(Conclusions) In diagnosis of BPH, conventional UDS has limitation for certain and some caution showed be taken in interpretation of the data. However
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1 DIAGNOSTIC VALUES AND LIMITATIONS OF CONVENTIONAL URODYNAMIC STUDIES (UROFLOWMETRY RESIDUAL URINE MEASUREMENT CYSTOMETRY) IN BENIGN PROSTATIC HYPERTROPHY Momokazu Gotohl, Yoko Yoshikawal, Atsuya Kondol, Norio Kato2, Yoshinari Ono2, Tetsushi Kondo3, Tatsuya Nagai3, Toshifumi Sakakibara3, Atsuo Kondo4 and Koji Miyake4 'Department of Urology, Hekinan Municipal Hospital (Chief: M. Gotoh) 2Department of Urology, Komaki Shimin Hospital (Chief: Y. Ono) 3Department of Urology, Nishio Municipal Hospital (Chief: T. Sakakibara) 4Department of Urology, Nagoya University School of Medicine (Director: Prof. K. Miyake) (Purpose and Methods) Diagnostic values and limitation of conventional urodynamic study (UDS) were assessed in 380 patients with benign prostatic hypertrophy (BPH), in terms of uroflowmetry, measurement of postvoid residual urine and cystometry. (Results) Maximum and average flow rate on uroflowmetry improved with increasing voided volume. Neither maximum nor average flow rate correlated with size of the prostate, subjective symptom (International Prostate Symptom Score) and bothersomeness for prostatism. Pre-TUR maximum flow rate did not predict outcomes on postoperative flow rate and surgical treatment failures. Uroflowmetry did not differentiate between obstruction and weakness of detrusor contraction. The intraindividual variation of postvoid residual urine was great and the volume of residual urine correlated poorly with subjective symptom, size of the prostate, maximum and average flow rate. On filling cystometry, although uninhibited detrusor contraction was much more frequently observed in patients with urege incontinence as compared with continent patients, there was no significant difference in other parameters between the two groups. Every parameter on cystometry did not correlate with nocturnal frequency. Postoperative persisitence of urge incontinence did not correlate with the bladder volume at the first desire to void or at the maximum desire to void, an amplitude of uninhibited detrusor contractions, or bladder compliance. In some cases, evaluation of the intravesical pressure on voiding phase and uroflowmetry was diagnostic of apparent obstruction.
2 (Conclusions) In diagnosis of BPH, conventional UDS has limitation for certain and some caution showed be taken in interpretation of the data. However, since conventioanl UDS provides important and objective information on obstruction and dertrusor function, which are independent of subjective symptom and prostate size, these should be necessary in diagnosis, determination of treatment options and evaluation of treatment outcomes in BPH. Key words: benign prostatic hypertrophy, urodynamic study, diagnosis
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6 1326 図3 TURP, 薬 物 治療 前 後 で の1-PSSと 最 大 尿 流 率 の変 化 MFR (ml/sec) 治療 前 TURP前 治療 後 治療前 治療後 治療前 治療後 後 薬 物 治療 前後 MFR (ml/sec) 治療 前 で は12.1±1.5ml/secか 治療 後 ら17.6±5.1m1/secへ れ も有 意 に改 善 した が(p<0-001), とい ず 図4 TURP術 前 の最 大 尿 流率(MFR)レ ベ ル の違 い に よ る術 後 最大 尿 流 率 の相 違 3群 間 の 術 後 の 値 に は 有 意 差 が 認 め られ な か っ た(図4). 術 後 の 尿 流 測 定 パ ラ メ ー タ-改 善 の 不 良 例 は, 術 前 最 大 尿 流 率5m1/sec未 ml/sec群 満 で は11-7%(2/17), で7-8%(4/57), 12-9%(4/31)に 満群 で は n=31 3群 間 に お け る不 良 例 の 出 n=57 10以 上15ml/sec未 み ら れ, n=705 5以-上1o (10<MFR<15) (S<MFR<10J 現 頻 度 に は 大 き な差 は認 め られ な か っ た. 外 尿 道 狭 窄, n=17 (MFRく5) 膀 胱 頸 部 狭 窄 の な い こ と を確 認 後, 不 良 例10例 中5例 でPressure-Flow Studyが Abram-Gri伍tl gram3)に nomograln4)に 例, very weak て 閉 茎 は な く, Schafer 2例)の detrus(, r: 3 所 見 を 示 した. こ れ ら の 症 例 の 術 前 尿 流 測 定 の 尿 流 カ ー ブ の パ タ-ン を retrospectiveに TUR-P後 術 後 行 わ れ た が, 全 例 て排 尿 筋 収 縮 障 害(weak detrunor: TUR-P前 検 討 した が, 閉 塞 と排 尿 筋 収 縮 障 害 と も不 良 で あ っ た(図5d, 表1). 膀胱 内圧 測 定 (1)切 迫 性 尿 失 禁 の 有 無 と膀 胱 内 圧 測 定 パ ラ メ ー ターの関係 の 区 別 は 困 難 で あ っ た. 