgical procedures to manage uterine prolapse associated with bladder exstrophy and to alleviate intractable groin pain following suburethral sling placement (Palma et al). Other articles on topics of interest to the practicing urologist and associated professionals are included.

Our heartfelt thanks go to the authors who have shared their work with us during the past year. We look forward to your future submissions as we continue to grow.

Kind regards,

K-E Andersson
Editor-In-Chief
UIJ

Peripheral Zone Sonographic Changes of the Prostate

ABSTRACT

INTRODUCTION: The aim of the investigation was to identify the diagnostic importance of peripheral zone sonographic findings in correlation with total prostatic specific antigen (tPSA) and pathological findings.

METHODS: Between January 2005 and January 2007, the transrectal biopsy records of 407 patients were reviewed for different prostatic indications. Echogenicity, calcific, and cystic changes of the peripheral zone were correlated with tPSA, total volume of the gland, digital rectal exam (DRE), and pathological findings.

RESULTS: The patients were divided into 3 groups (A, B, and C) according to tPSA: <4 ng="" ml="" n="159)," 4-10="" and="">10 ng/mL (n = 229), respectively. Heterogenicity was detected in 59.9% of cases and was higher when tPSA increased. Heterogenicity was found in the malignant biopsies of 78.7% of the patients (sensitivity = 78.78%; specificity = 44.6%). Calcific changes were found in 52% (n = 90) of group C (P < .05). Calcification was demonstrated in 41.4% (n=41) of malignant findings, but group comparisons were not statistically significant (sensitivity = 41.4%; specificity = 55.5%). Cystic changes were detected in 7.1% (n = 7) of malignant findings, but group comparisons were not statistically significant (sensitivity = 7.1%; specificity = 9.1%). However, 10.3% (n = 23) of patients with cystic peripheral zonal changes had high but not statistically significant PSA.

CONCLUSION: Heterogenicity of the peripheral zone is correlated with malignant pathology (positive predictor value = 31.9%) and high tPSA. Whenever a peripheral zone calcific change in prostatic sonography occurs, the urologist should suspect an increase of tPSA but without characteristic indicator of malignant anticipations (positive predictor value = 23.03%). Cystic changes in the peripheral zone are not specific findings and do not reflect any changes in tPSA or prostatic pathology.

KEYWORDS: Transrectal ultrasound; Echogenicity; Prostate calcification; Prostate cystic changes.

CORRESPONDENCE: El-Housseiny Ismail Ibrahiem (El- Zalouey) MD, Urology Department, Urology and Nephrology Center, Mansoura, Egypt. E-mail:

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Comparison of Ultrasonographic and Operative Findings in Undescended Testes

ABSTRACT

INTRODUCTION: A patient with a nonpalpable testis (NPT) is a diagnostic challenge. Use of ultrasonography (US) for the diagnosis of NPT is controversial. The purpose of the present study was to compare US with surgical findings.

METHODS: Between January 2000 and January 2007, 65 patients with a diagnosis of undescended testis (UDT) were evaluated. The 65 patients had 77 UDT. The patients had a physical examination that was followed by US and then surgery. All patients had a second physical examination in the operating room while under anesthesia

RESULTS: US localized 57 (74%) nonpalpable testes. Of these, 50 were in the inguinal region and 7 were in the abdomen. The sensitivity of US was 100% for the inguinal canal and 39% for intraabdominal viable testes.Enter text

CONCLUSION: All patients with presumed nonpalpable, undescended testes should be referred to a urologist for physical examination before receiving US. The authors recommend US as a first instrumental test for all patients with NPT. When US is negative, they advise laparoscopy.

KEYWORDS: Undescended testes; Ultrasonography; Cryptorchidism; Operative Finding

CORRESPONDENCE: Dr. Ahmed Al-ahnoumi, PO Box 16913, Sana’a Yemen ().

