Urethral resistance factor (URA) versus Schäfer's obstruction grade and Abrams-Griffiths (AG) number in the diagnosis of obstructive benign prostatic hyperplasia

Different methods of analyzing pressure/flow plots to quantify bladder outlet resistance in men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) were developed in the past. The aims of this study were to quantify the degree of agreement between the diagnosis of obstruction by the different methods, and to compare the applicability of the different methods in the evaluation of bladder outflow conditions, in a large group of these men. In consecutive men with LUTS basic initial evaluations, recommended diagnostic tests, and urodynamic investigations were performed. From pressure/flow studies, the group-specific resistance factor (URA), Sch?fer's obstruction grade, and Abrams-Griffiths (AG) number were estimated. Men with 21 cm H(2)O < or = URA < or = 29 cm H(2)O and men with Sch?fer's grade equal 2 were classified as equivocal. In conformity with the provisional ICS definition, men with 20 < or = AG number < or = 40 were classified as equivocal. In 78% of the 565 included men Sch?fer's classification agreed with URA classification. In 82% ICS classification agreed with URA classification. Most agreement (94%) existed between Sch?fer's classification and ICS classification. All differences were near the points of intersection of the different boundaries, and a decision whether to perform surgery on a patient is not likely to be influenced by this disagreement. Males with relatively low detrusor pressure at maximum flow and relatively low maximum flow had a high prevalence among those in whom URA and Sch?fer's classifications and among those in whom URA and ICS classifications differed.     

Interactions between prostate volume, filling cystometric estimated parameters, and data from pressure-flow studies in 565 men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

The aim of this study was to establish the characteristics and to investigate the interactions between prostate volume, degree of obstruction, bladder contractility, the prevalence of residual volume, bladder compliance, bladder capacities, and the prevalence of instability in a large, well-defined group of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). The 565 consecutive men included in this study met the criteria of the International Consensus Committee on BPH and voided more than 150 mL during uroflowmetry. Their residual urine volume and prostate size were estimated, and filling cystometry and pressure-flow studies were performed. Fifty-three percent of the men appeared to have obstruction. We found a positive correlation between prostate volume and Sch?fer's obstruction grade, except that mean prostate volume decreased at Sch?fer's grades 5 and 6. Significant negative correlations existed between Sch?fer's grade and cystometric bladder capacity and effective capacity. Bladder outlet obstruction results in incomplete emptying. Of all men, 26% had a significant residual volume ( > 20% of cystometric capacity). Thirty-nine percent did not have residual volume. Of the 565 men, 46% had an unstable bladder. In particular, patients with an unstable bladder in the sitting and lying positions have a significantly higher Sch?fer's grade and contractility grade and a significantly lower cystometric and effective bladder capacity compared with patients without instability. Patients with a residual volume or instability were significantly older. We conclude that in men with LUTS suggestive of BPH, abnormalities of bladder and bladder outlet function vary greatly and have complex mutual interactions.     

良性前列腺增生膀胱出口梗阻评判指标分析

目的 :探讨良性前列腺增生 (BPH)患者评判膀胱出口梗阻 (BOO)程度临床指标的应用价值。　方法 :35 8例BPH患者 ,根据膀胱镜下前列腺尿道梗阻的程度分为 3级 :1级为轻度梗阻 ;2级为中度梗阻 ;3级为重度梗阻 ;并根据Sch fer图定量划分梗阻程度 :0～Ⅵ级。结合相应的前列腺体积、最大尿流率、残余尿、国际前列腺症状评分(IPSS)以及膀胱的稳定性等项指标 ,进行单因素方差分析和相关分析 ,并计算相关指数。　结果 :按膀胱镜观测到的前列腺挤压尿道的程度将患者划分为 3级 :其中 1级 2 7例 ,2级 2 36例 ,3级 95例。前列腺体积为 16～ 14 5(4 7.0 4± 15 .6 1)ml。前列腺体积与前列腺挤压尿道的程度成正相关 (r =0 .2 9,R2 =0 .0 8) ,随着患者前列腺体积增大 ,前列腺挤压尿道的程度加重 (F =4 .2 16 ,P <0 .0 5 )。前列腺挤压尿道的程度与IPSS成正相关 (r =0 .35 ,R2 =0 .12 ) ,I PSS伴随着前列腺挤压尿道程度的增高而增高 (F =8.4 0 8,P <0 .0 0 1) ;生活质量评分随着前列腺挤压尿道程度的加重而增高 (F =10 .2 0 4 ,P <0 .0 0 1) ,两者成正相关 (r =0 .17,R2 =0 .0 3)。整个研究人群的平均最大尿流率为 (10 .0 2± 2 .12 )ml/min ,残余尿量为 (84 .0 6± 36 .5 0 )ml。最大自由率随着前列腺挤压尿道程度的加?     

