http://repub.eur.nl/res/aut/3456/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/33300/ 2011-09-01T00:00:00Z Purpose: We evaluated the results of sacral neuromodulation after 5-year followup in women with refractory idiopathic urge urinary incontinence. Materials and Methods: A neuromodulation system with an original (nontined) lead was implanted by open surgery after a positive percutaneous nerve evaluation in 60 women from 1990 to 2004. Voiding incontinence diary parameters were used to evaluate efficacy. Success was defined as at least a 50% decrease in the number of incontinence episodes or pads used daily. Safety was also evaluated. Results: The success rate gradually decreased from 52 patients (87%) at 1 month to 37 (62%) at 5 years. Complete continence persisted in 15% of patients. The system was still used by 80% of patients at 5 years. In 32 patients a total of 57 adverse events occurred, which were not severe (Clavien grade I and IIIb in 61% and 39%, respectively). Conclusions: Sacral neuromodulation appears to be a safe technique for refractory idiopathic urge urinary incontinence in women. The success rate gradually decreased to 62% after 5 years with 15% of patients completely continent. http://repub.eur.nl/res/pub/33556/ 2011-01-01T00:00:00Z Purpose Although functional bladder capacity, as expressed by maximum voided volume and other frequency-volume chart parameters, are important determinants of lower urinary tract symptoms, to our knowledge no population based data are available on changes in voided volume. We determined changes in and determinants of voided volume and voiding frequency with advancing age and with time, as measured by frequency-volume charts. Materials and Methods We performed a longitudinal, population based study in 1,688 men 50 to 78 years old with followup at 2.1, 4.2 and 6.5 years. Data were obtained using frequency-volume charts for maximum, 24-hour and average voided volume, and 24-hour voiding frequency as well as physical and urological measurements, and self-administered questionnaires. We used a linear mixed effect model to determine factors predicting volume changes. Results Median maximum and average voided volume decreased with time from 400 to 380 and 245 to 240 ml, respectively, and were smaller in older age groups while 24-hour voided volume showed no change. The 24-hour voiding frequency increased with time and with advancing age. Maximum, 24-hour and average voided volumes were positively related to alcohol intake. Maximum and average voided volumes were negatively related to higher age at baseline and the passage of time. Hypertension, diuretics and post-void residual volume were related to higher 24-hour voided volume. Conclusions In older men maximum and average voided volume show a small but statistically significant decrease with time and with advancing age while 24-hour voided volume does not. Factors predicting the change in maximum or average voided volume are alcohol intake and higher age. http://repub.eur.nl/res/pub/28468/ 2010-08-01T00:00:00Z Study Type - Therapy (RCT) Level of Evidence 1b Objective: To compare the effect on the recovery of incontinence after retropubic radical prostatectomy (RRP) of intensive physiotherapist-guided pelvic floor muscle exercises (PG-PFME) in addition to an information folder, with PFME explained to patients by an information folder only (F-PFME), and to determine independent predictors of failure to regain continence after RRP. Patients and Methods: We postulated that a 10% increase in the proportion of men who regained continence at 6 months with PG-PFME compared with men treated with F-PFME only would constitute a clinically relevant effect. To show statistical significance of this difference with a power of 80%, 96 men should be randomized to each of the two arms. One day before operation, all patients received verbal instruction and an information folder on PFME. Patients randomized to the F-PFME arm received no further physiotherapist guidance, whereas those in the PG-PFME arm received a maximum of nine sessions with the physiotherapist. The men underwent a 1-h pad-test at 1, 12 and 26 weeks, and a 24-h pad-test at 1, 4, 8, 12 and 26 weeks after catheter removal. We defined 'continence' as urine loss of <1 g at the 1-h and <4 g at the 24-h pad-test. Results: During the 2-year recruitment period, the number of patients randomized fell short of the target determined by the sample size calculation, because of limitations of resources and unexpected changes in treatment preferences. Despite this, we analysed the data. Of the 82 randomized patients, 70 completed the study. Of these, 34 and 36 men had been assigned to the PG-PFME and the F-PFME group, respectively. At 6 months after RRP, 10 (30%) and nine (27%) men were completely dry on both the 1-h and 24-h pad-test in the PG-PFME and the F-PFME group, respectively (difference not significant). In a multivariate analysis the amount of urine loss at 1 week after catheter removal seemed to be an independent prognostic factor for failure to regain continence. CONCLUSION PG-PFME seems to have no beneficial effect on the recovery of continence within the first 6 months after RRP, over an instruction folder-guided approach. However, due to under-powering there is a high risk of type II error. Nevertheless, these findings add to the knowledge base for availability in meta-analyses and can serve as a starting point for the design of new randomized studies. Journal Compilation http://repub.eur.nl/res/pub/32771/ 2010-07-01T00:00:00Z Introduction: In the general population, erectile dysfunction (ED) is surrounded by a " taboo." Epidemiologists studying this problem have to be aware of the phenomenon of the " tip-of-the-iceberg." Aims: Our aim is to describe the iceberg phenomenon for ED and their help-seeking behavior in the general population during a period when public interest in ED heightened and waned after the introduction of the drug sildenafil. Methods: The data were obtained as part of a large longitudinal community-based study, i.e., the Krimpen study. With four rounds of data collection with an approximate 2.1 years interval, the local pharmacists provided data on medication use, whereas abstracts from the medical record and history were provided by the local general practitioners (GPs). The data from the questionnaires were entered into the Krimpen study database but were not communicated to the GPs. Main Outcome