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Urodynamic Evaluation of Patients With Chronic Pelvic Pain Syndrome

ABSTRACT

INTRODUCTION: The purpose of the investigation was to conduct urodynamic evaluation on patients with chronic pelvic pain syndrome (CPPS) and thus define a specific urodynamic profile that might add to the pathophysiology of the syndrome. This profile may also aid definitive treatment.

METHODS: Participants were 34 men with mean age 34.2 (SD = 8.5; range, 24-45 years). All patients presented with symptoms of chronic prostatitis (eg, dysuria, frequency of micturition, burning perineal sensation, lower abdominal discomfort and/or suprapubic pain). They were classified as having CPPS after excluding prostatic infection by standard bacteriological methods. The patients were then evaluated with urodynamic measures including free-flow rate, filling (water) cystometry, a pressure -flow study of micturition, and electromyography of the external urethral sphincter.

RESULTS: Of the 34 total patients, 22 (64.7%) had a low mean Qmax of 10.4 ± 1.6 mL/s (range, 4-14 mL/s); 25 (73.5%) had a first sensation of filling and 27 (79.4%) a first desire to void at low volumes (<150 and="" 250="" respectively="" nine="" patients="" 26="" 5="" 7="" obstructed="" 2="" unobstructed="" had="" idiopathic="" detrusor="" overactivity="" regarding="" pressure-flow="" measures="" 25="" 73="" an="" obstructive="" pattern="" of="" micturition="" as="" defined="" by="" a="" low="" qmax="" 9="" 1="" 44="" ml="" s="" high="" intravesical="" pressure="" at="" maximum="" flow="" 87="" 4="" cmh2o="" increased="" opening="" 76="" the="" emg="" external="" sphincter="" was="" normal="" in="" all="" p="">

CONCLUSION: A significant proportion of the patients with CPPS had a particular urodynamic pattern of functional infravesical obstruction and sensory bladder deficit.

KEYWORDS: Urodynamic; Chronic pelvic pain syndrome

CORRESPONDENCE: Hashem Hafez, M.D., Department of Urology, Faculty of Medicine, Suez Canal University, Ring Road, Ismailia 41105, Egypt ()

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Post Radiotherapy Leiomyosarcoma of the Prostate: Can Radiation Therapy Induce a Secondary Cancer? A Case Report

ABSTRACT

Sarcoma of the prostate is a rare neoplasm, accounting for less than 0.1% of prostate malignancies. There are only a few cases reported in the literature. The prognosis for this cancer is poor and the average survival is variable. The authors present a case report on a patient diagnosed with prostate sarcoma following initial diagnosis and treatment for adenocarcinoma of the prostate. What makes this case interesting is that the patient had a history of failed treatment for prostate adenocarcinoma that consisted of external beam therapy and palladium seed implants. Eight years later, the patient was diagnosed with leiomyosarcoma of the prostate. There may be a causal relationship between radiation therapy to the prostate and the development of the leiomyosarcoma.

KEYWORDS: Prostate cancer; Prostate leiomyosarcoma; Sarcoma; Radiation induced sarcoma; Prostate adenocarcinoma; Secondary prostate cancer; Secondary prostate leiomyosarcoma

CORRESPONDENCE: Ihor S. Sawczuk MD, John Theuer Cancer Center, Hackensack University Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601, USA ().

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Left-Sided Inferior Vena Cava with Renal Carcinoma: A Case Report

ABSTRACT

The authors present a rare case of left-sided inferior vena cava (IVC) in a patient with renal cell carcinoma of the right kidney. The anomalous IVC poses significant challenge to the surgeon. Preoperative identification of this congenital anomaly prevents complications during the surgical procedure. In this patient, the suprarenal portion of the IVC is on the right side and the infrarenal portion is on the left side, with the cava taking a left to right turn at the level of the renal veins anterior to the aorta.

