Bladder Outflow Tract Obstruction and Urinary Retention from Benign Prostatic Hypertrophy Treated by Balloon Dilatation

Abstract

Forty-eight men with urodynamically proven bladder outflow tract obstruction (BOO) and 19 with retention secondary to benign prostatic hypertrophy were treated by balloon dilatation of the prostate as out-patients; 31 were dilated with 20 mm and 36 with 25 mm balloons. Of the 48 men with BOO, 37 had repeat cystometrograms at intervals ranging from 3 to 11 months after dilatation and 33 (89%) remained obstructed by urodynamic criteria. Of 6 who only had a peak flow rate assessment, 5 had a flow less than 12 ml/s. Of the 19 patients in retention only 3 were able to void and all are obstructed. Symptoms of hesitancy, poor stream, frequency and nocturia were improved in less than 50% of patients. No reliable correlation was found between objective response and balloon size, length of time of dilatation, prostate size or morphology, detrusor pressure or stability, or post-dilatation urethrogram appearances. Balloon dilatation to 25 mm is not adequate therapy for bladder outflow tract obstruction or urinary retention from prostatic hypertrophy.

Balloon dilatation of the prostatic urethra ? should it have a place in the urologist's armamentarium?

“…When the symptoms of the condition are variable, and when without treatment only 10 of 107 patients with symptoms of prostatic obstruction required surgical treatment over a period of 5 years and in the majority symptoms did not worsen [3], it is difficult to advocate any form of operative treatment with its associated morbidity and mortality unless objective criteria for making a specific diagnosis are used. Only two studies of balloon dilatation of the prostatic urethra have used urodynamic criteria to define patients with objective evidence of bladder outflow obstruction with or without detrusor instability [11,16]. According to the criterion of a urethral resistance of less than 0.5, only 3 patients remained unobstructed at 6 months, and there was a trend towards predilatation parameters in nearly all patients, including those who remained unobstructed.…”

“…Following dilatation only 7 of 21 men with instability reverted to stability, which further supports our findings that dilatation is not an efficient means of relieving bladder outflow obstruction. Following efficient relief of obstruction, 75% of men with preoperative instability may be expected to revert to stability [11]. Balloon dilatation does not appear to have a role in the treatment of either acute or chronic retention of urine, with very few patients being able to void and those who can still having obstruction, with a high incidence of repeat episodes of retention.…”

“…Cystometric assessment of patients subjected to dilatation with 20-and 25-mm balloons revealed that only 11%0 had been rendered unobstructed, despite nearly 50% obtaining symptomatic relief [11]. In a later study from the same unit, using a purpose-built 35-mm balloon, it was found that in patients presenting with acute retention, none was rendered unobstructed, and at 6 months only 3 of 27 with bladder outflow obstruction were unobstructed although in 15 the symptoms remained improved [16].…”

Balloon dilatation of the prostate as compared with transurethral resection of the prostate for treatment of benign prostatic hypertrophy

“…It challenges the fundamental concept of most urologists that the cause of prostatism is enlargement of the prostate gland, which, by virtue of its size, blocks the flow of urine, requiring a reduction of the obstructing bulk. When first presented with the idea of balloon dilatation, urologists tend to be skeptical of its efficacy, but empirical studies from many centers indicate that it is indeed efficacious [7,8,10,15,16], although some reports show less favorable results [9,12].…”

“…Patient selection seems critical; for example, most authors agree that middle lobe hypertrophy mitigates successful dilatation [18]. The size of the gland is also important; the average weight of the gland was 69 g in one study showing poor effectiveness of dilatation [9], whereas that obtained in a study showing good effectiveness was 36 g [10].…”