1. No category

ISSUE 1
VOLUME 26
JANUARY - FEBRUARY - MARCH 2014
Hellenic
Urology
QUARTERLY PUBLICATION BY THE HELLENIC UROLOGICAL ASSOCIATION
Reviews
Original Articles
Case Reports
Hellenic
UROLOGY
QUARTERLY PUBLICATION BY THE
HELLENIC UROLOGICAL ASSOCIATION
JANUARY - FEBRUARY - MARCH 2014
ISSUE 1 - VOLUME 26
GR - ISSN 1105 - 1272
Hellenic
Urology
HELLENIC UROLOGY
OFFICIAL JOURNAL OF THE H.U.A.
ISSUE 1
VOLUME 26
JANUARY - FEBRUARY - MARCH 2014
EDITOR
George Moutzouris
President of H.U.A.
EDITORIAL BOARD
EDITOR-IN-CHIEF:
Ioannis Varkarakis
ASSISTANT EDITOR-IN-CHIEF:
Andreas Skolarikos
ASSOCIATE EDITORS:
Nikolaos Ferakis
Stilianos Giannakopoulos
Athanasios Papatsoris
ASSISTANT EDITORS:
Ioannis Adamakis
Iraklis Mitsogiannis
Konstantinos Stamatiou
MEMBERS:
Charilaos Katsifotis
Iraklis Poulias
Grigorios Raptidis
Distributed at no charge to all members of the Hellenic Urological Association
INDEXED IN IATROTEK AND THE NATIONAL DOCUMENTATION CENTRE
GR-ISSN 1105-1272
HELLENIC UROLOGY OFFICIAL JOURNAL OF THE H.U.A.
Hellenic
Urology
Contents
ISSUE 1
VOLUME 26
JANUARY - FEBRUARY - MARCH 2014
REVIEWS
A. Bourdoumis, Th. Stasinou, Ath. G. Papatsoris
Penile size and its correlation with other somatometric parameters
16-21
Ch. Komninos, I. C. Mitsogiannis
Obstruction-induced pathological alterations within the urinary bladder
due to Benign Prostate Hyperplasia (BPH). A review of the literature
22-29
ORIGINAL ARTICLES
Ch. Asvestis, Th. Varvadesis, P. E. Maravelakis
Greek Version of the National Institutes
of Health Chronic Prostatitis Symptom Index (NIH-CPSI),
its linguistic adaptation and the pilot test of its validity (ÍÇÉ)
30-35
A.I. Archodakis, S. Bolometes
Functional and ongological results of radical perineal
prostatectomy for the management of clinically locally
advanced prostate cancer. Single centre experience
36-44
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias
Urodynamic findings in voiding symptoms after
radical prostatectomy: Analysis of our experience
45-53
CASE REPORTS
K. Stamatiou, G. Makris, D. Zavradinos, E. Geropappas, K. Fokas, Ath. Papatsoris
Malakoplakia of the bladder associated with advanced obstructive uropathy
54-56
M. Stavropoulos, C. Bouropoulos, N. Ferakis, I. Poulias
Emergency embolisation of a spontaneously ruptured
angiomyolipoma in a solitary kidney
57-61
Ô Å Ë Å Õ ÔÁ É Á Í Å Á
Ãíùìïäüôçóç ó÷åôéêÜ ìå ôçí áñìïäéüôçôá êáé ôéò ðñïûðïèÝóåéò
÷ïñÞãçóçò Üäåéáò ëåéôïõñãßáò éäéùôéêïý éáôñåßïõ
ÁðÜíôçóç ôïõ Ãåí.ÃñáììáôÝá ôçò EAU
ÁðÜíôçóç ôïõ Ãåí.ÃñáììáôÝá ôçò EAU, Êáèçãçôïý Ïõñïëïãßáò ê.
Abrahamsson, ó÷åôéêÜ ìå ôï Ðñïó÷Ýäéï Íüìïõ ðïõ áöïñÜ ôçí ßäñõóç
íÝùí Åðéóôçìïíéêþí Åôáéñåéþí ôùí Éáôñéêþí Åéäé...
ÄéáäéêôõáêÝò ìåôáäüóåéò Óõíåäñéþí ÅÏÅ óôï ÍÉÌÔÓ
Óáò åíçìåñþíïõìå üôé óõíå÷ßæïíôáé êáé ôï 2009 êáôÜ ôç äéÜñêåéá ôùí
ìçíéáßùí óõíåäñéþí ôçò Åôáéñåßáò ìáò óôï ÍÉÌÔÓ, ïé äéáäéáêôõáêÝò
ìåôáäüóåéò e-learning óôá Ðåñéöåñåé...
«ÅéóáãùãÞ ÊùäéêïðïéÞóåùí ÉáôñéêÞò Ðëçñïöïñßáò»
Êýñéïé, Ìå ôçí ðáñïýóá åðéóôïëÞ èá èÝëáìå íá óáò åíçìåñþóïõìå ãéá
ôï Ýñãï «ÅéóáãùãÞ ÊùäéêïðïéÞóåùí ÉáôñéêÞò Ðëçñïöïñßáò», ôï ïðïßï
õëïðïéåßôáé óôï ðëáßóéï ôïõ ÌÝôñïõ 2.7 ...
ÃÍÙÓÔÏÐÏÉÇÓÇ
Áãáðçôïß Êýñéïé ÓõíÜäåëöïé, üðùò ìáò åíçìÝñùóå ç ÖáñìáêåõôéêÞ
Åôáéñåßá AMGEN, ôï óêåýáóìÜ ôçò XGEVA (denosumab), äýíáôáé íá
óõíôáãïãñáöåßôáé êáíïíéêÜ óå áóèåíåßò ìå ...
JUNIOR CLINICAL FELLOW IN UROLOGY/GENERAL SURGERY
visit our new website: www.huanet.gr
Instructions to Authors
“Hellenic Urology” is the official scientific journal of
the Hellenic Urological Association. Its main
objective is to publish original articles, reviews and
case reports on diseases of the genitourinary
system. The journal “Hellenic Urology” is also concerned in the continuous education of the Urologists and aims at promoting the science of Urology. The journal publishes papers, which concern
clinical research and scientific achievements. It
also welcomes clinical investigations as well as
basic and applied laboratory research; new data
and recent developments of urological interest are
also welcomed. Papers published in another journal are not accepted.
Submission of Papers
1. General Information:
The official language of “Hellenic Urology” is
English. Authors whose native language is not
English will have their manuscripts proofread by a
professional copyeditor offered by the editorial
team. The authors are allowed to submit their
manuscript into Greek and translation will be
provided.
All the authors are jointly responsible for the
contents of the paper and sign together the
Authorship Responsibility, Financial Disclosure
and Acknowledgment form. The list of authors
should not exceed six (6) otherwise the
participation of those exceeding the above
numbers should be justified accordingly. In case
reports, the authors should not exceed four (4). In
review articles the authors should not exceed the
number of two.
The following should be observed in the case of
clinical studies:
a) The authors should state that the research
was conducted according to the principles
as have set forth by the Helsinki Declaration
of 1975.
b) In the Studies that involve human subjects, a
statement-approval from the appropriate
human ethics committees should be
obtained.
c) A statement - approval of the competent
scientific committee of the centre in which
the research work was carried out,
pertaining to the protocol of the perspective
studies, should be included.
In the case of the experimental studies on animals a
statement should be made that the paper has
adhered to the international guidelines for research
involving animals, which has been recommended
by the WHO, stating that “all research on animals
was conducted in accordance with guidelines
tendered by international law”.
2. Copyright Transfer:
Papers published in Hellenic Urology constitute
copyright ownership of the manuscript to the
Hellenic Urological Association (HUA). Thus any
reproduction and/or copying of said manuscript is
allowed only after consent of the Editorial Board of
the Journal.
3. Procedure:
The corresponding author is informed for
receipt of the manuscript and number of
registration. The manuscripts are first checked whether they have been written and
submitted according to the instructions of
the journal (instructions to authors). Manuscripts which do not meet the requirements
of correct submission are returned to the
corresponding author with instructions for
due corrections. The manuscript is double
–blind checked by special consultantsreviewers of the journal.
The revised manuscript with an accompanying letter signed by the corresponding
author, in which he declares that all corrections have been done.
The final decision for acceptance of the manuscript
lies on the Editorial Board that decides for approval,
or return of manuscript for supplementary information, decision for re-approval or to reject the
Hellenic
UROLOGY
11
manuscript. As soon as the paper is accepted and
has been allotted final publication, a proof is
dispatched to the authors for final checking.
Article types
Conclusions
The main conclusions of the study may be
presented in a short conclusions section, which
may stand alone or form a subsection of a
Discussion section.
Title page information
Reviews - maximum 4,000 words, 50 references, 6
tables and 10 figures, Abstract 300 words
Original Articles - maximum 3,000 words, 30
references, 6 tables and 10 figures, Abstract 200
words
Case Reports - maximum 1,500 words, 10 references and 6 figures, Abstract 100 words
Letter to the editor - maximum 600 words, 6
references, 1 table and 1 figure
All article types should be accompanied by an
abstract in Greek. For authors whose native
language is not Greek, a Greek translation will be
provided by the Editorial Board.
Article structure
Subdivision
Divide your article into clearly defined sections. Any
subsection may be given a brief heading. Each
heading should appear on its own separate line.
Introduction
State the objectives of the work and provide an
adequate background, avoiding a detailed
literature survey or a summary of the results.
Material and methods
Provide sufficient detail to allow the work to be
reproduced. Methods already published should be
indicated by a reference: only relevant
modifications should be described. Statistical
methods should be included in Material and
Methods section.
Results
Results should be clear and concise.
Discussion
This should explore the significance of the results of
the work, not repeat them. Avoid extensive citations
and discussion of published literature.
12
Hellenic
UROLOGY
Title Concise and informative. Titles are often
used in information-retrieval systems. Avoid
abbreviations and formulae where possible.
Author names and affiliations Where the
family name may be ambiguous (e.g., a double
name), please indicate this clearly. Present the
authors' affiliation addresses (where the actual
work was done) below the names. Indicate all
affiliations with a lower-case superscript letter
immediately after the author's name and in front of
the appropriate address. Provide the full postal
address of each affiliation, including the country
name and, if available, the e-mail address of each
author.
Corresponding author Clearly indicate who
will handle correspondence at all stages of
refereeing and publication. Ensure that phone
numbers (with country and area code) are provided
in addition to the e-mail address and the complete
postal address. Contact details must be kept up to
date by the corresponding author.
Summary
A concise and factual abstract is required. The
abstract should state briefly the purpose of the
research, the principal results and major
conclusions. An abstract is often presented
separately from the article, so it must be able to
stand alone. For this reason, references should be
avoided, but if essential, then cite the author(s) and
year(s). Also, non-standard or uncommon
abbreviations should be avoided, but if essential
they must be defined at their first mention in the
abstract itself. Abstracts should be structured to
include items of Objectives, Methods, Results and
Conclusions.
Keywords
Immediately after the abstract, provide a maximum
of 6 keywords, using American spelling and
avoiding general and plural terms and multiple
concepts (avoid, for example, 'and', 'of'). Be
sparing with abbreviations: only abbreviations
firmly established in the field may be eligible. These
keywords will be used for indexing purposes.
Abbreviations
In the main text, abbreviation should be detailed at
their first mention. Ensure consistency of
abbreviations throughout the article.
Acknowledgements
Collate acknowledgements in a separate section at
the end of the article before the references. List
here those individuals who provided assistance
during the research.
Math formulae
Present simple formulae in the line of normal text
where possible and use the solidus (/) instead of a
horizontal line for small fractional terms, e.g., X/Y. In
principle, variables are to be presented in italics.
Powers of e are often more conveniently denoted
by exp. Number consecutively any equations that
have to be displayed separately from the text (if
referred to explicitly in the text).
Footnotes
Footnotes should be used sparingly. Number them
consecutively throughout the article, using superscript Arabic numbers. Many word processors
build footnotes into the text, and this feature may be
used. Should this not be the case, indicate the
position of footnotes in the text and present the
footnotes themselves separately at the end of the
article. Do not include footnotes in the reference list.
Table footnotes
Indicate each footnote in a table with a superscript
lowercase letter.
Artwork
Image manipulation
Whilst it is accepted that authors sometimes need
to manipulate images for clarity, manipulation for
purposes of deception or fraud will be seen as
scientific ethical abuse and will be dealt with
accordingly. For graphical images, this journal is
applying the following policy: no specific feature
within an image may be enhanced, obscured,
moved, removed, or introduced. Adjustments of
brightness, contrast, or color balance are
acceptable if and as long as they do not obscure or
eliminate any information present in the original.
Electronic artwork
General points
Make sure you use uniform lettering and
sizing of your original artwork.
Embed the used fonts if the application
provides that option.
Aim to use the following fonts in your
illustrations: Times New Roman, 12.
Number the illustrations according to their
sequence in the text.
Use a logical naming convention for your
artwork files.
Provide captions to illustrations separately.
Size the illustrations close to the desired
dimensions of the printed version.
Submit each illustration as a separate file.
Formats
If your electronic artwork is created in a Microsoft
Office application (Word, PowerPoint, Excel) then
please supply 'as is' in the native document format.
Regardless of the application used other than
Microsoft Office, when your electronic artwork is
finalized, please 'Save as' or convert the images to
one of the following formats (note the resolution
requirements for line drawings, halftones, and
line/halftone combinations given below):
PDF or JPEG. Keep to a minimum of 300 dpi Vector
drawings, embed all used fonts.
Please do not
Supply files that are optimized for screen use
(e.g., GIF, BMP, PICT, WPG); these typically have a
low number of pixels and limited set of colors;
Supply files that are too low in resolution;
Submit graphics that are disproportionately
large for the content.
Hellenic
UROLOGY
13
Figure legends
Ensure that each illustration has a legend. Supply
legends separately, not attached to the figure. A
legend should comprise a brief title (not on the
figure itself) and a description of the illustration.
Keep text in the illustrations themselves to a
minimum but explain all symbols and abbreviations
used. Legends should be sent separately.
Tables
Number tables consecutively in accordance with
their appearance in the text. Place footnotes to
tables above the table body and indicate them with
superscript lowercase letters. Avoid vertical rules.
Be sparing in the use of tables and ensure that the
data presented in tables do not duplicate results
described elsewhere in the article.
References
Citation in text
Please ensure that every reference cited in the text
is also present in the reference list. Any references
cited in the abstract must be given in full.
Unpublished results and personal communications
are not recommended in the reference list, but may
be mentioned in the text. If these references are
included in the reference list they should follow the
standard reference style of the journal and should
include a substitution of the publication date with
either 'Unpublished results' or 'Personal
communication'. Citation of a reference as 'in
press' implies that the item has been accepted for
publication.
Web references
As a minimum, the full URL should be given and the
date when the reference was last accessed. Any
further information, if known (DOI, author names,
dates, reference to a source publication, etc.),
should also be given. Web references can be listed
separately (e.g., after the reference list) under a
different heading if desired, or can be included in
the reference list.
14
Hellenic
UROLOGY
Reference style
Text: Indicate references by number(s) in square
brackets in line with the text. The actual authors can
be referred to, but the reference number(s) must
always be given. However, for more than one
author, only the first should be listed followed by "et
al”.
List: Number the references (numbers in square
brackets) in the list in the order in which they appear
in the text.
Examples:
Reference to a journal publication:
1. Van der Geer J, Hanraads JAJ, Lupton RA.
The art of writing a scientific article. J Sci Commun
2000;163:51–9.
Reference to a book:
2. Strunk Jr W, White EB. The elements of style.
3rd ed. New York: Macmillan; 1979.
Reference to a chapter in an edited book:
3. Mettam GR, Adams LB. How to prepare an
electronic version of your article. In: Jones BS,
Smith RZ, editors. Introduction to the electronic
age, New York: E-Publishing Inc; 1999, p. 281–304.
Note shortened form for last page number. e.g.,
51–9, and that for more than 6 authors the first 6
should be listed followed by "et al." For further
details you are referred to "Uniform Requirements
for Manuscripts submitted to Biomedical Journals"
(J Am Med Assoc 1997;277:927–934) (see also
http://www.nlm.nih.gov/bsd/uniform_requirement
s.html).
REVIEW
Penile size and its correlation
with other somatometric parameters
Andreas Bourdoumis1, Theodora Stasinou2, Athanasios G. Papatsoris3
1
Department of Urology, Royal London Hospital, Bartshealth NHS Trust, London, UK
2
Department of Urology, North Devon District Hospital, North Devon Healthcare NHS Trust, Barnstaple, UK
3
Second University Department of Urology, Sismanoglio General Hospital, Athens, Greece
Corresponding Author:
Andreas Bourdoumis
Royal London Hospital,
Whitechapel Road, E1 1BB, London, UK
e-mail: [email protected]
Summary
The concept that penile size is related to various
other body features is commonly encountered. In
the current review, we seek evidence based results
from studies investigating the correlation between
the penile size and various other somatometric
parameters. Parameters under investigation
included penile circumference, flaccid and
stretched penile lengths, age, height, weight, body
mass index as well as shoe size and index finger
length. The various investigated penile parameters
were found to be positively correlated with
somatometric parameters such as height, weight
and body mass index.
Key words
Penile size, penile length, somatometric parameter
Introduction
Variations in penile shape and size may have
considerable consequences in relationships and
1
quality of life . Concerns regarding the ideal penile
size are commonly encountered in the male
2
population . Measurement of penile length is an
important part in the assessment of microphalia
and other external genitalia abnormalities3,4. Expert
consultation and reassurance is often sought,
driven by concern about adequacy of penile size,
and this is also reinforced by the commercial
campaigns from the industry (i.e. manufactures of
condoms)5. The objective of this review was to
highlight the evidence from the various studies in
the literature that investigate the potential
correlation of the average penile size to other
somatometric parameters.
16
Hellenic
UROLOGY
Materials and Methods
An electronic database (i.e. PubMed, E-medicine)
literature search was performed by using relevant
key words, such as penis, penile, size, penile
length, somatometric parameter, penle
enlargement, phalloplasty, microphalia, and
micropenis syndrome (alone or in combination).
Retrospective and prospective studies with more
than one hundred male participants were analyzed.
The selected journals were written in English, and
the majority was published during the last decade.
The impact of penile size
There is a steady increase in the number of men
who are not satisfied with their penile size and
therefore seek penile enlargement2. In a recently
published series of 250 patients complaining of a
small-sized penis, 64% of them admitted that their
anxiety arose after comparing their penis to their
6
friends during childhood . Penile size related
anxiety may lead to negative affect disorders and
7
decreased self esteem . In an internet-based
survey among 52,301 men and women, most men
rated their penis as being of average size (66%) and
only 12% rated their penis as small. In the same
study, 85% of the female participants felt satisfied
8
with their partner's penile size . The results seem to
be related to the subjective perception and selfesteem of the individual.
Micropenis syndrome is considered to be a
subjective perception of a small penis in flaccid
state, despite a normal physical examination9. A
psychological disorder known as dysmorphophobia is associated with an altered subjective
perception of normal physical characteristics as
Penile size and its correlation with other somatometric parameters
inadequate or abnormal9. In a study conducted
among 112 students, a subjective perception of a
small sized penis was observed in 26% of
participants and similar results were reported in
another study from men serving in the military10,11.
Also, it has also been postulated that most men
who request penile augmentation surgery
exaggerate as to the perception of what a normal
penile size is. In a series of 67 men complaining for
their size, none of the participants was proven to
2
actually have an objectively small penis . In the
same cohort, 19 men (28.3%) continued to
investigate the possibility of a surgical
augmentation despite the detailed and scientifically
2
evidence based consultation provided . In other
studies comprising of 331 volunteers, 67% was
relatively satisfied with their penile size (mean:
13.6±2.3 cm) in flaccid length, although 62%
believed that a larger penis would offer more
12,13
satisfaction to their female partners . However,
women participants claimed that larger size is not
14
necessarily associated with sexual pleasure .
Shortening of the penile shaft can be observed after
prostate cancer treatment, in erectile dysfunction
cases, after treatment of the Peyronie's disease or
15
in congenital penile deformity. Munding et al
evaluated changes in the penile length after
retropublic radical prostatectomy 3 months after
the surgery. The authors reported a decrease in
71% of patients, with 48% measuring at least 1cm
less in stretched measurement. Similarly, Savoie et
16
al reported a statistically significant reduction in
68% of the patients. Objective shortening is also
reported following hormonal and external beam
17,18
radiation treatment of prostate cancer . Awwad
19
et al compared penile size lengths between
normal adults and patients with erectile
dysfunction. A statistically significant difference
was demonstrated between the mean flaccid to the
mean stretched length (9.3 cm vs. 7.7 cm and 13.5
cm vs. 11.6 cm, respectively) which was attributed
to the inability of the tunica albuginea to expand. In
patients with Peyronie's disease, postoperative
measurements revealed a 30-50% shortening,
especially following circumferential incision of the
tunica albuginea and placement of a penile
20
implant . In cases who underwent a Nesbit
operation that proportion was reported to be as
high as 100% 21.
True microphalia may be encountere as a result of
defective gonadotropin secretion from the
hypothalamus, or in mixed gonadal dysgenesis22-25.
The epispadias-extrophy complex is also
associated with penile shortening due to a relative
25
reduction in length of the copora cavernosa .
Determination of normal penile length
In a meta-analysis by Templer et al26 the average
length of a normal range penis was identified to be
8.9cm in flaccid state and 15.2cm during erection.
Although there is no standard technique for penile
length measurement, some researchers prefer to
measure penile dimensions from the pubic ramus
to the distal tip of the glans penis on the dorsal
12,27
surface . During penile measurement, care
should be taken to avoid pressure against the
pubic fat pad, which may alter results.