KEYWORDS: Left Inferior vena cava; Nephrectomy; Renal cell carcinoma

CORRESPONDENCE: M. Manoharan, M.D. Associate Professor, Department of Urology, University of Miami Miller School of Medicine, P.O. Box 016960 (M814), Miami, Fl 33101, USA ().

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Artisanal Transobturator Sling Removal for Intractable Groin Pain

ABSTRACT

INTRODUCTION: The transobturator approach was first described by Delorme in 2001. It has become the preferred approach for suburethral sling placement in many centers due to its efficacy and low morbidity. Nevertheless, complications have been associated with it.

METHODS: The authors describe management of a female subject with intractable groin pain after the insertion of an artisanal transobturator sling. The right side of the sling was removed.

RESULTS: The patient described significant but incomplete pain improvement at the time of hospital discharge. After one week, she had no pain but moderate stress urinary incontinence recurred.

CONCLUSION: The present case illustrates that a partial removal is not indicated for complete treatment. Time-related intractable groin pain may completely subside after sling tape removal. However, possible recurrence of urinary incontinence following intervention must be reinforced during patient counseling.

KEYWORDS: Synthetic slings; Transobturator; Groin pain

CORRESPONDENCE: Paulo Palma, MD, PhD, Division of Urology, Department of Surgery, Rua Jose Pugliesi Filho 265, Campinas, Sao Paulo, Brazil 13085-415 ()

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Ureteroscopy With Two Guide Wires: A New Technique

ABSTRACT

INTRODUCTION: The purpose of the investigation was to evaluate the use of the two-wire technique for acute dilatation of the intramural ureter for ureteroscopy.

METHODS: Between April 2003 and April 2007, 400 consecutive ureteroscopic procedures were performed. There were 55 patients (40 male, 15 female) with a mean age of 28 years (range, 20-45 years). Patients had acute dilatation of the intramural ureter by the two-wire technique.

RESULTS: The mean operation time was 34 minutes (range, 20–70 minutes). All patients underwent successful ureteroscopy with a semirigid ureteroscope using the two-wire technique. Perforation or intramural false passage of the ureter did not occur. Patients were discharged from the hospital within 6–12 hours. The mean follow-up was 9.7 months (range, 6–18 months). Ultrasonography, intravenous urogram, and voiding cystourethrography were obtained at 3 and 6 months. Ultrasonography was done every 3 months until the end of the follow-up period. Follow-up imaging showed no distal-ureteral stricture or vesicoureteral reflux.

CONCLUSION: Acute dilatation of the intramural ureter by the two-wire technique is cost effective, easy, and time saving with no associated complications

KEYWORDS: Ureteroscopy; Ureteral dilatation; Two-wire technique

CORRESPONDENCE: Wael M Gamal, MD, Department of Urology, Sohag University, 31 el nasr Street, Sohag, Egypt ().

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Efficacy of Darifenacin in Patients with Varying Baseline Symptom Severity

ABSTRACT

INTRODUCTION:The severity of overactive bladder (OAB) symptoms such as incontinence episodes (IEs), urgency episodes, and micturition frequency varies between patients. It is therefore of interest to determine if patients respond differently to OAB antimuscarinic therapy according to symptom severity.

The objective of the present study was to evaluate data on symptom reduction and time of onset of action for patients in a pooled analysis of three phase III darifenacin studies. These data were analyzed in relation to darifenacin dose received and OAB symptom severity at baseline, as defined by IE frequency at randomization.

METHODS: The investigation was a retrospective analysis of pooled data from three 12-week, fixed-dose, double-blind studies involving 1053 adults (19-88 years old) who received darifenacin 7.5 mg or 15 mg once daily and matched patients who received placebos. Patients with mild/moderate OAB (defined as < 21 IEs/week at baseline) or severe OAB (≥ 21 IEs/week) were analyzed at 2, 6, and 12 weeks or the end of the study. Measurements included the absolute and percentage change from baseline in IEs/week, urgency episodes/day, micturitions/day, and mean volume/void.

