膀胱超声测量膀胱壁厚度

膀胱超声测量膀胱壁厚度 Review ArticleUltrasound Estimated Bladder Weight and Measurement ofBladder Wall Thickness—Useful Noninvasive Methods forAssessing the Lower Urinary TractElizabeth Bright Matthias Oelke Andrea Tubaro? and Paul AbramsFrom the Bristol Urological Institute Southmead Hospital Bristol United Kingdom EB PA Department of Urology Hanover MedicalSchool Hanover Germany MO Department of Urology Academic Medical Centre University of Amsterdam AmsterdamThe Netherlands MO and 2nd School of Medicine ―La Sapienza‖ University of Rome Rome Italy ATPurpose: In the last decade interest has arisen in the use of ultrasound derived Abbreviationsmeasurements of bladder wall thickness detrusor wall thickness and ultrasound and Acronymsestimated bladder weight as potential diagnostic tools for onditions known to AUR acute urinary retentioninduce detrusor hypertrophy. However c to date such measurements have not BOO bladder outlet obstructionbeen adopted into clinical practice. We performed a comprehensive review of theliterature to assess the potential clinical usefulness of these measurements. BVWI bladder volume and wall thickness indexMaterials and Methods: A MEDLINE search was conducted to identify allpublished literature up to June 2009 investigating measurements of bladder BWT bladder wall thicknesswall thickness detrusor wall thickness and ultrasound estimated bladder weight. DO detrusor overactivityResults: Measurements of bladder and detrusor wall thickness and ultrasound DWT detrusor wall thicknessestimated bladder weight have been studied in men women and children. A LUTS lower urinary tractconvincing trend has been shown in the ability of these measurements to differ- symptomsentiate men with from those without bladder outlet obstruction. In addition OAB overactive bladdermeasurements of bladder wall thickness have revealed a considerable difference PFS pressure ow studiesbetween detrusor overactivity and urodynamic stress incontinence. A number ofconfounding variables and a lack of standardized methodology has resulted in TAUS transabdominal ultrasounddiscrepancies among studies. Therefore reproducible diagnostic ranges or cutoffvalues have not been established. TVUS transvaginal ultrasoundConclusions: Ultrasound derived measurements of bladder and detrusor wall UDS urodynamicsthickness and ultrasound estimated bladder weight are potential noninvasive UEBW ultrasound estimatedclinical tools for assessing the lower urinary tract. bladder weight USI urodynamic stress Key Words: urinary bladder urinary bladder neck obstruction incontinence ultrasonography review Submitted for publication November 18 2009. Supported by a research grant provided byLOWER urinary tract symptoms are a BOO respectively. Adequate noninva- Verathon Medical. Correspondence: Bristol Urological Institutesignicant source of burden to the pa- sive methods for diagnosing these con- Southmead Hospital Bristol BS10 5NB Unitedtient. Of men older than 50 years in ditions do not exist and thus pressure- Kingdom telephone: 44117 9595690 FAX:the United Kingdom 41 report mod- volume studies of lling and PFS of 44117 9502229 e-mail: ebrightdoctors.net.uk. Financial interest and/or other relationshiperate to severe LUTS.1 LUTS are sec- voiding remain the gold standard in- with Verathon.ondary to uid handling disorders eg vestigations. However these tests are Financial interest and/or other relationshippolyuria/nocturnal polyuria or dys- invasive expensive and time-consum- with Pzer Astellas Verathon Polil-Boskcamp and Bayer.function of the lower urinary tract ing with associated morbidity.2 ? Financial interest and/or other relationshipbladder outow tract or both. In Animal studies have revealed with Astellas Novartis Pzer Takeda and Orion.neurologically normal patients stor- bladder wall hypertrophy and in- Financial interest and/or other relationship with Pzer Astellas Ono Novartis and Verathon.age and voiding symptoms are com- creased bladder weight after par-monly due to detrusor overactivity and tially induced BOO3– 8 within as lit-0022-5347/10/1845-1847/0 Vol. 184 1847-1854 November 2010THE JOURNAL OF UROLOGY Printed in U.S.A. www.jurology.com 1847 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH INC. DOI:10.1016/j.juro.2010.06.0061848 BLADDER WEIGHT AND WALL THICKNESS ON ULTRASOUNDtle as 2 weeks.5 Mean bladder wall thickness in with a mean DWT of 1.4 and 1.2 mm in males andcontrol partially obstructed and severely ob- females respectively