Measurements are generally made during flaccid,
stretched and erect states. The first study about
penile length is attributed to Loeb in 1899, and the
average flaccid penile length as he measured it was
28
29
9.41 cm . Ponchietti et al conducted a study in
3300 men and managed to develop a nomogram
including penile dimensions in percentiles during
flaccid and erect state. Several studies have shown
that there is a strong correlation between stretched
9, 27
penile length and erect length . As shown in Table
1, for a range between 8-10cm, flaccid length is
usually 3-4cm shorter than the stretched penile
length and 5-6cm shorter than the erect length. It is
widely accepted that true microphalia corresponds
in penile lengths which are shorter than the mean
length at least at 2.5 standard deviations (SD) and it
refers to penile length below 4cm in the flaccid state
Hellenic
UROLOGY
17
Andreas Bourdoumis, Theodora Stasinou, Athanasios G. Papatsoris
27
30
and under 7cm in stretched state . Brondil et al
performed a study in 905 men and recorded
measurements of 10.7cm and 16.74cm during
flaccid and stretched state respectively. Their
conclusion was that penile compliance is
significantly decreased with aging. In other studies
about microphalia it was appreciated that the
shortest penile length sufficient for penetration and
insemination was 4cm22, 23.
Correlation to somatometric parameters
The variability amongst measurements of penile
size reflects the ethnic diversity of populations that
were studied, the different age groups as well as
the different measurement techniques that were
applied. Somatometric parameters that were
correlated with penile size in the studies included
height, weight, ratio of circumference to waist/hip,
12, 29, 31, 32
shoe size and index finger length (Table 2)
.
31
Shah et al reported that there was no correlation
between shoe size and penile length. A study of 52
Greek males, aged 19–38, revealed that the penile
length is weakly correlated inversely to age, weight,
BMI and height/weight ratio, weakly correlated to
height and directly statistically significant only with
index finger length32. The largest relative study
conducted by Ponchietti et al29 among 3300 Italian
men demonstrated that penile measurements
(length and circumference at the midshaft)
correlated to height but no correlation between
weight and the BMI. In a series of 1500 men,
4
Mehraban et al reported a significant positive
correlation with age, height, index finger length, but
not with waist/hip ratio or weight. In a Turkish study
among 2247 men, weak positive correlations were
identified between penile circumference, flaccid
and stretched lengths and height and weight. Although those correlations were found between the
mean circumference penile length and BMI, there
were no correlations between length and BMI 33. In
other words, there is enough evidence to suggest
that penile size is positively correlated to the height
and inversely correlated to the weight and BMI. In
18
Hellenic
UROLOGY
contrast to socially spread beliefs correlating index
finger and shoe size length, such correlations are
not supported by the current literature. For an
accurate estimate of penile length, we recommend
measurement starting at the pubopenile junction to
the tip of the glans, during flaccid, stretched and
27
erect state .
Surgical augmentation techniques
The management of patients with microphalia
should be multidisciplinary, including urological
and psychological consultations. There are no
clear recommendations for penile augmentation in
the literature11. The respective surgical techniques
are few, and the relative studies include only small
numbers of patients and a short follow up.
Liposuction can only provide a subjective visual
lengthening effect. Skin enhancement techniques
may lead to severe deformities and hypertrophic
34
scarring . Dissection of the penile suspensory
ligament followed by postoperative penile
stretching increases penile length by 1-2cm;
however it may be followed by reduced erection
angle and penile instability35, 36. There are few
reports on the effect of circumcision on penile
37
size . A study showed a statistically important
penile length difference between children
submitted to circumcision compared to children
who were not38. In the same study the penile length
of the corpora cavernosa measured by ultrasound
was not found to be statistically different 38.
Conclusion
During consultation for penile augmentation procedures, it is important for the urologists to be familiar with the respective range of normal penile
length for the particular age and population group.
In the present review, there were a few significant
correlations among penile dimensions and other
somatometric parameters, especially height,
weight and BMI. Further studies are required to
evaluate the safety and effectiveness of surgical
augmentation techniques.
Penile size and its correlation with other somatometric parameters
Table1. Studies evaluating penile length (mean values)
Year of
publication
Studies
28
Kinseyetal.
Country
1948
29
Ajmanietal.
1985
Number
of
partici
pants
Age
2770
USA
NIGERIA
Stretched
penile
length
(cm)
Penile
circumfe
rence
(cm)
2059
9,7
15,5
NR*
320
1723
8,16
NA
8,83
1
8,85
12,45
9,71
Bartshealth NHS Trust, London, UK
Wessellsetal.20
1996
USA
80
Chenetal.23
2000
ISRAEL
55
2178
8,3
12,5
NA
Ponchiettietal.9
2001
ITALY
3300
1719
9,0
12,5
10,0
200
2022
6,8
Spyropoulo
8
setal.
2002
GREECE
52
1939
7,76
12,18
8,68
Awwadetal.30
2005
JORDANIA
271
1783
9,3
13,5
8,98
Mehrabanetal.4
2007
IRAN
1500
2040
ÄÁ*
11,58
8,66
Promoduetal.31
2007
INDIA
301
1860
8,21
10,88
9,14
2010
TURKEY
1132
1930
9,3
13,7
NA
8,95
13,98
8,89
8,64
12,87
9,11
Söylemezet al.
2011
TURKEY
2276
1839
Average
length in
total of all
studies.
19482011
UNIVE
RSALLY
12
257
1783
1
ÁíäñåÜò Ìðïõñäïýìçò, 2Èåïäþñá Óôáóéíïý,
3
ÁèáíÜóéïò Ã. Ðáðáôóþñçò
Department of Urology, Royal London Hospital,
Department of Urology, North Devon District Hospital,
North Devon Healthcare NHS Trust, Barnstaple, UK
2
TURKEY
25
óùìáôïìåôñéêÝò ðáñáìÝôñïõò
2
2002
Aslanetal.6
Ðåúêü ìåãÝèïò êáé óõó÷Ýôéóç ìå Üëëåò
Flaccid
penile
length
(cm)
2182
Sengezeretal.3
Ðåñßëçøç
12,7
NA
Â' ÐáíåðéóôçìéáêÞ ÏõñïëïãéêÞ ÊëéíéêÞ, Óéóìáíüãëåéï
Ãåíéêü Íïóïêïìåßï, ÁèÞíá
Õðåýèõíïò åðéêïéíùíßáò: ÁíäñÝáò Ìðïõñäïýìçò
Royal London Hospital,Whitechapel Road, E1 1BB,
London, UK
e-mail: [email protected]
Ç áíôßëçøç ôïõ óõó÷åôéóìïý ôïõ ìåãÝèïõò
ôïõ ðÝïõò ìå äéÜöïñåò Üëëåò óùìáôéêÝò
ðáñáìÝôñïõò áðáíôÜôáé óõ÷íÜ óôïí áíäñéêü
ðëçèõóìü.
NA: Not Applicable
Table 2. Studies correlating penile length to somatometric
parameters
Ï óêïðüò ìáò åßíáé ç áíáóêüðçóç ôçò âéâëéïãñáößáò þóôå íá äéåñåõíçèåß ç ðéèáíÞ óõó÷Ýôéóç ôïõ ìÝóïõ öáëëéêïý ìÞêïõò êáé Üëëùí óùìá-
Studies
Country
Number
of men
Flaccid
penile
length
(cm)
Heigh
Weight
(cm)
(kgr)
BMI
Index
finger
length
(cm)
Waist/
hip
circum
ference
ôïìåôñéêþí ðáñáìÝôñùí. ÁíáóêïðÞèçêáí ìåëÝôåò ó÷åôéêÜ ìå ôç ðåñéöÝñåéá ôïõ ðÝïõò, ôï ìÞêïò
êáôÜ ôç ÷áëáñÞ êáé ôåôáìÝíç öÜóç, ôçí çëéêßá, ôï
25
Söylemezet al.
Ponchiettietal.9
TURKEY
ITALY
2276
3300
8,95*
174,79*
69*
22,59*
_
+/-
+/-
+/-
+/-
1,04
5,44
6,93
1,97
9,0***
175***
69
22,53***
_
179.4
82,5
25,7
9,6*
+/-
+/-
+/-
+/-
6,5
13
3,65
0,73
_
ýøïò, ôï âÜñïò, ôï äåßêôçò ìÜæáò óþìáôïò, ôï
ìÝãåèïò ôçò Üêñáò ðïäüò êáé ôï ìÝãåèïò ôïõ äåß-
_
êôç ôçò Üêñáò ÷åéñüò. Ïé äéÜöïñåò ðåúêÝò äéáóôÜóåéò ðïõ åîåôÜóôçêáí ðáñïõóßáóáí èåôéêÞ óõ-
Spyropoulo
GREECE
setal.8
52
7,76***
174,3***
Mehrabanetal.
Promoduetal.
4
31
IRAN
INDIA
1500
301
11,58
8,21
$
78,67
+/-
+/-
6,31
8,41
167,27
65,53**
+/-
+/-
6,91
10,8
ó÷Ýôéóç ìå óùìáôïìåôñéêÝò ðáñáìÝôñïõò, üðùò
0,89
ôï ýøïò, ôï âÜñïò êáé ôï äåßêôç ìÜæáò óþìáôïò.
8,97***
25,87
+/-
0,91
ËÝîåéò åõñåôçñéáóìïý: Ðåúêü ìÝãåèïò, ðåúêü ìÞ-
0,89
23,5**
_
_
êïò, óùìáôïìåôñéêÞ ðáñÜìåôñïò.
*Positive correlation p<0.05
**Positive correlation p<0.01
***Positive correlation p<0.001
Hellenic
UROLOGY
19
Andreas Bourdoumis, Theodora Stasinou, Athanasios G. Papatsoris
References
1. Diseth Th, Bjordal R, Schultz A, Stange M,
Emblem R. Somatic function, mental health and
psychosocial functioning in 22 adolescents with
bladder exstrophy and epispadias. J Urol 1998; 159:
1684–1689; discussion 1689–1690.
2. Mondaini N, Ponchietti R, Gontero P, Muir
Gh, Natali A, Caldarera E Et Al. Penile length is normal
in most men seeking penile lengthening procedures.
Int J Impot Res 2002; 14: 283–286.
3. Sengezer M, Ozturk S, Deveci M. Accurate
method for determining functional penile length in
Turkish young men. AnnPlastSurg 2002; 48: 381–385.
4. Mehraban D, Salehi M, Zayeri F. Penile size
and somatometric parameters among Iranian normal
adult men. Int J ImpotRes 2007; 19: 303–309.
5. Schneider T, Sperling H, Lummen G,
Syllwasschy J, Rubben H. Does penile size in younger
men cause problems in condom use? a prospective
measurement of penile dimensions in 111 young and
32 older men. Urology 2001; 57: 314–318.
6. Ghanem H, Shamloul R, Khodeir F, Elshafie
H, Kaddah A, Ismail I. Structured management and
counseling for patients with a complaint of a small
penis. J Sex Med 2007; 4: 1322–1327.
7. Alter Gj. Augmentation phalloplasty. UrolClin
North Am 1995; 22: 887–902.
8. Lever J, Fredereicjk Da, Peplau La. Does size
matter? Men's and women's views on penis size
across the lifespan. Psychol Men Masculinity 2006; 3:
129–43.
9. Wylie Kr, Eardley I. Penile size and the 'small
penis syndrome'. BJU Int 2007; 99: 1449–1455.
10. Lee Pa. Survey report: concept of penis size.
J Sex Marital Ther1996; 22:131–5.
11. Son H, Lee H, Huh Js, Kim Sw, Paick Js.
Studies on self-esteem of penile size in young Korean
military men. Asian J Androl2003;5: 185–9.
12. Aslan Y, Atan A, Omur Aydin A, Nalcacioglu
V, Tuncel A, Kadioglu A. Penile length and somatometric parameters: a study in healthy young Turkish
men. Asian J Androl 2010; 13: 339–341.
20
Hellenic
UROLOGY
13. Kuzgunbay B, Turunç T, Güvel S, Özkardeº H.
The average penile size of the Turkish men and their
opinions about the penile size. Turk J Urol 2007; 33:
290–293.
14. Francken Ab, Van De Wiel Hb, Van Driel Mf,
Weijmar Schultz Wc. What importance do women
attribute to the size of the penis? EurUrol 2002; 42:
426–431.
15. Munding Md, Wessells Hb, Dalkin Bl. Pilot
study of changes in stretched penile length 3 months
after radical retropubic prostatectomy. Urology 2001;
58: 567–569.
16. Savoie M, Kim Ss, Soloway Ms. A prospective
study measuring penile length in men treated with
radical prostatectomy for prostate cancer. J Urol
2003; 169: 1462–1464.
17. Haliloglu A, Baltaci S, Yaman O. Penile length
changes in men treated with androgen suppression
plus radiation therapy for local or locally advanced
prostate cancer. J Urol 2007; 177: 128–130.
18. Hall Sj, Basile G, Bertero Eb, De Las Morenas
A, Goldstein I. Extensive corporeal fibrosis after penile
irradiation. J Urol 1995; 153: 372–377.
19. Awwad Z, Abu-hijleh M, Basri S, Shegam N,
Murshidi M, Ajlouni K. Penile measurements in normal
adult Jordanians and in patients with erectile
dysfunction. Int J Impot Res 2005; 17: 191–195.
20. Porst H, Buvat J. Standard Practice in Sexual
Medicine. Blackwell: Malden, MA, 2006.
21. Rigaud G, Berger Re. Corrective procedures
for penile shortening due to disease. J Urol 1995; 153:
368–370.
22. Aaronson Ia. Micropenis: medical and
surgical implications.J Urol 1994; 152: 4–14.I
23. Campbell Mf, Wein Aj, Kavoussi Lr.
Campbell-Walsh Urology. editor-in-chief, Alan J,
Wein; Louis R Kavoussi, et al.(eds), 9th edn. W.B.
Saunders: Philadelphia, 2007 pp 3751–3754.
24. Moncada-irribaren I. Managing penile
shortening after disease surgery. J Urol 2007; 177:
750A. Silver RI, Yang A, Ben Chaim J, Jeff RD,
Gearheart JP. Penile length in adulthood after
Penile size and its correlation with other somatometric parameters
exstrophy reconstruction. J Urol 1997; 157: 999–1003.
25. Silver Ri, Yang A, Ben Chaim J, Jeff Rd,
Gearheart Jp. Penile length in adulthood after
exstrophy reconstruction. J Urol 1997; 157: 999–1003.
26. Templer D I. (2002). Is size important?
Pittsburgh, PA: CeShore.
27. Wessells H, Lue Tf, Mcaninch Jw. Penile
length in the flaccid and erect states: guidelines for
penile augmentation. J Urol 1996; 156: 995–997.
28. Loeb H. Harnrohrencapacitat und Tripperspritzen. Munch Med Wochenschr 1899; 46: 17.
29. Ponchietti R, Mondaini N, Bonafe M, Di Loro
F, Biscioni S, Masieri L. Penile length and circumference: a study on 3,300 young Italian males. EurUrol
2001; 39: 183–186.
30. Bondil P, Costa P, Daures Jp, Louis Jf,
Navratil H. Clinical study of the longitudinal
deformation of the flaccid penis and of its variations
with aging. EurUrol 1992; 21: 284–286.
33. Söylemez H, Atar M, Sancaktutar Aa, Penbegül N, Bozkurt Y, Onem K. Relationship between
penile size and somatometric parameters in 2276
healthy young men. Ént J Impot Res. 2012 MayJun;24(3):126-9.
34. Vardi Y, Gruenwald I. The status of penile
enhancement procedures. CurrOpinUrol 2009; 19:
601–605.
35. Murtagh J. The 'small' penis syndrome.
AustFamPhysician 1989; 18: 218, 220.
36. Li Cy, Kayes O, Kell Pd, Christopher N,
Minhas S, Ralph Dj. Penile suspensory ligament
division for penile augmentation: indications and
results. EurUrol 2006; 49: 729–733.
37. Burgu B, Aydogdu O, Tangal S, Soygur T.
Circumcision: Pros and cons. Indian J Urol 2010; 26:
12–15.
38. Smith Dp, Rickman C, Jerkins Gr. Ultrasound
evaluation of normal penile (corporeal) length in
children. J Urol 1995; 154(2 Part 2): 822–824.
31. Shah J, Christopher N. Can shoe size predict
penile length? BJU Int 2002; 90: 586–587.
32. Spyropoulos E, Borousas D, Mavri-kos S,
Dellis A, Bourounis M, Athanasiadis S. Size of external
genital organs and somatometric parameters among
physically normal men younger than 40 years old.
Urology 2002; 60: 485–489; discussion 490–481.
Hellenic
UROLOGY
21
REVIEW
Obstruction-induced pathological alterations within
the urinary bladder due to Benign Prostate Hyperplasia (BPH)
A review of the literature
1
2
Christos Komninos , Iraklis C. Mitsogiannis .
1
Department of Urology, Nikaia General Hospital, Athens, Greece
2
nd
2 Department of Urology, Sismanoglio Hospital, University of Athens
Medical School, Athens, Greece.
Corresponding Author:
Iraklis C. Mitsogiannis
2nd Department of Urology, University of Athens
Sismanoglio Hospital,
1 Sismanogliou str., 15126 Maroussi, Athens, Greece
Tel: +30 2132058253, Fax: +30 2108044703
email: [email protected]
Summary
Introduction
Benign prostatic hyperplasia (BPH) is a frequent
cause of Bladder Outlet Obstruction (BOO) and
Low Urinary Tract symptoms (LUTS). BPH process
induces functional, biochemical and morphological alterations, in order for the urinary bladder to
maintain a normal functionality. There is substantial
evidence that detrusor blood flow significantly
decreases in the presence of BOO. This review
addresses the bladder response to BOO and
focuses on the alterations and biochemical adaptability of the bladder wall in the presence of hypoxia.
Methods
A literature review of published articles has been
performed, including both in vivo and in vitro studies on human and animal tissue.
Results
In the presence of obstruction and hypoxia, muscle
enlargement and collagen deposition comes upon,
mitochondria sustain damage, mitochondrial DNA
deletions and decrease mitochondrial enzyme
activity occur leading to a decreased oxidative
metabolism and ATP synthesis. Anaerobic metabolism and probably glycogen deposit increase, in
order for the muscle cells to find alternative energy
supplies. As a result, lactic acid due to the anaerobic metabolism accumulates in the smooth
muscle causing contractile dysfunction. Furthermore, hypoxia induces bladder wall denervation
and reduces cholinergic nerve density.
22
Hellenic
UROLOGY
Conclusion
BOO is a key factor in the aetiology of LUTS/BPH.
Obstruction is associated with a variety of morphological, contractile and biochemical changes within
the bladder.
Key words
Benign prostatic hyperplasia; bladder outlet obstruction; urinary bladder; detrusor muscle.
Introduction
BPH affects 50% to 90% of men between 50 and 85
years of age1. It is a common disorder of the male
urogenital tract typically accompanied by LUTS
(hesitancy, straining, weak urine flow, frequency,
nocturia and urgency)2. BPH-related symptomatology is attributed to obstructed outflow (BOO),
which results from either prostate enlargement
(static component) and/or increased á-adrenergic
activity at the level of bladder neck and prostatic
urethra (dynamic component)3,4. BOO has been
shown to be associated with a variety of morphological, contractile and biochemical changes
within the bladder in both experimental and clinical
studies. In general, the bladder modifies its structure to compensate the increased resistance to
flow. Furthermore, it is known that in partial outlet
obstruction significant hypoxia ensues because of
the high resistance to flow and consequent high
intravesical pressure.
The present review addresses current data on the
response of the bladder to BOO particularly
Obstruction-induced pathological alterations within the urinary bladder
due to Benign Prostate Hyperplasia (BPH). A review of the literature
focusing on the bladder wall alterations and biochemical adaptability in the presence of hypoxia.
Methods
For this publication, both in vivo and in vitro studies
on human and animal tissue were used to estimate
the consequences of outlet obstruction on the
bladder wall. A search of the PubMed using the
terms “Benign Prostate Hyperplasia”, “Bladder
Outlet Obstruction”, “bladder hypoxia” and “detrusor ischemia” was conducted. The search was
limited to the period 1980-2013. Forty-six manuscripts were selected for their relevance to the subject of the review.
Results
Bladder response to outlet obstruction
The urinary bladder often responds to BOO with
hypertrophy, accompanied by an augmentation of
connective tissue components and replacement of
proteins of the contractile apparatus of the smooth
muscle cell, with their non-muscle (embryonic) isoforms, such as non-muscle myosin heavy chain, a5-8
isoform of tropomyosyn, calponin, â- and ã-actin .
High bladder pressure induces adaptive changes
in the bladder structure, which, in the long term, are
visible as muscle enlargement and collagen de9-11
position . The increase in connective tissue between muscle fibres and muscle bundles significantly decreases bladder elasticity and therefore
12
bladder compliance . Obstruction-induced
smooth muscle remodelling and hypertrophy are
compensatory responses aimed to produce the
increased force required to expel urine against the
obstruction. These compensatory changes are
associated with altered expression of contractile
proteins and various signalling and regulatory
proteins such as calmodulin, Rho-activated kinase
13-15
and caveolins . Rho-kinase constitutes a main
++
pathway, which regulates detrusor Ca
sensitisation, which is necessary for the detrusor
13
muscle to maintain contraction .
Bladder outlet obstruction and the ensuing muscle
hypertrophy and collagen deposition within the
bladder wall results in a significant decrease in
detrusor blood flow and hence impaired oxygen
16-23
diffusion to the tissues ; furthermore an increased expression of Hypoxia Inducible Factor-a
21
(HIF-a) is observed (Fig. A) . During obstruction,
the detrusor reduces its own oxygen supply by
producing pressures that compress the small
21-23
blood vessels . As a result to hypoxia, obstructed
bladders appear hypervascular and partially
denervated24 and exhibit alterations in the mito25
chondrial structure and function and the glycogen
26,27
content . Obstruction also induces protein oxidation in the detrusor smooth muscle28 and lactic
acid due to the anaerobic metabolism accumulates
29
causing contractile dysfunction . These findings
suggest that ischemia and hypoxia may be responsible for the development of bladder dysfunction in BOO17,18. It is not known whether this is
mediated directly through an effect on the detrusor
30
smooth muscle or as a result of neuronal loss and
31
subsequent smooth muscle changes .