Measures: ED: according to the ICS-questionnaire, GP consultation: search of electronic medical dossier for ED or reports from any specialist, use of ED medication as delivered by the pharmacy. Results: The age-standardized prevalence of ED is stable, i.e., around 40%. During the period 1995 to 2000, the incidence increased from 5% to 6.5%, then it stabilizes around 5% per year. The first-time use of ED medication increases exponentially between 1995 and 2000, then it stabilizes at about 3.5% per year. The number of GP consultations by men with ED increases up to 1999, after which it stabilizes at about 1.8% per year. Conclusion: We suggest that the availability and awareness of a new pharmacological option induced a change of behavior among GPs and their patients. http://repub.eur.nl/res/pub/27001/ 2009-09-01T00:00:00Z Objectives: To unravel the extent to which gender plays a role in the epidemiology, aetiology, risk of rupture and treatment of abdominal aortic aneurysms (AAAs) and to give an overview of these factors. Design, Materials and Methods: A literature review was performed in the Medline database and Cochrane Library for gender-specific articles on epidemiology, aetiology, risk of rupture and treatment of AAAs. Results: Our literature review suggests that the prevalence of AAA in women is underestimated. Regarding aetiology, an oestrogen-mediated reduction in macrophage MMP-9 production seems to be an important mechanism causing gender-related differences in AAA development. We found consensus in the literature that women run a greater risk of rupture compared to men under the current management rules for AAAs. Their treatment mortality also seems to be higher for both elective and ruptured repair. Conclusions: Gender-specific guidelines should be put into place for the management of AAAs and awareness for this disease should be increased, both in women themselves and in their doctors. http://repub.eur.nl/res/pub/24771/ 2009-04-01T00:00:00Z This report from the Krimpen study explored the relationship between the determinants for worsening of erectile function in the open population. In Krimpen aan den IJssel (a municipality near Rotterdam), all men aged 50-75 years, without cancer of the prostate or the bladder and without a history of radical prostatectomy or neurogenic bladder disease, were invited to participate in June 1995. The response rate was 50%. The follow-up was until June 2004. At baseline a visit to a health centre for the measurement of urinalysis, height, weight and blood pressure was part of the ongoing study. During baseline and at the first follow-up, second follow-up and third follow-up, a self-administered booklet consisting of a compilation of validated questionnaires including the International Continence Society male sex questionnaire was completed. At the urology outpatient clinic, a urological workup was measured. All participants were asked to keep a frequency-volume chart for 3 days. A multivariate Cox-proportional hazard model was constructed to find the determinants of worsening of erectile function, correcting for age. Total follow-up time was 4948 person years consisting of 975 men. During follow-up, 441 events of worsening of erectile function occurred. Multivariate Cox-proportional hazard ratio analyses showed that body mass index (BMI), irritative lower urinary tract symptoms, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and sexual inactivity were determinants with significant hazard ratios. In addition to age, determinants for a deterioration of erectile function based on multivariate longitudinal analyses are BMI, diabetes mellitus, COPD, sexual inactivity and irritative IPSS. The mechanism of various determinants is discussed. http://repub.eur.nl/res/pub/30544/ 2008-12-09T00:00:00Z Objective: Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation. Data Sources: Best-available evidence was retrieved from literature and combined with primary data from 231 patients. Methods: We developed a Markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of $75 000 was used. Results: ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44 251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95% CI: -0.17, 0.29) at a threshold willingness-topay of $75 000/ QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30 246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:-0.24, 0.46) compared to current practice. The results were robust for other different input parameters. Conclusion: ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only. http://repub.eur.nl/res/pub/29781/ 2008-12-01T00:00:00Z Background: The optimal first-line treatment for intermittent claudication is currently unclear. Objective: To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claudication during a 12-month follow-up period. Design: Randomized controlled trial with patient recruitment between September 2002-September 2006 and a 12-month follow-up per patient. Setting: A large community hospital. Participants: Patients with symptoms of intermittent claudication due to an iliac or femoro-popliteal arterial lesion (293) who fulfilled the inclusion criteria (151) were recruited. Excluded were, for example, patients with lesions unsuitable for revascularization (iliac or femoropopliteal TASC-type D and some TASC type-B/C. Intervention: Participants were randomly assigned to endovascular revascularization (76 patients) or supervised hospital-based exercise (75 patients). Measurements: Mean improvement of health-related quality-of-life and functional capacity over a 12-month period, cumulative 12-month costs, and incremental costs per quality-adjusted life year (QALY) were assessed from the societal perspective. Results: In the endovascular revascularization group, 73% (55 patients) had iliac disease vs 27% (20 patients) femoral disease. Stents were used in 46/71 iliac lesions (34 patients) and in 20/40 femoral lesions (16 patients). In the supervised hospital-based exercise group, 68% (51 patients) had iliac disease vs 32% (24 patients) with femoral disease. There was a non-significant difference in the adjusted 6- and 12-month EuroQol, rating scale, and SF36-physical functioning values between the treatment groups. The gain in total mean QALYs accumulated during 12 months, adjusted for baseline values, was not statistically different between the groups (mean difference revascularization versus exercise 0.01; 99% CI -0.05, 0.07; P = .73). The total