Can We Predict Whether A Man with Acute Or Chronic Urinary Retention Will Void after Bladder Outflow Resistance Reduction Surgery?

This subject, which has lately become a more frequent topic of discussion, was reviewed by a committee at the International Consultation on Incontinence-Research Society (ICI-RS), and a summary of pertinent discussion points published in 2024. Controversies regarding the utility of invasive urodynamic studies in men with lower urinary tract symptoms suggestive of benign prostatic obstruction aside, the decision to operate or not would be especially easy if a detrusor contraction existed and the magnitude and configuration were such that everyone agreed that it was sufficient to empty the bladder in the absence of outlet obstruction.

The committee points out that, unfortunately, urodynamics can not define bladder outlet obstruction in the absence of a detrusor contraction or with a detrusor contraction of very low magnitude or very brief duration. Tarcan and colleagues documented that some patients achieve adequate voiding despite invasive urodynamics suggesting absent contractility, and they emphasized that more complete outflow resistance reduction—particularly with conventional resection or enucleation procedures—is associated with greater procedural success.¹

There does seem to be agreement that detrusor underactivity and inadequate relief of prostatic obstruction are the main causes of unsuccessful voiding after bladder outlet resistance reduction surgery (BORRS). At this point in time, however, good clinical judgment and shared decision making, based on a number of factors, seem to be the best guidance, but with both patient and urologist recognizing that failure to void adequately is going to occur a certain percentage of the time. How often that failure occurs will depend on a number of factors, all of which could serve as research questions: age and general health of the patient; presence/absence of neurologic disease, diabetes, chronic renal disease; duration of urinary retention; presence of severe symptoms before retention; presence of chronic inflammation; poor lower urinary tract sensation; large bladder capacity or residual urine; detrusor acontractility or significant underactivity on invasive UDS; type of procedure and location/extent of tissue removal; and, structural or ultrastructural factors such as connective tissue/smooth muscle ratio, percent of degenerated myocytes or axons. Doubtless, there are others. Currently, there seems to be no “magic”; will AI ultimately be helpful in offering a recommendation? Maybe.

Finally, the committee brought up another interesting question: is there any worth in “preparing “the outlet for potentially lifelong intermittent catheterization with bladder outlet reduction in patients with chronic urinary retention and an apparently acontractile detrusor?¹

Written by: Alan J Wein, MD, PhD(hon), FACS, Professor of Urology and Director of Business Development and Mentoring at the Desai Sethi Institute of Urology, University of Miami Miller School of Medicine.

Reference:

Tarcan T, Drake MJ, Igawa Y, et al. Can we predict whether a man with acute or chronic urinary retention will void after bladder outflow resistance reduction surgery? ICI-RS 2023. Neurourol Urodyn. 2024;43(6):1439–1446.doi:10.1002/nau.25404

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