[speaker001:] both of our eyes here... possibility that that could be er switched down? Cos it's really very, oh that's much better. I think at that stage we can we can proceed. Erm, this is er I, I suspect this is er a session that er will generate a interest. We are restricted somewhat by time, because I want to get everybody back in the main auditorium to listen to what I know is going to be a fantastic lecture by Professor Don, er from Baltimore, which I would certainly recommend that everybody go and see. Er the moderators this morning are myself, John from Dublin, and Stuart, who is from Newcastle, New South Wales, who is President of the Urological Society of Australasia. And er this is one of the er new things that's happening really er with BAUS this year is that er people are coming from far and wide and chairing session so I'd like to welcome Stuart very much indeed.... Th there are a number of papers, and we're going to start off this morning er with, when people, just I've started actually speaking here so that er to allow people time to come into the room and I know that here we are. So we're having in the first instance There's two seats over there. . He actually is reading a paper from Atlanta, but if he's speaking with a slight Scottish accent then er that's only because he's actually from Scotland. [LAUGHTER] Er he's going to read his paper now. Neil. just over to the other side.
[speaker002:] Thank you very much John. Er Mr Chairman, members of, it's a great pleasure to be here today. Before I... erm.... Before I am going to talk about er urodynamic evaluation of patients with symptoms of outflow obstruction, I think it's a good time to be talking about this when, particularly in North America, we're being encouraged to move towards a questionnaire or score in order to select patients for treatment, whether that treatment be surgical treatment or, or other treatment. This is a study of more than two hundred patients that have been entered into a prospective study er since my move to Emery in Atlanta in nineteen eighty nine.... I'll just give these folks coming in the door a moment to
[speaker001:] Don't give them too much time. [LAUGHTER] just encourage them to hang around.
[speaker002:] This is a very straightforward study, and we don't need to dwell on the, on the er the design. We had two hundred and twelve men, all of these men had er clinical B P H or one or two carcinoma. Er all of these men had moderate or severe symptoms, and all of these patients were candidates for surgery. And instead of taking them to the operating room for a T U R, instead we took them to the urodynamics lab.... In the urodynamics lab, we conducted a comprehensive study that included a uroflow a post-void residual, cystometry and a pressure flow study, and also er simultaneous voiding fluoroscopy. I'd like to report these results. The uroflow er revealed a volume of less than a hundred and fifty mil in the great majority of patients and we've, we would dismiss that er data. Er also patients who had a volume of more than a hundred and fifty mils, er the maximum flow was less than fifteen in, in er only fifty patients.... The post-void study revealed a, a residual volume of more than a hundred mils in about a third of patients,. Cystometry was normal in half and there was instability in the other half. Erm these patients were pretty much equally split between patients who had obstruction and patients who did not have obstruction on a pressure flow study. This is an example of a patient who has a stable cystometogram and in the course of the voiding study voids with a high pressure, the stylus is going up and down the whole time
[speaker001:] [LAUGHTER] another kind of. [LAUGHTER]
[speaker002:] But er here the patient who has a maximum flow of ten, and a voiding pressure of seventeen, and he voids in the course of the study. Here we have a patient who is unstable during the course of filling, and is also obstructed with a low flow, and a high voiding pressure... and finally a patient who is unstable who has a perfectly normal voiding pressure of er thirty five, and a maximum flow of twenty. Unfortunately, we don't have any standardization of characteristics or parameters for obstruction. And this was a hot topic for debate at the I C S in, in er Nova Scotia, and we made absolutely no progress at all er with this issue during that meeting. Er what I have chosen to do is to do what we were doing in the nineteen eighties, which is to take the simplest measure of the maximum flow and the detrusor pressure at that volume... and when we do that, you can see that these patients, instead of being a single group of patients with a single kind of bladder pressure and flow, these patients are all over the map.... If we're going to draw some lines perhaps it would be reasonable to say well patients with a flow of greater than fifteen certainly are unlikely to be obstructed, and patients whose detrusor pressure is less than fifty would seem to fail to satisfy our criteria for obstruction, because obstruction in a urodynamic sense implies a high pressure and a low flow. Now if we put these two parameters on here, we end up with only a small proportion of patients who actually have high pressure and low flow.... So here we've got only thirty seven percent,just o about a third of patients who have high pressure and low flow, although all of these patients would have gone to the operating room for a T U R. If we look at the information that we have on fluoroscopy, erm this was quite helpful er a hundred and thirty five patients seemed to have a fairly open prostatic fissure and the fissure was narrow in seventy seven erm most of the patients with obstructions had a narrow fissure. So if we concentrate our remarks on the findings in those patients who satisfy our criteria, this is just thirty seven percent of two hundred and twelve patients. We find that the sensitivity of the flow rate was less than we had hoped. The sensitivity of the residual urine er was also er very unhelpful. Erm the unstable bladder was present more often amongst our obstructed group although erm this was not something that would distinguish the obstructed patients from the non-obstructed.... So to our surprise of this cohort of patients who would have had a T U R, only about a third had obstruction. The flow rate and the post-void residual did not seem in this study to distinguish the group of patients who had obstruction. Instability was common in the those who were unobstructed as well as those were obstructed, and we felt that really clinical evaluation alone may not be enough to suggest who needs surgery and who doesn't. We felt that this study was weak. Er partly because it's completely impractical to suggest that all patients should have an expensive er video flow study. Partly because this is one void pressure flow study, and so we have evolved from here to take on the sort of technology that was pioneered in this country by David, using a simple ambulatory erm study, and we've added to this... erm er a hard wire connection from a flowmeter. So that as well as measuring pressures, we can have flow and volume data on the same patients and the technique that we now use is to bring these patients in er to challenge them with a large fluid load, er they get an antibiotic, which is actually part of the way that we fund this study, they have a
[speaker001:] [LAUGHTER]
[speaker002:] They have a, a uroflow here, before the catheter is placed, and then using the diuresis period, we take several measurements of pressure and flow. This has the potential to be a very economic, very easy way to help us to distinguish those pressures Those patients who have high pressures and low flow. Thank you.