RESULTS: There was a statistically significant improvement in OAB symptoms at week 12 or the last visit for patients with mild/moderate OAB taking darifenacin 7.5 mg and 15 mg, when compared with patients taking the placebo. There was also a statistically significant improvement in OAB symptoms at week 12 for patients with severe OAB taking darifenacin 15 mg, when compared with patients taking the placebo. Patients taking darifenacin 15 mg had statistically significant improvements in as few as 2 weeks for all OAB symptoms measured when compared with patients taking the placebo, regardless of baseline severity.

CONCLUSION: Both darifenacin 7.5 mg and 15 mg effectively relieved OAB symptoms, with statistically significant reductions in symptoms seen in as few as 2 weeks. For patients with mild/moderate OAB, 7.5 mg was sufficient to achieve a statistically significant effect; for patients with severe OAB, 15 mg was the most effective dose. These findings highlight the importance of dose titration according to individual patient needs.

KEYWORDS: Antimuscarinic; Darifenacin; Detrusor overactivity; Symptom severity; OAB

CORRESPONDENCE: Roger R Dmochowski, Vanderbilt University School of Medicine, Department of Urology, A1302, Medical Center North, Nashville, TN 37232, USA ().

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Commentary on New Developments in Sling Procedures for Treatment of Female Stress Urinary Incontinence

ABSTRACT

Despite its long-standing history, surgical treatment of female stress urinary incontinence is still a developing medical field. Better understanding of its physiopathology has allowed the creation of novel approaches. Slings have become the mainstay of treatment. The authors provide a brief overview of the development and progress of sling techniques throughout the years.

KEYWORDS: Urinary stress incontinence; Sling; Transobturator tape; Synthetic slings; Mini slings

CORRESPONDENCE: Ricardo Miyaoka, M.D., State University of Campinas, Department of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. Email:

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Basal Cell Carcinoma of the Prostate: A Case Report and Review of the Literature

ABSTRACT

We report a case of an adenoid cystic variant of basal cell carcinoma (BCC) of the prostate in a patient diagnosed following transurethral resection (TURP). A single focus of adenoid cystic carcinoma (ACC) was found. One year later the patient had an episode of hematuria, for which a second TURP was performed; the specimen showed diffuse ACC. The patient then underwent a total prostatectomy (TP). There was no remaining tumor. The patient has been followed for 6 years with no recurrence.

KEYWORDS: Adenoid cystic carcinoma; Basal cell carcinoma; Immunohistopathology; Prostate

CORRESPONDENCE: Mark S. Soloway, MD, Professor and Chairman, Department of Urology, University of Miami, Miller School of Medicine, P.O. Box 016960, Miami, FL 33101, USA. ()

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Appendicovesical Fistula: A Case Report

ABSTRACT

The author reports a case of a young boy with appendicular vesical fistula. He presented to the University Teaching Hospital, Lusaka, Zambia with urinary retention. He was also passing stool in the urine. Appendicular vesical fistula is one of the intestinal vesical fistulas. It is a very rare condition. The most common form is vesical colonic fistula, which is caused by diverticulosis (50-60%), colonic cancer (20-25%), or Crohn's disease (10%). Appendicular cancer, especially carcinoid tumor, is another underlying cause. Appendicular vesicle fistula is a rare but well known complication of appendicitis. The most common presentation is pneumaturia, fecaluria, and recurrent or chronic urinary tract infections.

KEYWORDS: Appendix; Urinary bladder; Fistula

CORRESPONDENCE: Mohamed Awny Labib, University Teaching Hospital, Nationalist Road, PO Box 33982, Lusaka, 10101, Zambia ()

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Transcoccygeal Sacropexy Using a Mesh Repair for Resolution of High Grade Uterine Prolapse Associated with Bladder Exstrophy

ABSTRACT

Management of pelvic prolapse in women with bladder exstrophy is challenging. Anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina can result in technical difficulties. An abdominal approach and the use of mesh repair have been encouraged to deliver more durable results. The authors report on a case of high grade uterine prolapse successfully managed with a transcoccygeal approach and use of a polypropylene mesh.

