We present two cases of patients with hypocontractile bladder whose voiding efficiency completely resolved following radical prostatectomy. 

Keywords: prostatic neoplasms, prostatectomy, urinary retention, treatment outcome
Authors:

Stone AR, Evans CP
Institution: Department of Urology. University of California Davis Medical Center, Sacramento, CA. 

Corresponding Author: Stanley A. Yap 4860 Y Street, Suite 3500 Sacramento, CA 95817 Email: yapsat@gmail.com

Abstract

We currently have a poor understanding of the outcomes of patients with detrusor hypocontractility who undergo radical prostatectomy. This information is important in treatment selection for prostate cancer, as well as for defining expectations following surgery. We present two cases of patients with hypocontractile bladder whose voiding efficiency completely resolved following radical prostatectomy. 

Introduction

The goals of treatment for patients undergoing radical prostatectomy for prostate cancer include achieving complete continence as well as a normal voiding and emptying pattern. We currently have a poor understanding of our ability to achieve such goals in patients with hypocontractile bladder function and how to appropriately select those with the greatest likelihood of success.  In order to shed some light on this, we present two cases of patients with hypocontractile bladder whose voiding efficiency resolved immediately following radical prostatectomy.

Case Reports

Patient 1: 
62 year-old male with a history of insulin-dependant diabetes and a stroke with minimal residual deficit. He has had a long history of lower urinary tract symptoms (LUTS) and a poor ability to void spontaneously. He carries a post void residual of 500ml and manages his bladder with clean intermittent catheterization (CIC). Urodynamic evaluation demonstrated a hyposensitive bladder. Calculations of bladder outlet obstruction index and bladder contractility index suggest an element of obstruction, though he also demonstrated poorly sustained bladder contractions suggestive of myogenic failure. His bladder was filled to 700ml before reporting a strong desire to void, and he was only able to void 350ml. He had no leakage and no abnormal contractions during filling. 
He was also found to have an elevated PSA of 5.8ng/ml on routine screening. Subsequent transrectal ultrasound-guided (TRUS) biopsy of the prostate demonstrated a Gleason 6 (3+3) adenocarcinoma of the prostate and, after discussion, he elected to undergo robotic-assisted laparoscopic prostatectomy (RALP). This was performed uneventfully with final pathology demonstrating a pT2a, Gleason 6 (3+3), margin negative adenocarcinoma of the prostate on the left side of the gland. He was managed in the standard fashion during his postoperative recovery, except his catheter was left for a total of two weeks (one week longer than our standard for patients undergoing RALP). At 15 months follow-up his PSA remains undetectable. He reports a strong stream, and he empties completely. He has only minimal leak with strain.
Repeat urodynamic studies performed 10 months following surgery demonstrate volitional detrusor contractions with a maximum detrusor pressure of 29cm of H2O. Bladder compliance was normal and the patient successfully voided to completion with a maximum flow rate of 18ml/sec.

Patient 2: 
70 year-old male with an eight year history of complete urinary retention managed with CIC. Urodynamic studies demonstrated an acontractile bladder and associated pelvic floor dysfunction. He was filled to 420 ml and was unable to void. Cystoscopy was completely normal. 
He was found to have an elevated PSA of 4.2 (16% free) and underwent TRUS biopsy demonstrating a Gleason 7(4+3) adenocarcinoma of the left base and mid gland. He subsequently underwent open radical prostatectomy. His pathology demonstrated a T2aN0, Gleason 9(4+5) adenocarcinoma with negative margins. His catheter was left post-operatively for one week longer than our standard for open radical prostatectomy (three weeks total). He continued to perform CIC, initially, but stopped shortly after he noticed that he was able to void spontaneously. He has now been followed for 5 years since his surgery. His PSA remains undetectable. He gained full continence at 4 months post-operatively and since the surgery he has voided with a strong stream. Uroflow studies demonstrate a normal appearing flow curve with a maximum flow rate of 24ml/s. Ultrasound assessment of postvoid residual was zero after voiding a volume of 528ml. In addition, his erectile function has returned to full potency pre-surgery levels without the use of Phosphodiesterase inhibitors.