mean cumulative costs per patient was significantly higher in the revascularization group (mean difference €2318; 99% CI €2130, € 2506; P < .001) and the incremental cost per QALY was 231 800 €/QALY adjusted for the baseline variables. One-way sensitivity analysis demonstrated improved effectiveness after revascularization (mean difference 0.03; CI 0.02, 0.05; P < .001), making the incremental costs 75 208 €/QALY. Conclusion: In conclusion, there was no significant difference in effectiveness between endovascular revascularization compared to supervised hospital-based exercise during 12-months follow-up, any gains with endovascular revascularization found were non-significant, and endovascular revascularization costs more than the generally accepted threshold willingness-to-pay value, which favors exercise. http://repub.eur.nl/res/pub/30198/ 2008-07-01T00:00:00Z Objectives: Various utility measures have been used to assess preference-based quality of life of patients with end-stage renal disease (ESRD). The purposes of this study were to summarize the literature on utilities of hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation (RTx) patients, to compare utilities between these patient groups, and to obtain estimates for quality-of-life adjustment in economic analyses. Methods: We searched the English literature for studies that reported visual analog scale (VAS), time trade-off (TTO), standard gamble (SG), EuroQol-5D (EQ-5D), and health utilities index (HUI) values of ESRD patients. We extracted patient characteristics and utilities and calculated mean utilities and 95% confidence intervals (CIs) for categories defined by utility measure and treatment modality using random-effects models. Results: We identified 27 articles that met the inclusion criteria. VAS articles were too heterogeneous to summarize quantitatively and we found only one study reporting HUI values. Thus, we summarized utilities from TTO, SG, and EQ-5D studies. Mean TTO and EQ-5D-index values were lower for dialysis compared to RTx patients, though not statistically significant for TTO values (TTO values: HD 0.61, 95% CI 0.54-0.68; PD 0.73, 95% CI 0.61-0.85; RTx 0.78, 95% CI 0.63-0.93; EQ-5D-index values: HD 0.56, 95% CI 0.49-0.62; PD 0.58, 95% CI 0.50-0.67; RTx 0.81, 95% CI 0.72-0.90). Mean HD versus PD associated TTO, EQ-5D-index and EQ-VAS values were not statistically significantly different. Conclusion: RTx patients tended to have a higher utility than dialysis patients. Among HD and PD patients, there were no statistically significant differences in utility. http://repub.eur.nl/res/pub/29621/ 2008-04-01T00:00:00Z Objective: We used the database of a longitudinal community-based study to investigate whether real changes in prostate volume (PV) (ie, changes greater than the combination of intra- and interobserver variation of volume measurement) corresponded with significant changes in symptom severity. Methods: In a community-based study of men aged 50-78 yr, the International Prostate Symptom Score (IPSS) and PV were measured at baseline and at 4.2-yr follow-up. Of 1417 men, 864 completed both rounds. A significant change in IPSS was defined as a change of ≥ 4 points. A real change in PV was defined as a percent change of ≥ 26%, or an absolute change of ≥ 10 cc. Results: After 4.2 yr, about 20% of the men had experienced a significant increase in IPSS and 16-23% had a real increase in PV. The age-adjusted odds ratio for a significant increase in symptom severity, which contrasts men who have a real increase in PV and men who do not show such an increase, is 1.38 (95%CI, 1.05-1.85]. The age-adjusted odds ratio for a significant decrease in symptom severity, which contrasts men with a real increase in PV and those without such an increase, is 1.50 (95%CI, 1.11-2.85). Conclusions: Benign prostatic hyperplasia can be characterised as a progressive disease in a certain proportion of men older than 50 yr. Men with growing prostates are at a greater risk of symptomatic deterioration. Men who have prostates that do not grow significantly are more likely to improve symptomatically. http://repub.eur.nl/res/pub/29928/ 2008-04-01T00:00:00Z Objective: A systematic review of studies assessing the effectiveness of acupuncture-type interventions (moxibustion, acupuncture, or electro-acupuncture) on acupuncture point BL 67 to correct breech presentation compared to expectant management, based on controlled trials. Data sources: Articles published from 1980 to May 2007 in databases of Medline, EMBASE, the Cochrane Central Register of Controlled Trials, AMED, NCCAM, Midirs and reference lists. Study selection: Studies included were original articles; randomised controlled trials (RCT) or controlled cohort studies; acupuncture-type intervention on BL 67 compared with expectant management; ultrasound confirmed breech presentation and position of the fetus after treatment confirmed with ultrasound, position at delivery, and/or the proportion of caesarean sections reported. Data extraction: Three reviewers independently extracted data. Disagreements were resolved by consensus. Data synthesis: Of 65 retrieved citations, six RCT's and three cohort studies fulfilled the inclusion criteria. Data were pooled using random-effects models. In the RCT's the pooled proportion of breech presentations was 34% (95% CI: 20-49%) following treatment versus 66% (95% CI: 55-77%) in the control group (OR 0.25 95% CI: 0.11-0.58). The pooled proportion in the cohort studies was 15% (95% CI: 1-28%) versus 36% (95% CI: 14-58%), (OR 0.29, 95% CI: 0.19-0.43). Including all studies the pooled proportion was 28% (95% CI: 16-40%) versus 56% (95% CI: 43-70%) (OR 0.27, 95% CI: 0.15-0.46). Conclusions: Our results suggest that acupuncture-type interventions on BL 67 are effective in correcting breech presentation compared to expectant management. Some studies were of inferior quality to others and further RCT's of improved quality are necessary to adequately answer the research question. http://repub.eur.nl/res/pub/35885/ 2007-12-01T00:00:00Z BACKGROUND. We aim to establish the normal pattern of prostate volume change with age to provide a baseline from which accelerated prostate growth might be identified in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). METHODS. In a community-based study, prostate volume was determined at baseline and after 2.1 and 4.2 years in men without prostate cancer. A bivariate multilevel growth curve model