Diagnosing Bladder Outlet Obstruction in Women

Νitti, Victor W.; Tu, Le Mai; Gitlin, Jordan

doi:10.1016/s0022-5347(05)68947-1

Cited by 377 publications

(229 citation statements)

References 30 publications

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“…[ 25 ] , being a combination of symptoms, urethral meatal appearance, a history of diffi cult instrumentation with supportive urodynamic testing. The urodynamic studies seemed to support the clinical impression and were very similar to those stated by Nitti et al [ 26 ] . being a combination of voiding pressures, urinary fl ow rates, and fl uoroscopic imaging.…”

Section: Discussionsupporting

confidence: 88%

Dorsal vaginal graft urethroplasty for female urethral stricture disease

et al. 2012

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Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Female urethral stricture disease has been described for almost 200 years. The symptoms of female stricture disease may range from clinically insignificant to severe and debilitating with the exact aetiology being unclear. No strict criteria for diagnosis have been established with the diagnosis often relying on a combination of presenting symptoms and objective findings. Initial therapy for female urethral stricture disease has often rested on urethral dilatations and self‐intermittent catheterisation with surgery reserved for patients that failed conservative measures. Female urethroplasty currently is a topic of increasing attention with multiple surgical approaches described including use of both grafts (vaginal wall, buccal mucosal membrane, lingual mucosa, and labia minus) and flaps (vaginal vestibule, anterior vagina, and lateral vagina).We describe our approach to female urethroplasty using a suprameatal (dorsal) approach (described by Tsivian and Sidi) with an autologous vaginal epithelium inlay graft. The technique and modern approaches to female urethroplasty are contrasted and discussed. The success of the approach including continence rates and lack of need for long‐term self‐intermittent catheterisation is noted.OBJECTIVE To review the technique and outcomes of using a dorsal vaginal graft to perform urethroplasty for the treatment of urethral strictures in women. PATIENTS AND METHODS This is a retrospective chart review of 11 women who were treated with a dorsal vaginal graft urethroplasty by one surgeon. All women underwent preoperative evaluation that included history, physical examination, fluoro‐urodynamics and urethral calibration. After surgery interviews, physical examinations, and urinary flow and postvoid residual urine volumes (PVRs) were obtained. RESULTS In all, 11 women who had undergone dorsal vaginal graft urethroplasty were identified for review. The mean (range) age was 60.6 (39–75) years. The mean (range) follow‐up was 22.7 (6–46) months. There were no cases of new onset stress urinary incontinence. The mean PVRs before and after surgery were 187.1 mL and 75.8 mL, respectively (P= 0.003). The mean urinary flows before and after surgery were 7.3 mL/s and 21.8 mL/s, respectively (P= 0.001). No patient has required repeat surgery. Self‐reporting satisfaction scores using the Patient Global Impression of Improvement showed that four patients scored 1 (very much better), three scored 2 (much better), two patients scored 3 (a little better), and one scored 4 (no change). Only one patient scored a 5 (worse). CONCLUSION Dorsal graft urethroplasty with vaginal mucosa may be considered as a first‐line option for definitive management of female urethral stricture disease. No consensus exists for the surgical treatment of female urethral stricture disease.

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Section: Discussionsupporting

confidence: 88%

Dorsal vaginal graft urethroplasty for female urethral stricture disease

et al. 2012

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“…VCC definition of obstruction itself had the highest agreement with the video urodynamics definition of obstruction (1,4). This may be due to the similarity between the tests as a urethral imaging based study.…”

Section: Discussionmentioning

confidence: 81%

“…When patient history or time frame does not offer this diagnostic advantage, more thorough evaluation is warranted than just proceeding to urethrolysis, especially if she has already had a history of that operation (14). The complex nature of female voiding dysfunction may require additional parameters besides pressure-flow criteria (1)(2)(3)(4)(5)(6)(7)15). We desired to see if the VCC, as a non-pressure-flow based test, would assist in positively predicting those patients that would have a successful urethrolysis.…”

Section: Discussionmentioning

confidence: 99%

Voiding Chain Cystourethography: Assessing A Historical Test's Role in Selection for Urethrolysis

et al. 2013

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Objective: To analyze the benefit of voiding chain cystourethrography (VCC) [placing a radiographic opaque chain into the urethra and bladder and asking the patient to void under fluoroscopy] in the urodynamic evaluation of female bladder outlet obstruction (BOO). Materials and Methods: Females with post anti-incontinence operation voiding dysfunction who underwent urodynamic evaluation augmented with VCC and later had urethrolysis were identified. Six diagnostic criteria for obstruction were applied to each patient: (1) VCC ( obstructed: chain was angulated and could not be voiding out) (2) Video urodynamic study (VUDS) (detrusor contraction combined with radiographic obstruction) (3) maximum flow (Q max ) ≤ 15 cc/sec, detrusor pressure (pDet)@ Q max ≥ 20 cm H 2 0 (4) Q max ≤ 11 cc/sec, pDet@ Q max ≥ 25 cm H 2 0 (5) Q max ≤ 12 cc/sec, pDet@ Q max ≥ 25 cm H 2 0 (6) Blaivas-Groutz (B-G) nomogram. Urethrolysis results were reviewed. Agreement in assessment of BOO criteria was assessed by estimating the proportion of pair-wise agreements along with an exact binomial 95% confidence interval (CI) and by estimating kappa along with a 95% CI. Results: Twenty-one patients were identified. Twenty of the 22 urethrolyses (91%) were clinically successful. Diagnosis of BOO was most common for VCC (86%) and then B-G Nomogram (67%). Agreement with the VCC was relatively poor for each of the five other methods (14%-62%) with the video urodynamic study (VUDS) being the best. Three patients with successful urethrolysis were diagnosed only by the VCC. All of kappa values regarding agreement with the VCC were low; the highest value of 0.15 was observed for VUDS. Conclusion: VCC may augment selection criteria for urethrolysis. INTRODuCTIONSelection for urethrolysis in symptomatic females with a history of an anti-incontinence procedure may be challenging, especially in the absence of immediate temporal association and/ or with a history of previous failed urethrolysis. While recognizing the value of the various pressure flow criteria developed for female bladder outlet obstruction (BOO), our clinic relies principally on the video urodynamic appearance of the bladder and urethra with voiding as described by Nitti et al.(1) and the Blaivas Groutz (B-G) nomogram (2). In some patients with a high index of clinical suspicion, the pressure flow criteria for obstruction were not strictly met and/or it was difficult to identify the urethra during testing.

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“… Oravanet al 7 in his study shows that, mean age of the study population was 53.7 ± 13.6 years. Nitti et al 8 showed in their study of 76 obstructed cases the mean age was 57.5 years. Metinet al 9 in his study found the mean age is 52.6 years.…”

Section: Age Distribution In Female Bladder Outlet Obstruction:-mentioning

confidence: 93%