Mitochondria-ATP-Glucose metabolism
Mitochondrial enzyme activity is crucial in the
energy production and contractility of detrusor
muscle32 and it has been shown to increase with the
severity of partial bladder outlet obstruction in the
male33. As the obstruction progresses, increased
oxidative stress in the detrusor muscle occurs,
leading to a significantly higher incidence and
34
proportion of mitochondrial DNA deletions .
Electron microscopy evaluation of the obstructed
rabbit bladder showed that mitochondria within
detrusor muscle cells become progressively more
swollen. Six weeks post-obstruction, similarly swollen mitochondria are also present in other cell types
within the bladder wall, such as fibroblasts,
Schwann cells, endothelium and perivascular smooth muscle. These findings of mitochondrial damage have been interpreted as evidence of ischemic
Hellenic
UROLOGY
23
Christos Komninos, Iraklis C. Mitsogiannis
damage of the bladder wall as a conse-quence of
35
outflow obstruction . Similar mitochondrial damage has been noted in human detrusor smooth
muscle cells in biopsy samples removed from
12
patients with bladder outflow obstruction .
Currently, many investigators consider mitochondrial alteration as a crucial factor in voiding dysfunction and hypothesise that severe and irreversible
mitochondrial damage, marked by disruption of
outer membrane, could explain the frequent persistence of symptoms after removal of bladder outlet
obstruction in men36.
Furthermore, during obstruction, mitochondrial
enzyme activity subsides thus leading to impaired
oxidative metabolism, as evidenced by specific
decreases in the activity of citrate synthase (CS),
37
malate dehydrogenase and cytochrome oxidase .
ATP provides most of the cellular energy required
38
for maintenance of cell function . Adequate cytosolic ATP concentration is maintained by anaerobic metabolism of glucose to pyruvate and subsequent oxidative metabolism of pyruvate to CO2
and H2O within the mitochondria through the
tricarboxylic acid (TCA) cycle and respiratory chain
pathway39. CS is the rate-limiting enzyme of the TCA
cycle, which provides substrates for the respiratory
chain. A reduction in respiratory chain substrates
would lead to decreased oxidative phosphorylation
(i.e., decreased ATP synthesis). Bladder biopsies
from men with significant obstructive symptoms,
secondary to BPH, have demonstrated a marked
decrease in CS activity compared to bladder samples isolated from unobstructed men of the same
age40.
There is also evidence of reduced aerobic and increased anaerobic metabolism in obstructed bladders. Partial bladder outlet obstruction of the rabbit
induces a shift from aerobic to anaerobic metabolism, as evidenced by the shift in glucose metabo41
lism from CO2 to lactic acid generation . Similarly,
there is a marked decrease in the metabolism of
24
Hellenic
UROLOGY
41
pyruvate to CO2.
Glycogen content
During obstruction, the bladder muscle reduces its
own oxygen supply by producing pressures that
22,23
compress the small blood vessels . This prompts
parts of the muscle to function anaerobically and
glycogen may be used as an alternative energy
supplier27. Upon chronic ischemic periods the bladder may adapt by increasing the amount of gly26
cogen stored in muscles cells . In an animal
model, Bas W.D. de Jong et al showed that glycogen deposition in the bladder wall is directly
26
related to bladder function during obstruction ; the
strongest glycogen deposition was found in bladders having experienced the highest pressures,
lowest compliance and highest contractility. At first,
little deposition occurred close to the serosal side
of the detrusor layer and later on, strongest accumulation appeared throughout the whole de-trusor
layer up to the urothelium. The authors concluded
that glycogen content is a clear marker of the severity of the functional changes that urinary bladder
has undergone during obstruction and claimed
that analysing glycogen deposits may give insight
in the severity of bladder damage and therefore
contribute in making an accurate prognosis of
bladder function26.
Maintenance of normal detrusor function relies on
sufficient oxygen and energy supplies and there is
probably a crucial level below which hypoxia - induced muscle dysfunction ensues. In the compensated bladder, relief of the ischemia should result in
an immediate restore of contractility. However, at
some stage, ischemia-induced changes might become less reversible and the potential of the blad42
der to regenerate its function might be reduced .
Denervation
Several human bladder studies showed that there
is a significant loss of innervation (denervation)
associated with obstructive dysfunction secondary
Obstruction-induced pathological alterations within the urinary bladder
due to Benign Prostate Hyperplasia (BPH). A review of the literature
to BPH24. Neurones are known to be very sensitive
to hypoxic damage, with grey matter more easily
43
damaged than white . Denervation may arise because of damage to postganglionic parasympathetic neurones within the bladder wall and this damage may be caused by the transient bladder
ischemia that occurs during obstructed micturi44
tion . Moreover, partial bladder denervation during BOO is more prominent on the cholinergic than
on the sympathetic side of the system, as the
45
former is dominant in the bladder . Cumming et al,
reported a 56% reduction in the number of acetylcholine-positive nerves in bladder biopsies obtained from obstructed compared to nonobstru46
cted men . Counts of nerve profiles confirmed reduced density of autonomic innervation and not
merely decreased concentration of AchE.
mage may become irreversible and this could
explain the persistence of symptoms after relief of
BOO in the male. Detrusor glycogen content could
be probably used as a marker of the severity of
alterations that have occurred within the bladder
wall during obstruction. However, more studies in
the human urinary bladder are required in order to
confirm that hypothesis.
Conclusion
Bladder dysfunction secondary to BPH is a major
affliction of aging men. Bladder modifies its structure in order to compensate the increased resistance to flow. As a result there is a significant decrease in detrusor blood flow, especially in the late
period of the obstruction.
During the obstruction and hypoxia period, six
major alterations of bladder wall morphology and
detrusor biochemistry may be recognised (Fig. B):
1) Muscle enlargement and collagen deposition, 2)
mitochondrial DNA deletions, mitochondrial damage and reduced mitochondrial substrate (e.g. glucose) utilisation, 3) decreased mitochondrial enzyme activity which leads to decreased oxidative metabolism and ATP synthesis, 4) reduced aerobic and
increased anaerobic metabolism which leads to
lactic acid accumulation, 5) glycogen deposition, as
an alternative energy supplier and 6) reduced cholinergic nerve density and denervation.
In the case of long-lasting BOO, mitochondrial da-
Fig. A,B. Pathophysiology of BPH and obstruction-induced alterations within the urinary bladder. BPH – benign
prostate hyperplasia; BOO – bladder outlet obstruction;
HIF-á – hypoxia induced factor á.
Hellenic
UROLOGY
25
Christos Komninos, Iraklis C. Mitsogiannis
Ðåñßëçøç
ÁðïôåëÝóìáôá: ÊáôÜ ôç äéÜñêåéá ôçò áðüöñáîçò êáé ôçò õðïîßáò åðÝñ÷åôáé ìõúêÞ õðåñ-
ÐáèïöõóéïëïãéêÝò ìåôáâïëÝò óôçí
ôñïößá, åíáðüèåóç êïëëáãüíïõ, âëÜâç óôá
ïõñïäü÷ï êýóôç áðü ôçí õðïêõóôéêÞ
ìéôï÷üíäñéá, äéáãñáöÝò ìéôï÷ïíäñéáêïý DNA êáé
áðüöñáîç ðïõ ðñïêáëåß ç ÊáëïÞèçò
ì å ß ù ó ç ô ç ò ì é ôï÷ï í ä ñ é á ê Þ ò å í æ õ ì é ê Þ ò
Õðåñðëáóßá ôïõ ÐñïóôÜôç (ÊÕÐ).
äñáóôçñéüôçôáò, ìå áðïôÝëåóìá ôïí ìåéùìÝíï
Áíáóêüðçóç ôçò âéâëéïãñáößáò
ïîåéäùôéêü ìåôáâïëéóìü êáé ôçí åëáôôùìÝíç
Êïìíçíüò ×.1, ÌçôóïãéÜííçò Çñ.2
óýíèåóç ATP. Åðßóçò, ðáñáôçñåßôáé óôñïöÞ
1
ÏõñïëïãéêÞ ÊëéíéêÞ, Ãåíéêü Íïóïêïìåßï Íéêáßáò «´Áãéïò
åíáðüèåóç ãëõêïãüíïõ, ðñïêåéìÝíïõ íá
ÐáíôåëåÞìùí», 2´ ÏõñïëïãéêÞ ÊëéíéêÞ Ðáíåðéóôçìßïõ
áíåõñåèïýí åíáëëáêôéêÝò ðçãÝò åíÝñãåéáò áðü ôá
Áèçíþí, Óéóìáíüãëåéï ÃÍÁ
ìõúêÜ êýôôáñá. ÁðïôÝëåóìá áõôþí ôùí
Õðåýèõíïò Åðéêïéíùíßáò: ÇñáêëÞò ×. ÌçôóïãéÜííçò
ïîÝïò óôéò ëåßåò ìõúêÝò ßíåò ëüãù ôïõ áíáåñüâéïõ
ðñïò ôïí áíáåñüâéï ìåôáâïëéóìü êáé ðéèáíüí
äéáäéêáóéþí åßíáé ç óõóóþñåõóç ãáëáêôéêïý
´ ÏõñïëïãéêÞ ÊëéíéêÞ Ðáíåðéóôçìßïõ Áèçíþí
ìåôáâïëéóìïý, ç ïðïßá ðñïêáëåß óõóôïëéêÞ
Óéóìáíüãëåéï ÃÍÁ
äõóëåéôïõñãßá ôïõ åîùóôÞñá. Åðéðñüóèåôá, ç
Óéóìáíïãëåßïõ 1, 15126 Ìáñïýóé, ÁèÞíá
ôçë. +30 2132058253, fax: +30 2108044703
email: [email protected]
õðïîßá ðñïÜãåé ôçí áðïíåýñùóç ôïõ ôïé÷þìáôïò
ôçò êýóôçò êáé ôç ìåßùóç ôçò ðõêíüôçôáò ôùí
÷ïëéíåñãéêþí íåõñþíùí.
Óêïðüò: Ç ÊáëïÞèçò Õðåñðëáóßá ôïõ Ðñï-
ÓõìðÝñáóìá: Ç õðïêõóôéêÞ áðüöñáîç ó÷å-
óôÜôç (ÊÕÐ) áðïôåëåß óõíÞèç áéôßá õðïêõóôéêÞò
ôßæåôáé ìå ðïéêßëåò ìïñöïëïãéêÝò êáé âéï÷ç-ìéêÝò
áðüöñáîçò êáé ðñüêëçóçò óõìðôùìÜôùí áðü
ìåôáâïëÝò óôï ôïß÷ùìá ôçò êýóôçò ðïõ
ôï êáôþôåñï ïõñïðïéçôéêü óýóôçìá (LUTS).Óôï
åðçñåÜæïõí ôç óõóôáëôéêüôçôÜ ôçò. Ç ìáêñï-
ôïß÷ùìá ôçò ïõñïäü÷ïõ êýóôçò óõìâáßíïõí
÷ñüíéá áðüöñáîç ìðïñåß íá ïäçãÞóåé óå ìç
óçìáíôéêÝò ëåéôïõñãéêÝò, âéï÷çìéêÝò êáé
áíáóôñÝøéìåò âëÜâåò óôïí åîùóôÞñá ìõ, ìå
ìïñöïëïãéêÝò ìåôáâïëÝò êáôÜ ôçí åîÝëéîç ôçò
ðáñáìïíÞ ôçò óõìðôùìáôïëïãßáò áêüìç êáé ìåôÜ
ÊÕÐ, þóôå íá äéáôçñçèåß ç öõóéïëïãéêÞ
ôçí Üñóç ôïõ êùëýìáôïò.
ëåéôïõñãéêüôçôÜ ôçò. ÌåëÝôåò Ý÷ïõí êáôáäåßîåé
ìåéùìÝíç áéìÜôùóç ôïõ åîùóôÞñá ìõüò üôáí
õðÜñ÷åé õðïêõóôéêÞ áðüöñáîç. Ç ðáñïýóá
óôÜôç, ÕðïêõóôéêÞ Áðüöñáîç, Éó÷áéìßá Åîù-
áíáóêüðçóç ðáñïõóéÜæåé ôçí áðÜíôçóç ôçò
óôÞñá, Óõìðôþìáôá Êáôþôåñïõ Ïõñïðïéçôéêïý.
ïõñïäü÷ïõ êýóôçò êáôÜ ôçí õðïêõóôéêÞ
áðüöñáîç êáé åóôéÜæåé óôéò ìåôáâïëÝò êáé
âéï÷çìéêÝò ðñïóáñìïãÝò ôïõ êõóôéêïý
ôïé÷þìáôïò ðáñïõóßá ôçò õðïîßáò.
ÌÝèïäïò: ÐñáãìáôïðïéÞèçêå áíáóêüðçóç ôçò
äçìïóéåõìÝíçò âéâëéïãñáößáò, ç ïðïßá
óõìðåñéÝëáâå in vivo êáé in vitro ìåëÝôåò óå
áíèñþðéíïõò êáé æùéêïýò éóôïýò.
26
ËÝîåéò ÊëåéäéÜ: ÊáëïÞèçò Õðåñðëáóßá Ðñï-
Hellenic
UROLOGY
Obstruction-induced pathological alterations within the urinary bladder
due to Benign Prostate Hyperplasia (BPH). A review of the literature
References
1. Berry, S. J., Coffey, D. S., Walsh, P. C. and
Ewing, L. L.: The development of human benign
prostatic hyperplasia with age. J Urol, 1984;132:
474.
2. Shapiro, E. and Lepor, H.: Pathophysiology
of clinical benign prostatic hyperplasia. Urol Clin
North Am,1995; 22: 285.
3. Andersson KE. Storage and voiding symptoms: pathophysiologic aspects. Urology
2003;62:3-10.
4. Lepor H. Nonoperative management of
benign prostatic hyperplasia. J Urol 1989;141:12839.
5. Madsen FA, Bruskewitz RC. Clinical manifestations of benign prostatic hyperplasia. Urol Clin
North Am 1995;22:291-8.
6. Lu SH, Chang LS, Yang AH, Lin AT, Chen KK,
Wei YH. Mitochondrial DNA deletion of the hu-man
detrusor after partial bladder outlet obstru-ctioncorrelation with urodynamic analysis. Uro-logy
2000;55:603-7.
7. Lu SH, Wei YH, Chang LS, Lin AT, Chen KK,
Yang AH. Morphological and morphometric analysis of human detrusor mitochondria with urodynamic correlation after partial bladder outlet obstruction. J Urol 2000;163:225-9.
8. Backhaus BO, Kaefer M, Haberstroh KM, et
al. Alterations in the molecular determinants of
bladder compliance at hydrostatic pressures less
than 40 cm. H2O. J Urol 2002; 168:2600-4.
9. Yamaguchi O. Response of bladder smooth
muscle cells to obstruction: signal transduction &
the role of mechanosensors. Urology 2004;63:11-6.
10. Araki I, Du S, Kamiyama M, et al. Overexpression of epithelial sodium channels in epithelium of human urinary bladder with outlet obstruction. Urology 2004; 64: 1255-60.
11. Burkhard FC, Lemack GE, Zimmen Pe,et al.
Contractile protein expression in bladder smo-oth
muscle is a marker of phenotypic modulation after
outlet obstruction in the rabbit model. J Urol 2001;
165:963-7.
12. Uvelius B, Arner A, Malmqvist U. Contractile
and cytoskeletal proteins in smooth muscle during
hypertrophy and its reversal.Am J Physiol 1991;
260:C1085-93.
13. Sjuve R, Haase H, Ekblad E, Malmqvist U,
Morano I, Arner A. Increased expression of nonmuscle myosin heavy chain-B in connective tissue
cells of hypertrophic rat urinary bladder. Cell Tissue
Res 2001; 304:271–8.
14. Mannikarottu AS, Disanto ME, Zderic SA,
Wein AJ, Chacko S. Altered expression of thin
filament-associated proteins in hypertrophied urinary bladder smooth muscle. Neurourol Urodyn
2006; 25:78–88.
15. Lee SD, Akbal C, Jung C. Intravesical pressure induces hyperplasia and hypertrophy of human
bladder smooth muscle cells mediated by
muscarinic receptors. J Pediatric Urol 2006; 2:271-6.
16. Deveaud CM, Macarak EJ, Kucich U, et al.
Molecular analysis of collagens in bladder fibrosis. J
Urol 1998; 160:1518-27.
17. Levin R.M, Wein A.J, Butyan R, et.al: update
on bladder smooth-muscle physiology. World
J.Urol. 1994 12:226-232.
18. Robert M. Levin, Niels Haugaard, Laura
O'Connor, Ralph Buttyan, Anurag Das, John S.
Dixon, John A. Gosling. Obstructive Response of
Human Bladder to BPH vs. Rabbit Bladder Response to Partial Outlet Obstruction: A Direct Comparison. Neurourology and Urodynamics
2000;19:609–629.
19. Bing W., Chang S., Hypolite J.A., DiSanto
M.E., Zderic S.A., Rolf L., Wein A.J., Chacko S.
Hellenic
UROLOGY
27
Christos Komninos, Iraklis C. Mitsogiannis
Obstruction-induced changes in urinary bladder
smooth muscle contractility: a role for Rho kinase.
Am J Physiol Renal Physiol. 2003;285:F990–F997.
20. Polyák E., Boopathi E., Mohanan S., Deng
M., Zderic S.A., Wein A.J., Chacko S. Alterations in
caveolin expression and ultrastructure after bladder
smooth muscle hypertrophy. J Urol.
2009;182:2497–2503.
21. Boopathi E. et al.Transcriptional Repression of Caveolin-1 (CAV1) Gene Expression by
GATA-6 in Bladder Smooth Muscle Hypertrophy in
Mice and Human Beings. Am J Pathol. 2011 May;
178(5): 2236–2251.
22. Greenland JE, Brading AF.The effect of
bladder out flow obstruction on detrusor blood flow
changes during the voiding cycle in conscious
pigs.J Urol 2001; 165:245-8.
23. Loran OB, Vishnevskii EL, Vishnevskii AE.
The role of detrusor hypoxia in the pathogenesis of
urination disorders in patients with benign prostatic
hyperplasia. Urol Nefrol Mosk 1996; 6: 33-7.
24. Elbadawi A, Meyer S, Regnier CH. Role of
ischaemia in structural changes in the rabbit
detrusor following partial bladder outlet obstruction:
a working hypothesis and a
biomechanical/structural model proposal.
Neurourol Urodyn 1989; 8: 151-62.
25. Macnab A., Stothers L.,Shadgan B.
Monitoring detrusor oxygenation and
hemodynamics noninvasively during dysfunctional
voiding. Advances in Urology 2012
doi:10.1155/2012/676303.
26. Rosen R, Altwein J, Boyle P, Kirby RS,
Lukacs B, Meuleman E,et al. Lower urinary tract
symptoms and male sexual dysfunction: the
multinational survey of the aging male (MSAM-7).
Eur Urol. 2003;44:637-649.
27. Rosen RC, Giuliano F, Carson CC. Sexual
dysfunction and lower urinary tract symptoms
(LUTS) associated with benign prostatic hyperplasia
(BPH). Eur Urol. 2005; 47: 824-837.
28
Hellenic
UROLOGY
28. Koritsiadis G, Stravodimos K, Koutalellis G,
Agrogiannis G, Koritsiadis S, Lazaris A,
Constantinides C. Immunohistochemical estimation
of hypoxia in human obstructed bladder and
correlation with clinical variables.BJU Int. 2008
;102(3):328-32.
29. Greenland JE, Hvistendahl JJ, Andersen H,
et al. The effect of bladder outlet obstruction on
tissue oxygen tension and blood flow in the pig
bladder. BJU Int 2000;85:1109-14.
30. Azadzoi KM, Pontari M, Vlachiotis J, et al.
Canine bladder blood flow and oxygenation:
Changes induced by filling, contraction and outlet
obstruction. J Urol 1996;155:1459-65.
31. Lin AT, Chen MT, Yang CH, et al. Blood flow
of the urinary bladder: Effects of outlet obstruction
and correlation with bioenergetic metabolism.
Neurourol Urodyn 1995;14:285-92.
32. Chapple, C. R., Milner, P., Moss, H. E., &
Burnstock, G. Loss of sensory neuropeptides in the
obstructed human bladder. Br J Urol 1992;70, 373381.
33. Damaser MS, Haugaard N, Uvelius B. Partial
obstruction of the rat urinary bladder: effects on
mitochondria and mitochondrial glucose
metabolism in detrusor smooth muscle cells.
Neurourol Urodyn. 1997; 16(6):601-7.
34. Bas W.D. de Jong, Katja P. Wolffenbuttel,
Jeroen R. Scheepe, Dirk J. Kok The detrusor
glycogen content of a de-obstructed bladder
reflects the functional history of that bladder during
PBOO. Neurourology and Urodynamics 2008; 27,
454-460.
35. Pessina F, Solito R, Maestrini D, et al. Effect
of anoxia-glucopenia and resuperfusion on intrinsic
nerves of mammalian detrusor smooth muscle:
Importance of glucose metabolism. Neurourol
Urodyn 2005;24:389-96.
36. Siflinger-Birnboim A, Levin RM, Hass
MA.Partial outlet obstruction of the rabbit urinary
Obstruction-induced pathological alterations within the urinary bladder
due to Benign Prostate Hyperplasia (BPH). A review of the literature
bladder induces selective protein oxidation.
Neurourol Urodyn.2008 ;27(6): 532-9.
cular smooth muscle: quantitation of Na-pump activity and aerobic glycolysis. FASEB J 1988; 2:A755.
37. Alex Tong-Long Lin, Ming-Shi Shiao, ChingJu Chen, Luke S et.al. Energetics of detrusor
contraction: Effects of outlet obstruction.
Neurourology and Urodynamics 1992; 11: 605-614.
46. Siegman MJ, Butler TM, Mooers SU, Davies
RE.Chemical energetics of force development, force
maintenance, and relaxation in mammalian smooth
muscle. J Gen Physiol 1980;76:609-29.