Principles and clinical application of advanced urodynamic analysis of voiding function.

There are no reliable, sensitive, and specific clinical measures or symptoms from which to judge the severity of prostatic outflow obstruction. Urodynamics has developed the methodology for analyzing and measuring the mechanics of urinary tract voiding function in detail. There is a consensus in the urodynamic research community about realistic models of detrusor muscle mechanics and bladder outlet hydrodynamics, as is reflected in the very similar concepts proposed for clinical application. The pressure-flow diagram offers a simple graphical procedure for detailed assessment of the individual voiding balance. Most clinically relevant is the specific characterization of outlet function, because detrusor contraction strength cannot be pharmacologically influenced. It is difficult to accept that the best way to measure "prostatic obstruction" is symptom assessment rather than urodynamic measurement of the clearly mechanical entity "outlet obstruction". Urodynamics has evolved into scientifically accurate and specific techniques for voiding analysis. It is unreasonably to continue to use terms such as "outflow obstruction" or "weak detrusor" and all their synonyms in an undefined, speculative way. If we maintain that the clinical relevance of BPH is entirely related to outflow obstruction, then we must demonstrate obstruction objectively before surgery. If we aim at the treatment of symptoms alone, then we must become more specific in terminology and demonstrate that transurethral prostatic resection is indeed the optimum therapy for unobstructed symptomatic patients with BPH. Similarly, we must use the advanced urodynamic concepts to investigate the efficacy of newly suggested alternatives to resection such as prostatic balloon dilatation or pharmacologic therapy.     

Definition of normality of pressure-flow parameters based on observations in asymptomatic men

AIMS: Clinical nomograms for differentiating obstructed from unobstructed voiding and poor detrusor contractility from normal contractility have traditionally been drawn on the basis of symptomatic response to outflow tract surgery or on urodynamic changes in men with LUTS before and after surgery. The aim of this study was to examine pressure-flow parameters in asymptomatic male volunteers before age-related changes in the lower urinary tract had taken place and to assess detrusor contractility and outflow conditions during physiological bladder filling against clinically used pressure-flow nomograms. METHODS: Thirty-seven healthy male subjects between the ages of 18 and 40 years volunteered to undergo AUM. A total of 66 fill-void cycles in 25 individuals were evaluable. RESULTS: Mean p(det.Qmax) for the group was 53 +/- 3 cmH(2)O with a mean Q(max) of 24 +/- 2 ml sec(-1). URA of 21 cmH(2)O defined the upper border of normality for the outflow condition. Sch?fer's OCO showed the most consistent relationship between estimated urethral pressure at minimal flow and true measured urethral closure pressure. From a clinical perspective, the linear nomograms (ICS and Sch?fer) are more easily accessible with the ICS BOOI and obstruction index being the simplest to calculate manually. Minimal differences found between these urodynamic nomograms confirm the clinical value of recommending a single method to facilitate future comparisons between studies. CONCLUSIONS: An upper limit of normality for the male outflow condition can be defined by an URA of 21 cmH(2)O, AGN of 40 cmH(2)O or OCO of 1. Results above these reference values should be considered abnormal in this age group and where identified in a different age-group should be explained by physiological or pathophysiological events.     

A randomized controlled trial comparing transurethral resection of the prostate,contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia: urodynamic effects

PURPOSE: We compared urodynamic and uroflowmetry improvements in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) after transurethral prostate resection, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in men with lower urinary tract symptoms suggestive of BPH who met the criteria of the International Scientific Committee on BPH, had a prostate volume of between 20 and 65 ml., and a Sch?fer obstruction grade of 2 or greater. Before and 6 months after treatment urodynamics and free uroflowmetry were performed. RESULTS: A total of 50, 45 and 46 men were randomized to transurethral prostate resection, laser treatment and electrovaporization, respectively. Baseline characteristics were similar in the 3 groups. Detrusor contractility did not change in any of the treatment groups. The average maximum free flow rate increased by a factor of 2.4 after transurethral prostate resection, 2.5 after laser prostatectomy and 2.4 after electrovaporization. The Sch?fer obstruction grade decreased by a factor of 0.3 in all groups. Obstruction (Sch?fer grade greater than 2) was not noted after transurethral prostate resection or electrovaporization but it was evident in 2 patients after laser prostatectomy. Effective capacity increased by a factor of 1.5 or more. The incidence of detrusor instability was decreased by half in all groups. The incidence of significant post-void residual urine volume decreased in all groups. CONCLUSIONS: There were no significant differences in the improvement in urodynamic and uroflowmetry parameters 6 months after treatment when comparing transurethral prostate resection, contact laser prostatectomy and electrovaporization in men with lower urinary tract symptoms suggestive of BPH.     