was used to estimate the pattern of change of prostate volume with age. RESULTS. The average percentage increase of total prostate volume and transition zone volume per year of follow-up was 2.2% and 3.5%, respectively. The final model showed that prostate volume was related to age only. The future prostate volume of an individual can be predicted based on his age and known history of prostate volume. The model was also used to calculate time needed for the prostate volume to increase with a certain percentage, for men with different baseline prostate volume values at different ages. CONCLUSIONS. This method establishes normal prostate volume values by age using prostate volume history in men without prostate cancer. The model provides baseline data from which disease progression might be detected. http://repub.eur.nl/res/pub/35159/ 2007-10-01T00:00:00Z Purpose: To perform a systematic review of studies in which endovascular repair was compared with open surgery in the treatment of patients with a ruptured abdominal aortic aneurysm (AAA). Materials and Methods: A search of the English-language literature from January 1994 until March 2006 was performed. Inclusion criteria for studies were that they were about a comparison between patients who underwent endovascular repair and patients who underwent open surgery, that each treatment group included at least five patients, that information about patients' hemodynamic condition at presentation was reported, and that 30-day mortality was reported for each treatment group. Two reviewers independently extracted the data, and discrepancies were resolved by an arbiter. Random-effects models and meta-regression analysis were used to calculate crude and adjusted odds ratios (ORs) for endovascular repair versus open surgery. Ten studies, in which the results of 478 procedures (n = 148 for endovascular repair, n = 330 for open surgery) were reported, met the inclusion criteria. All studies were observational; no randomized controlled trials were found. The pooled 30-day mortality was 22% (95% confidence interval [CI]: 16%, 29%) for endovascular repair and 38% (95% CI: 32%, 45%) for open surgery. The pooled rate for total systemic complications was 28% (95% CI: 17%, 48%) for endovascular repair and 56% (95% CI: 37%, 85%) for open surgery. The crude OR for 30-day mortality for endovascular repair compared with open surgery was 0.45 (95% CI: 0.28, 0.72). After adjustment for patients' hemodynamic condition, the OR was 0.67 (95% CI: 0.31, 1.44). Conclusion: In this systematic review, after adjustment for patients' hemodynamic condition at presentation, a benefit in 30-day mortality for endovascular repair compared with open surgery for patients with a ruptured AAA was observed, but it was not statistically significant. http://repub.eur.nl/res/pub/35153/ 2007-10-01T00:00:00Z Objective: The present study aims to determine the influence of coping on quality of life (QOL) in elderly men developing lower urinary tract symptoms (LUTS). Materials and Methods: Longitudinal population-based study with a follow-up period of 6.5 years on 1,688 men aged 50-78 years. Data were collected through self-administered questionnaires, including the Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS), and the Utrecht Coping List (UCL). Various physical and urological measurements were completed. Multiple linear regressions were used to determine the change in QOL in men with incident LUTS in relation to coping behavior. Results: Overall no significant association is found between changes in LUTS with a change in QOL. However, a positive change in QOL is significantly associated with a change in LUTS when men use the coping style active problem solving and a negative relation exists with coping style reassuring thoughts. Conclusion: Different coping styles have a different impact on the relation between a change in LUTS and a change in generic QOL in community-dwelling elderly men. This makes a future exploration of the clinical treatment possibilities warranted. Copyright http://repub.eur.nl/res/pub/35332/ 2007-07-01T00:00:00Z http://repub.eur.nl/res/pub/36085/ 2007-06-01T00:00:00Z Objectives: Serum prostate-specific antigen (PSA) is considered a proxy for prostate volume (PV). This study investigates which range of PSA values has the best utility in the determination of PV (<30 cc, at 30, 40, and 50 cc), and whether PSA performs better than digital rectal examination (DRE) when estimating PV. Methods: In a population-based follow-up study of 1688 men in Krimpen aan den IJssel, The Netherlands, at baseline we estimated PV by DRE and by transrectal planimetric ultrasound (TRUS), in addition to measuring PSA. Men who tested positive for prostate cancer (PCa) at baseline and at 2 and 4 yr of follow-up were excluded from the analyses (n = 142). Of the men without PCa, PSA and PV data were available in 1524 participants. Results: Of all 1524 men analysed, 76.7% had a PSA of 0-2.0, 15.0% had a PSA of 2.1-4.0, and 8.3% a PSA > 4. Low PSA ranges (0-2 and 2.1-4.0) discriminate better for a PV of 30 cc (eg, in men with a PSA range of 2.1-2.5 ng/ml there was a 72% chance of having a PV > 30 cc). Higher ranges of PSA (>4.0) discriminate better for a PV > 40 or 50 cc. (eg, in men with a PSA in the range of 4.1-7.0 ng/ml there was a 69% chance of having a PV > 40 cc and in men with a PSA > 10 ng/ml there was a 75% chance of a PV > 50 cc). The receiver operating curve (ROC) for the performance of PSA in estimating a PV > 30 cc shows an area under the curve (AUC) of 0.79, denoting reasonable discrimination, and AUCs of 0.86 and 0.92, denoting good discrimination of PVs > 40 cc and >50 cc, respectively. PSA performed significantly better than DRE at estimating PV. Multiple regression analysis shows that both DRE and an interaction term for age and PSA provided minimal additional information beyond PSA in the prediction of PV; however, their contribution is numerically minimal/not clinically meaningful. Conclusions: In men for whom a diagnosis of PCa has been ruled out, PSA can be used to detect an enlarged prostate (>30 cc and with more accuracy PV > 40 or 50 cc). More precision in estimating PV can be obtained when using a formula that contains PSA, age, DRE, and an interaction term between age and PSA; however, the clinical advantage of the formula over PSA alone is only modest as shown by the ROC curves. Thus, for clinicians looking for an easy and fast way to