RETROGRADE TRANSURETHRAL BALLOON DILATION OF PROSTATE: INNOVATIVE MANAGEMENT OF ABACTERIAL CHRONIC PROSTATITIS AND PROSTATODYNIA WILLIAM B. LOPATIN, M.D. MICHAEL MARTYNIK, M.D. DAVID R HICKEY, M.D.
CARLOS VIVAS, M.D. THOMAS R. HAKALA, M.D.
From the Department of Surgery, Division of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
ABSTRACT--Retrograde transurethral balloon dilatation (RTBD) of the prostate rec~ suggested as alternative therapy for patients with benign prostatic hyperplasia (BP1 tients with documented functional urinary outlet obstruction at the level of the blc prostatic urethra underwent RTBD of prostate. Each patient had a classic diagnosis chronic prostatitis or prostatodynia based on history, physical examination, and loc tures. Prior to BTBD of prostate, patients underwent cystoscopy, voiding cystouret~ dynamic and uroflow studies. RTBD of prostate was done as an outpatient proced intravenous sedation or general anesthesia. Dilation was performed with a 25-ram balloon catheter inflated at 3.5 arm of pressure for twenty minutes. Improvement in vo matology was noted in all patients and graded numerically (0-10 scale), with ten indic voiding. Follow-up to date ranges from one to five months. This technique may haw treatment option in patients with abacterial chronic prostatitis and prostatodynia.
Patients diagnosed with abaeterial chronic prostatitis or prostatodynia are a perplexing management problem for the urologist. Urodynamic studies of these patients have shown that most have an unstable or nonrelaxing bladder neek or prostatic urethra, j a Barbalias, Meares, and Sant in 19831 reported signifieant inereases in maximal urethral closure pressure in patients with prostatodynia, as well as decreases in peak and average urinary flow rates eompared with age-matched controls. Alphablocking agents, such as prazosin hydrochloride (Minipress), have been suggested as a possible treatment option beeause of the aforementioned urodynamie profile. 4 Patients often fail alpha-blocker therapy either because of significant side effects or no relief of voiding symptoms. 5
508
Considering the documente bladder outlet obstruction in thesq high failure rate of medical thera 1 cent availability of retrograde balloon dilatation (RTBD) of the treatment option in benign prost~ sia (BPH), 6 we were eneourage( clinical trial using RTBD of pro ment for functional bladder outlc Our series includes 7 patients w chronic prostatitis or prostatod} had symptoms despite previous treatment with alpha-blockers anti-inflammatory agents, and/oi ants. This study is an analysis of approach to the management oJ patient with the abacterial ehrm prostatodynia eomplex.
UROLOGY
/
D E C E M B E R 1990
/
VOLUME X
: I.
TABLEII.
Clinical data on patients, pre-RTBDP* Age (Yrs.)
Duration of Symptoms (Yrs.)
43
9,
Pre-RTBDP Medication
Minipress Penieillin Septra Tetracycline 33 1.5 Septra Vibramycin 21 2 Septra Percoeet Vibramycin 63 > l0 Septra Tetracycline 27 8 Septra Penicillin Tetracycline Minipress 62 2 Septra Tetracycline 33 11 Septra Tetracycline Penicillin rade transurethral balloon dilatation of prostate.
Material and Methods nen, twenty-one to sixty-three years 'ed the study. All patients had been the past for either abaeterial chronic or prostatodynia by a urologist, and m o r m a l voiding symptoms for more gear. Patients had been treated in the various eombinations of antibiotics, ~ u s c l e relaxants, and alpha-blockers. Table I ~ t s patients, duration of symptoms, and prior ~atment modalities. ~Voiding eystourethrogram (VCUG), urom .: . . . . roflow studies, eystoseopy, and stream urine and prostatic seere all performed prior to dflaexaminations were performed r RTBD of prostate, and instudies and subjective grading ,oiding symptoms: zero equals or worsening of symptoms and fl voiding. Urine cultures were each visit. prostate is done as an outpa~ P a ~ p ~ y e id'~rev eTht t YP~ 2f 2 e;nt~e~£a theeded ,~sthetic. Under sterile eonditions and atient in the lithotomy position the examination is earried out. Cystosessary to be assured that there is no bnormality that was possibly missed BD of prostate investigations. Pa-
Patient W.B. C.C. E.B. J.M. G.R J.R. D.G.