Discussion

We present two cases of patients with hypocontractile bladder managed with CIC who subsequently underwent radical prostatectomy for prostate cancer. Both men experienced complete resolution of their voiding symptoms following surgery. These patients represent a subgroup of which we have a poor understanding of the impact of radical prostatectomy on their voiding patterns and subsequent satisfaction. An understanding of the voiding outcomes in such patients is essential as we discuss treatment options and present an informed discussion of expectations and recovery. 
No previous studies to our knowledge directly address this issue. Extrapolating from experience in patients undergoing TURP for LUTS due to impaired detrusor contractility, we would expect them to do poorly in regards to their post operative voiding function. These patients consistently have poor outcomes compared to their cohorts with bladder outlet obstruction and normal bladder contractility. Han et al demonstrated that unobstructed patients with weak bladder contractility undergoing TURP can achieve improvements in International Prostate Symptom Score (IPSS) and Quality of Life questionnaire, though these improvements were significantly less than that seen in the control group consisting of obstructed patients with normal bladder contractility.(1) In another series, Seki et al demonstrated that degree of bladder outlet obstruction represents one of the most significant independent predictors of improvements in Qmax following TURP for patients with detrusor hypocontractility.(2) Thomas et al report the only series with pre and post-operative urodynamic studies. They found no significant changes in urodynamic profiles as well as no improvements in flow rate or detrusor contractility in this subgroup of patients.(3) A few studies have demonstrated equivalent outcomes in these patients after undergoing TURP, though they remain the minority.(4, 5)
Other studies offer insight into the functional changes that occur following radical prostatectomy. Changes that are consistently described include decreases in bladder compliance, outlet obstruction, and detrusor contractility. During the initial months following radical prostatectomy, new impairment in detrusor contractility are found in 29-51% of patients and in long-term follow up, these findings persist in approximately 25% of patients.(6, 7) Despite the prevalence of hypocontractile detrusor function, the majority of patients will develop adequate voiding efficiency. Multiple studies report increases in maximum flow rate(8), decreases in PVR(8-11), and an absence of patient complaints of voiding symptoms(8) following radical prostatectomy. These outcomes, though, are taken in the context of increased intravesical and abdominal pressure during maximum flow(10, 11) and decreased urethral opening pressure(6, 10, 11). Despite worsening bladder contractility, these patients develop a compensated voiding with increased abdominal strain working against a decreased outlet pressure.
Although a patient with normal preoperative detrusor contractility may retain enough function to adequately compensate for the myriad of changes, the impact of radical prostatectomy on the individual with pre-existing detrusor hypocontractility may be of greater detriment. This was not the case in our two patients who report a strong stream, demonstrate no residual volumes, and have no symptomatic voiding complaints. Objective measures of voiding function obtained in the post-operative period further confirm these findings, providing evidence of recovered detrusor activity.
These findings emphasize the potential for a return of normal voiding patterns following radical prostatectomy in patients with hypocontractile detrusor function, while demonstrating the complex and unpredictable nature of these cases. This is a population that would benefit from further studies and clinical trials to elucidate the true mechanisms at work. 

Conclusion

We have a poor understanding of the outcomes of patients with detrusor hypocontractility who undergo radical prostatectomy. We present two cases of patients with hypocontractile bladder whose voiding efficiency completely resolved following such surgery. These findings demonstrate the potential for successful outcome in these patients as well as the unpredictable nature of these cases. 

References

1. Han DH, Jeong YS, Choo MS, Lee KS. The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index. Urology. 2008 Apr;71(4):657-61.
2. Seki N, Kai N, Seguchi H, Takei M, Yamaguchi A, Naito S. Predictives regarding outcome after transurethral resection for prostatic adenoma associated with detrusor underactivity. Urology. 2006 Feb;67(2):306-10.
3. Thomas AW, Cannon A, Bartlett E, Ellis-Jones J, Abrams P. The natural history of lower urinary tract dysfunction in men: the influence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10-year urodynamic follow-up. BJU Int. 2004 Apr;93(6):745-50.
4. Bruskewitz R, Jensen KM, Iversen P, Madsen PO. The relevance of minimum urethral resistance in prostatism. J Urol. 1983 Apr;129(4):769-71.
5. Van Venrooij GE, Van Melick HH, Eckhardt MD, Boon TA. Correlations of urodynamic changes with changes in symptoms and well-being after transurethral resection of the prostate. J Urol. 2002 Aug;168(2):605-9.
6. Giannantoni A, Mearini E, Zucchi A, Costantini E, Mearini L, Bini V, et al. Bladder and urethral sphincter function after radical retropubic prostatectomy: a prospective long-term study. Eur Urol. 2008 Sep;54(3):657-64.
7. 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 Jun;163(6):1767-70.
8. Hellstrom P, Lukkarinen O, Kontturi M. Urodynamics in radical retropubic prostatectomy. Scand J Urol Nephrol. 1989;23(1):21-4.
9. Majoros A, Bach D, Keszthelyi A, Hamvas A, Romics I. Urinary incontinence and voiding dysfunction after radical retropubic prostatectomy (prospective urodynamic study). Neurourol Urodyn. 2006;25(1):2-7.
10. Kleinhans B, Gerharz E, Melekos M, Weingartner K, Kalble T, Riedmiller H. Changes of urodynamic findings after radical retropubic prostatectomy. Eur Urol. 1999;35(3):217-21; discussion 21-2.
11. Constantinou CE, Freiha FS. Impact of radical prostatectomy on the characteristics of bladder and urethra. J Urol. 1992 Oct;148(4):1215-9; discussion 9-20.



Date added to bjui.org: 23/09/2010 (publication information)
This content is exclusive to bjui.org website.

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CASE REPORTS: The Hypocontractile Bladder and Radical Prostatectomy: complete restoration of voiding efficiency. 

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