It is known that satisfactory voiding function requires both adequate detrusor contractility and an unobstructed outflow tract. It has been demonstrated that impaired detrusor contractility can reduce the success of transurethral resection of the prostate (TURP). Due to the limitations of urodynamic studies in diagnosis of hypocontractile detrusor (HCD), detrusor ultrastructural studies have been proposed as a method of assessing detrusor failure. Our previous ultrastructural studies (1) showed that features such as the ‘myohypertrophy pattern’ were associated with poorer voiding outcomes after TURP. The objective of this study is to report on the longer term voiding outcomes in men with hypocontractile bladders who have had TURP, and correlate voiding outcomes with detrusor ultrastructure studies.

Patients who had urodynamic diagnosis of bladder outflow obstruction or evidence of impaired detrusor contractility and were selected to undergo TURP at a single centre as part of their treatment, were included in the study. Detrusor biopsies were obtained at cystoscopy and processed for analysis by transmission electron microscopy. Detrusor ultrastructural features such as myohypertrophy pattern (cell size, irregularity), degenerative features and elastosis were scored by consensus and observers were blinded to clinical and urodynamic data. Postoperative voiding outcomes were correlated with ultrastructural features. Longer term follow up (mean 16 years) was conducted and reviewed in the context of initial voiding outcomes and ultrastructural features.

Seventeen patients were recruited for the study, 12 with hypocontractile detrusor on urodynamic studies and 5 with bladder outlet obstruction (BOO) on urodynamic studies. In the HCD group of patients, the mean postvoid residual urine (PVR) measurement was 930ml (range 400ml to 1600ml). Postoperatively all BOO patients voided, three HCD patients voided immediately, three HCD patients had delayed recovery of voiding, and six patients failed to void.  Ultrastructural studies of the 12 patients with HCD showed severe degeneration in nine patients (75%), severe collagenosis in ten (83%), myocyte size variability in ten (83%) and severe fascicle derangement in nine (75%). Voiding outcome after TURP was significantly associated fascicle derangement (p=0.03), degeneration (p<0.05), collagenosis (p=0.01) and elastosis (p=0.005). At longer term follow up (mean 16 years), three patients had deceased, and an additional two were lost to follow up. There was association between successful initial post TURP voiding outcome and rate of subsequent catheter freedom, with poorer voiding outcome and detrusor ultrastructural features of hypocontractile detrusor associated with subsequent urinary retention and requirement for long term catheterisation.

Detrusor ultrastructural features of fascicle derangement, degeneration, collagenosis and elastosis appear to be associated with impaired detrusor contractility and are associated with poorer voiding outcomes after transurethral resection of the prostate in the short term as well as on longer term follow-up (mean 16 years).

Detrusor biopsy with ultrastructural analysis may be a useful diagnostic and prognostic tool in men with urinary retention considering surgical treatment options in the short term and long term.

Transurethral prostate resection in patients with hypocontractile detrusor--what is the predictive value of ultrastructural detrusor changes? Blatt A, Brammah S, Tse V, Chan L  J Urol . 2012 Dec;188(6):2294-9. doi: 10.1016/j.juro.2012.08.010

Continence 2S2 (2022) 100225
DOI: 10.1016/j.cont.2022.100225