38. Zhao Y, Levin SS, Wein AJ, Levin RM.
Correlation of ischemia/reperfusion or partial outlet
obstruction-induced spectrin proteolysis by calpain
with contractile dysfunction in rabbit bladder.
Urology 1997; 49: 293-300.
47. Levin RM, Haugaard N, Mogavero L, Leggett
RE, Das AK. Biochemical evaluation of obstructive
bladder dysfunction in men secondary to BPH: a
preliminary report. Urology 1999;53: 446-50.
39. Yokoyama O, Kawaguchi K, Hisazumi H.
Denervation supersensitivity of the detrusor muscle
due to bladder overdistension, with special
reference to the relationship between
supersensitivity, and changes in the connective
tissue. Hinyokika Kiyo 1985; 31: 2127-34.
40. Lin AT, Chen KK, Yang CH, Chang LS.
Effects of outlet obstruction and its reversal on
mitochondrial enzyme activity in rabbit urinary
bladders. J Urol 1998;160: 2258-62.
41. Gosling JA, Kung LS, Dixon JS, Horan P,
Whitbeck C, Levin RM. 2000. Correlation between
the structure and function of the rabbit urinary
bladder following partial outlet obstruction. J Urol
163:1349-56.
42. Mirone V, Imbimbo C, Longo N, Fusco F.
The detrusor muscle: an innocent victim of bladder
outlet obstruction. Eur Urolog 2007;51:57-66.
43. Flameng W, Borgers M, Daenen W, Stalpaert G. Ultra-structural and cytochemical correlates of myocardial protection by cardiac hypothermia in man. J Thorac Cardiovasc Surg
1980;79:413-24.
48. Kato K, Lin AT-L, Wein AJ, Levin RM. Effect of
outlet obstruction on glucose metabolism of the
rabbit urinary bladder. J Urol 1990; 143:844-7.
49. De Jong BWD, Wolffenbuttel K., Arentshorst
ME, et al. Detrusor Glycogen reflects the functional
history of bladders with partial outlet obstruction .
BJU Int 2007; 100: 846-52.
50. Haddad GG, Jiang C. O2 deprivation in the
central nervous system: on mechanisms of neuronal
response, differential sensitivity and injury. Prog
Neurobiol 1993; 40: 277-318.
51. GelosoDA, Levin RM. Effect of partial outlet
obstruction on the myogenic response to field
stimulation. Gen Pharmacol 1998;31:291-5.
52. Martin C. Michel , Maurits M. Barendrecht.
Physiological and pathological regulation of the
autonomic control of urinary bladder contractility.
Pharmacology & Therapeutics 2008;117:297-312.
53. Cumming JA, Chisholm GD. Changes in
detrusor innervation with relief of outflow tract
obstruction. Br J Urol 1992;69:7-11.
44. Hsu TH-S, Levin RM, Wein AJ, Haugaard N.
Alterations of mitochondrial oxidative metabolism in
rabbit urinary bladder after partial outlet obstruction.
Mol Cell Biochem 1994;141:47-55.
45. Campbell JD, Agubosim S,Paul RJ. Compartmentation of metabolism and function in vas-
Hellenic
UROLOGY
29
ORIGINAL ARTICLE
Greek Version of the National Institutes
of Health Chronic Prostatitis Symptom Index (NIH-CPSI),
its linguistic adaptation and the pilot test of its validity (ÍÇÉ)
1
2
3
Charalambos Asvestis , Theodoros Varvadesis , Petros E. Maravelakis
1.Urologist-Andrologist.
2.Associate Professor, Department for Hygiene and Epidemiology,
Medical School of Aristotle University, Thessaloniki.
Corresponding Author:
Charalambos Asvestis
Tel: +30 2108948213
email: [email protected]
3.Lecturer, Department of Business Administration, University of Piraeus.
Summary
Introduction
To formulate the Greek version of the National
Institute of Health Chronic Prostatitis Symptom
Index (NIH-CPSI), its linguistic adaptation and the
pilot test of its validity.
Methods
The classical method of linguistic vali-dation was
adopted. Seven patients with chronic prostatitis
(CP) histologically confirmed parti-cipated in
cognitive debriefing. The sample of the pilot study
consisted of 45 CP patients based on clinical
diagnosis according to symptoms and 42 healthy
individuals aged 21 to 68 years old. In retest 22 of
the above CP patients were included. Statistical
analysis was carried out with the Statistical
Package PASW Statistics 18. The statistical
analysis was based on the chi-square, t and
ANOVA tests. Internal consistency was examined
by Cronbach's á and Pearson's r while for test-retest
reproducibility k statistic and Wilcoxon test were
used.
Results
Cultural adaptation was not required since the
sample consisted of Greek citizens with common
socio-religious characteristics. Cognitive
debriefing revealed that the Greek version of the
NIH-CPSI was easily understood and answered.
During the pilot validation it was assured that the
patients and healthy individuals were comparable
regarding age, education and marital status.
30
Hellenic
UROLOGY
Key Words
Greek Version of the National Insti-tutes of Health
Chronic Prostatitis Symptom Index (NIH-CPSI).
Introduction
The chronic prostatitis is the most frequent cause
for visiting a urologist for primary care2. Epidemiological data from other countries such as the
United States of America3, Italy4, Germany and
China5 have shown different rates of occurrence of
the disease in these different populations.
The questionnaires have been widely used, as
tools of epidemiological study, aids to diagnosis
and monitoring of the effectiveness of treatments
and instruments of evaluation of the quality of life
caused by various diseases as well. In urology, the
most widely used questionnaires are that of the
benign hyperplasia of the prostate (AUA-SI)6,
erectile dysfunction (IIEF) 7 and premature
ejaculation (IELTs) 8.
The use of such questionnaires, appropriately
translated into different languages, allows
comparative studies between different population
groups. The Diagnostic Questionnaire for Chronic
Prostatitis- Chronic Pelvic Pain of the American
National Health Institute has already been
translated into the Italian4, German9, Spanish10,
Japanese11, and French languages12 and studies
have been made in many countries as in
Australia13, Korea14, China15, Turkey16 and in all
those countries mentioned above.
Standardized methodology for cultural adjustment
Greek Version of the National Institutes of Health Chronic Prostatitis
Symptom Index (NIH-CPSI), its linguistic adaptation and the pilot test of its validity (ÍÇÉ)
and control of linguistic validity was used. The
original questionnaire in English language was
translated into the Greek language by two
professional translators with their native language
being Greek. The two translators worked
independently without any contact between them.
Then the scientific coordinator made the
comparison between the two translations. After the
required clarifications requested by the two
translators, the first draft Greek questionnaire was
completed. This questionnaire was then translated
into English by a professional translator with
English as a native language.
The reverse English translation has been checked
with the original English questionnaire in order to
confirm the conceptual match. After the
clarifications requested by the translator the
second draft Greek questionnaire was completed.
Then the text was corrected and edited to maintain
the same form as the English original.
The next step was that of the cognitive testing of the
chronic prostatitis/chronic pelvic pain questionnaire on seven patients who had undergone Multiple transrectal ultrasound guided biopsies of the
prostate gland due to high measure of the Prostatic-Specific Antigen (PSA) and in whom inflammatory infiltrate been found histologically, which
conforms to the histological diagnosis of prostatitis.
ction of the text. The next step was the pilot study
for the validity of the final questionnaire (Appendix
I). Patients were chosen from a private andrology
clinic who had been diagnosed with prostatitis, on
the basis of clinical symptomatology.
The ages of the patients ranged from 59 to 80 years.
The recruitment of participants was joined with a
detailed explanation of the objective of the
research, the assurance of anonymity and of
course oral consent was obtained. For each patient
selected for the pilot study the next patient that
came to the clinic with any diagnosis other than
prostatitis that belonged to the same age group
was added to the control group.
If someone chose not to take part, the next patient
was chosen. Every third participant from each
group (ill-healthy) responded to the questionnaire
at the next appointment which had been arranged
for about 10 days later. The collection of data
occurred during the period between October 2011
and February 2012. The process of approaching
patients for the test included detailed reference to
the purpose of the investigation, as well as absolute
assurances of anonymity17 with a view to obtaining
oral consent.
These patients were given the questionnaire with
written instructions and stated that it should be read
and that no consideration should be given to the
grade (after completing the questionnaire)
because the objective of our study at this stage is
the degree of understanding and not evaluation of
the medical condition.
In this group there were 45 patients (approaching
50-degree response 90 %) and the control group
were 42 patients (also approaching 50-degree
response 84 % ). Each participant answered the
questionnaire anonymously. The questionnaire
consisted of demographic questions and questions regarding pain, urination and quality of life.
Pain was assessed using the sum of questions 1a,
1b, 1c, 2a, 2b, 3 and 4. Urination symptomatology
was assessed using the sum of questions 5 and 6.
Effects on quality of life were assessed via the sum
of questions 7,8 and 9.
For each patient the completion time for the questionnaire was measured and then followed by
personal interview to investigate whether the patient understood the questionnaire (questions, instructions for its completion, response scales,
understanding concepts, level of difficulty).
After the completion of this stage there were further
amendments which led to the third draft of the
questionnaire. There was further detailed corre-
After completion the questionnaire was codified
and the data was entered on a computer. For the
statistical analysis the statistical package PASW
Statistics 18 was used. The statistical analysis used
the checks chi-squares, t and ANOVA. The Cronbach alpha coefficient was calculated for the
assessment of internal consistency.
The Pearson coefficient was calculated for which
the lowest acceptable value was set to 0.7 for the
Hellenic
UROLOGY
31
Charalambos Asvestis, Theodoros Varvadesis, Petros E. Maravelakis
reliability test, (test/retest reliability).
Results
The average age of the respondents in the group
who suffered from prostatitis was 68.2+/- 6.3 years
and the control group was 63.4+ /-8.3 years. The
observed statistical significance was p=0,109,
showing that there was no statistically significant
difference between the two groups.
The assessment of pain the average value of the
sum for the group of patients was 4.5+ /-0.9 and for
the control group was 0.8+ / -0.5.
The observed statistical significance was p=0,007
showing that there was a statistically significant
difference between the two groups. Regarding
urinary symptomatology it was found that the
average value of the sum for the group of patients
was 6.5+ /-1.2 and for the control group was 1.1+ /
-0.7. The observed statistical significance was
p=0,006 showing that there was a statistically
significant difference between the two groups.
For the impact on the quality of life it was found that
the average value of the sum for the group of
patients was 1.9+ /-0.6 and for the control group
was 0.5+ / -0.4. The observed statistical
significance was p=0,012 stating that there was a
statistically significant difference between the two
groups.
The scores for pain, urinary symptomatology and
the impact on the quality of life were not found to
have a statistically significant correlation with age,
marital status and education (all observed
significance levels is greater than 0.05).
Next the reliability of the questionnaire was
checked for internal consistency. Cronbach's
alpha was for the whole sample was 0.89. The value
for the group of patients was 0.71 and for the
control group was 0.77.
Discussion
From its first publication1 in 1999, the questionnaire for Chronic Prostatitis/ Chronic Pelvic Pain by
the National Institute of Health United has received
wide acceptance in many countries, and many
studies, in particular of an epidemiological nature,
have been based on its application.
It is important that two teams from the United
18,19
20
States
and Germany reevaluated its effectiveness as a tool for the diagnosis of Chronic Pro-
32
Hellenic
UROLOGY
statitis/ Chronic Pelvic Pain. With the translation of
the Greek text we hope it will offer to Greek urologists the possibility of conducting comparative
studies with other countries in order to better
understand the disease.
Ðåñßëçøç
ÌåôÜöñáóç óôçí ÅëëçíéêÞ Ãëþóóá êáé
ÐéëïôéêÞ ÌåëÝôç Åãêõñüôçôáò ôïõ
Äéáãíùóôéêïý Åñùôçìáôïëïãßïõ ×ñüíéáò
Ðñïóôáôßôéäïò-Óõíäñüìïõ ×ñüíéïõ Ðõåëéêïý
¢ëãïõò ôïõ ÁìåñéêÜíéêïõ Åèíéêïý
Éíóôéôïýôïõ Õãåßáò (ÍÇÉ)
×áñÜëáìðïò ÁóâÝóôçò1, Èåüäùñïò ÄáñäáâÝóçò2,
ÐÝôñïò Å. ÌáñáâåëÜêçò
3
1.
Ïõñïëüãïò-Áíäñïëüãïò
2.
ÁíáðëçñùôÞò ÊáèçãçôÞò, ÅñãáóôÞñéï ÕãéåéíÞò, ÉáôñéêÞ
Ó÷ïëÞ ÁñéóôïôÝëåéïõ Ðáíåðéóôçìßïõ Èåóóáëïíßêçò
3.
ËÝêôïñáò, ÔìÞìá ÏñãÜíùóçò êáé Äéïßêçóçò
Åðé÷åéñÞóåùí, ÐáíåðéóôÞìéï Ðåéñáéþò
Õðåýèõíïò åðéêïéíùíßáò: ×áñÜëáìðïò ÁóâÝóôçò
ôçë: +30 2108948213 - email: [email protected]
Óêïðüò: Ç äçìéïõñãßá ôïõ Åëëçíéêïý Äéáãíùóôéêïý Åñùôçìáôïëïãßïõ ×ñüíéáò Ðñïóôáôßôéäïò-×ñüíéïõ Ðõåëéêïý ¢ëãïõò (ÅÄÅ×ÐÁ), ç
ãëùóóéêÞ ðñïóáñìïãÞ ôïõ êáé ç ðéëïôéêÞ áîéïëüãçóç ôçò åãêõñüôçôáò ôïõ âáóéæüìåíïé óôï äéáãíùóôéêü Åñùôçìáôïëüãéï ×ñüíéáò Ðñïóôáôßôéäïò-×ñüíéïõ Ðõåëéêïý ¢ëãïõò ôïõ ÁìåñéêÜíéêïõ
1
Åèíéêïý Éíóôéôïýôïõ Õãåßáò (ÍÇÉ) .
ÌÝèïäïò: ×ñçóéìïðïéÞèçêå ç êëáóéêÞ ìåèïäïëïãßá ãëùóóéêÞò ðñïóáñìïãÞò óôçí ÅëëçíéêÞ
ãëþóóá. ÅðôÜ áóèåíåßò ìå ÷ñüíéá ðñïóôáôßôéäá
åðéâåâáéùìÝíç éóôïëïãéêÜ ðÞñáí ìÝñïò óôïí
ãíùóôéêü Ýëåã÷ï. Ôï äåßãìá ãéá ôçí ðéëïôéêÞ ìåëÝôç áðïôÝëåóáí 45 áóèåíåßò ìå ÷ñüíéá ðñïóôáôßôéäá ðïõ âÜóåé ôçò êëéíéêÞò äéÜãíùóçò
óôçñéæüìåíïé óôçí óõìðôùìáôïëïãßá êáé óáí
ïìÜäá åëÝã÷ïõ 42 õãéåßò Üíäñåò çëéêßáò áðü 21
Ýùò 68 åôþí. Óôïí åðáíÝëåã÷ï óõììåôåß÷áí 22
áðü ôïõò ðáñáðÜíù ðÜó÷ïíôåò óõììåôÝ÷ïíôåò.
Ç óôáôéóôéêÞ åðåîåñãáóßá Ýãéíå ìå ÷ñÞóç ôïõ
Greek Version of the National Institutes of Health Chronic Prostatitis
Symptom Index (NIH-CPSI), its linguistic adaptation and the pilot test of its validity (ÍÇÉ)
óôáôéóôéêïý ðáêÝôïõ PASW Statistics 18. Óôçí
óôáôéóôéêÞ áíÜëõóç ÷ñçóéìïðïéÞèçêáí ïé Ýëåã÷ïé
÷é-ôåôñÜãùíï, t êáé ANOVA. Ç áîéï-ðéóôßá
åëÝã÷èçêå ùò ðñïò ôçí åóùôåñéêÞ óõíÝðåéá ìå
ôïõò óõíôåëåóôÝò Cronbach's á êáé Pearson's r
åíþ ùò ðñïò ôçí áíáðáñáãùãéêü-ôçôá óôïí
åðáíÝëåã÷ï ìå ôï óôáôéóôéêü k êáé ôïí Ýëåã÷ï ôïõ
Wilcoxon.
ÁðïôåëÝóìáôá: ÐïëéôéóôéêÞ ðñïóáñìïãÞ ôïõ
åñùôçìáôïëïãßïõ äåí áðáéôÞèçêå åðåéäÞ ôï
äåßãìá Þôáí ¸ëëçíåò õðÞêïïé ìå êïéíÜ êïéíùíéêüèñçóêåõôéêÜ ÷áñáêôçñéóôéêÜ. Ï ãíùóôéêüò
Ýëåã÷ïò Ýäåéîå üôé ôï ÅÄÅ×ÐÁ Ýãéíå åýêïëá
êáôáíïçôü êáé ïé áðáíôÞóåéò Þôáí åýêïëï íá
äïèïýí. Óôçí ðéëïôéêÞ ìåëÝôç åãêõñüôçôáò
äéáóöáëßóôçêå üôé ïé áóèåíåßò êáé ïé õãéåßò Þôáí
óõãêñßóéìïé üóïí áöïñÜ ôçí çëéêßá, ôçí
åêðáßäåõóç êáé ôçí ïéêïãåíåéáêÞ êáôÜóôáóç.
ËÝîåéò Åõñåôçñéáóìïý: Åëëçíéêü Äéáãíù-óôéêü
Åñùôçìáôïëüãéï ×ñüíéáò Ðñïóôáôßôé-äïò×ñüíéïõ Ðõåëéêïý ¢ëãïõò (ÅÄÅ×ÐÁ).
References
4. Giubilei G. Mondaini N. Crisci A. Raugei A.
Lombardi G. Travaglini F. Del Popolo G. Bartoletti R.
The Italian Version of the National Institutes of Health
Chronic Prostatitis Symptom Index. European
Urology 47. 805-811. 2005.
5. Liang C.Z. Zhang X.J. Zong Y.H. Qiang H.
Wang K.X. Prevalence of sexual dysfunction in
Chinese men with chronic prostatitis. BJU
INTERNATIONAL 93.568-570. 2004.
6. Barry M.J. Fowler F. J. Jr. O'leary M. P.
Bruskewitz R.C. Logan H.H. Mebust K. W. Cockett A.
T. K. and the measurement comitte of the American
Urological Association. The American urological
association symptom index for benign prostatic
hyperplasia.The Journal of Urology Vol.148, 15491557. 1992.
7. Ê.Xáôæçìïõñáôßäçò, Æ.Ôóéìôóßïõ, Á.ÊáñáíôÜíá,
Ä.×áôæç÷ñÞóôïõ. ÐïëéôéóìéêÞ êáé ãëùóóïëïãéêÞ áîéïëüãçóç ôïõ ÄéåèíÞ Äåßêôç Ëåéôïõñãßáò (ÄÄÓË) óôçí
åëëçíéêÞ ãëþóóá. ÅëëçíéêÞ ÏõñïëïãéêÞ Åôáéñåßá.
13:313-321. 2001.
1. Litwinm.s. Mc Naughton-collins M. Fowler F.j.
Jr., Nickel C. J. Calhoun E.a. Pontari M.a. Richard B. A.
Farrar J.t. O'leary M.p. And The Chronic Prostatitis
Collaborative Research Network.
The national institutes of health chronic prostatitis
symptom index: development and validation of a new
outcome measure. The Journal of Urology. Vol. 162,
369-375. 1999
2. Collins Mc Naughton M. Stafford S.r.o'leary
P.m. Barry J.m. Distingishing chronic prostatitis and
benign prostatic yperplasia symptoms: results of a
national survey of physician visits. Adult Urology 53
(5). 1999.
3. Clemens Q.j. Meenan R.t. Maureen C. Rosetti
O.K. Gao S.Y. Brown S.O. Calhoun E.A. Prevalence of
prostatitis-Like Symptoms in a Managed Care Population. Volume 176, issue 2, pages 593-596. 2006.
8. Althofs. PHD. Rosen R. PHD. Symonds
T.PHD.Mundayat, R.Msc.May, K.PHD. Abraham L.
Msc. Development and Validation of a new
Questionnaire to Assess Sexual Satisfaction, Control,
and Distress Accosiated with Premature Ejaculation.
J. Sex Med; 3:465-475. 2006.
9. Hochreiter W. Ludwig M. Weidner W. et al.
National Institutes of Health (NIH) Chronic pro-statitis
Symptom Index. The German version (in German).
Urologe A 40:16-7. 2001.
10. Collins MM, O'leary MP, Calhoun EA, Pontari
MA, Adler A, Eremenco S, Chang Ch, Odom L, Litwin
MS. The Spanish National Institutes of Health-Chronic
Prostatitis Symptom Index: translation and linguistic
validation. J Urol. 2001 Nov;166(5):1800-3.
11. Koichi M. Masaya T. Yuko N. Eiichi A. Hiromi K.
Ajapanese. Version of the National Insti-tutes of
Health Chronic Prostatitis SymptomIndex (NIH-CPSI,
Okayama version) and the clinical eva-luation
Hellenic
UROLOGY
33
Charalambos Asvestis, Theodoros Varvadesis, Petros E. Maravelakis
ofcernitin pollen extract for chronic non-bacte-rial
prostatitis. Nihon HinyokikaGakkaiZasshi. 2002 May
;93 (4):539-47.
12. Karakiewicz PI, Perrotte P, Valiquette L,
Benard F, Mccormack M, Menard C, Mcnaughton
Collins M, Nickel JC. French-Canadian linguistic
validation of the NIH Chronic Prostatitis Symptom
Index.Can J Urol. 2005 Oct:12(5):2816-23.
13. Ferris Ja. Pitts Mk. Richters J. et al. National
prevalence of urogenital pain and prostatitis-like
symptoms in Australian men using the National
Institutes of Health Chronic Prostatitis Symptom
Index. BJU Int. 2009. 105:373-9.
14. Ahn Sg, Kim Sh, Chung Ki, Park Ks, Cho Sy,
Kim Hw. Depression, anxiety, stress perception, and
coping strategies in Korean military patients with
chronic prostatitis/chronic pelvic pain syndrome.