Results of RTBDP*
- - U r o f l o w (ce/see)-PrePostRTBDP RTBDP Mean 6 Peak 15 Mean 12 Peak 20 Mean 14 Peak 22 Mean 7 Peak 15 Mean i4 Peak 21 Mean 6 Peak 13 Mean 12 Peak 22
Mean 11 Peak 22 Mean 15 Peak 27 Mean 13 Peak 22 Mean 10 Peak i9 Mean 14 Peak 22 Mean 11 Peak 20 Mean 14 Peak 27
Post RTBDP (Grade) Symptoms 9 10 2 7 6 7 8
*Retrograde transurethral balloon dilatation of prostate.
tients are then taken down from the lithotomy position and placed obliquely at approximately 30-degree rotation. The proper position of the prostatic balloon must be precise. The balloon apparatus is positioned above the urogenital diaphragm over a guide wire under fluoroscopic control. Location of the verumontanum and the prostatic urethra is determined by retrograde urethrogram. Onee the balloon is appropriately positioned, it is inflated to 3.5 atm pressure. This is maintained for twenty minutes. The balloon catheter is removed and a 16F Foley catheter is inserted. The patient is instructed to remove the Foley catheter at home the following day. Results After RTBD of prostate, all 7 patients have reported an improvement in their urinary stream, and a decrease in daytime frequency, irritability, and noeturia. Uroflow studies also doeumented an improvement in peak flow in all patients. Table II lists the graded results of the voiding symptoms for each patient and the quantitative results of post-procedure uroflow studies. All VCUGs performed prior to RTBD of prostate revealed that the bladder neck was dosed during voiding. CMGs were unremarkable, and uroflow studies revealed an average ftow rate of 10.1 ec per second. After RTBD of prostate, all patients reported improved voiding, and the urinary flow rates were increased. The average flow rate post procedure was 12.6 ee per second.
DECEMBER i990 / VOLUMEXXXVI, NUMBER 6
509
All patients tolerated the procedure well and were discharged home the same day. They were instructed on how to remove the Foley catheter at home the following day. To date, there are no reported complications from the procedure. The longest follow-up to date is five months. The mean score for subjective grading of symptoms was 7, with a range of 2 to 10. Six patients have been very satisfied with the results, and in 1 patient only slight improvement in symptoms was noted. The procedure has not had to be repeated in anyone. Comment Urodynamic studies of patients with prostatodynia have revealed significant increases in maximal urethral closure pressure, decreases in flow rates, and urethral narrowing at the level of the external urethral sphincter. ~ In the absence of anatomic obstruction or dyssynergia, these findings suggest a functional obstruction of the prostatic urethra or bladder neck. The treatment of abacterial chronic prostatitis-prostatodynia by traditional means (alpha-blockers, muscle relaxants, antibiotics) is often unsatisfactory, and we believe that treatment which is directed at the functional obstruction may offer the best option to date. Prior to the RTBD of prostate, all VCUGs performed revealed that the bladder neck was closed during voiding, although this may be ar-
510
tifaet due to the testing situation were negative for detrusor instab compliance, and uroflow studies average flow rate of 10.1 cc per s~ RTBD of prostate, all patients r proved voiding, and the urinary were increased. These initial results are encouraging. T~ role of repeated RTBD of prostate in treatmei of abacterial chronic prostatitis-prostatodyni awaits data from more patients as weli~; longer follow-up. In our early experience, t~ technique was associated with no morbidi~ with gratifying results. 4414 Presbyterian Universi~i Pittsburgh, Pennsylvania 152i~ (DR. L OPATI I References
:,i~
1. Barbalias GA, Meares EM Jr, and Sant GPt: Prostatod~ clinical and urodynamic characteristics, J Urol 130:514 (198~ 2. Hellstrom WJ, Schmidt RA, Lue TF, and Tanagho ~ Neuromuscular dysfunction in non-bacterial prostatitis, Uro~!~ 30:183 (1987). :~ 3. Murnaghan GF, and Millard RJ: Urodynamic evaluatiQrt~ bladder neck obstruction in chronic prostatitis, Br J Uro156:,!~ (1984). ..... 4. Orland SM, Hanno PM, and Wein AJ: Prostatitis, prost~i~ sis, and prostatodynia, Urology 25:439 (1985). ~ 5. Meares EM Jr, and Barbalias GA: Prostatitis: bacterial, ~ bacterial, and prostatodynia, 8emin Urol 1:146 (1983). ~ 6. Castaneda E et al: BPH: retrograde transurethral d i I ~ of the prostatic urethra in humans, Radiology 163:649 (198~)~!