切 迫 性 尿 失 禁 を 有 す る群 で は, 尿 失 禁 の な い群 に比 残 尿 測定 べ て無 抑 制 収 縮 が 高 率 に 認 め られ た(失 禁 群65%, (1)残 尿 量 の ば ら つ き 失 禁 群8%)が, 発 尿 意 容 量, 同 一 症 例 で の, 2回 の 異 な る測 定 で の 残 尿 量 に は あ る程 度 の 連 関 が み ら れ た が(表1), 絶 対 値 と して は 大 他 の パ ラ メ ー タ ー(初 最 大 尿 流 容 量, 膀 胱 コ ン プ ラ イ ア ンス)に は有意 差 が 認 め られ な か っ た(図6). き な ば らつ きが 認 め られ た(図5a). (2)夜 間 排 尿 回 数 と膀 胱 内 圧 測 定 パ ラ メ ー タ-の (2)残 尿 量 と 自 覚 症 状 ス コ ア 前 立 腺 サ イ ズ と の 関 係 残 尿 量 と1-pSS(図5b), 尿 意 容 最 の 連 関 は み られ な か っ た(表1). 係 夜 間 排 尿 回 数 と膀 胱 内 圧 測 定 の 初 発 尿 意 容 量, c)と お よ び 前 立 腺 サ イ ズ(図5 の 連 関 は い ず れ も不 良 で あ っ た(表1). (3)残 尿 量 と尿 流 測 定 パ ラ メ-夕 非 一 との 関 係 残 尿 量 と最 大 尿 流 率, 平 均 尿 流 率 と の連 関 は い ず れ (3)TURP術 関 最大 後 の 切 迫 性 尿 失 禁 の 消 失 残 存 と術 前 膀 胱 内 圧 測 定 パ ラ メ ー タ ー の 関係 術 前 切 迫 性 尿 失 禁 が あ り, 術 後3カ 月以 後 の尿失 禁
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9 1) Recommendations of the International Consultation on Benign Prostatic Hyperplasia (BPH). Edited by A. T. K., Cockett, Y. Aso, C. Chatelain, L. Denis, K. Grifl'iths, S. Khoury and G. Murphy, Paris, p , Jun 27-30, ) Ireton, R. C., Krieger, J. N., Cardenas, D. D., Williams-Burden, B., Kelly, E., Souci, T. and Chapman, W. H.: Bladder volume determination using a dedicated, portable ultrasound scanner. J. Urol., 143, , ) Abrams, P. H. and Griffiths, D. J.: The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Br. J. Urol., 51, , 1979.
10 4) Schafer, W., Rubben, H., Noppeney, R. and Deutz, F. J.: Obstructred and unobstructed prostatic obstruction. A plea for urodynamic objectivation of bladder outflow obstruction in benign prostatic hyperplasia. World J. Urol., 6, , ) Barry, M. J., Fowler, F. J. Jr., O'Leary, M. D., et al. and the Measurement Committee of the American Urological Association: The American Urological Association Symptom Index for benign prostatic hyperplasia. J. Urol., 148, , 1992, 6) US Department of Health and Human Service, Public Health Service, Agency for Health Care Policy and Research: Clinical Practice Guideline: Benign Prostatic Hyperplasia: Diagnosis and Treatment. AHCPR Publication No , February ) Yalla, S. V., Sullivan, M. P., Lecamwasam, H. S., DuBeau, C. E., Vickers, M. A. and Cravalho, E. G.: Correlation of American Urological Association Symptom Index with obstructive and nonobstructive prostatism. J. Urol., 153, , ) Diokno, A. C., Brown, M. B., Goldstein, N. G. and Herzog, A. R.: Urinary flow rates and voiding pressures in elderly men living in a community. J. Urol., 151, , 1994, 9) Ko, D. S. C., Fenster, H. N., Chambers, K., Sullivan, L. D., Jens, M. and Goldenberg, S. L.: The correlation of multichannel urodynamic pressure flow studies and american urological association symptom index in the evaluation of benign prostatic hyperplasia. J. Urol., 154, , ) van Venrooij, G. E. P. M. and Gier, R. P. E.: International prostate symptom score and quality of life assessment versus urodynamic parameters in men with benign prostatic hyperplasia symptoms. J. Urol., 153, , 1995, 11) Siroky, M. B., Olsson, C. A. and Krane, R. J.: The flow rate nomogram I: Development. J. Urol., 122, , ) Kuo, H. C. and Tsai, T. C.: The predictive value of urine flow rate and voiding pressure in the operative outcome of benign prostatic hypertrophy. Taiwan I. Hsueh Hui Tsa Chih, 87, , ) Resnick, N. M. and Yalla, S. V.: Detrusor hyperactivity with impaired contractile function. J. A. M. A., 257, , ) Turner-Warwick, P., Whiteside, C. G., Arnold, E. P., Bates, C. P., Worth, P. H. L., Milroy, E. G. J., Webster, JR. and Weir, J.: A urodynamic view of prostatic obstruction and the results of prostatectomy. Br. J. Urol., 45, , ) Andersen, J. T.: Prostatism: Clinical, radiological and urodynamic aspects. Neurourol. Urodynam., 1, , ) Ameda, K., Koyanagi, T., Nantani, M., Taniguchi, K. and Matuno, T.: The relevance of preoperative cystometrography in patients with benign prostatic hyperplasia: Correlating the findings with clinical features and outcome after prostatectomy. J. Urol., 152, , 1994.
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