Korean J Urol. 2012 Sep: 53(9):643-8.
15. Liang Cz. Li Hj. Wang Zp.et al. The prevalence
of prostatitis-like symptoms in China.
J. Urol 2009. 182:558-63
34
Hellenic
UROLOGY
16. Yalcinkaya A. R. Gokce A. Davarci M. Guven E.
O. Inci M. Kartal S. B. Ayyildiz A. Balbay M. D.The
impact of NIH-IV prostatitis on early post-operative
outcomes of transurethral resection of the prostate in
patients with symptomatic benign prostate
hyperplasia. TurkJMedSci. 2011: 41 (3) 515-519.
17.http://www.ncbi.nlm.nih.gov/pubmed?term=Ch
ronic%20Prostatitis%20Collaborative%20Research%
20Network%5BCorporate%20Author%5D.ÄÁËËÁÂÏ
ÑÃÉÁÐ. Áðüññçôç êáé ÉáôñéêÞ ¸ñåõíá: ÍïìéêÜ êáé çèéêÜ
èÝìáôá êáôÜ ôç ÷ñÞóç éáôñéêþí óôïé÷åßùí óôçí
åðéäçìéïëïãéêÞ Ýñåõíá. ÄéáôñéâÞ åðß äéäáêôïñßáò:
ÐáíåðéóôÞìéï Áèçíþí. ÁèÞíá 1983: 45-75.
18. Litwinms. A review of the development and
validation of the National Institutes of Health Chronic
Prostatitis Symptom Index. Urology. 2002. 60:14-8.
19. Turner Ja, Ciol Ma, Von Korff M, Berger R.
Validity and responsiveness of the national institutes
of health chronic prostatitis symptom index. J Urol.
2003 Feb: 169(2):580-3.
20. Schneider H. Brahler E. Ludwig M. et al. Two
year experience with the German-translated version of
the NIH-CPSI in patients with CP/CPPS. Urology.
2004. 63:1027-30
Greek Version of the National Institutes of Health Chronic Prostatitis
Symptom Index (NIH-CPSI), its linguistic adaptation and the pilot test of its validity (ÍÇÉ)
PROSTATITIS SYMPTOMS QUESTIONNAIRE/ CHRONIC PELVIC PAIN SYNDROME.
1. In the last week, have you experienced any pain or
6. How often have you had a sensation of not emptying
discomfort in the following areas?
your bladder completely after youfinish urinating, over the
a) Area between rectum and testicles (perineum)
(crotch). YES
1
b) Testicles YES
NO
1
Less than 1 to 5 times
0
c) Tip of the penis (not related to urination).
YES
1
NO
1
NO
Less than half the time
About half the time
0
d) Below your waist, in your bladder or pubic area .
YES
0
Not at all
0
NO
last week?
2
3
More than half the time
4
5
Almost always
0
1
2. In the last week have you experienced:
a) Pain or burning during urination?
YES
1
NO
things you would usually do, overthe last week?
0
b) Pain or discomfort during or after ejaculation?
YES
1
NO
7. How much have your symptoms kept you from doing
0
None
1
Only a little
0
2
Some
3. How often have you had pain or discomfort in any of
A lot
3
these areas over the last week?
Never
0
Rarely
1
8. How much did you think about your symptoms, over the
last week?
Sometimes
Often
4
Always
5
A lot
days that you had it, over the last week?
1
2 3
4
2
Some
4.Which number describes your pain or discomfort on the
0
1
Only a little
3
Usually
0
None
2
5
6
7 8
9
10
No pain Excruciating pain.
3
9.If you were to spend the rest of your life with your
symptoms just the way they have beenduring the last week,
how would you feel about that?
0
Delighted
Pleased
1
Mostly satisfied
2
Mixed (about equally satisfied and unsatisfied)
5. How often have you had the sensation of not emptying
your bladder completely after you finish urinating, over the
last week?
Never
Disappointed
Unhappy
Miserable
3
4
5
6
0
Less than 1 to 5 times
Less than half the time
About half the time
5
Pain: Total of questions 1a, 1b, 1c, 2a, 2b, 3 êáé 4 =
2
3
More than half the time
Almost always
1
Urinary symptoms:total of questions 5 êáé 6=
4
Evaluation of life quality: total of questions 7, 8 êáé 9=
Hellenic
UROLOGY
35
ORIGINAL ARTICLE
Functional and ongological results of radical perineal
prostatectomy for the management of clinically locally
advanced prostate cancer. Single centre experience
Athanasios I. Archodakis, Stefanos Bolometes
Department of Urology, 401 Genaral Military Hospital of Athens
Corresponding Author:
Athanasios I. Archodakis
Department of Urology, 401
General Military Hospital of Athens
Tel: +30 2107494179
email: [email protected]
Summary
Introduction
Radical prostatectomy is considered to be the best
choice for managing localized prostate cancer.
There is increased evidence that a surgical
approach has an important role to play as a method
of treatment for locally advanced prostate cancer.
According to the European Association of Urology
(EAU), radical prostatectomy is an option for
properly chosen patients with locally advanced
prostate cancer.
The aim of our study is to evaluate the oncological
and functional results of radical perineal
prostatectomy for the management of patients with
clinically locally advanced prostate cancer.
Methods
Between 1993 and 2012, 627 patients underwent
radical perineal prostatectomy for histologically
confirmed prostate cancer. Eighty three out of 627
patients had clinically advanced disease.
Perioperative morbidity, functional results and
early oncological outcomes were examined and
compared between the two groups.
Results
There was no statistically significant difference
between the two groups regarding operation time,
intraoperative blood loss, length of hospital stay
and duration of catheterization. The rate of
complications was also similar, with the exception
of two rectal injuries in the locally advanced group,
36
Hellenic
UROLOGY
though these were successfully repaired at the
same time. In the locally advanced group, 17.3% of
the clinically advanced patients had pathologically
confined disease. Out of the patients 99.8%
remained continent and 36.1% remained potent in
the locally advanced group. In the organ confined
group the rates were 100% and 62.5%,
respectively. Between the two groups there was no
significant difference regarding the cancer-specific
survival rate.
Conclusion
Radical perineal prostatectomy is considered to be
the best choice for treating locally advanced
disease, provided patients are fully informed and
that they consent to undergo this treatment.
Key Words
Radical perineal prostatectomy, locally advanced
prostate cancer.
Introduction
Treatment of clinically locally advanced prostate
cancer is considered to be a medical challenge for
a urologist. Even today, selecting an appropriate
treatment is a subject of research. Surveys show
that a greater overall benefit results from combined
treatment (radiotherapy together with hormone therapy) instead of monotherapy (using only radiotherapy). However, no study has ever proved that
combined treatment is a better choice than radical
prostatectomy1.
Functional and ongological results of radical perineal prostatectomy
for the management of clinically locally advanced prostate cancer. Single centre experience
In the past, surgical treatment of locally advanced
2
prostate cancer was not often resorted to due to an
increased risk of positive surgical margins, and
3,4
also due to existence of lymph node metastases .
Nowadays there is an increasing number of reports
in the literature that support radical prostatectomy
as a legitimate solution to manage locally adva5-10
nced disease . This has led the European
Association of Urology (EAU) to consider radical
prostatectomy as a potential option to a selective
range of patients with locally advanced disease.
11
(cT3) .
The literature refers to retropubic radical prostatectomy and perhaps for the first time in this study
we attempt to promote the significant role of
perineal access to deal with pre-operatively diagnosed, locally advanced prostate cancer. In our
clinic (Department of Urology 401 G.M.H.A) since
1993, radical perineal prostatectomy has been not
only the method of choice, but the only surgical
method of access to prostate cancer. In our given
material we do not have any other method, and for
that reason in this study we attempt to compare our
results to other authors, as these are found in the
international literature.
Material and methods
This study refers to 627 radical perineal
prostatectomies that were conducted in the
Department of Urology in the 401 Military Hospital
of Athens, between 1993 and 2012. Diagnosis of
this disease was conducted with a transrectal ultrasonographically guided prostate biopsy. Typically,
5 or 6 tissue blocks were extracted from each lobe
and also from suspicious areas detected in a digital
examination or in the transrectal ultrasound,
regarding either intraprostatic fat, or the seminal
vesicles. Clinical staging was accomplished
through digital examination, transrectal ultrasound
and CT scan, and showed 83 patients with locally
advanced disease. There was no patient selection
in reference to prostate size or somatometric
measurements, while 35 of the patients had already
been submitted to pre-operative hormonal manipulation to achieve shrinking of the tumor.
Properties of each group are shown in Table 1.
Table1 Characteristics of the patients treated with radical
perineal prostatectomy
Average age (years)
62,7 (51-73)
Gleason score biopsy
7 (4-9)
PSA
13,38 (3,5-42)
Laparoscopic Lymphadenectomy
77,1%
Unilateral preservation of
Neurovascular bundle (NVB)
43,3%
Follow up (months)
37 (8-62)
Evaluation of lymph node metastasis was achieved
through CT scans, and bone metastasis was
evaluated using bone scintigraphy. The first
postoperative measurement of PSA occurred after
six weeks. During the first year follow up
examination took place every three months, during
the second and third year, every fourth-month, and
later every six months. Patients with positive
surgical margins were submitted to adjuvant
radiotherapy, while those with lymph node
metastases were submitted to hormonal
12
manipulation . As for biochemical relapse, the EAU
guidelines were followed, based on whether PSA
doubling time (PSADT) showed local relapse or
distant metastasis. To be more specific, if an
increase of PSA was noted after the third
postoperative year, PSA DT was >11months, and
the specimen Gleason score was <6, then it would
be considered as a local relapse and automatically
followed by radiotherapy. On the other hand, if an
increase of PSA was noted within the first
postoperative year PSA DT was <6 months and the
specimen Gleason score was 8-10, then it would be
considered as a systematic relapse and the patient
would undergo hormonal therapy. In the case of
preservation of neurovascular bundles, patients
received post-operative phosphodiesterase
inhibitors. Selection of patients who underwent
Hellenic
UROLOGY
37
Athanasios I. Archodakis, Stefanos Bolometes
laparoscopic lymphadenectomy, which has been
practiced since 1994, was based on the preoperative PSA value and the biopsy Gleason score.
Patients with PSA lower than 10 and a Gleason
13
score <7 (19 patients) were excluded.
For the statistical analysis, we used Pearson chisquared test for independence. Due to the zerofrequency of some parameters (no appearance),
the calculation of p-value (observed statistic level of
importance) for this test was not asymptotic (that is,
with the use of the chi-squared distribution), but
was calculated with the use of a Monte-Carlo
simulator. The result was considered to be
statistically significant when p-value was less than
0,05(the level of statistical significance).
Results
Average duration of the operation was 175min,
including the average 60min duration time of laparoscopic lymphadenectomy for the locally advanced group. Average blood loss was 280ml. In comparison to the 544 patients with localized disease,
the difference was statistically insignificant (pvalue=0.150)(168min and 250ml. respectively).
There was also an insignificant difference in postoperative complications as well, with the exception
of two intraoperative rectal injuries in the group of
locally advanced disease, which were successfully
repaired. Also in one patient from the locally
advanced group, the formation of a urinary fistula
was observed. The removal of the penrose drain
was difficult, possibly being caught on the stitches
of the pelvic musculature.
st
After penrose drain removal, on the 1 post-operative day, an outflow of urine was observed through
the wound that continued for 2 weeks, when a small
penrose drain remnant was spontaneously rejected. The urinary incontinence was successfully
resolved via additional catheterization for the following 2 weeks, without any further intervention (table 2).
38
Hellenic
UROLOGY
Erectile Function was tested 12 months postoperatively. 36.1% of the patients reported erection
capable of vaginal penetration in the group of locally advanced disease (30 patients), significantly
lower than the respective rate of localized disease
Table 2 Complications after radical perineal prostatectomy
LOCAL DISEASE
LOCALLY
disease
Death rate
0
0
Bowel injury
0
2 (2,4%)
Pulmonary Embolism
0
0
Lymphocele
0
0
Anastomotic stricture
11 (2%)
2 (2,4%)
Compartment Syndrome
1 (0,18%)
0
Urinary Fistula
0
1 (1,2%)
ADVANCED
(62.5%) (P-value<0, 05). This is due to the unilateral preservation of neurovascular bundle only in
43.3% of the patients with clinically locally advanced disease, due to local extention of the disease.
In a single patient with invasion of the prostate
apex, incontinence persisted 12 months postoperatively which was resolved with implantation of an
artificial urinary sphincter. As for the oncological
results, pathologic down staging was observed in
16.8% of the patients with clinically diagnosed,
locally advanced disease (p-value<0, 05)(Table 3).
Table 3: Pathological stage distribution after radical perineal prostatectomy
pT2
16,8%
pT3a
48,2%
pT3b
31,4%
pT4
3,6%
Positive surgical margins were found in 14.4% of
the group with clinically advanced disease in
comparison to 12.5% of the group with the localized disease. Positive lymph nodes were detected
in 10 out of 83 patients with clinically locally advanced disease (12%). The preoperative CT scan
evaluation showed no sign of lymphnode metastasis. In the first case patients underwent adjuvant
Functional and ongological results of radical perineal prostatectomy
for the management of clinically locally advanced prostate cancer. Single centre experience
radiotherapy while in the second case they underwent hormonal deprivation. During the follow-up
period, 28.1% of the patients received adjuvant or
salvage radiotherapy due to positive surgical
margins or biochemical relapse, indicative of local
relapse, and 33.7% received hormonal therapy due
to lymphatic metastasis or biochemical relapse indicative of systemic disease. The disease specific
survival in the first three years was 93.9% in the
group of clinically locally advanced disease and
96% in the group of localized disease.
Discussion
Selection of the therapeutic treatment of clinically
advanced cancer is a challenge for the urologist14.The goals of treatment should include:
healing; extension of life, although this should be
achieved without any metastasis; localized control
of the tumor; and improvement of quality of life. The
therapeutic choices for the achievement of the
above are various. Prognosis varies widely, and the
choice of treatment depends on predictive factors
such as PSA value, Gleason score and tumor size.
According to the EAU guidelines, watchful waiting
may be conducted even inpatients without
symptoms, with well-or moderately-differentiated
T3 disease, and life expectancy of less than
10years, who are not able to undergo surgery or
radiation treatment. Radical prostatectomy is
considered an option in a selective range of
patients with T3a, PSA<20ng/ml, biopsy Gleason
score <8 and life expectancy lower than 10 years.
According to the EAU, those patients should be
aware that radical prostatectomy is related to
increased risk of positive surgical margins and
lymph-node metastasis, which need adjuvant
radiotherapy or hormonal therapy, respectively.
Amongst the patients with clinically diagnosed,
locally advanced disease in the study, 16.8% were
eventually diagnosed with pT2 disease and as a
result it was not necessary to follow adjuvant
treatment. If we take into consideration the low rate
of intraoperative complications and the satisfactory
functional results, these patients benefited from
undergoing an operation of lower severity such as
perineal prostatectomy, which in our experience
allows for the preservation of critical structures, just
as much in the case of locally advanced disease, as
in that of localized. During the follow-up the percentage of patients who received treatment was 28.1%
and 33.7% for local radiotherapy and hormonal
therapy respectively.
In the literature there are not series of patients with
clinical locally, advanced cases of the disease who
underwent radical perineal prostatectomy, and
therefore comparisons can be made only with series which have undergone retropubic prostatectomy. The reported results in those cases arise
from strictly selected cases; such selection did not
occur in our study for the reasons explained above.
Downstaging in clinical locally advanced disease in
15-19
pT2, ranges in the literature from 13-27% . Those
patients have an increased chance of a cure by
means of radical prostatectomy only. Also, the 5year disease specific survival rate varies from 85100%19-22.
An additional benefit of surgical treatment is the
prevention of local complications that relate to the
tumor but also to the fact that it is easier to follow up
and diagnose relapse in comparison to radiotherapy.
Pre-operative hormonal therapy, despite the fact
that it improves pathological - anatomical parameters, such as positive surgical margins, does not
affect biochemical or clinical progress of the
24
disease and does not improve survival rates .
The EORTC 22911 survey presented a distinct
survival benefit without disease progress and with
improved local control of the disease in patients
with positive surgical margins or PT3 disease,
Hellenic
UROLOGY
39
Athanasios I. Archodakis, Stefanos Bolometes
when radical prostatectomy was combined
postoperatively with radiotherapy23. In a recent
17
study , the 5-year, 10-year and 15-year diseasefree survival and disease specific survival incT3
disease in patients who had undergone radical
prostatectomy, where the majority received adjuvant radio -or hormone- treatment, were 85%, 73%
and 67%, and 95%,90% and 79%, respectively.
Radical prostatectomy is an option even to high risk
patients with locally advanced disease, without
increasing morbidity11. A recent study from the USA
showed that patients submitted to radical
prostatectomy for cT4 disease, had an improved
survival rate in comparison to those who received
radiotherapy or hormonal therapy as monotherapy,
and similar survival rates to those who received
24
combined therapy (RT and HT) .
Despite many reports in the literature, where
survival rates of radical prostatectomy with or
without additional treatment, are comparable to
those of combined therapy, more randomized
prospective studies are required to compare
surgical treatment to the combination of radio- and
hormonal therapy. The latter is considered by many
as the treatment of choice to manage locally
advanced prostate cancer. This was reinforced by
the EORTC 22863 survey, showing that 5-year
disease free survival improved from 79% to 94%
and overall survival improved from 62% to 78%
23
when combined treatment was utilized .
Hormonal therapy contributes to improved results
of radiotherapy by suppressing or probably
eliminating the latent systematic disease.
Moreover, the above combination seems to have
additional effects on local control with the
promotion of apoptosis invarious clone cancer
cells24, 25. In our opinion this provides another
advantage of surgical removal of the affected organ
in cases of locally advanced prostate cancer.
Removal of these different cancer cell clones
40
Hellenic
UROLOGY
possibly changes the natural progress of the
disease, combined when necessary with adjuvant
radio- or even hormonal- therapy. This should
constitute a subject of study in further research,
which will compare radical prostatectomy,
supplemented when necessary with radio- or
hormonal- therapy, with the combined treatment
for the management of clinically locally advanced
prostate cancer.
In the present study, all the prostate cancer cases
underwent perineal prostatectomy, and as a result
the comparison between perineal prostatectomy
results and retropubic prostatectomy was not
possible in patients within a single centre.
However, comparison with published results from
centers experienced in retropubic prostatectomy
may lead to safer conclusions regarding the
effectiveness of the two treatment approaches.
Also, despite the fact that pre-surgical selection of
patients participating in similar clinical surveys is
appropriate, long-term experience in the particular
technique and the volume of patients that
underwent surgery have led us to the conclusion
that preoperative selection is not mandatory when
perineal prostatectomy is applied, and actually the
non-necessity of the preoperative selection should
be considered as an important advantage of
perineal prostatectomy in comparison to
retropubic prostatectomy.
Until the publication of results from further studies,
modern data, from both the literature and also from
our study show that radical prostatectomy,
combined when necessary with radiotherapy or
hormonal therapy, has results comparable to those
of combined therapy whilst avoiding localized
complications related to the tumour.
Improvement of quality of life is the result. The
avoidance of morbidity related to the surgical
procedure is also of great importance, something
Functional and ongological results of radical perineal prostatectomy
for the management of clinically locally advanced prostate cancer. Single centre experience
which is also shown by our results with perineal
access, as also occurs in localized disease. The
low rate of positive surgical margins in our study,
28-32
relative to that of the international literature , is
attributable to the fact that perineal access allows
the affected organ and the extent of neoplasms to
be removed in total without dissection of the
prostate.
remains a relevant choice in the face of new
challenges in modern oncological surgery. This is
verified by the low rates of positive surgical margins
and complications, and also by the satisfactory
functional results relative to those of other surgical
approaches in the existing literature.
Conclusion
Radical perineal prostatectomy is a safe option for
well-informed patients with clinically diagnosed,
locally advanced prostate cancer. The combination
of the technique, when necessary, with adjuvant
radiotherapy and hormonal therapy contributes to
better control of the disease with lower morbidity
and maintenance of good quality of life.
Ðåñßëçøç
Despite the fact that there was no strict preoperative patient selection there were comparable
results to those in patients with clinically localized
disease that underwent similar surgery, not only
relating to postoperative complications but also to
positive surgical margins and urinary incontinence.
The markedly low rates of preservation of erectile
function are a result of local tumor extension to
neurovascular tissue blocks unilaterally or
bilaterally. The latest imaging methods of detailed
representation of localized tumor extension may
also further increase chances of preservation of
neurovascular bundles and increase as a result the
rates of erectile function maintenance.