前列腺增生症患者逼尿肌收缩力的定量判断与分级

为了对前列腺增生症（ＢＰＨ）患者逼尿肌收缩力进行定量判断与分级，作者选择１２０例年龄于５８～８９岁之间的ＢＰＨ患者，采用高级型尿动力测定仪进行压力－流率测定。测定结果由直线性被动尿道阻力关系（ＰＵＲＲ）及Ｓｃｈｆｅｒ列线图进行分析，将逼尿肌收缩力分为极弱（ＶＷ）、弱（Ｗ）、正常（Ｎ）及强（ＳＴ）四个等级。结果表明：１２０例ＢＰＨ患者中ＶＷ、Ｗ、Ｎ及ＳＴ级逼尿肌收缩力所占百分比各为１２．５％、２６．７％、４７．５％及１３．３％；高压－低流、高压－高流及正常或低压－低流等类型各占５５％、１．７％及４３．３％，并且逼尿肌损害经治疗及功能训练后收缩力级别可以增加。逼尿肌收缩力定量分级在ＢＰＨ患者的临床诊断、治疗方法选择、疗效评价及愈后等方面均具有重要的临床意义与应用价值，同时对其所依据的流体力学原理与尿动力学基础也进行了探讨。     

相对膀胱出口梗阻的研究及临床意义

目的:研究相对膀胱出口梗阻参数与膀胱排空能力之间的关系,探讨其对于BPH患者的临床意义。方法:66名年龄在55岁以上并表现有下尿路症状的BPH患者被纳入本研究。所有患者均行尿动力学检查,对相对膀胱出口梗阻参数和排尿后剩余尿(PVR)之间的相关性进行研究。结果:相对膀胱出口梗阻参数(AG值/WFmax和URA/WFmax)与PVR之间的相关性强于AG值和URA。结论:相对膀胱出口梗阻参数能够更好地评价膀胱排空能力,有重要的临床指导意义。     

前列腺增生症尿动力学检查的临床研究

目的 评价尿动力学检查(UDS)在良性前列腺增生症(BPH)诊治中的意义。方法 对102例BPH病人进行详细尿动力学检查,包括尿流率、充盈期膀胱测压、压力-流率测定、残余尿测定,应用P-Q图进行分析是否存在膀胱出口梗阻。术后随访,行残余尿、尿流率测定。结果 尿流率Qmax<15ml/s 98例;低顺应性膀胱17例,高顺应性膀胱22例,顺应性正常63例;通尿肌不稳定42例;通尿肌收缩力正常或增强84例,减弱18例;压力-流率测定P-Q图示膀胱出口梗阻84例;残余尿<100ml 50例,>100 ml 52例。术后随访80例症状消失,排尿顺畅。结论 尿流动力学检查能明确BPH有无膀胱出口梗阻、逼尿肌的顺应性和收缩功能,对术前合理选择病人和提高手术疗效有重要意义。     

Quantification of urethral resistance and bladder function during voiding,with special reference to the effects of prostate size reduction on urethral obstruction due to benign prostatic hyperplasia

In pressure/flow studies of adult voiding the behaviour of the urethra can be distinguished from that of the bladder, and quantified separately, as follows. Different degrees of urethral obstruction can be quantified and ranked using a group-specific resistance factor (URA) that is based empirically on the pressure/flow plots obtained in a large number of voidings of adult patients. Different detrusor contractions can be similarly quantified using a physiologically based measure (WF, abbreviated from power [W] factor) of the contraction strength. Both URA and WF can be calculated by computer from measurements of detrusor pressure, voiding flow rate, and the residual volume in the bladder after voiding. For other groups of patients, e.g., children, different group-specific resistance factors are appropriate. In men with obstructed voiding due to benign prostatic hyperplasia (BPH), “chemical castration” with cyproterone acetate or buserelin caused a substantial, reversible reduction in the size of the prostate. The effect on the degree of urethral obstruction and the voiding bladder contraction has been studied using the above-mentioned methods. There was an increase in peak urinary flow rate, a reduction in residual urine, and a decrease in daytime voiding frequency. Surprisingly, however, there was on average no decrease in urethral resistance but only an increase in the average detrusor contraction strength. In individual patients large increases and decreases of urethral resistance and detrusor contraction strength occurred, which largely cancelled each other out. These large changes masked the relatively modest urethral resistance decrease caused directly by prostate size reduction.     