identify patients with an enlarged prostate, PSA is a good approximation for men without PCa. http://repub.eur.nl/res/pub/36308/ 2007-03-01T00:00:00Z Improvement in quality of life is the ultimate goal of healthcare for the treatment of intermittent claudication. Until recently, the measures of success after therapy were those derived from the vascular laboratory, including ankle-brachial indices and ankle and toe pressures. There are now several validated and reliable survey tools that can assess patient-reported quality of life in a generic or disease-specific manner. Major survey instruments are reviewed. The information gathered through these quality-of-life assessment tools is important to all those involved in the care of patients with peripheral arterial disease. Although claudication is neither life- nor limb-threatening, it has a significant negative impact on quality of life, as measured by these instruments. Patients so afflicted report more bodily pain, worse physical function, and worse perceived health, in addition to limited walking ability. These measures of quality of life do not correlate with standard parameters of ankle-brachial index or ankle pressures. Treatment of the claudicant with exercise therapy and percutaneous or open revascularization also impacts quality of life. Each of these modalities is capable of improving quality of life, but some are associated with decline over time. The major benefits and risks to quality of life of these specific forms of treatment for the claudicant are reviewed. This data demonstrates that patients suffering from symptoms of intermittent claudication are best served by therapies that address their major self-reported impediments to quality of life. http://repub.eur.nl/res/pub/35642/ 2007-01-01T00:00:00Z Background: Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain. Methods: A systematic literature review was performed to identify studies investigating the influence of different types of nerve management. Results: Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all. Conclusion: The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results. Copyright http://repub.eur.nl/res/pub/36226/ 2007-01-01T00:00:00Z Aims: To characterize the determinants of diabetes-related emotional distress by treatment modality (diet only, oral medication only, or insulin). Methods: A total of 815 primary care patients with Type 2 diabetes completed the Problem Areas in Diabetes (PAID) Scale and other questions. We linked survey data to a diabetes clinical research database and used linear regression models to assess the associations of treatment with PAID score. Results: PAID scores were significantly higher among insulin-treated (24.6) compared with oral-treated (17.8, P < 0.001) or diet-treated patients (14.7, P < 0.001), but not different between oral- vs. diet-treated patients (P = 0.2). Group scores remained similar, but the statistical significance of their differences was reduced and ultimately eliminated after sequential adjustment for diabetes severity, HbA1c, body mass index, regimen adherence, and self-blood-glucose monitoring. Insulin-treated patients reported significantly higher distress than oral- or diet-treated patients on 16 of 20 PAID items. 'Worrying about the future' and 'guilt/anxiety when ... off track with diabetes' were the top two serious problems (PAID ≥ 5) in all treatment groups. Not accepting diabetes diagnosis was a top concern for oral- and diet-treated patients, and unclear management goals distressed diet-treated patients. Conclusions: Primary care patients treated with insulin reported higher diabetes-related emotional distress compared with oral- or diet-treated patients. Greater distress was largely explained by greater disease severity and self-care burdens. To improve diabetes-specific quality of life, clinicians should address patients' sense of worry and guilt, uncertain acceptance of diabetes diagnosis, and unclear treatment goals. http://repub.eur.nl/res/pub/14611/ 2006-02-14T00:00:00Z PURPOSE: We evaluated the effect of sacral (S3) nerve neuromodulation on voiding in women with idiopathic detrusor overactivity incontinence. MATERIALS AND METHODS: Urodynamic measurements in all patients implanted in 1990 to 2003 were reconsidered. Patients were included if these measurements, which were done at baseline and after 6 months, could be analyzed completely and reliably. Maximum detrusor pressure, amplitude of the highest involuntary detrusor contraction and end fill volume were used as parameters characterizing the degree of detrusor overactivity. Urethral resistance and bladder contraction strength during voiding were characterized by the bladder outlet obstruction index, the urethral resistance factor, average pressure, the slope of the low pressure side of the pressure flow plot, the bladder contractility index and the bladder contraction strength parameter. RESULTS: A total of 33 women were included. Detrusor overactivity parameters were significantly improved at followup. In addition, the supine position of the patient during filling in followup measurements proved less provocative with respect to overactivity than the standing position in the majority of measurements at baseline. Consequently bladder volumes at which voiding was initiated were considerably higher at followup. Changes in the parameters characterizing urethral resistance and bladder contraction strength during voiding were not unambiguous. However, exactly those parameters that appeared volume independent in a previous study were not significantly different. CONCLUSIONS: Our study confirmed the depressant effect of sacral (S3) nerve neuromodulation on detrusor overactivity. No effect on urethral resistance and bladder contraction strength during voiding could be demonstrated using volume independent parameters http://repub.eur.nl/res/pub/9028/ 2006-01-01T00:00:00Z We studied epidemiological aspects of recruitment of volunteers for a non-invasive urodynamic study. MATERIALS AND METHODS: 9,236 volunteers were invited by 20 general practitioners (GPs), using two different recruitment methods, i.e. by mail only, or during a subsequent visit to the GP's office. Factors influencing the response rates were analyzed. We also tested how much the recruited population of volunteers differed from the general population, by comparing it to another, proven representative study carried out earlier in 1,662 subjects. RESULTS: In the