ÏõñïëïãéêÞ ÊëéíéêÞ, 401 ÃÓÍÁ
More prospective, randomized studies are required
to compare surgery with other methods of treatment, but also to compare various different surgical
techniques between themselves, in relation to
oncological outcomes and complications, and
patient quality of life for those patients with clinical
locally advanced prostate cancer. It appears that
radical perineal prostatectomy, although it remains
the oldest form of surgical access to the prostate,
ËåéôïõñãéêÜ êáé ïãêïëïãéêÜ áðïôåëÝóìáôá
ôçò ñéæéêÞò ðåñéíåúêÞò ðñïóôáôåêôïìÞò óôçí
áíôéìåôþðéóç ôïõ êëéíéêÜ ðñï÷ùñçìÝíïõ
ôïðéêÜ êáñêßíïõ ðñïóôÜôç. Ç Åìðåéñßá ôçò
ïõñïëïãéêÞò êëéíéêÞò ôïõ 401 ÃÓÍÁ
Á.É. Áñ÷ïíôÜêçò, Ó. Ìðïëïìýôçò
Õðåýèõíïò åðéêïéíùíßáò: Á.É. Áñ÷ïíôÜêçò
Tçë: +30 2107494179
email:[email protected]
ÅéóáãùãÞ. Ç ñéæéêÞ ðñïóôáôåêôïìÞ èåùñåßôáé ùò ç èåñáðåßá åêëïãÞò óôïí åíôïðéóìÝíï êáñêßíï ôïõ ðñïóôÜôç. Ôá ôåëåõôáßá
÷ñüíéá ðëçèáßíïõí ïé âéâëéïãñáöéêÝò áíáöïñÝò ðïõ õðïóôçñßæïõí ðùò ç ÷åéñïõñãéêÞ
áíôéìåôþðéóç Ý÷åé èÝóç óôçí áíôéìåôþðéóç
ôçò, ôïðéêÜ, ðñï÷ùñçìÝíçò íüóïõ. Óýìöùíá ìå ôéò ïäçãßåò ôçò ÅõñùðáúêÞò ÏõñïëïãéêÞò Åôáéñåßáò, ç ñéæéêÞ ðñïóôáôåêôïìÞ èåùñåßôáé ðñïáéñåôéêÞ (optional) åðéëïãÞ óå êáëÜ
åðéëåãìÝíïõò áóèåíåßò ìå, ôïðéêÜ, ðñï÷ùñçìÝíç íüóï. Óêïðüò ôçò ðáñïýóáò åñãáóßáò
åßíáé íá áíáäåßîåé ôïí ñüëï ôçò ðåñéíåúêÞò
ðñïóðÝëáóçò óå áóèåíåßò ìå, ôïðéêÜ, ðñï÷ùñçìÝíï êáñêßíï ðñïóôÜôç.
Õëéêü êáé ìÝèïäïò. Ìåôáîý 1993 êáé 2012,
627 áóèåíåßò ìå êáñêßíï ðñïóôÜôç õðïâëÞèçêáí óå ñéæéêÞ ðåñéíåúêÞ ðñïóôáôåêôïìÞ.
Áðï ôïõò áóèåíåßò áõôüõò 83 åß÷áí êëéíéêÜ,
Hellenic
UROLOGY
41
Athanasios I. Archodakis, Stefanos Bolometes
ôïðéêÜ, ðñï÷ùñçìÝíç íüóï. Óõãêñßíáìå ôç
ìåôåã÷åéñçôéêÞ ðïñåßá êáé ôá ðñþéìá ïãêïëïãéêÜ áðïôåëÝóìáôá ìåôáîý ôùí äýï ïìÜäùí.
4. Boccon-Gibod L, Bertaccini A, Bono AV, et al.
Management of locally advanced prostate cancer: a
European Consensus. Int J ClinPract 2003
Apr;57(3):187-94.
ÁðïôåëÝóìáôá. Äåí ðáñáôçñÞèçêå äéáöïñÜ
üóïí áöïñÜ óôï ìÝóï ÷åéñïõñãéêü ÷ñüíï, ôçí
áðþëåéá áßìáôïò , ôçí ðáñáìïíÞ óôï íïóïêïìåßï êáé ôç äéÜñêåéá êáèåôçñéáóìïý ìåôáîý
ôùí äýï ïìÜäùí. Äåí õðÞñ÷å óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôéò ìåôåã÷åéñçôéêÝò åðéðëïêÝò êáé 2 äéåã÷åéñçôéêÝò ôñþóåéò ïñèïý
óôçí ïìÜäá ôçò ôïðéêÜ ðñï÷ùñçìÝíçò íüóïõ
áðïêáôáóôÜèçêáí óå ðñþôï ÷ñüíï, åðéôõ÷þò. Óôçí ïìÜäá ôçò ôïðéêÜ ðñï÷ùñçìÝíçò
íüóïõ õðÞñîå ðáèïëïãïáíáôïìéêÞ õðïóôáäéïðïßçóç óôï 17,3% ôùí ðåñéðôþóåùí. Ôï
99,8% äéáôÞñçóáí ôçí åãêñÜôåéá ôïõò êáé ôï
36,1 % ôçí óôõôéêÞ ôïõò ëåéôïõñãßá Ýíáíôé 100
êáé 62,5% óôçí ïìÜäá ôçò åíôïðéóìÝíçò
íüóïõ. Äåí õðÞñîå óôáôéóôéêÜ óçìáíôéêÞ
äéáöïñÜ óôçí åéäéêÞ ôçò íüóïõ åðéâßùóç
ìåôáîý ôùí äýï ïìÜäùí.
5. Yamada AH, Lieskovsky G, Petrovich Z, et al.
Results of radical prostatectomy and adjuvant therapy
in the management of locally advanced, clinical stage
TC, prostate cancer. Am J ClinOncol 1994
Aug;17(4):277-85.
6. Hsu CY, Joniau S, Oyen R, et al. Outcome of
surgery for clinical unilateral T3a prostate cancer: a
single-institution experience. EurUrol 2007
Jan;51(1):121-8; discussion 128-9.
7. Gerber GS, Thisted RA, Chodak GW, et al.
Results of radical prostatectomy in men with locally
advanced prostate cancer: multi-institutional pooled
analysis. EurUrol 1997;32(4):385-90.
8. Ward JF, Slezak JM, Blute ML, et al. Radical
prostatectomy for clinically advanced (cT3) prostate
cancer since the advent of prostate-specific antigen
testing: 15-year outcome. BJU Int 2005 Apr;95(6):
751-6.
References
1. Bolla M, Collette L, Blank L, et al. Long-term
results with immediate androgen suppression and
external irradiation in patients with locally advanced
prostate cancer (an EORTC study): a phase III
randomised trial. Lancet 2002 Jul;360(9327):103-6.
2. Hodgson D, Warde P, Gospodarowicz M. The
management of locally advanced prostate cancer.
UrolOncol 1998;(4):3-12.
3. Fallon B, Williams RD. Current options in the
management of clinical stage C prostatic carci-noma.
UrolClinNorthAm 1990 Nov;17(4):853-66.
42
Hellenic
UROLOGY
9. Isorna Martinez de la Riva S, BelónLópezTomasety J, Marrero Dominguez R, et al. [Radical
prostatectomy as monotherapy for locally advanced
prostate cancer (T3a): 12 years follow-up]. ArchEspUrol 2004 Sep;57(7):679-92. [ArticleinSpanish]
10. Van den Ouden D, Hop WC, Schröder FH.
Progression in and survival of patients with locally
advanced prostate cancer (T3) treated with radical
prostatectomy as monotherapy. J Urol 1998 Oct;
160(4):1392-7.
11. A. Heidenreich (chairman), P.J. Bastian, J.
Bellmunt, M. Bolla, S. Joniau, M.D. Mason, V.
Functional and ongological results of radical perineal prostatectomy
for the management of clinically locally advanced prostate cancer. Single centre experience
Matveev, N. Mottet, T.H. van der Kwast, T. Wiegel, F.
Zattoni. EAU GuidelinesonProstateCancer 2012.
12. Koutsilieris M, et al. Combination of
somatostatin analogues and dexamethasone (antisurvival-factor concept) with luteinizing hormonereleasing hormone in androgen ablation-refractory
prostate cancer with bone metastasis. BJU Int. 2007
Jul;100 Suppl 2:60-2.
13. S. Joniau, C. Y. Hsu, E. Lerut et al., “A pretreatment table for the prediction of final histopathology after radical prostatectomy in clinical unilateral
T3a prostate cancer,” European Urology, vol. 51, no.
2, pp. 388–394, 2007.
14. S.G.Fletcher and D. Theodorescu, “Surgery or
radiation:what is the optimal management for locally
advanced prostate cancer?” The Cana-dianjournalofurology, vol. 12, no. 1, supplement 1, pp. 58–61,
2005.
15. S. E. Lerner,M. L. Blute, and H. Zincke, “Extended experience with radical prostatectomy for clinical stage T3 prostate cancer: outcome and contemporary morbidity,” Journal of Urology, vol. 154, no.
4, pp. 1447–1452, 1995.
16. W. R. Morgan, E. J. Bergstralh, and H. Zincke,
“Long-term evaluation of radical prosta-tectomy as
treatment for clinical stage C (T3) prostate cancer,”
Urology, vol. 41, no. 2, pp. 113–121, 1993.
17. J. F. Ward, J. M. Slezak, M. L. Blute, E. J.
Bergstralh, and H. Zincke, “Radical prostatectomy for
clinically advanced (cT3) prostate cancer since the
advent of prostate-specific antigen testing: 15-Year
outcome,” BJU International, vol. 95, no. 6, pp.
751–756, 2005.
18. K. A. Roehl, M. Han, C. G. Ramos, J. A. V.
Antenor, and W. J. Catalona, “Cancer progression
and survival rates following anatomical radical
retropubic prostatectomy in 3,478 consecutive
patients: long-term results,” Journal of Urology, vol.
172, o. 3, pp. 910–914, 2004.
19. D. Van den Ouden, P. J. T. Davidson, W. Hop,
and F. H. Schroder, “Radical prostatectomy as a
monotherapy for locally advanced (stage T3) prostate
cancer,” Journal of Urology, vol. 151, no. 3, pp.
646–651, 1994.
20. H. Van Poppel, H. Goethuys, P. Callewaert, L.
Vanuytsel, W. Van De Voorde, and L. Baert, “Radical
prostatectomy can provide a cure for well-selected
clinical stage T3 prostate cancer,” European Urology,
vol. 38, no. 4, pp. 372–379, 2000.
21. G. S. Gerber, R. A. Thisted, G. W. Chodak et
al., “Results of radical prostatectomy in men with
locally advanced prostate cancer:multi-institutional
pooled analysis,” European Urology, vol. 32, no. 4,
pp. 385–390, 1997.
22. S. M. de la RivaIsorna, L.-T. J. Belon, D. R.
Marrero, C. E. Alvarez, and B. P. Santamaria, “Radical
prostatectomy asmonotherapy for locally advanced
prostate cancer (T3a): 12 years follow-up,”
ArchivosEspa˜noles de Urolog´ýa, vol. 57, no. 7, pp.
679–692, 2004.
23. M. Bolla, H. Van Poppel, L. Collette et al.,
“Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial
22911),”The Lancet, vol. 366, no.9485, pp. 572–578,
2005.
24. Shelley MD, Kumar S, Wilt T, et al. A systematic review and meta-analysis of randomised trials of
neoadjuvant hormone therapy for localised and
locally advanced prostate carcinoma. Cancer
TreatRev 2009 Feb;35(1):9-17.
Hellenic
UROLOGY
43
Athanasios I. Archodakis, Stefanos Bolometes
25. Johnstone PA, Ward KC, Goodman M, et al.
Radical prostatectomy for clinical T4 prostate cancer.
Cancer 2006 Jun;106:2603-9.
26. Zietman AL, Prince EA, Nakfoor BM, et al.
Androgen deprivation and radiation therapy:
sequencing studies using the Shionogi in vivo tumour
system. Int J RadiatOncolBiolPhys 1997
Jul;38(5):1067-70.
27. Joon DL, Hasegawa M, Sikes C, et al. Supraadditive apoptotic response of R3327-G rat prostate
tumours to androgen ablation and radiation. Int J
RadiatOncolBiolPhys 1997 Jul;38(5):1071-7.
28. C. Obek, S. Sadek, S. Lai, F. Civantos, D.
Rubinowicz, and M. S. Soloway, “Positive surgical
margins with radical retropubic prostatectomy:
anatomic site-specific pathologic analysis andimpact
on prognosis,” Urology, vol. 54, no. 4, pp. 682–688,
1999.
29. R. B.Watson, F. Civantos, and M. S. Solo-way,
“Positive surgical margins with radical prostatectomy:detailed pathological analysis and
prognosis,” Urology, vol. 48, no. 1, pp. 80–90, 1996.
44
Hellenic
UROLOGY
30. D. I. Quinn, S. M. Henshall, A. M. Haynes et al.,
“Prognostic significance of pathologic features in
localized prostate cancer treated with radical
prostatectomy: Implications for staging systems and
predictive models,” Journal of Clinical Onco-logy, vol.
19, no. 16, pp. 3692–3705, 2001.
31. S. S. Connolly, G. C. O'Toole, K. J. O'Malley et
al., “Positive apical surgical margins after radical
retropubic prostatectomy, truth or artefact?” ScandinavianJournalofUrologyandNephrology, vol. 38, no.
1, pp. 26–31, 2004.
32. S. R. Bott, A. A. Freeman, S. Stenning et al.,
“Radical prostatectomy: pathology findings in 1001
cases compared with other major series and over
time,” BJU International, vol. 95, no. 1, pp. 34–39,
2005.
ORIGINAL ARTICLE
Urodynamic findings in voiding symptoms after
radical prostatectomy: Analysis of our experience
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias.
Hellenic Red Cross Hospital.Department of Urology, Athens, Greece.
Corresponding Author:
Constantinos Bouropoulos
Hellenic Red Cross Hospital Department of Urology
11526, Athens
e-mail: [email protected]
Summary
Introduction
To determine and assess urodynamic findings in
patients with persistent post-radical prostatectomy
(R.P) voiding symptoms. Furthermore, the purpose
of the study is to estimate the effect of age, body
mass index (B.M.I) and nerve sparing techniques
on the presence of these symptoms.
Methods
A total of 45 patients reported incontinence or lower
urinary tract symptoms, at least 12 months
following radical retropubic prostatectomy (R.P)
were enrolled in the study. All patients underwent
clinical evaluation and standardized urodynamic
test. Patients with urinary tract infections,
anastomotic strictures, hormonal or radiation
therapy were excluded.
Results
The mean patient age was 68.5 years (59-74).
2
Mean B.M.I was 27.5kg/m and the mean follow-up
period after R.P was 15.3 months. Stress urinary
incontinence was the most common urodynamic
finding, occurring in 26 patients (57.8%). Detrusor
overactivity was identified in 14 patients (31, 3%).
However, in 15 patients (33.3%) complaining of
urgency, involuntary detrusor contractions were
not recorded during urodynamic study. In 9 cases
(20%) reduced bladder compliance was noted.
Four (4) patients (8.9%) were diagnosed with
detrusor hypocontractility, who were also found to
have symptoms of obstruction. Moreover, B.M.I
was found to be significantly correlated with stress
urinary incontinence, detrusor hypocontractility
and bladder outlet obstruction (p<0.001, p=0.038
and p=0.038 respectively). Old age was
significantly related to stress urinary incontinence
(p=0,019).
Conclusion
There is a large variety of urodynamic findings after
radical prostatectomy with stress urinary
incontinence being the most common. Most of the
patients' complain of urgency but involuntary
detrusor contractions are recorded in only half of
the cases. Increased B.M.I is associated with stress
urinary incontinence, bladder outlet obstruction
and detrusor hypocontractility. Detrusor deficiency
is a prevalent medical problem in older patients.
Key words
Radical prostatectomy, stress urinary incontinence, urodynamic testing.
Introduction
It is well-known that radical prostatectomy is
considered to be the treatment of choice for
patients with prostate cancer. The widespread
application of PSA measurement has led to an
1-3
increase in early-stage diagnosis of the disease .
This fact, in combination with better understanding
of male pelvic anatomy, as well as developments in
surgical techniques have led to a rapid increase in
the number of patients who undergo both open and
minimally-invasive surgery1-3. However, despite the
developments in surgical techniques, urinary
incontinence remains a relatively frequent complication of radical prostatectomy which may have
negative effects on patients' quality of life1-4. Furthermore, after RP further complications may be
observed, apart from urinary incontinence, such as
overactive bladder, detrusor hypocontractility,
poor bladder control, and bladder outlet voiding
Hellenic
UROLOGY
45
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias
1-12
symptoms .
Urodynamic findings observed in patients with
urinal incontinence complaints after radical
prostatectomy are described and evaluated in the
present study.
Material and Methods
45 Patients, who had undergone radical
prostatectomy and complained of persistent
disturbances in urination, such as irritative of
obstructive bladder problems, as well as urinary
incontinence were included in the study.
As urinary incontinence was considered according to International Continence Society
guidelines- the involuntary urine loss or urine
leakage (ICS) 13. Minimum follow-up period postoperatively was 12 months.
None of these patients reported recurrence or
development of the disease and no one required
adjuvant radiotherapy or hormonal therapy. All
patients were examined with cystourethroscopy in
order to exclude the possibility of the urethral
anastomosis narrowing. Also patients with
comorbid diseases such as diabetes, neuron
disease or infections detected in the urinalysis were
excluded from the study. Patients were stratified
according to the stage of the disease, localization
of the tumor, age and pre-surgical erectile function
as indicated by the questionnaire of the
International Index of Erectile Function (IIEF-5).
They underwent non-nerve sparing or nerve
sparing open retropubic radical prostatectomy.
The nerve sparing technique was conducted with
intrafascial or an interfascial access, but also with
extrafascial access with a partial preservation of
neurovascular bundles. Doctors recorded the
medical history and performed a physical
examination of all patients prior to evaluating the
urodynamic test outcomes. Urodynamic tests
included cystomanometry, voiding pressure-flow
test and intravesical pressure and flow
measurement (UVJ). We used a double lumen
catheter with a 6FCh diameter and a rectal catheter
with a 16Ch diameter. UVJ was measured during
the filling phase with a volume of 200ml, with the
patient in an upright position, and by increasing the
46
Hellenic
UROLOGY
intraversical pressure either with cough or Valsalva
maneuver. UVJ levels of <60cm H2O were
indicative of an Intrinsic Sphincter Deficiency. At full
capacity, the patient is asked to urinate and
maximum urinary flow rate is measured (Qmax),
the detrusor pressure during maximum flow
(Pdetmax) and the post voiding residual volume.
Bladder outlet obstruction and detrusor
contractility were quantified according to the
Schafer Nomogram. Categories 0-2 included nonobstructive patients whereas categories 3-6
included obstructive patients. Furthermore the
nomogram was applied to distinguish between
normal and reduced detrusor contractility. The four
categories of overactive bladder reviewed in this
study are related to urodynamic assessment of the
patients with an overactive detrusor as described
15
by Blaivas JG et al. Regression analysis was
performed to delineate threshold between patients'
clinical characteristics and urodynamic findings. Tvalue indicates the risk factors whereas p values
greater 0, 05 were statistically insignificant.
Results
The mean patient age was 68.5 years (59-74).
Mean BMI was 27.3 ± 2.8 kg/m2 and mean followup period after radical prostatectomy was 15.3
months (Table 1).
Stress urinary incontinence was the most common
urodynamic finding, occurring in 26 patients (57,
8%) (Table 2). Twety nine patients (64, 4%)
complained of urgency, however, during the
urodynamic testing involuntary detrusor
contractions (types II, III, IV), were observed in 14
patients (31.1%). Although intrinsic sphincter
deficiency was the most common urodynamic
finding in the present study, it was recorded as a
primary disorder in only 7 patients (15.5%). In the
remaining patients it co-existed with functional
bladder disorders. Urinal urgency in combination
with overactive detrusor was exclusively found in
15% patients (33.3%). In most of these cases it was
diagnosed overactive detrusor type I without
involuntary contractions. A statistically significant
correlation (p<0.001) was found between high BMI
and stress urinary incontinence and detrusor
hypocontractility and bladder outlet obstruction as
Urodynamic findings in voiding symptoms after radical prostatectomy:
Analysis of our experience
well. Older age was significantly correlated to
stress urinary incontinence (p=0.019). No
statistically significant correlation was observed
between the nerve-sparing techniques and the
patients' urodynamic disorders (Tables 3, 4).
Discussion
It has been shown by many authors that the
elimination of prostatic obstruction during radical
prostatectomy following the excision of the
prostate gland may lead to an improvement of
voiding symptoms especially in patients with
severe voiding symptoms pre-surgically (high IPSS
10
values) . However during radical prostatectomy
apart from the removal of the prostate, the
separation of the bladder trigone from the anterior
of the urethra at the level of the bladder neck may
1-3,10
cause innervational and vascular disorders . As
a result, symptoms of the urinary tract system and
the related reduction of the quality of life may not be
improved1-4. In the present study, urodynamic
findings of stress incontinence (UVJ< 60 cm H2O),
indicating intrinsic sphincter deficiency (ISD) were
reported in 26 patients. Currently, the underlying
mechanism of urinary incontinence following RP is
not fully understood. Anatomical changes that take
place after radical prostatectomy seem to play an
important role. More specifically, damage to the
sphincter may occur either as a result of direct
injury during the excision of the prostate apex or
during suturing of the cysteourethral anastomosis
or indirectly as a result of its innervation damage. In
fact, several nerves responsible for urinary
continence are located in the neurovascular
bundles and may be damaged in non-nerve
1, 2
sparing radical prostatectomy . Furthermore an
injury in the pelvic plexus which is located on the
lateral sidewall of the rectum and provides
innervation to the pelvic organs may occur during
the excision of the apex of seminal vesicles 1, 2, 16.
Loss of continuity of the smooth bladder muscles
and the reduction of the circumferential sphincter
lining of muscles and fascias seems also to play an
important role1,2. For this reason, disruption of the
innervation of the sphincter which originates from
the pelvic branch of the pudendic nerve as well as
of the branches of the lower hypogastric plexus,
and the muscular components surrounding the
sphincter should be avoided. In fact, the above
disruptions lead to loss of support from a stable
point of the sphincter, and lead to its relaxation and
insufficient contraction1, 2.
Some authors consider that the frequency of
urinary incontinence after radical prostatectomy
seems to correlate with the reduction of the
1,2
functional length of the urethra length . Finally,
preservation of the bladder neck increases the rate
of premature continence without affecting the long17
term results . Other investigators concluded that
the age of the patient is an independent prognostic
factor for the radical prostatectomy induced
incontinence19.. The above observation is in
accordance with the statistically significant
correlation between patients' age and in the
frequency of urodynamic findings of urinary stress
incontinence found in the present study. Reasons
explaining this fact are not well known. However, it
is reported that older patients who underwent
radical prostatectomy have more severe voiding
symptoms18 and tend to suffer by comorbident
diseases which possibly affects the pre-operative
level of urinary continence1,2,19. On the other hand,
nerve-sparing techniques are performed less often
in older than in younger patients. Moreover, age
related histological changes of the bladder
muscolar and connective tissue are less likely to
adapt changes of urodynamic parameters introduced by the radical prostatectomy. Therefore, the
patients' age should be taken into consideration
during the data evaluation concerning functional
outcomes after radical prostatectomy.