UROLOGY / DECEMBER 1990 / VOLUME XXXVI,
CARLOS VIVAS, M.D. THOMAS R. HAKALA, M.D.
From the Department of Surgery, Division of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
ABSTRACT--Retrograde transurethral balloon dilatation (RTBD) of the prostate rec~ suggested as alternative therapy for patients with benign prostatic hyperplasia (BP1 tients with documented functional urinary outlet obstruction at the level of the blc prostatic urethra underwent RTBD of prostate. Each patient had a classic diagnosis chronic prostatitis or prostatodynia based on history, physical examination, and loc tures. Prior to BTBD of prostate, patients underwent cystoscopy, voiding cystouret~ dynamic and uroflow studies. RTBD of prostate was done as an outpatient proced intravenous sedation or general anesthesia. Dilation was performed with a 25-ram balloon catheter inflated at 3.5 arm of pressure for twenty minutes. Improvement in vo matology was noted in all patients and graded numerically (0-10 scale), with ten indic voiding. Follow-up to date ranges from one to five months. This technique may haw treatment option in patients with abacterial chronic prostatitis and prostatodynia.
Patients diagnosed with abaeterial chronic prostatitis or prostatodynia are a perplexing management problem for the urologist. Urodynamic studies of these patients have shown that most have an unstable or nonrelaxing bladder neek or prostatic urethra, j a Barbalias, Meares, and Sant in 19831 reported signifieant inereases in maximal urethral closure pressure in patients with prostatodynia, as well as decreases in peak and average urinary flow rates eompared with age-matched controls. Alphablocking agents, such as prazosin hydrochloride (Minipress), have been suggested as a possible treatment option beeause of the aforementioned urodynamie profile. 4 Patients often fail alpha-blocker therapy either because of significant side effects or no relief of voiding symptoms. 5
508
Considering the documente bladder outlet obstruction in thesq high failure rate of medical thera 1 cent availability of retrograde balloon dilatation (RTBD) of the treatment option in benign prost~ sia (BPH), 6 we were eneourage( clinical trial using RTBD of pro ment for functional bladder outlc Our series includes 7 patients w chronic prostatitis or prostatod} had symptoms despite previous treatment with alpha-blockers anti-inflammatory agents, and/oi ants. This study is an analysis of approach to the management oJ patient with the abacterial ehrm prostatodynia eomplex.
UROLOGY
/
D E C E M B E R 1990
/
VOLUME X
: I.
TABLEII.
Clinical data on patients, pre-RTBDP* Age (Yrs.)
Duration of Symptoms (Yrs.)
43
9,
Pre-RTBDP Medication
Minipress Penieillin Septra Tetracycline 33 1.5 Septra Vibramycin 21 2 Septra Percoeet Vibramycin 63 > l0 Septra Tetracycline 27 8 Septra Penicillin Tetracycline Minipress 62 2 Septra Tetracycline 33 11 Septra Tetracycline Penicillin rade transurethral balloon dilatation of prostate.
Material and Methods nen, twenty-one to sixty-three years 'ed the study. All patients had been the past for either abaeterial chronic or prostatodynia by a urologist, and m o r m a l voiding symptoms for more gear. Patients had been treated in the various eombinations of antibiotics, ~ u s c l e relaxants, and alpha-blockers. Table I ~ t s patients, duration of symptoms, and prior ~atment modalities. ~Voiding eystourethrogram (VCUG), urom .: . . . . roflow studies, eystoseopy, and stream urine and prostatic seere all performed prior to dflaexaminations were performed r RTBD of prostate, and instudies and subjective grading ,oiding symptoms: zero equals or worsening of symptoms and fl voiding. Urine cultures were each visit. prostate is done as an outpa~ P a ~ p ~ y e id'~rev eTht t YP~ 2f 2 e;nt~e~£a theeded ,~sthetic. Under sterile eonditions and atient in the lithotomy position the examination is earried out. Cystosessary to be assured that there is no bnormality that was possibly missed BD of prostate investigations. Pa-
Patient W.B. C.C. E.B. J.M. G.R J.R. D.G.