recruited population the prostate volumes were not significantly different from the proven representative study, but the symptom score was statistically significantly higher, although the difference was so small it may be called clinically irrelevant. Recruitment of volunteers in two steps, i.e. asking them first to visit the GP's office, and inviting them there to visit the outpatient clinic, rather than directly inviting them (in writing) to the clinic seemed to lead to a higher response, although this effect could not be statistically discriminated from the difference in response rates between GPs. CONCLUSION: The population recruited was not urologically different from the general population. The response depended on age, being highest around the age of 60, and increased with social economic status. It also depended on the GP who recruited the subjects, and/or on the recruitment method. http://repub.eur.nl/res/pub/14403/ 2004-08-13T00:00:00Z OBJECTIVES: We conduct a longitudinal non-invasive study of changes in urinary bladder contractility secondary to benign prostatic enlargement. In that study, the prostate volume is estimated by transabdominal ultrasonography. The accuracy of those measurements was verified by comparison of transabdominal to transrectal stepwise planimetric ultrasonography as the gold standard. Also, two different transabdominal devices used were compared, and the influence of different operators was studied. MATERIALS & METHODS: Two series of measurements in 100 patients each were done. In the first series, transabdominal and transrectal sonography were pairwise compared in each patient. In the second series, transabdominal measurements were done with two devices (a hospital Aloka SSD-1700 and a portable Aloka SSD-900). Transrectal scannings were done by three investigators whilst all transabdominal scannings were done by one. Regression graphs, ratio plots and statistical analyses of the data quantified the reproducibility of different methods, observers and device types. RESULTS: In the transrectal-transabdominal series of prostate volume measurements (in cm3), the Pearson correlation coefficient was 0.84 (p < 0.001), the mean of the means was 51.8 +/- 23.0 (mean +/- S.D.), and the mean of the differences was 1.0 +/- 1.4. In the series with two devices, the Pearson correlation coefficient was 0.73 (p < 0.001), the mean of the means was 31.0 +/- 10.9, and the mean of the differences was 1.0 +/- 1.3. CONCLUSION: No statistically significant differences were found between the transabdominal- transrectal ultrasonography, two different transabdominal devices nor between different observers. However, for those using these measurements in everyday clinical practice, it is worth to point out that in our data a transabdominal scan and a transrectal scan in the same patient, on the same day, differed more than 30% in one fourth of the patients and that two transabdominal scans in the same patient (with two different devices, on two different days) differed more than 30% in every fifth patient http://repub.eur.nl/res/pub/14392/ 2004-01-31T00:00:00Z OBJECTIVES: To report on the applicability, reproducibility, and adverse events of the noninvasive condom catheter method in the first 730 subjects of a longitudinal survey of changes in urinary bladder contractility secondary to benign prostatic hyperplasia, in which 1300 men will be evaluated three times in 5 years using this method. METHODS: Subjects were recruited by general practitioners, general publicity, and e-mail. Only those meeting the study criteria were entered in the study. If the free flow rate exceeded 5.4 mL/s, at least two consecutive condom pressure measurements were attempted using the condom catheter method. The condom pressure measured reflected the isovolumetric bladder pressure, a measure of urinary bladder contractility. The reproducibility of the method was quantified by a difference plot of the two maximal condom pressures measured in each subject. RESULTS: In 618 (94%) of 659 eligible participants, one condom pressure measurement was completed; two measurements were done in 555 (84%). The maximal condom pressure ranged from 28 to 228 cm H2O (overall mean 101, SD 34). A difference between the two pressures of less than +/-21 cm H2O was found in 80%. The mean difference was -1 cm H2O (SD 18), significantly different from 0. Some adverse events such as terminal self-limiting hematuria were encountered. CONCLUSIONS: The condom catheter method is very suitable for large-scale use. It has a success rate of 94% and a reproducibility comparable to that of invasive pressure flow studies http://repub.eur.nl/res/pub/31837/ 2002-06-01T00:00:00Z Objective: To study health status and its correlates in older men with and without lower urogenital tract dysfunction. Methods: Cross-sectional population-based study on 1688 men aged 50-78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction or a negative advice from their general practitioner. Data were collected through self-administered questionnaires, including Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS) and International Continence Society (ICS) Male Sex questionnaire, medication use, socio-economic and lifestyle factors. Additional information was collected by measurement of blood pressure, transrectal ultrasonography of the prostate and uroflowmetry. Four health status domains were analyzed using the ISH and three domains of the SIP. Lower urinary tract symptoms (LUTS) were categorised using IPSS, erectile and ejaculatory dysfunction were defined using the ICS questionnaire. Results: All urogenital characteristics and parameters were related to at least two of the health status domains. Multivariate regression analyses yielded that LUTS and cardiac symptoms were associated with suboptimal scores of all four domains. Chronic obstructive pulmonary disease and drugs for abdominal symptoms were related to three domains; erectile and ejaculatory dysfunction, muskuloskeletal or psycho(ana)leptic drugs and marital status to two domains. Conclusions: The impact of LUTS on health status was equally important as the impact of cardiac symptoms. The impact of sexual dysfunction was smaller than expected. Longitudinal studies are needed to determine how health status and illnesses interact. http://repub.eur.nl/res/pub/14365/ 2002-02-22T00:00:00Z To diagnose bladder outlet obstruction in male patients with lower urinary tract symptoms (LUTS), it