Year : 2006 | Volume
: 22 | Issue : 2 | Page : 125--129
Uroflowmetry, trans rectal ultra sonography and power doppler to develop a less invasive bladder outlet obstruction score in benign prostatic hyperplasia: A prospective analysis
Rajiv Goyal, Deepak Dubey, Anil Mandhani, Aneesh Srivastava, Rakesh Kapoor, Anant Kumar
Departments of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
OBJECTIVE : To evaluate the ability of transrectal power doppler sonography (TRPDS) in combination with conventional grey scale transrectal ultrasonography (TRUS), uroflowmetry and clinical parameters, to predict bladder outlet obstruction (BOO) in benign prostatic hyperplasia (BPH). MATERIALS AND METHODS : Sixty-nine male patients with more than 50 years of age, presenting with lower urinary tract symptoms were evaluated prospectively for BOO secondary to BPH. TRUS was done to estimate prostate volume (PV), transition zone volume (TZV), median lobe projection in the bladder (ML) and bladder wall thickness (BWT). TRPDS was done to measure resistive index (RI) of transition zone vessels. All patients also underwent PFS and depending upon its results, the patients were divided into Group 1 [Abram-Griffiths (AG) number < 40] and Group 2 (AG number >40). Mean values of TRUS and TRPDS parameters and uroflowmetry in the two groups were compared to identify predictive factors for BOO. RESULTS : Demographic profile of Group 1 (n= 42) was similar to that of Group 2 (n= 27). Significant independent factors for prediction of BOO were maximum flow rate, resistive index of transition zone, median lobe projection into the bladder and post void residue. BOO scoring system was developed based on these 4 factors, which showed a specificity of 77.8% and a sensitivity of 85.7%, with an overall predictive value of 82.6%. CONCLUSIONS : Transrectal power doppler ultrasonography (resistive index) in combination with uroflowmetry, median lobe projection in bladder and post void residue measurement can predict BOO with a high specificity and sensitivity.
|How to cite this article:|
Goyal R, Dubey D, Mandhani A, Srivastava A, Kapoor R, Kumar A. Uroflowmetry, trans rectal ultra sonography and power doppler to develop a less invasive bladder outlet obstruction score in benign prostatic hyperplasia: A prospective analysis.Indian J Urol 2006;22:125-129
|How to cite this URL:|
Goyal R, Dubey D, Mandhani A, Srivastava A, Kapoor R, Kumar A. Uroflowmetry, trans rectal ultra sonography and power doppler to develop a less invasive bladder outlet obstruction score in benign prostatic hyperplasia: A prospective analysis. Indian J Urol [serial online] 2006 [cited 2022 Jan 28 ];22:125-129
Available from: https://www.indianjurol.com/text.asp?2006/22/2/125/26566
Currently, pressure flow study (PFS) is considered a reference standard for the diagnosis of bladder outlet obstruction (BOO). However it is invasive, costly and may be associated with urinary tract infection in a small number of patients. Thus, there is an obvious need for other simpler and less invasive modalities to predict BOO. Transrectal ultrasonography (TRUS) is a useful modality to evaluate prostatic dimensions accurately. Resistive index (RI) of the prostatic tissue calculated on power doppler imaging has shown good correlation with severity of BOO., Many attempts have been made to make a non-invasive model for predicting BOO in BPH patients, but power doppler imaging has never been included as a parameter in few such predictions. This study was performed to evaluate the predictability of BOO with the help of transrectal power doppler sonography (TRPDS) in combination with conventional grey scale TRUS, uroflowmetry and clinical parameters to find a less invasive method for clinical use.
Materials and Methods
From June 2003 to May 2004, 106 male patients of more than 50 years of age with lower urinary tract symptoms (LUTS), were analyzed prospectively. Mean age was 66 years (51-81 years). Chief complaints and AUA symptom score were recorded. Patients with urinary retention, on treatment for BPH with PSA greater than 10 or presence of prostate cancer and previous history of urethral trauma or surgery, were excluded.
Those with PSA values between 4-10 ng/ml underwent TRUS- guided sextant prostatic biopsy. Patients with histologically proven carcinoma prostate were excluded from the study.
Uroflowmetry was done twice for all the patients (Medtronic, Denmark) and more representative flow was taken into consideration. Post void residual urine (PVR) and bladder wall thickness (BWT) were noted in all patients with the help of trans-abdominal sonography. BWT was noted at two different points and mean of two values was noted.
TRUS and TRPDS were done with a 7.5 MHz transrectal probe (B-K Medical, Denmark). To avoid inter-observer variability, the same investigator did all TRUS examinations. Prostate volume (PV) and transition zone volume (TZV) were calculated with the help of in built software, by measuring three dimensions of prostate in transverse and longitudinal sections. Transition zone index (TZI = TZV / PV) was calculated for all patients. The median lobe (ML) projecting into the urinary bladder was measured in sagittal scan. A line was drawn joining the posterior bladder wall and bladder neck and perpendicular distance from the tip of median lobe projection into the bladder was measured [Figure 1]. Blood flow samplings were taken from the transition zone and spectral waveform analyses were done. Maximum and minimum velocities were marked on the waveform as shown in [Figure 2]. The in- built software calculated RI. RI was measured at four points in the transition zone and the mean value was selected as representative RI of the prostate. We did not specifically target any vessel, as those were only the peri- urethral vessels.