KEYWORDS: Uterine prolapse; Bladder exstrophy; Nazca R Mesh; Transcoccygeal sacropexy

CORRESPONDENCE: Paulo Palma MD, State University of Campinas, Division of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. ().

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Analysis of Bone Density Among Patients with Urolithiasis: The Role of Hypercalciuria in Bone Loss

ABSTRACT

INTRODUCTION: A kidney stone is a common urologic complaint. The association between hypercalciuria and bone mineral density (BMD) is well known. However, BMD reduction is also recognized among normocalciuric patients.

OBJECTIVE: Bone density in patients with stones was analyzed for the variables of age, sex, and stone configuration. Data were compared with a control group.

METHODS: Participants were 340 randomly chosen patients with upper urinary calcium stones. The control group included 340 healthy participants who were age and sex matched with the patient group. The quantitative variables included age, body mass index, T-score of bone densitometry in the lumbar vertebrae (L2-L4) and femoral neck, and the serum levels of uric acid, calcium, potassium, sodium, phosphor, alkaline phosphatase and parathyroid hormone. Furthermore, each patient’s 24-hour urine was studied for levels of creatinine, oxalate citrate, uric acid calcium, urea, and total volume.

RESULTS: The mean age of the patients was 43.22 years (SD =12.62); mean body mass index (BMI) was 27.44 kg/m2 (SD = 6.16). Lumbar vertebral bone densitometry bone mineral density (BMD) was normal in 144 patients (42.4%) and low normal in an additional 20 patients. One hundred forty patients (41.2%) had osteopenia and 56 (16.5%) were osteoporetic. Femoral neck BMD was normal in 188 patients (55.3%) and low normal in 28 patients. In comparison with the control group, lumbar and femoral BMD were significantly lower in patients with renal stones (P < .05). There were no significant differences among groups in quantitative variables, with the exception of serum uric acid level. There was a significant correlation between both lumbar T-score and femoral neck T-score with 24 hour urine uric acid. Lumbar T-scores increased in inverse relationship with age (P = .03).

CONCLUSION: The authors established that patients who form renal stones have a reduction in bone density. There was no significant difference in bone loss between hypercalciuric and normocalciuric patients, which indicates the existence of some interfering factors other than increased calcium loss. A low-calcium diet does not decrease stone formation, and it also leads to calcium imbalance and bone loss. Considering that the role of hypercalciuria in bone loss was not proven in this study and considering that a low-calcium diet has no proven role in renal stone prevention, the authors do not suggest low-calcium diets for renal stone formers.

KEYWORDS: Bone mineral density; Urolithiasis; Low-calcium diet; Hypercalciuria

CORRESPONDENCE: Dr. Mahmood Molaei, Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran ()

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The Small Intestinal Submucosa (SIS) as a Suburethral Sling for Correction of Stress Urinary Incontinence: Preliminary Experience

ABSTRACT

INTRODUCTION: The purpose of the present investigation was to demonstrate the authors’ preliminary experience with the use of small intestine submucosa (SIS) as a suburethral sling in the treatment of stress urinary incontinence (SUI) in females.

METHODS: The participants were a carefully selected cohort of 17 women (mean age = 55 years; range, 44–63 years) with SUI based on clinical and urodynamic evidence. Patients with mixed incontinence, prior anti-incontinence, or transvaginal surgery were excluded. The SIS sling was placed as a midurethral sling via a transvaginal retropubic approach. Patients were followed up at 1 week and 3, 6, and 12 months after the procedure. Urodynamic evaluation was repeated at the last postoperative visit.