is necessary to measure the bladder pressure via a transurethral (or suprapubic) catheter. This procedure incurs some risk of urinary tract infection and urethral trauma and is sometimes painful to the patient. We developed an external condom catheter to measure non-invasively the bladder pressure and developed a strategy to classify bladder outlet obstruction (BOO) based on this measurement. Seventy-five patients with a wide range of urological diagnoses underwent a pressure-flow study followed by a non-invasive study. We tested five different strategies to classify the patients using the provisional International Continence Society (ICS) method for definition of obstruction as the gold standard. Leakage of the external catheter occurred in eight (40%) of the first 20 tested patients. In the remaining 55 patients, only five (9%) of the measurements failed because of leakage. Of the 75 patients, 56 were successfully tested non-invasively. According to the ICS nomogram, the PFS showed that 22 of these patients were non-obstructed, 12 patients were equivocal, and 22 patients were obstructed. Ten of these 56 patients strained, and we found that the relatively high abdominal pressures in these patients were not reflected in the externally measured bladder pressure. Of the remaining 46 patients, 12 of 13 non-obstructed patients and 30 of 33 combined equivocal and obstructed patients could be correctly classified. We developed a simple, non-invasive classification strategy to identify BOO in those male patients who did not strain during voiding http://repub.eur.nl/res/pub/14299/ 2000-12-23T00:00:00Z PURPOSE: We previously described an automatic procedure for diagnosing and grading detrusor instability using a cystometric study. In our current study we applied a modified version of the program in patients with urge incontinence treated with sacral neuromodulation to test its capacity to detect changes after therapeutic intervention and understand the mode of action of neuromodulation. MATERIALS AND METHODS: We analyzed cystometric studies before and after neuromodulation in 26 consecutive patients, including 22 women and 4 men, and evaluated parameter changes. We also assessed the relationship of instability parameters at baseline with symptomatic results, which were derived from voiding-incontinence diaries, in female patients to identify urodynamic prognosticators of success. RESULTS: The automatic procedure correctly diagnosed stability and instability in our patients in 51 of the 52 measurements considered. Neuromodulation had an average suppressive effect on the amplitude of unstable contractions. At baseline the amplitude of the maximum unstable contraction and mean active pressure during unstable episodes were significantly less in the 7 women who achieved stability than in the 15 who did not. However, no urodynamic parameters were identified that predicted the symptomatic outcome of treatment. CONCLUSIONS: Our algorithm accurately diagnoses and grades detrusor instability, and provides parameters with predictive value in regard to the probability that a bladder may or may not become stable with neuromodulation. However, the symptomatic result of this treatment option seems to depend on noncystometric factors http://repub.eur.nl/res/pub/14246/ 2000-06-13T00:00:00Z Voiding parameter values measured with ambulatory urodynamic monitoring (AM) are generally found to be different from those measured with conventional cystometry (CMG). The reason for this is unclear, but might be related to differences in the voided volume. To verify this hypothesis, we compared voidings from female patients at an initial bladder volume that was close to the modal volume (that is, the volume most often voided by the patient as derived from frequency/volume charts) with voidings at maximum cystometric capacity during a routine video urodynamic examination. A first group of 35 patients voided at the modal volume before they did at capacity. The order was reversed in a second group of 12 patients. The dependence of the voiding parameters on the voided volume and the order of the measurements were examined. It was found that the maximum flow rate depended significantly on the voided volume, but the associated detrusor pressure did not. Urethral resistance and bladder contraction strength were not volume dependent either. It was concluded that the differences between AM and CMG cannot be explained from possible differences in the voided volume http://repub.eur.nl/res/pub/14773/ 1998-05-01T00:00:00Z PURPOSE: Detrusor instability and hyperreflexia are characterized by involuntary detrusor contractions in the filling phase of the voiding cycle. The diagnosis is made when urodynamic evaluation reveals such contractions. To compare patients and evaluate treatment a method is needed to quantify the degree of instability. We developed an instability parameter based on the area under the curve of involuntary detrusor contractions on conventional filling cystometry. MATERIALS AND METHODS: We developed an automatic method to calculate the area under the curve of involuntary detrusor contractions in conventional filling cystometry. Logistic regression was used to construct decision rules to differentiate stable from unstable bladders. These rules, derived from a group of 100 children, were applied to a second group of 77 who were independently assessed by 3 urodynamics experts. RESULTS: Typically 88% of the second group were correctly classified as stable or unstable by the automatic procedure. In the unstable subgroup there was poor correlation between the calculated instability parameter and the instability score assigned by the experts. Most likely this difference occurred because the experts based their opinion mainly on the amplitude of the highest unstable contraction and the percentage of filling time that instability was found. CONCLUSIONS: The proposed method of automatically grading detrusor instability based on the area under detrusor contractions differs from the intuitive method used by experts. Since no standard is available, it cannot be concluded which method is better. Our proposed method is objective and it results in a single physical value. http://repub.eur.nl/res/pub/9025/ 1996-01-01T00:00:00Z Purpose: The resistance offered to urinary flow by the urethra is one of the factors determining the course of micturition. It was the aim of the present work to study the dependence of urethral