In the present study patients with a high BMI showed increased urinary stress incontinence and detrusor hypocontractility. Several studies on large
series of patients who underwent both laparoscopic and open radical prostatectomy (via either
the transperineal or suprapubic approach) or robotically assisted radical prostatectomy, have shown
that increased BMI is significantly related to increased post-operative rates of morbidity and more
frequent complications20-25. In fact, increased deposition of adipose tissue, adds difficulty in the access
to the pelvic organs, and therefore renders the
operation more difficult. Conclusively, these pa-
Hellenic
UROLOGY
47
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias
tients have a greater chance of reporting negative
functional results, and a longer period of time is
required for them to return to original levels of
continence.
Post radical prostatectomy urinary complications
may also occur due to detrusor dysfunction (such
as involuntary detrusor contractions, reduced
bladder contractility, detrusor hypocontractility) or
bladder outlet obstruction. Data related to bladder
1-12
dysfunctions vary and are often contradictory .
They are usually found in combination with stress
urinary incontinence and as a single urodynamic
finding in a small number of cases. It is possible that
these dysfunctions occur in a pre-existing, urinary
obstruction, although several authors report that
they may occur de novo as a result of denervation
and ischemic alterations which occur during radical
1-12
prostatectomy . Urodynamic testing is a fundamental tool for the detection and accurate description of the above disorders even in the absence of
incontinence or other symptoms as indicated by
the patient.
The present study presents certain limitations,
apart from its retrospective nature. It includes uro-
dynamic findings from a selective group of patients
who underwent radical prostatectomy. Those patients complained of persistent urinary dysfunction
for more than one year while their urodynamic preoperative data was not available. However, our
study reflects the current clinical practice that not
include the urodynamic evaluation for the radical
prostatectomy candidates as a routine examination.
Conclusion
In conclusion despite the radical development of
surgical techniques urinary incontinence remains
one of the most frequent complications of the
radical prostatectomy procedure significantly
affecting patient quality of life. Besides intrinsic
sphincter deficiency which is the most common
urodynamic finding after radical prostatectomy a
variety of bladder complications may be observed.
Several patients complain of urinary urgency but
involuntary detrusor contractions are not recorded
in all cases. Stress urinary incontinence may occur
in overweight and elderly patients.
Table 1. Demographic Characteristics of Patients
Patients(n)
45
Age (yrs)1
68,33 (59-74)
Age > 68,5 yrs
28 (62,22%)
Age < 68,5 yrs
17 (37,78%)
2 2
BMI (kgr/m )
27,34+2,83
BMI > 27,5 kgr/m2
22 (48,89%)
2
23 (51,11%)
BMI < 27,5 kgr/m
1
48
Hellenic
Nerve-sparing radical prostatectomy (n%)
24 (53,33%)
Non Nerve-sparing radical prostatectomy (n%)
21 (46,67%)
Follow up (months)3
15,33+2,39
Average value (åýñïò)
UROLOGY
2,3
Average value ± Standard deviation
Urodynamic findings in voiding symptoms after radical prostatectomy:
Analysis of our experience
Table 2. Urodynamic findings in voiding symptoms after radical prostatectomy.
15 (33,33%)
Detrusor Overactivity Type I (n, %)
Detrusor Overactivity Type II, III, IV (n, %)
14 (31,1%)
Stress Urinary Incontinence (n, %)
26 (57,77%)
Reduced Bladder Compliance (n, %)
9 (20%)
Detrusor Hypocontractility (n, %)
4 (8,88%)
Bladder Outlet Obstruction (n, %)
4 (8,88%)
Stress Urinary Incontinence single (n, %)
7 (15,55%)
Detrusor Overactivity Single / all Types (n, %)
15 (33,33%)
Reduced Bladder Compliance Single (n, %)
0 (0%)
Detrusor Hypocontractility / Bladder Outlet Obstruction
1 (2,22%)
Single (n, %)
Stress Urinary Incontinence + Detrusor overactivity (n, %)
9 (20%)
Stress Urinary Incontinence + Detrusor overactivity
7 (15,55%)
+Reduced Bladder Compliance (n, %)
Stress Urinary Incontinence + Reduced Bladder Compliance (n, %)
1 (2,22%)
Stress Urinary Incontinence + Detrusor Hypocontractility
2 (4,44%)
/ Bladder Outlet Obstruction (n, %)
Hellenic
UROLOGY
49
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias
Table 3. Urodynamic Findings and Demographic characteristics of patients.
Urodynamic
Age < 68,5 BMI > 27,5 BMI < 27,5
kgr/m2
kgr/m2
years
N.P1
N.N.P2
Age > 68,5
years
Detrusor
overactivity Type I
10(66,7%)
5(33,3%)
3(20%)
12(80%)
3(20%)
12(80%)
Detrusor overactivity
Type ÉÉ,ÉÉÉ,ÉV
3(21,4%)
11(78,6%)
13(92,9%)
1(7,1%)
10(71,4%)
4(28,6%)
Stress Urinary
Incontinence
9(34,6%)
17(65,4%)
24(92,3%)
2(7,7%)
22(84,6%)
4(15,4%)
1(11,1%)
8(88,9%)
9(100%)
0(0%)
7(77,8%)
2(22,2%)
Detrusor
Hypocontractility
0(0%)
4(100%)
4(100%)
0(0%)
1(25%)
3(75%)
Bladder Outlet
Obstruction
0(0%)
4(100%)
4(100%)
0(0%)
1(25%)
3(75%)
Findings
Reduced Bladder
Compliance
1
Nerve sparing radical prostatectomy
2
Non-nerve sparing radical prostatectomy
Table 4. Correlation among demographic characteristics of the patients and urodynamic findings
D.O1 TYPE I
Demographic
Characteristics
D.O1 TYPE
I,III,IV
Stress Urinary
Incontinence
Reduced
Bladder
Compliance
Detrusor
Hypocontractility
Bladder
Outlet
Obstruction
value p
value t
value p
value t
value p
value t
value p
value t
value p
value t
value p
value t
Operation type2
0,092
1,722
0,819
-0,229
0,630
-0,456
0,089
-1,740
0,389
-0,869
0,389
-0,869
Age
0,633
-0,480
0,867
0,167
0,019
2,423
0,980
0,025
0,204
1,290
0,204
1,290
BMI
0,604
0,522
0,739
-0,334
<0,001
6,871
0,282
-1,080
0,038
2,136
0,038
2,136
1
Detrusor Overactivity
2
nerve-sparing or non nerve-sparing
50
Hellenic
UROLOGY
Urodynamic findings in voiding symptoms after radical prostatectomy:
Analysis of our experience
Ðåñßëçøç
ÏõñïäõíáìéêÞ åõñÞìáôá óôéò äéáôáñá÷Ýò
ôçò ïýñçóçò ìåôÜ áðü ñéæéêÞ
ðñïóôáôåêôïìÞ: ÁíÜëõóç ôçò åìðåéñßáò ìáò
Ì. Óôáõñüðïõëïò, Ö. ÂåíåôóÜíïò, Ð.
Áíáóôáóüðïõëïò, Ê. Ìðïõñüðïõëïò, Í. ÖåñÜêçò, Ç.
Ðïýëéáò
ÏõñïëïãéêÞ ÊëéíéêÞ Íïóïêïìåßïõ Åëëçíéêïý Åñõèñïý
Óôáõñïý
Õðåýèõíïò åðéêïéíùíßáò: Ìðïõñüðïõëïò
Êùíóôáíôßíïò
Íïóïêïìåßï Åëëçíéêïý Åñõèñïý Óôáõñïý ÏõñïëïãéêÞ
ÊëéíéêÞ, 11526 ÁèÞíá
tel:2106414000 - email: [email protected]
Óêïðüò: Ï êáèïñéóìüò êáé ç áîéïëüãçóç ôùí
ïõñïäõíáìéêþí åõñçìÜôùí óå áóèåíåßò ìå
åðßìïíåò äéáôáñá÷Ýò ôçò ïýñçóçò ìåôÜ áðü
ñéæéêÞ ðñïóôáôåêôïìÞ (ÑÐ). ÅðéðëÝïí, óêïðüò ôçò ìåëÝôçò åßíáé íá åêôéìçèåß åðßäñáóç
ôçò çëéêßáò, ôïõ áõîçìÝíïõ äåßêôç ìÜæáò óþìáôïò (ÄÌÓ) êáé ôùí íåõñïðñïóôáôåõôéêþí
ôå÷íéêþí óôçí ðáñïõóßá ôùí äéáôáñá÷þí
áõôþí.
Õëéêü êáé ìÝèïäïò: ÓõíïëéêÜ 45 áóèåíåßò
ðïõ åìöÜíéóáí áêñÜôåéá ïýñùí ç óõìðôùìáôïëïãßá áðü ôï êáôþôåñï ïõñïðïéçôéêü,
ôïõëÜ÷éóôïí 12 ìÞíåò ìåôÜ ôçí ïðéóèïçâéêÞ
ÑÐ óõìðåñéëÞöèçóáí óôç ìåëÝôç. ¼ëïé ïé
áóèåíåßò áîéïëïãÞèçêáí êëéíéêÜ êáé õðïâëÞèçêáí óå ïõñïäõíáìéêü Ýëåã÷ï. Áóèåíåßò ìå
ëïßìùîç ôïõ ïõñïðïéçôéêïý, óôÝíùìá ôçò ïõñçèñïêõóôéêÞò áíáóôüìùóçò, éóôïñéêü ïñìïíïèåñáðåßáò, ç áêôéíïâïëßáò áðïêëåßóèçêáí
áðü ôç ìåëÝôç.
èçóçò ôùí áóèåíþí ìåôÜ ôçí ÑÐ 15.3 ìÞíåò.
ÁêñÜôåéá áðü ðñïóðÜèåéá ðáñïõóéÜóèçêå óå
26 áóèåíåßò (57.8%) êáé Þôáí ôï ðéï óõ÷íü
ïõñïäõíáìéêü åýñçìá. Õðåñëåéôïõñãéêüò
åîùóôÞñáò äéáðéóôþèçêå óå 14 áóèåíåßò
(31.3%). Ùóôüóï, óå 15 áóèåíåßò (33.3%) ðïõ
ðáñáðïíÝèçêáí ãéá åðéôáêôéêÞ ïýñçóç äåí
êáôáãñÜöçêáí áêïýóéåò óõóðÜóåéò ôïõ åîùóôÞñá êáôÜ ôïí ïõñïäõíáìéêü Ýëåã÷ï. Óå 9
ðåñéðôþóåéò (20%) ðáñáôçñÞèçêå ìåéùìÝíç
ðñïóáñìïóôéêüôçôá ôçò ïõñïäü÷ïõ êýóôçò.
Õðïóõóôïëéêüò åîùóôÞñáò äéáãíþóèçêå óå
4 áóèåíåßò (8.9%), ïé ïðïßïé âñÝèçêáí åðßóçò
íá Ý÷ïõí êáé áðïöñáêôéêÜ óõìðôþìáôá.
ÅðéðëÝïí, äéáðéóôþèçêå óçìáíôéêÞ óõó÷Ýôéóç ôïõ õøçëïý ÄÌÓ ìå ôçí áêñÜôåéá ðñïóðáèåßáò, ôïí õðïóõóôïëéêü åîùóôÞñá êáé ôçí
áðïöñáêôéêÞ ïýñçóç (p<0.001, p=0.038 êáé
p=0.038 áíôßóôïé÷á). Ç ìåãÜëç çëéêßá ó÷åôßóèçêå óçìáíôéêÜ ìå ôçí áêñÜôåéá áðü ðñïóðÜèåéá (p=0.019).
ÓõìðÝñáóìá: ÌåôÜ áðü ÑÐ ðáñáôçñåßôáé
ìåãÜëç ðïéêéëßá ïõñïäõíáìéêþí åõñçìÜôùí,
ìå ôçí áêñÜôåéá áðü ðñïóðÜèåéá íá åßíáé ôï
ðéï óõ÷íü. Ïé ðåñéóóüôåñïé áóèåíåßò ðáñáðïíïýíôáé ãéá åðéôáêôéêüôçôá, ùóôüóï áêïýóéåò óõóðÜóåéò ôïõ åîùóôÞñá êáôáãñÜöïíôáé
ìüíï óôïõò ìéóïýò áðü áõôïýò. Ï õøçëüò
ÄÌÓ ó÷åôßæåôáé ìå áêñÜôåéá áðü ðñïóðÜèåéá,
õðïóõóôïëéêüôçôá ôïõ åîùóôÞñá êáé áðïöñáêôéêÞ ïýñçóç. Ç åíäïãåíÞò áíåðÜñêåéá
ôïõ óöéãêôÞñá åìöáíßæåôáé ðéï óõ÷íÜ óå ðéï
çëéêéùìÝíïõò áóèåíåßò.
ËÝîåéò åõñåôçñéáóìïý:
ÑéæéêÞ ðñïóôáôåêôïìÞ, áêñÜôåéá áðü ðñïóðÜèåéá, ïõñïäõíáìéêüò Ýëåã÷ïò.
ÁðïôåëÝóìáôá: Ç ìÝóç çëéêßá ôùí áóèåíþí
Þôáí 68.5 Ýôç (59-74 Ýôç). Ï ìÝóïò ÄÌÓ Þôáí
2
27.5 kg/m êáé ï ìÝóïò ÷ñüíïò ðáñáêïëïý-
Hellenic
UROLOGY
51
M. Stavropoulos, P. Venetsanos, P. Anastasopoulos, C. Bouropoulos, N. Ferakis, I. Poulias
References
1. Giannantoni A, Mearini E, Zucchi A, Constantini
E, Mearini L, Bini V et al. Bladder and urethral sphincter
function after radical retropubic prostatectomy: a
prospective long-term study. Eur Urol 2008, 54: 657664.
2. Porena M, Mearini E, Mearini L, Vianello A,
Giannantoni A. Voiding dysfunction after radical
retropubic prostatectomy:more than external urethral
sphincter deficiency. Eur Urol 2007, 52: 38-45.
3. Bauer RM, Bastian PJ, Gozzi C, Stief CG.
Postprostatectomy incontinence: all about diagnosis
and management. Eur Urol 2009, 55: 322-333.
4. Alivizatos G, Skolarikos A. Incontinence and
erectile dysfunction following radical prostatectomy: a
review. Sci World J 2005, 13: 747-58.
5. Groutz A, Blaivas JG, Chaikin DC, Weiss JP,
Verhaaren M. The pathophysiology of post-radical
prostatectomy incontinence: a clinical and video
urodynamic study. J Urol 2000, 163: 1767-70.
6. Kleinhans B, Gerharz E, Melekos M, Weingartner K, Kalble T, Riedmiller H. Changes of urodynamic
findings after radical retropubic prostatectomy. Eur
Urol 1999, 35: 217-21.
7. Namiki S, Ishidoya S, Saito S, Satoh M, Tochigi
T, Ioritani N et al. Natural history of voiding function
after radical retropubic prostatectomy. Urology 2006,
68: 142-7.
8. Dubbelman Y, Groen J, Wildhagen M, Rikken B,
Bosch R. Quantification of changes in detrusor
function and pressure-flow parameters after radical
prostatectomy: relation to postoperative continence
status and the impact of intensity of pelvic floor muscle
exercises. Neurourol Urodyn 2012, 31: 637-41.
52
Hellenic
UROLOGY
9. Kielb SJ, Clemens JQ. Comprehensive urodynamics evaluation of 146 men with incontinence
after radical prostatectomy. Urology 2005, 66: 392-6.
10. Song C, Lee J, Hong Jh, Choo Ms, Kim Cs, Ahn
H. Urodynamic interpretation of changing bladder
function and voiding pattern after radical
prostatectomy: a long-term follow-up. BJU Int 2010,
106: 681-6.
11. Huckabay C, Twiss C, Berger A, Nitti Vw. A
urodynamics protocol to optimally assess men with
post-prostatectomy incontinence. Neurourol Urodyn
2005, 24: 622-6.
12. Chung D, Dillon B, Kurta J, Maschino A, Cronin
A, Sandhu J. Detrusor underactivity is prevalent after
radical prostatectomy: a urodynamic study including
risk factors. Can Urol Assoc J 2013, 7: E33-E37.
13. Thuroff Jw, Abrams P, Andersson KE, Atribani
W, Chapple CR, Drake MJ et al. EAU guidelines on
urinary incontinence. Eur Urol 2011, 59: 389-400.
14. SCHAFER W. Principles and clinical application of advanced urodynamic analysis of voiding
function. Urol Clin North Am 1990, 17: 553-66.
15. Blaivas JG, Flisser AJ, Wamsley K. Urodynamic classification of patients with symptoms of
overactive bladder. J Urol 2003, 169: 529–533.
16. John H, Hauri D. Seminal vesicle-sparing
radical prostatectomy: a novel concept to restore early
urinary continence. Urology 2000, 55: 820-4.
17. Grasso M, Torelli F, Lania C, Blanco S. The role
of bladder neck preservation during radical
prostatectomy: clinical and urodynamic study. Arch
Ital Urol Androl 2012, 84: 1-6.
18. Deliveliotis C, Liakouras C, Delis A, Skolarikos
Urodynamic findings in voiding symptoms after radical prostatectomy:
Analysis of our experience
A, Varkarakis J, Protogerou V. Prostate operations:
long-term effects on sexual and urinary function and
quality of life. Comparison with an agematched control
population. Urol Res 2004, 32: 283-9.
22. Wolin Ky, Luly J, Sutcliffe S, Andriole Gl, Kibel
AS. Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol
2010, 183: 629-33.
19. Eastham JA, Kattan MW, Rogers E, Goad JR,
Ohori M, Boone TB et al. Risk factors for urinary
incontinence after radical prostatectomy. J Urol 1996,
156: 1707-13.
23. Herman Mp, Raman Jd, Dong S, Samadi D,
Scherr DS. Increasing body mass index negatively
impacts outcomes following robotic radical prostatectomy. JSLS 2007, 11: 438-42.
20. Ahlering TE, Eichel L, Edwards R, Skarecky
DW. Impacts of obesity on clinical outcomes in robotic
prostatectomy. Urology 2005, 65: 740-4.
24. Yates J, Munver R, Sawczuk I. Robot-assisted
laparoscopic radical prostatectomy in the morbidly
obese patient. Prostate Cancer 2011.
21. Ampeggi A, Xylinas E, Ploussard G, Ouzaid I,
Fabre A, Allory Y et al. Impact of body mass index on
perioperative morbidity, oncological, and functional
outcomes after extraperitoneal laparoscopic radical
prostatectomy. Urology 2012, 80: 576-84.
25. Bae JJ, Choi SH, Kwon TG, Kim TH. Advantages of robot-assisted laparoscopic radical prostatectomy in obese patients: comparison with the
open procedure. Korean J Urol 2012, 53: 536-40.
Hellenic
UROLOGY
53
CASE REPORT
Malakoplakia of the bladder associated
with advanced obstructive uropathy
Konstantinos Stamatiou1, Georgios Makris1, Dimitris Zavradinos1,
1
1
2
Eleutherios Geropappas , Konstantinos Fokas , Athanasios Papatsoris .
1. Urology Department, Tzaneio General Hospital, Piraeus, Greece
nd
2. 2 Department of Urology, University of Athens, Athens, Greece
Corresponding Author:
Konstantinos Stamatiou
Urology Department, Tzaneio General Hospital, Piraeus, Greece
Salepoula 2, 18536, Piraeus - Tel: +30 2104592387
e-mail: [email protected]
Summary
Malakoplakia is an inflammatory condition that
rarely occurs in the urogenital tract. The most
frequently affected organ is the urinary bladder,
while involvement of the testis is extremely rare.
This condition has the features of a granulomatous
inflammation. In this article we present a case of
bladder malakoplakia associated with advanced
obstructive uropathy.
Key Words
Malakoplakia, inflammatory disease, urinary bladder, kidney failure.
Introduction
Malakoplakia is a granulomatous inflammation
which was originally described in 1902 by Michaelis
and Gutmann. Malakoplakia most often occurs in
patients above 40 years old, and usually in women.
Symptoms in the affected bladder are not specific
and are similar to cystitis1. The pathogenesis of
malakoplakia remains poorly understood, though it
is speculated to be caused by defective
macrophage elimination of bacteria.
Defective macrophage killing results in an
accumulation of bacterial degradation products
and a granulomatous reaction, which clinically
manifests as the formation of a papule, plaque or
ulceration. It is hypothesized that the disease
occurs in patients with history of E. coli infections,
immunosuppression (usually connected to kidney
transplantation and in rare cases due to lymphoma
or cancer), diabetes, and chronic steroid use,
although the relationship has not been clearly
described. Macroscopically, on the internal surface
of the affected organ, yellow- soft plaques are
detected, whilst microscopically the disease is
characterized by the presence of large
macrophages (foamy hystiocyotic cells-also
known as von Hansemann cells) containing
pathognomonic Michaelis-Gutmann bodies.
54
Hellenic
UROLOGY
Case report description
A male, 72 years old was brought to the Emergency
Department (E.R) reporting inability to urinate and
fever. He also reported weakness, fatigue and
dysuria all starting a month ago. The patient's
medical history was relevant for diabetes,
hypertension and peripheral vascular disease. His
past surgical history was relevant for a transvesical
prostatectomy 3 years ago, due to urinary
retention. This occurred after a significant history of
recurrent urinary tract infections. During their
evaluation a bladder biopsy of a membranous
mucosal lesion was performed indicating
nonspecific inflammation.
Upon admission the patient presented with
increased creatinine and glucose levels (21mg/dl,
300 mg/dl respectively). Anemia (Hct: 19%) with a
normal white cell count however was noted.
Ultrasound of the urinary system revealed bilateral
hydronephrosis due to obstructive uropathy
indicated by bladder wall thickening and
trabeculation. Nevertheless bladder capacity was
minimal with no residual urine observed (Image 1).