[speaker001:] [clapping] Thank you very much Neil, particularly for being patient with the er the late arrivals erm early on. Thank you very much indeed. Are there any questions that people would, would like to ask, er I think it's a very important paper, er important also because as most of you know it was all these new technologies and new drug treatments and things like that that are coming in, an awful lot of rather easy criteria are being used to, to look at the, the various things, and I think that's why there's a lot of confusion about what is and is not a good method of treatment.?... Is that mike on? Chris, if you want to come round to this... Neil, what do you do with the patients who don't satisfy your criteria?
[speaker002:] Er... what we tell these patients is that they don't have evidence of obstruction, or if they do have obstruction, then that obstruction does not threaten their kidney and that it would be appropriate to wait and watch their symptoms. And as we wait and watch the findings are very much those of Paul in Bristol, that a great deal of these patients get better, and only very few fall into problems. None of these patients are dismissed without any further follow up.
[speaker001:] How many of them accepted?
[speaker002:] Erm... I don't know how many vote with their feet in going elsewhere, but few of them challenge us at home. Erm
[speaker001:] [LAUGHTER]
[speaker002:] wanting a different treatment.
[speaker001:] Yes? Andrew, Newcastle. Actually, I'm afraid I'm sorry that mike seems to be dead, you're going to have to come round and... stand in front of all these hundred and fifty, three hundred people here doctor.... Andrew from Newcastle, I work with er Professor. Er I'd like to draw your attention to my poster upstairs actually cos we, we have now performed major study of er obstruction in the before and after prostatectomy. We have found that are very much more sensitive, for example in detecting instability, erm we found differences pressures of were much higher in ambulatory studies. We haven't looked the correlation to.
[speaker002:] Well I think this is partly one of the reasons that as urologists we need to be thinking about changing gear. It's been a very big step to use pressure flow studies at all, and now that we're used to using pressure flow studies, we're going to have to go back to the drawing board and perhaps learn to use a different kind of technology that's ambulatory, that allows us
[speaker001:] [cough]
[speaker002:] to take multiple measurements of the same patient, rather than making a treatment decision based on a single observation.
[speaker001:] , London. [LAUGHTER] Neil, you're, I'm, I'm not quite clear on exactly your definition of obstruction. Your figure of thirty seven percent is much lower than most other series but most other series have different definitions er of obstruction. What, just tell me exactly what you, how you define obstruction.
[speaker002:] Well Roger I, I made great pains in the presentation to make clear that this is not a standard, because we don't have a standard. I feel that if a patient has a flow greater than fifteen that that flow is adequate, normal, probably. Of course there's always
[speaker001:] [LAUGHTER]
[speaker002:] of course you're going to find one or two patients, but rar a relatively small group, who have flows that are greater than fifteen who have obstruction. I have some patients like that. Erm, clearly you need to have a detrusor pressure in order to be behind that flow, and if this pressure is less than fifty then I think it's unlikely that there's much in the way of obstruction. I'm looking to select patients who have a high pressure and a low flow and for the sake of this study I've drawn my lines at fifty centimetres of water for detrusor pressure during voiding and, and er fifteen mils per second.
[speaker001:] So
[speaker002:] If we had, if we'd been a bit more rigorous with our criteria, our group would have got smaller.
[speaker001:] So y what you're saying is that sixty three percent of patients in America presenting with B P H have a flow rate above fifteen a and voiding pressure below fifty, right?
[speaker002:] That's correct.
[speaker001:] That's amazing. That's, that's not our experience here. You must be looking at different patients to Would you like to answer that Neil?
[speaker002:] I cannot comment
[speaker001:] No.
[speaker002:] Well, I have, I have, I'm sure Roger will believe me they're
[speaker001:] Okay Neil, we'd better... proceed. Thank you very much indeed for a very provocative programme. I think er a number of the things that are, are meant to be provocative this morning, for example how we get a clinical er evaluation er of patients selected for a T U R P or earlier treatment B P H, but also now