resistance on the degree of relaxation of the urethra. Materials and Methods: Experiments were done in the guinea pig. Ten animals were used. In 5 animals saline was forced through the (unrelaxed) urethra at imposed flow rates in the range of 1.1 to 43.0 ml. per minute while the urethral pressure was measured. Second degree polynomials were fitted to the pressure/flow data. In the other 5 animals micturition contractions were evoked and pressure/flow plots were derived from the measured signals. A straight line was fitted to the lowest pressure values at each flow rate in these plots. These pressure values represent the most relaxed state of the urethra in these voidings. Results: The pressures measured in the unrelaxed urethra were much higher than the pressures measured during voiding in the same flow rate range, but the intercepts of the mathematical equations fitted to the pressure/flow data on the pressure axis were not significantly different in the 2 groups. Conclusions: The unrelaxed urethra has a much "steeper" pressure/flow characteristic than the relaxed urethra. However, the urethral closing pressure, that is, the intercept of the pressure/flow characteristic on the pressure axis, does not depend on the state of relaxation of the urethra. http://repub.eur.nl/res/pub/21646/ 1995-06-07T00:00:00Z http://repub.eur.nl/res/pub/14820/ 1995-01-01T00:00:00Z The course of micturition depends on bladder contractility and urethral resistance. The former is determined by geometrical, muscular and neurogenic factors. The muscular aspects of bladder contractility can be characterized by the parameters Pisv, the isovolumetric detrusor pressure, and vmax, the maximum (unloaded) shortening velocity of the detrusor muscle. The neurogenic control system of the urinary tract modulates bladder contractility, which might effectively change the values of Pisv and vmax. These parameters also depend on the instantaneous bladder volume. In previous work the dependence of Pisv on the intensity of stimulation and bladder volume was measured in guinea pig bladders in vivo and in vitro. In the present work vmax was derived in 5 guinea pig bladder in vitro, using electrical stimulation and the stop-flow technique. This technique implies that pressure values measured at a certain shortening velocity of the bladder circumference and in an isovolumetric contraction at the same volume are used to derive vmax mathematically from the Hill equation. vmax was independent of the bladder volume in the range of 0.6 to 6.1 ml., but it was significantly different for the two intensities of stimulation used. Therefore, it is concluded that the maximum shortening velocity of the guinea pig detrusor muscle depends on the intensity of stimulation. During submaximal stimulation the detrusor not only generates lower pressures, it also contracts more slowly. A possible explanation for this phenomenon is that the bladder is not uniformly stimulated. The isovolumetric pressure measured in the stop-flow test was compared with the isovolumetric pressure measured at the same bladder volume some minutes later. It was observed that shortening had a depressant effect of approximately 33% on the isovolumetric pressure. This implies that the clinically employed stop-flow test might underestimate detrusor contraction strength. http://repub.eur.nl/res/pub/9026/ 1995-01-01T00:00:00Z The influence of age, urethral resistance and bladder contractility on voiding efficiency was evaluated by pressure-flow studies in 138 men of a mean age of 60 years (range 18 to 86). From these studies the urethral resistance parameter was calculated and the maximum bladder contraction strength was determined. Premature fading of the bladder contraction was quantified by a bladder contraction strength decay factor. Voiding efficiency was expressed by the parameter of post-void residual urine volume as a percentage of the initial bladder volume. Multiple regression analysis showed that voiding efficiency depended significantly in descending order of importance on urethral resistance, maximum bladder contraction strength and bladder contraction strength decay factor. Patient age was not an independent factor. Maximum bladder contraction strength and bladder contraction strength decay factor were not correlated, suggesting that maximum bladder contraction strength and its decay constitute different properties of bladder contractile function. A voiding efficiency nomogram is proposed, making use of the values for maximum bladder contraction strength and urethral resistance in individual patients. Such a nomogram may have predictive value for the occurrence of acute retention but it must be tested prospectively. http://repub.eur.nl/res/pub/9027/ 1995-01-01T00:00:00Z In an attempt to increase our understanding of the clinical syndrome of benign prostatic hyperplasia (BPH) an analysis was made of the association between prostate volume as measured by transrectal ultrasound and several reported urodynamically determined urethral resistance parameters. Two types of obstruction can be recognized on the basis of urodynamic data: a compressive type characterized by a high urethral opening pressure and a prolonged isovolumetric contraction phase before urine flow can start, and a constrictive type characterized by a normal opening pressure and an increased slope of the urethral resistance relation. A combination of both types is often seen in BPH. In our study, parameters that selectively quantify compression correlate weakly to moderately with prostate volume, whereas parameters that mainly quantify constriction do not correlate at all with prostate volume. Parameters that combine a measure for compression and constriction correlate less well with prostate volume than parameters that mainly quantify compression. The variation in prostate volume was found to determine the variation in urethral resistance by 15% or less depending on the parameter used, which implies that the different pathophysiological mechanisms that can increase urethral resistance in the complex process of clinical BPH are mainly determined by factors other than the volume of the prostate. Thus, despite the lack of correlation between prostate volume and urethral resistance, pressure-flow studies and the determination of urethral resistance parameters provide a valuable contribution to the understanding of the pathophysiology of voiding dysfunction in men with symptoms of prostatism.