Image 1.Transabdominal ultrasonography: abnormally
thick bladder wall with the presence of exophytic lesion
Urine analysis indicated hematuria, pyuria and
microorganisms. Digital rectal examination
Malakoplakia of the bladder associated with advanced obstructive uropathy
revealed a small benign prostate. After immediate
antibiotic initiation and fluid replacement the
patient underwent initially hemodialysis due to the
presence of hyperkalemia, following nephrostomy
tube placement, which successfully stabilized renal
function.
Cystoscopic evaluation depicted atypical polypoid
lesions of the mucosa and scattered red-yellow
nodules sized 2 to 3.5cm in the trigone, left and
posterior bladder wall. A transurethral resection of
the lesions followed. Histology revealed malakoplakia of the urinary bladder (image 2-5). Despite
initial patient stabilization the patient died 8 months
later due to renal failure and complications of the
cardiovascular system since he continued to
present with urinary tract infections and chronic
hydronephrosis.
bioptic material with an absence of microscopic
pathognomonic findings such as acidophilic foamy
hystiocytic cells, or Michaelis-Gutmann bodies. In
these cases the emergence of positive results for
CD68 immunohistochemical staining confirms the
5
clinical hypothesis . This disease is frequently
considered an auto-immune disorder or a type of
5.
immunodeficiency Even though this inflammatory
disease is chronic, in certain cases progresses
acutely.
Image 3. Malakoplakia with the use of a PAS stain in von
Hausemann Çystiocyotic cells.
Image 2. Pathognomonic histological image of malakoplakia of the urinary bladder. (HEX 100).
Discussion
Malakoplakia is a benign self-limiting disease that
3
usually has a benign course . Initial management
consists of treating aggressively associated urinary
tract infections and transurethral removal of the
lesion mainly for histologic diagnosis. Few
incidents of renal impairment, caused by multifocal
malakoplakia, are reported in the literature. Indeed,
when the symptoms are severe, the disease is
4
promptly diagnosed . The reason for the delayed
diagnosis in the present case remains unknown.
As the symptoms were chronic, we hypothesize
that the bladder was already affected during the
first biopsy. Failure to diagnose the disease may
have occurred due to an insufficient amount of
In summary, malakoplakia of the bladder should be
carefully examined in patients with persistent infections of the urinary system and the presence of a
tumor-like mass in the cystoscopy. A numerous of
potential complications can be avoided with earlystage diagnosis and immediate antibiotic treatment.
Image 4. Malakoplakia of the Urinary Bladder
Hellenic
UROLOGY
55
K. Stamatiou, G. Makris, D. Zavradinos, E. Geropappas, K. Fokas, A. Papatsoris
Ðåñßëçøç
Ç ìáëáêïðëáêßá åßíáé ìéá öëåãìïíþäçò êáôÜóôáóç ðïõ óðÜíéá åìöáíßæåôáé óôïí ïõñïãåííç-
Ìáëáêïðëáêßá ôçò ïõñïäü÷ïõ êýóôçò
óõíäåüìåíç ìå ðñï÷ùñçìÝíç áðïöñáêôéêÞ
ïõñïðÜèåéá.
Kùíóôáíôßíïò Óôáìáôßïõ1, Ãåþñãéïò ÌáêñÞò1,
1
1
ÄçìÞôñçò Æáâñáäéíüò , ÅëåõèÝñéïò Ãåñüðáððáò ,
1
2
Êùíóôáíôßíïò ÖùêÜò , ÁèáíÜóéïò Ðáðáôóþñçò
ôéêü óýóôçìá. Óõ÷íüôåñá ðñïóâáëëüìåíï üñãáíï åßíáé ç ïõñïäü÷ïò êýóôç, åíþ åßíáé åîáéñåôéêÜ
óðÜíéá ç åìðëïêÞ ôïõ üñ÷åïò. Ç ðÜèçóç Ý÷åé ôá
÷áñáêôçñéóôéêÜ ìéáò êïêêéùìáôþäïõò öëåãìïíÞò. Óôï ðáñüí Üñèñï ðáñïõóéÜæïõìå Ýíá ðåñéóôáôéêü ìáëáêïðëáêßáò ôçò ïõñïäü÷ïõ êýóôçò
1
ÏõñïëïãéêÞ KëéíéêÞ, ÔæÜíåéï Ãåíéêü Íïóïêïìåßï ÐåéñáéÜ
óõíäåüìåíçò ìå ðñï÷ùñçìÝíç áðïöñáêôéêÞ ïõ-
2
 ÐáíåðéóôçìéáêÞ ÏõñïëïãéêÞ ÊëéíéêÞ, Óéóìáíüãëåéï
ñïðÜèåéá.
Ãåíéêü Íïóïêïìåßï Áìáñïõóßïõ
Õðåýèõíïò åðéêïéíùíßáò: Kùíóôáíôßíïò Óôáìáôßïõ
ÏõñïëïãéêÞ êëéíéêÞ, Ôæáíåéï ãåíéêü Íïóïêïìåßï ÐåéñáéÜ
Óáëåðïýëá 2, 18536 ÐåéñáéÜò
ôçë: 2104592387 - e-mail: [email protected]
ËÝîåéò Åõñåôçñéáóìïý: Ìáëáêïðëáêßá, öëåãìïíþäçò íüóïò, ïõñïäü÷ïò êýóôç, íåöñéêÞ áíåðÜñêåéá.
References
1. Ballesteros Sampol JJ. Urogenital malacoplakia. Report of 4 cases and review of the literature.
ArchEsp Urol. 2001;54(8):768-76.
2. Gupta R, Mahajan A, Atri S, Gupta CL. Recurrent painless hematuria secondary to malacoplakia of the urinary bladder: a case report and review
of literature. Urol J. 2013;10(1):821-3.
3. Bessim S, Heller DS, Dottino P, Deligdisch L,
Gordon RE. Malakoplakia of the female genital tract
causing urethral and ureteral obstruction. A case
report. J Reprod Med. 1991;36(9):691-4.
56
Hellenic
UROLOGY
4. Bylund J, Pais VM Jr. A case of acute renal
failure caused by bilateral, multifocal malacoplakia
lesions of the bladder and ureters. NatClinPract Urol.
2008;5(9):516-9.
5. Ristiæ-Petroviæ A, Stojnev S, Jankoviæ-Velickoviæ L, Marjanoviæ G. Malakoplakia mimics urinary
bladder cancer: a case report. VojnosanitPregl.
2013;70(6): 606-8.
CASE REPORT
Emergency embolisation of a spontaneously
ruptured angiomyolipoma in a solitary kidney
Marios. Stavropoulos, Constantinos Bouropoulos, Nikolaos Ferakis, Iraklis Poulias
Urological Clinic, Hellenic Red Cross Hospital
Corresponding Author:
Constantinos Bouropoulos
Hellenic Red Cross Hospital Urological Clinic
Athens 11526 - Tel: +30 2106414000
e-mail: [email protected]
Summary
Angiomyolipoma of the kidney is one of the most
common causes of spontaneous renal bleeding.
Here we present the case of a middle aged female
patient, who presented with automatic rupture of a
large angiomyolipoma in a solitary kidney. The
patient was treated with selective angioembolisation (SAE), and was discharged in good condition with unaltered renal function. SAE provides an
efficient control of haemorrhage in the acute stage,
but it has limited value in long-term treatment of
angiomyolipomas. In contrast, surgical treatment
allow the full removal of the tumour, however it is
associated with significant complications.
Description of the case
At admission, the patient was complaining of acute,
sudden pain in the left lumbar region without any
reference to prior injury. The patient did not present
macroscopic haematuria and the urinalysis was
normal. She had signs of hypobolaemic shock
(pallor, sweating and coldness of the extremities).
The medical history of the patient included
nephrectomy of the right kidney following a
diagnosis of renal cancer 5-years priory to the
admission. Furthermore, she reported an 8 cm AML
in the left kidney for which she was under
surveillance with regular imaging tests (Fig. 1).
Keywords
Angiomyolipoma, Wunderlich syndrome, embolisation.
Introduction
The spontaneous, non-traumatic renal haemorrhage, also known by the term Wunderlich syndrome, was described for the first time in the middle of
the 19th century1. It comprises an urgent clinical
situation, which requires immediate treatment. The
causes of automatic renal haemorrhage vary, with
angiomyolipoma (AML) being the most common14. AMLs are mesenchymal neoplasms found almost exclusively in the kidney and are comprised of
atypically developed blood vessels that are prone
to the formation of aneurysms, smooth muscle
fibbers and fatty tissue1. We describe the case of a
50-year-old patient with a history of previous right
nephrectomy, which was presented to the emergency department with automatic rupture of an
angiomyolipoma of the left kidney.
Figure 1. CT Scan of the upper and lower abdomen after
the application of intravenous contrast. The characteristic
radiological image of a large angiomyolipoma with a
largest diameter of 8 cm, is visible on the upper pole of
the left kidney. (Image from an older CT scan, in the
course of regular observation of the patient).
Upon examination, the patient had a pulse of 110
bpm, systolic arterial pressure of 80mmHg and was
non-feverish. Palpation of the left lumbar region
resulted in intense sensitivity and pain. Laboratory
test showed an 8.8g/dl and 26% levels of
haemoglobin and haematocrit count respectively.
Hellenic
UROLOGY
57
M. Stavropoulos, C. Bouropoulos, N. Ferakis, I Poulias
Serum creatinine level was at 1.2 mg/dl.
Revitalisation took place immediately, with
intravenous administration of fluids and colloidal
solutions and transfusion. When the the patient's
hemodynamic status was stabilized she underwent
a CT scan of the upper and lower abdomen. The
imaging test displayed the presence of a large
retroperotoneal haematoma extended as far as the
left iliac fossa, and the presence of a sizable AML on
the upper pole of the left kidney (Fig. 2).
Figure 2. CT scan of the upper and lower abdomen after
the application of intravenous contrast. A sizable mass
lesion resembling angiomyolipoma can be seen on the
upper pole of the left kidney, and signs of haemorrhaging
around the formation and the kidney.
For diagnostic and therapeutical purposes, the
patient was submitted to angiography: under local
anaesthesia the right femoral artery was
catheterised and under the guidance of an
angiographic hydrophilic wire, a Cobra type
angiographic catheter was placed. Via the
catheterization of the left renal artery, and the
subsequent angiogram, signs of haemorraging
were found, the control of which was achieved with
the appropriate placement of coils (Fig. 3).
The patient was transfused with a total of two units
of blood, and the treatment was not accompanied
by any particular complications. The first hours
after the embolisation the patient complained of
mild pain located in the right abdominal area and
presented low grade fever. Finally, the patient was
discharged in a generally good condition three
58
Hellenic
UROLOGY
days later with a haemocrit at 36%, haemoglobin at
12.2 g/dl and serum creatinine at 1.0 mg/dl. The
patient received instructions for retesting with a
new angiogram and CT scan of the abdomen, and
was scheduled for partial nephrectomy.
Discussion
AML are rarely malevolent tumours of the kidney.
Their frequency in the community is less than
0.5%1. Approximately 20% of these tumours grow
in patients with tuberous sclerosis1. However, the
majority of AMLs (80%) appear as sporadic
1,3
tumours in the general population . Sporadic AML
is more frequent in women (male to female ratio of
1:4) and especially those of middle and old age,
and are usually solitary and contralateral1,3. In
contrast, AMLs related to tuberous sclerosis
appear at a younger age and are usually bilateral,
multiple, and larger in size. AMLs displaying a large
percentage of atypical blood vessels, those related
with which tuberous sclerosis and large AMLs, are
in higher risk of spontaneous rupture and perirenal
1-4
haemorrhage .
CT scans of the abdomen are currently considering
the imaging test of choice for the detection of
perirenal haemorrhaging, with sensitivity as precise
as 100%. CT scan is also highly accurate in the
diagnosis of Wunderlicht syndrome attributable to
2
spontaneous ruptures of AMLs .
Figure 3. Angiography of the left renal artery after
embolisation. Spirals (as shown by the arrows) can be
seen, as well as the blockage of the feeder vessels of the
neoplasm.
Emergency embolisation of a spontaneously ruptured angiomyolipoma in a solitary kidney
Wunderlich syndrome constitutes a potentially fatal
complication of the AML rupture. It can occur in up
to 50% of patients and more precisely in those with
tumours larger than 4 centimetres in diameter. Of
note, 33% of patients with AML related renal blee4
ding may suffer from hypobolaemic shock . The
clinical picture involves the three classic symptoms, such as pain in the lower lumbar region, sensitivity during palpation and signs of hypobolae1,2
mic schock (Lenk's triad) .
Patients with AML that display symptoms such as
pain and haemorrhaging, or those for whom there
is a suspicion of malevolence, require therapeutic
treatment. Prophylactic intervention is excusable
for large tumours (usually larger than 4 centimetres, although the size is disputed), in woman of
reproductive age and in cases of insufficient
provision of emergency medical care or regular
5
check-ups .
Non-symptomatic AMLs with a diameter of up to 4
centimetres are usually placed under active surveillance with imaging techniques. Several authors
suggest the same treatment for patients with nonsymptomatic AML greater than 8 centimetres in
diameter and those with symptomatic tumours
1,3,5,6
greater than 4 centimetres
.
The two main therapeutic choices for the treatment
of spontaneous renal bleeding associated with
automatic rupture of angiomyolipomas involve
5,6
surgery and selective angioembolisations (SAE) .
Most usual methods of surgical treatment are the
conventional open nephrectomy and the partial
nephrectomy. Less invasive techniques such as
laparoscopic or robotically-assisted partial
nephrectomy, high-frequency thermotherapy (RF),
cryotherapy, as well as conservative methods such
as the administration of antiangiogenic agents
(mTOR inhibitors) have been developed over the
1,3,4,5
last few years
. However, the ideal therapeutic
method is not known. In fact, few randomized or
prospective comparative studies examining
surgical treatment and SAE exist in the international
literature. Furthermore, guidelines regarding this
specific subject are somehow unclear and therefore the choice of the right treatment is difficult.
Many factors such as the effectiveness and the
morbidity of each method, the renal function of the
patient, the characteristics of the tumour and the
preferences of the patient and the surgeon must all
be taken into consideration.
The benign nature of AML suggests the adoption,
of -as much as possible- nephron sparing
interventions. Under the light of this evidence, SAE
constitutes the least invasive method with
commonly a shorter treatment period than that is
required with the conventional surgical treatments
5-8. Nowadays, SAE is considered as the first line
treatment of acute haemorrhaging after an AML
rupture since it can safely control bleeding
stabilizing thus the patient quickly. Besides, the
related to SAE blood loss is limited.
SAE can lower the risk of AML haemorrhage
without placing the renal function in danger, even in
5-8
patients with pre-existing renal insufficiency . The
presence of multiple nutrient vessels renders the
embolisation of the tumour more difficult
technically and increases the risk of healthy renal
tissue damage6. Finally, SAE can be performed
preoperatively in cases of large AMLs in order to
lower the loss of blood during surgery, while it
could be offered in large AML in which partial
nephrectomy it is not possible 3,5.
SAE can be effective in the control of acute
haemorrhaging from AML, although it has limited
value as a long-term treatment. In fact, the tumour
continues to exist after embolisation, despite its
sizable reduction (about 40-50%)5. Tumours
relapse (increase in size, or haemorrhage) may
occur, mainly in patients with tuberous sclerosis
and thus, further embolisation may be required.
Consequently, such patients require long-term
observation. Complications of SAE usually involve
symptoms after embolisation (pain, fever, nausea),
which are the most common, being found in 85% of
cases, whilst necrosis of tissue and the formation of
Hellenic
UROLOGY
59
M. Stavropoulos, C. Bouropoulos, N. Ferakis, I Poulias
abscesses is rarer. The frequency of complications
5-8
is independent of the materials used . On the other
hand, surgical forms of treatment offer the
possibility of a complete removal of the tumour and
present exceptionally low rates of relapse. The
observation period for these patients is shorter than
that required after embolisation, a fact that is
favourable, especially for younger patients4,5.
However, the complications of surgical
intervention, whilst they are rare, are more serious,
a fact that is extremely important if we consider that
surgery treats a benign illness. These includes
renal haemorrhage, injury of the renal pelvis,
urinoma and the formation of fistulas. Generally,
radical nephrectomy for the removal of AML should
be avoided where possible. In the limited cases
where radical nephrectomy is considered, it is
either because the AML comprise a large
component of the renal tissue; when nephron
sparing techniques are not available or due to the
5,8
strong suspicion of malevolence in the AML .
In conclusion, it is worth mentioning that therapeutic treatment of AML is a complex process,
especially when regards large or multiple tumours.
Surgical forms of treatment, along with SAE,
comprise the cornerstone of treatment of AML. SAE
offers effective control of haemorrhaging in the
acute phase, but has limited value in the long term
treatment of AML. In contrast, partial nephrectomy
is accompanied by exceptionally low rates of
relapse of the illness and offers a more radical
treatment. Although it presents more complications
than SAE, we believe that it should comprise the
method of choice when the specific characteristics
of the illness allow it. Prospective, randomized
comparative studies between the two methods are
required, in order to determine their effects with
precision.
60
Hellenic
UROLOGY
Ðåñßëçøç
Åðåßãùí åìâïëéóìüò ìåôÜ áðü ñÞîç
áããåéïìõïëéðþìáôïò óå ìïíÞñç íåöñü
Ì. Óôáõñüðïõëïò, Ê. Ìðïõñüðïõëïò, Í. ÖåñÜêçò, Ç.
Ðïýëéáò
ÏõñïëïãéêÞ ÊëéíéêÞ Íïóïêïìåßïõ Åëëçíéêïý Åñõèñïý
Óôáõñïý
Õðåýèõíïò åðéêïéíùíßáò: Ìðïõñüðïõëïò Êùíóôáíôßíïò
Íïóïêïìåßï Åëëçíéêïý Åñõèñïý Óôáõñïý
ÏõñïëïãéêÞ ÊëéíéêÞ, 11526 ÁèÞíá
Tçë: +30 2106414000 - email: [email protected]
Ôï áããåéïìõïëßðùìá ôïõ íåöñïý áðïôåëåß ìéá
áðü ôéò ðéï óõ÷íÝò áéôßåò ðïõ ìðïñïýí íá
ðñïêáëÝóïõí áõôüìáôç ðåñéíåöñéêÞ áéìïññáãßá.
ÐáñïõóéÜæïõìå ôçí ðåñßðôùóç ìéáò ãõíáßêáò
áóèåíïýò, ìÝóçò çëéêßáò, ðïõ ðáñïõóéÜóèçêå ìå
áõôüìáôç ñÞîç åíüò ìåãÜëïõ áããåéïìõïëéðþìáôïò óå ìïíÞñç íåöñü. Ç áóèåíÞò áíôéìåôùðßóèçêå ìå åêëåêôéêü áããåéáêü åìâïëéóìü (ÅÁÅ)
êáé åîÞëèå óå êáëÞ êáôÜóôáóç ìå áíåðçñÝáóôç
íåöñéêÞ ëåéôïõñãßá. Ï ÅÁÅ ðñïóöÝñåé áðïôåëåóìáôéêü Ýëåã÷ï ôçò áéìïññáãßáò óôçí ïîåßá öÜóç,
áëëÜ Ý÷åé ðåñéïñéóìÝíç áîßá óôçí ìáêñïðñüèåóìç áíôéìåôþðéóç ôùí ÁÌË. Ïé ÷åéñïõñãéêÝò ìïñöÝò áíôéìåôþðéóçò åðéôñÝðïõí ôçí ðëÞñç áöáßñåóç ôïõ üãêïõ, áëëÜ åìöáíßæïõí óçìáíôéêüôåñåò åðéðëïêÝò.
ËÝîåéò åõñåôçñéáóìïý: áããåéïìõïëßðùìá,
óýíäñïìï Wunderlich, åìâïëéóìüò
Emergency embolisation of a spontaneously ruptured angiomyolipoma in a solitary kidney
References
1. Óôáõñüðïõëïò Ì, Ìðïõñüðïõëïò Ê,
Ðïýëéáò Ç. Áõôüìáôç ñÞîç íåöñïý: áéôéïëïãßá,
äéÜãíùóç êáé èåñáðåõôéêÞ áíôéìåôþðéóç. ÅëëçíéêÞ Ïõñïëïãßá 2012, 24:247-54.
5. Faddegon S, SO A. Treatment of angiomyolipoma at a tertiary care centre: the decision between surgery and angioembolization.
Can Urol Assoc J 2011, 5: 138-141.
2. Parameswaran B, Khalid M, Malik N.
Wunderlich syndrome following rupture of a
renal angiomyolipoma. Ann Saudi Med 2006,
26:310-12.
6. Chatziioannou A, Gargas D, Malagari K,
Kornezos I, Ioannidis I, Primetis E, et al. Transcatheter arterial embolization as therapy of
renal angiomyolipomas: the evolution in 15
years of experience. Eur J Radiol 2012,
81:2308-12.
3. Coskuner E R, Ozkan B, Yalcin V. The
role of partial nephrectomy without arterial
embolization in giant renal angiomyolipoma.
Case Rep Med 2012, 2012: 365762.
4. Ploumidis A, Katafigiotis I, Thanou M,
Bodozoglou N, Athanasiou L, Ploumidis A.
Spontaneous retroperitoneal hemorrhage
(Wunderlich syndrome) due to large upper
pole renal angiomyolipoma: does roboticassisted laparoscopic partial nephrectomy
have a role in primary treatment? Case Rep
Med 2013, 2013: 498694.
7. Lee Sy, Hsu Hh, Chen Yc, Huang Cc,
Wong Yc, Wang LJ, et al. Evaluation of renal
function of angiomyolipoma patients after
selective transcatheter arterial embolization.
Am J Med Sci 2009, 337:103-8.
8. Kothary N, Soulen Mc, Clark Tw, Wein Aj,
Shlansky-Goldberg Rd, Crino Pb, et al. Renal
angiomyolipoma: long-term results after
arterial embolization. J Vasc Inter Radiol 2005,
16:45-50.
Hellenic
UROLOGY
61