Effects of retrospective quality control on pressure-flow data with computer-based urodynamic systems from men with benign prostatic hyperplasia

Aim： To evaluate the effects of retrospective quality control on pressure-flow data with computer-based urodynamic systems from men with benign prostatic hyperplasia （BPH）. Methods： A total of 582 traces of pressure-flow study from 181 men with BPH was included in the study. For each trace, maximum urinary flow rate （Qmax） and detrusor pressure at Qmax （pdet.Qmax） were, respectively, read from manually smoothed and corrected uroflow and detrusor pressure curves from the computer print-outs. Obstruction coefficient, International Continence Society （ICS） and Schaefer nomograms were used to detect urethral resistance and to diagnose obstruction. The results obtained by manual reading were compared with those from computer-based systems. Results： After manual correction, Qmax underwent a consistently significant decrease by 1.2 mL/s on average （P 〈 0.001）, and had a change range of 0.5-10.4 mL/s. However, pdet.Qmax underwent inconsistently intra-individual changes after correction. The obstruction coefficient increased significantly, by an average of 0.07 （P 〈 0.05）. Using the ICS nomogram, the percentage of obstruction increased from 69.8% to 73.9%, and of the non-obstruction decreased from 8.8% to 5.3% （P 〈 0.05）. There were 11% of traces that changed the classifications using the ICS nomogram, and 28.9% that changed the grades for the Schaefer nomogram. Conclusion： Systematically significant differences in parameters from pres- sure-flow study between manual readings and computer recordings were demonstrated. Manual correction resulted in a consistently lower Q a higher urethral resistance, and an aggravating obstruction. Manual readings can correct considerable false diagnoses for obstruction. Retrospective quality control of pressure-flow data with com- puter-based systems is necessary.     

BPH伴糖尿病患者尿动力学检测的临床意义

目的：探讨糖尿病对BPH患者逼尿肌功能改变的影响。方法：对37例BPH伴糖尿病患者（糖尿病组）和46例单纯性BPH患者（对照组）进行尿动力学检测，并比较两组检测结果。结果：糖尿病组和对照组比较，最大膀胱压测定容积、膀胱顺应值、膀胱出口梗阻、比例、排尿期最大逼尿肌压力及排尿后剩余尿量差异有显著性意义（P〈0．01）；糖尿病组膀胱感觉减退、不稳定膀胱及顺应性增加比例与对照组比较差异有统计学意义（P〈0．05）。结论：出现下尿路症状伴有糖尿病的BPH患者，膀胱逼尿肌受损较单纯性BPH患者更显著；尿动力学检查对患者能否行手术治疗及预测术后效果具有重要的参考价值。     

BPH梗阻致膀胱功能改变的尿动力学研究

为探讨前列腺增生症（ＢＰＨ）梗阻致膀胱功能改变的临床意义，对５９例ＢＰＨ病人进行全面尿动力学检查。结果：（１）最大逼尿肌等容收缩压（Ｐｉｓｏ）与逼尿肌收缩速度呈正相关（ｒ＝０．７１６７，Ｐ＜０００１）。（２）Ｐｉｓｏ随膀胱充盈量增加而显著下降（Ｐ＜０００１）。（３）Ｐｉｓｏ与ＢＰＨ梗阻程度呈正相关性（ｒ＝０．６７８１，Ｐ＜０００１）。（４）当剩余尿量≥１００ｍｌ，逼尿肌储能显著下降（Ｐ＜０００１）。（５）不稳定膀胱组的Ｐｉｓｏ显著高于稳定膀胱组。结果认为：不稳定膀胱是引起ＢＰＨ病人临床症状的主要因素之一，膀胱等容收缩试验应用于ＢＰＨ病人有重要的临床价值     

前列腺增生症术后疗效不良的尿动力学分析

目的探讨前列腺增生症术后疗效不良的原因。方法应用尿动力学方法对50例BPH术后症状改善不良的患进行检查分析。结果本组患术后疗效不良的主要原因为逼尿肌不稳定20例(40％)，逼尿肌收缩无力12例(24％)，膀胱出口梗阻18(36％)例。结论BPH术后疗效不良的原因是多方面的，逼尿肌不稳定、逼尿肌收缩无力和膀胱出口梗阻是常见原因。尿动力学检查对确定前列腺术后疗效不良的原因具有重要意义。     

The prediction of bladder outlet obstruction with prostate volume, maximum flow rate, residual urine and the international prostate symptom score in patients with lower urinary tract symptoms