PFS was performed with Medtronic (Denmark) machine with 'DUET̉ logic' computer software for calculations and graphs. Uroflowmetry was done before starting the study. Urethra calibration was done with 16 F Foleys catheter to empty the bladder. Results of TRPDS were not revealed to the investigator doing the urodynamic study. PFS were performed through a 7 F triple lumen per urethral catheter with the patient in sitting posture, filling being done at the rate of 10-50 ml per minute. Intravesical pressures (Pves) were measured. Rectal pressures were recorded through a 10 F catheter connected to the pressure transducer. Filling was stopped when patient had strong desire to void. Opening pressures and Pdet at maximum flow were recorded and abrams-griffiths (AG) number was calculated (PdetQmax - 2Qmax).
Patients were divided in 2 groups; group 1 with AG number less than or equal to 40 and group 2 with AG number more than 40, to differentiate obstructed patients from non-obstructed ones. Mean values of TRUS parameters, MFR, PVR and AUA score were expressed as mean + standard deviation. Significance of difference between mean values was tested with paired sample t-test when appropriate or a non-parametric Wilcoxon matched pairs signed rank test as necessary. Pearson's coefficient of correlation was used for correlation analysis, as all the parameters were continuous variables. Logistic regression analysis was done to calculate relative power of each statistically significant factor for predicting bladder outlet obstruction. A bladder outlet obstruction score was developed by analyzing the histograms of various parameters. A commercially available computer software package (SPSS 10) was used for statistical analysis.
Sixty-nine patients were eligible for the evaluation as per the inclusion criteria. [Table 1] shows mean ± SD values of parameters evaluated in all the patients. Forty-two patients were found to have no obstruction (i.e., (AG) number 40, group 2). Mean ± SD values of the parameters in the two groups are shown in [Table 2]. Mean age was 66.64 ± 7.4 years in Group 1 and 65.3 ±10.6 years in Group 2. Mean values of median lobe projection into the prostate, resistive index of transition zone and post void residue were found to be significantly higher in group 2 ( P P et al studied normal prostatic vascular anatomy and concluded that power doppler of prostatic tissue demonstrates reproducible flow pattern. They also suggested that power doppler can help to compare vascular anatomy of normal prostate with that of diseased prostate. Use of contrast agents increases the effectiveness of visualizing blood vessels, but these are costly and may not be affordable.
Kojima et al in their preliminary report had noticed a significantly higher RI of prostate in BPH patients with BOO, as compared to healthy individuals (0.72 vs. 0.64, P et al have reported their experience with 214 patients of lower urinary tract symptoms. RI of capsular arteries was found to have correlation with international prostatic symptom score and peak flow rate; however they did not validate their findings with PFS. In a recent study, Nose et al used transperineal ultrasonography in 30 patients to measure the velocity flow of urine at the prostatic urethra and sphincteric urethra (doppler urodynamics). They combined this method with intravesical prostatic protrusion (IPP) grading, to diagnose BOO with high sensitivity and specificity. In contrast to our study, their analysis showed poor correlation of MFR and PVR with BOO. The method of calculation of IPP by Nose et al , was similar to the one adopted by us to calculate median lobe protrusion into the bladder. However, we have used RI of transition zone to assess functional component of the BOO. We took mean RI after measuring it at four different points in transition zone, probably from peri-urethral vessels. We feel that TRUS- based evaluation can be more easily and reproduced by a urologist. Moreover, our method does not require separate calculation of individual velocities. It needs to sample a vessel in TZ and to freeze the scan at a position where a typical waveform is visualized. As RI is ratio of two velocities, the exact values of the velocities are not needed to be calculated separately.
Many attempts have been made to formulate a clinical prostate score for BPH. Rosier PF et al developed a clinical prostate score by including prostate size, maximum free flow, post void residue and voided volume. The sensitivity of this score was 80.7%, but it had a low specificity (53%). Kuo HC also developed a clinical prostate score for diagnosis of BOO using parameters of uroflow and prostate measurements. The sensitivity of this score was similar to our study (87.2%), but specificity was again low (60.8%). The BOO score proposed by us has high sensitivity as well as very high specificity, perhaps because the measurement of median lobe projection into the bladder and resistive index of transition zone are the parameters specific for the BOO caused by BPH. The cut off value of RI in our study was 0.69. In our study, significant factors for prediction of BOO were maximum free flow, resistive index of transition zone, median lobe projection into the bladder and post void residue. We found poor correlation of prostate volume, transition zone volume, transition zone index and bladder wall thickness with bladder outlet obstruction.
In our study, the same investigator was involved in all the measurements of TRPDS and was blinded against the PFS findings of the patients; hence the observer bias was kept to the minimum. Advantage of TRPDS combined with clinical parameters in diagnosing BOO is that, it does not involve the risk of UTI. In addition to that, RI is a ratio of two velocities; therefore it is not direction- dependent and can be mastered easily. RI can be used as an objective parameter to compare the efficacy of different drugs on BPH.
Transrectal power doppler sonography (resistive index of transition zone of prostate) in combination with conventional transrectal sonography (median lobe projection), uroflowmetry (maximum flow rate) and post void residue measurements can predict BOO with high specificity and sensitivity. We have tried to develop urodynamically validated non-invasive bladder outlet obstruction score, which has a high predictability for BOO with a specificity of 77.8% and a sensitivity of 85.7%. This scoring system is much simpler to use in routine practice. Further use in a larger group of patients is required for its validation.
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