RESULTS: No adverse inflammatory reactions to the implanted sling or evidence of sling erosion or extrusion were noted in any patients throughout the follow-up period. No major complications were reported; however, minor complications were reported in 3 patients (17.6%). One year after the procedure, 14 patients (82.3%) were completely dry and 2 patients reported occasional episodes of leakage on more than usual daily exercise. The procedure failed to cure SUI in 1 patient, and 1 patient had persistent de novo urinary urgency requiring anticholinergic medication.

CONCLUSION: The preliminary results strongly support the feasibility of the use of SIS as a suburethral sling for treatment of SUI. However, long-term follow up is needed to confirm the durability of these encouraging initial observations.

KEYWORDS: Stress urinary incontinence; Suburethral slings; Small intestine submucosa (SIS).

CORRESPONDENCE: Yasser Farahat, Ph.D., Urology Department, Faculty of Medicine, Tanta University, 11 Ebn Elaas Str., Tanta, Ghr 31111, Egypt. Email:

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Tubularized Incised-Plate (TIP) Repair Augmented by Spongioplasty for Distal and Midpenile Hypospadias

ABSTRACT

INTRODUCTION:The objective of the study was to evaluate the cosmetic and functional results of tubularized incised-plate (TIP) repair of distal and midpenile hypospadias, using the hemicorpora spongiosa as an additional cover in the Y to I maneuver.

METHODS: From February 2004 to February 2007, 50 patients with distal (n=30) and midpenile (n=20) hypospadias had surgical repair. The mean age of the patients was 4.2 years (range, 2-6 years). All patients received primary TIP repair with bilateral dissection of the hemicorpora spongiosa to cover the neourethra (spongioplasty).

RESULTS: The mean follow-up period was 12.6 months (range, 10-17 months). Of the 50 cases, 48 patients (96%) had successful outcome with regard to a straight urine stream, vertically slit meatus, and acceptable cosmetic appearance. Two patients with midpenile hypospadias developed a small fistula at the site of the native meatus. Both patients had successful fistula closure through a secondary repair 3 months later.

CONCLUSION: Spongioplasty is a reliable and important adjunct for covering the neourethra in TIP hypospadias repair. This surgical technique results in a low rate of fistula formation.

KEYWORDS: Hypospadius; Spongioplasty; Urethra

CORRESPONDENCE: Wael M Gamal, MD, Department of Urology, Sohag University, 31 el nasr Street, Sohag, Egypt ()

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The Effect of Voiding Position on Uroflowmetry Findings and Postvoiding Residual Urine in Patients with Benign Prostatic Hyperplasia

ABSTRACT

INTRODUCTION: The purpose of the present study was to determine whether sitting or standing positions had an effect on voiding in patients with bladder outflow obstruction due to benign prostatic hyperplasia.

METHODS: The authors studied 100 male patients over the age of 45 years with benign prostatic hyperplasia. All underwent uroflowmetry and prevoiding and postvoiding estimation of the residual urine in standing and sitting positions. Patient group 1 had uroflowmetry maximum flow rate (Qmax) ≤ 10 mL/sec.; Group 2 had Qmax 10-15 mL/s. All parameters of uroflowmetry (eg, Qmax, average flow rate, time to maximum flow, and postvoiding residual) were compared for both groups in both positions.

RESULTS: Comparison of all parameters of uroflowmetry and postvoiding residual showed statistically significant differences in favor of sitting more than standing. This result was found for all patients and all variables except one: there was no statistically significant difference in the time to maximum flow in sitting and standing positions for patients in group 2.

CONCLUSION: Voiding in the sitting position in patients with benign prostatic hyperplasia is preferred due to a decrease in obstructive parameters shown by uroflowmetry and postvoiding residual urine volume. As a result, fewer complications such as UTI and bladder stone formation are expected.

KEYWORDS: Voiding Position; Uroflowmetry; Benign prostatic hyperplasia

CORRESPONDENCE: Dr. Mohamed Ali, Department of Urology, Faculty of Medicine, Suez Canal University, Ring Road, Ismailia 41115, Egypt ().

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