Results of RTBDP*
- - U r o f l o w (ce/see)-PrePostRTBDP RTBDP Mean 6 Peak 15 Mean 12 Peak 20 Mean 14 Peak 22 Mean 7 Peak 15 Mean i4 Peak 21 Mean 6 Peak 13 Mean 12 Peak 22
Mean 11 Peak 22 Mean 15 Peak 27 Mean 13 Peak 22 Mean 10 Peak i9 Mean 14 Peak 22 Mean 11 Peak 20 Mean 14 Peak 27
Post RTBDP (Grade) Symptoms 9 10 2 7 6 7 8
*Retrograde transurethral balloon dilatation of prostate.
tients are then taken down from the lithotomy position and placed obliquely at approximately 30-degree rotation. The proper position of the prostatic balloon must be precise. The balloon apparatus is positioned above the urogenital diaphragm over a guide wire under fluoroscopic control. Location of the verumontanum and the prostatic urethra is determined by retrograde urethrogram. Onee the balloon is appropriately positioned, it is inflated to 3.5 atm pressure. This is maintained for twenty minutes. The balloon catheter is removed and a 16F Foley catheter is inserted. The patient is instructed to remove the Foley catheter at home the following day. Results After RTBD of prostate, all 7 patients have reported an improvement in their urinary stream, and a decrease in daytime frequency, irritability, and noeturia. Uroflow studies also doeumented an improvement in peak flow in all patients. Table II lists the graded results of the voiding symptoms for each patient and the quantitative results of post-procedure uroflow studies. All VCUGs performed prior to RTBD of prostate revealed that the bladder neck was dosed during voiding. CMGs were unremarkable, and uroflow studies revealed an average ftow rate of 10.1 ec per second. After RTBD of prostate, all patients reported improved voiding, and the urinary flow rates were increased. The average flow rate post procedure was 12.6 ee per second.
DECEMBER i990 / VOLUMEXXXVI, NUMBER 6
509
All patients tolerated the procedure well and were discharged home the same day. They were instructed on how to remove the Foley catheter at home the following day. To date, there are no reported complications from the procedure. The longest follow-up to date is five months. The mean score for subjective grading of symptoms was 7, with a range of 2 to 10. Six patients have been very satisfied with the results, and in 1 patient only slight improvement in symptoms was noted. The procedure has not had to be repeated in anyone. Comment Urodynamic studies of patients with prostatodynia have revealed significant increases in maximal urethral closure pressure, decreases in flow rates, and urethral narrowing at the level of the external urethral sphincter. ~ In the absence of anatomic obstruction or dyssynergia, these findings suggest a functional obstruction of the prostatic urethra or bladder neck. The treatment of abacterial chronic prostatitis-prostatodynia by traditional means (alpha-blockers, muscle relaxants, antibiotics) is often unsatisfactory, and we believe that treatment which is directed at the functional obstruction may offer the best option to date. Prior to the RTBD of prostate, all VCUGs performed revealed that the bladder neck was closed during voiding, although this may be ar-
510
tifaet due to the testing situation were negative for detrusor instab compliance, and uroflow studies average flow rate of 10.1 cc per s~ RTBD of prostate, all patients r proved voiding, and the urinary were increased. These initial results are encouraging. T~ role of repeated RTBD of prostate in treatmei of abacterial chronic prostatitis-prostatodyni awaits data from more patients as weli~; longer follow-up. In our early experience, t~ technique was associated with no morbidi~ with gratifying results. 4414 Presbyterian Universi~i Pittsburgh, Pennsylvania 152i~ (DR. L OPATI I References
:,i~
1. Barbalias GA, Meares EM Jr, and Sant GPt: Prostatod~ clinical and urodynamic characteristics, J Urol 130:514 (198~ 2. Hellstrom WJ, Schmidt RA, Lue TF, and Tanagho ~ Neuromuscular dysfunction in non-bacterial prostatitis, Uro~!~ 30:183 (1987). :~ 3. Murnaghan GF, and Millard RJ: Urodynamic evaluatiQrt~ bladder neck obstruction in chronic prostatitis, Br J Uro156:,!~ (1984). ..... 4. Orland SM, Hanno PM, and Wein AJ: Prostatitis, prost~i~ sis, and prostatodynia, Urology 25:439 (1985). ~ 5. Meares EM Jr, and Barbalias GA: Prostatitis: bacterial, ~ bacterial, and prostatodynia, 8emin Urol 1:146 (1983). ~ 6. Castaneda E et al: BPH: retrograde transurethral d i I ~ of the prostatic urethra in humans, Radiology 163:649 (198~)~!
UROLOGY / DECEMBER 1990 / VOLUME XXXVI,