We determined whether prostate volume (PV), maximum flow rate (Qmax), residual urine (RU) and the International Prostate Symptom Score (I-PSS) predicted bladder outlet obstruction in patients having lower urinary tract symptoms (LUTSs). The study consisted of 114 patients aged 50 years or older with LUTSs who had scores of 8 or more on the I-PSS and 2 or more for the quality of life index. All patients received transrectal ultrasonography for estimation of PV and pressure-flow study (PFS). When PFS showed an obstruction grade of 2 or more in Sch?fer's p/Q diagram, the result was defined as bladder outlet obstruction. When we examined which criteria indicated that 90% of patients had bladder outlet obstruction (positive predictive value: 90%), we found that PV of 35 ml or more, Qmax of 8 ml/sec or less, RU of 110 ml or more, and I-PSS of 30 or more did so. Fifty-nine percent of patients met at least one of these criteria. The results suggested that 59% of patients with LUTSs had bladder outlet obstruction with a 90% positive predictive value based on the value of PV, Qmax, RU or I-PSS.     

压力－流率测定在诊断膀胱出口梗阻中的意义

对４２例前列腺病症候群患者进行压力－流率测定，３５例被诊断为膀胱出口梗阻，７例排尿异常症状为逼尿肌功能异常所致。与单纯尿流率测定结果比较，压力－流率测定可以降低假阳性及假阴性率，为诊断膀胱出口梗阻的最佳方法，具有重要的临床意义。     

Multichannel urodynamic studies in men with benign prostatic hyperplasia. Indications and interpretation.

Recent studies suggest that clinical "prostatism" encompasses at least four conditions that may be present singly or in combination: prostatic urethral obstruction, impaired detrusor contractility, detrusor instability, and sensory urgency. In addition, primary vesical neck obstruction may be present in the absence of benign prostatic hyperplasia (BPH). Thus, the purpose of diagnostic evaluation in men with BPH is to identify precisely the pathophysiology of the patient's symptoms so that rational therapy can be selected.     

良性前列腺增生并发膀胱过度活动症的尿动力学诊断

目的 探讨良性前列腺增生(BPH)合并膀胱过度活动症(OAB)的尿动力学特点,为正确合理的治疗提供参考.方法 回顾性分析2009年1月至2010年5月就诊的235例BPH患者的尿动力学检查资料.患者年龄52～88岁,平均(68±8)岁.根据患者主诉有无OAB症状分为BPH组和BPH合并OAB组;根据尿动力学检查有无逼尿肌过度活动(DO)又将其分为单纯性BPH组、单纯性BPH合并DO组、BPH合并OAB无DO组及BPH合并OAB伴DO组,比较各组年龄、国际前列腺症状评分(IPSS)、前列腺体积、最大尿流率、残余尿量、初感容量、强烈尿感容量、梗阻指数和逼尿肌收缩力情况.结果 最终入选219例患者,年龄56～88岁,平均年龄(66±8)岁,平均前列腺体积(35±24)ml,平均最大尿流率(11±6)ml/s.33.8%(74/219)的患者尿动力学检查出现DO.与BPH组(104例)比较,BPH合并OAB组(115组)年龄更大、IPSS评分更高、前列腺体积更大、初感容量及强烈尿感容量更小、梗阻指数及逼尿肌收缩力减弱比例更高(P＜0.05).单纯BPH组、BPH合并DO组、BPH合并OAB无DO组及BPH合并OAB伴DO组分别为93例(42.5%)、11例(5.0%)、52例(23.7%)、63例(28.8%).BPH合并OAB伴DO与BPH合并DO两组比较,前者DO最大逼尿肌压更高、持续DO时间更长.结论 了解BPH合并OAB患者的尿动力学特点对于合理治疗和预测疗效具有重要意义.     

尿动力学检查在前列腺增生症术前评估中的临床意义

目的探讨前列腺增生症(BPH)手术治疗前尿动力学检查的必要性。方法对166例拟行手术治疗的BPH患者的尿动力学检查结果进行分析。结果在166例患者中,125例(75.3%)证实存在膀胱出口梗阻(BOO ),25例(15.1%)为可疑BOO(BOO±),16例(9.6%)无BOO(BOO-),3组之间在最大尿流率(Qmax)、残余尿量(PVRV)、逼尿肌/外括约肌协同失调(DSD)上差异无统计意义,BOO( )组的逼尿肌不稳定(DI)、低顺应性膀胱的发生率明显高于其他两组,逼尿肌收缩力减弱(DUA)的发生率明显低于其他两组。结论尿动力学检查对诊断BPH、选择治疗方法和预测疗效有重要意义,手术治疗前应常规检查。