measured at a bladder volumestructed rabbits was 1.57 2.04 and 2.77 mm respec- of 250 ml or greater g. 1.17 Measurement of DWTtively with most thickening in the detrusor layer.4 was considered preferable to total BWT for 2 reasons.Histological analysis showed smooth muscle cell hy- 1 Previous animal studies have shown the musclepertrophy and hyperplasia and increased collagen layer to be mostly affected by pressure changes anddeposition ratio of type I-to-III collagen48 and mus- 2 the mucosa could be inuenced by other bladdercarinic cholinergic receptors.6 Similar histological pathology such as carcinoma or infection.patterns were observed in patients with BOO910 In both studies wall thickness was measured at aand DO11 and in those undergoing augmentation variety of lling volumes. Although both revealed asurgery for high intravesical pressure.12 Further- decrease in wall thickness with increasing lling vol-more bladder weight smooth muscle cell hypertro- ume only the latter study quantied this at incremen-phy and collagen deposition have been shown to tal measurements in the same individual.17 DWT de-partially reverse after BOO relief in pigs.7 Beamon creased at volumes up to 250 ml but beyond that pointet al demonstrated concurrent development of de- it remained relatively static. The authors recommendtrusor hypertrophy and DO with induced BOO in measuring DWT at a lling volume of 250 ml ormice at 6 weeks which is a well-known association greater when possible. In patients for whom llingin clinical practice.8 may not reach 250 ml such as those with DO DWT Historically urologists believed bladder trabecula- should be estimated with the help of the DWT-bladdertion to be a marker of BOO. Although studies have volume graphs generated by Oelke et al.17conrmed this relationship913 in some cases DO and Another study of asymptomatic healthy volun-not BOO may be the causative factor.14 Bladder wall teers revealed a slightly higher mean DWT of 2hypertrophy can be visualized on ultrasound. Ultra- mm.18 As only a single measurement was taken insonic measurements of BWT and bladder weight can each patient at a lling volume of 200 ml thesedistinguish between obstructed and nonobstructed results may reect an underestimation of DWT.17rabbit bladders.15 In the last decade increasing inter- Furthermore images were inadequately enlarged toest has arisen in the measurement of BWT/DWT and obtain an accurate measurement and some of thethe ultrasound estimation of bladder weight as a non- patients were pretreated with -blockers known toinvasive means of assessing LUTS. However to date decrease BWT/DWT. In conclusion there is no con-such measurements have not been adopted into clini- sensus in the literature for age and gender speciccal practice. We reviewed the literature to assess the diagnostic ranges or cutoffs for BWT/DWT.potential clinical usefulness of these measurements. BWT or DWT in BOO A handful of studies have attempted to quantify theMATERIALS AND METHODS diagnostic ability of TAUS measurements of BWT/ DWT in patients with suspected BOO. Hakenberg etA MEDLINE search was conducted to identify all pub-lished literature up to the end of June 2009 investigating al reported a mean BWT of 3.67 mm in 150 men withmeasurements of BWT DWT and UEBW. The search LUTS at a variety of lling volumes.16 However noterms used were bladder weight BWT and DWT. statistically signicant difference was found betweenRESULTSBWT/DWT in Healthy Asymptomatic AdultsBefore ultrasound measurement of BWT/DWT canbe used as a reliable clinical tool the quanticationof these measurements in the healthy asymptom-atic population must be established. However re-ports on normal measurements are few and difcultto compare because of fundamental differencesamong them particularly for BWT or DWT and thedegree of bladder lling at which such measure-ments should be taken. On TAUS at a variety of lling volumes in asymp-tomatic healthy volunteers mean BWT was 3.33 and3.04 mm in 172 men and 166 women respectively.16 Figure 1. Difference in BWT and DWT measurements in sameThis gender difference was also observed in measure- subject at bladder lling volume of 250 ml. Reduced from 8.ment of the detrusor layer in 55 healthy volunteers BLADDER WEIGHT AND WALL THICKNESS ON ULTRASOUND 1849these men and age matched asymptomatic controls. In to predict BOO with an AUC of 0.93. In additionanother study a similar mean of 4 mm was obtained in adjusting the DWT threshold to 2.5 mm as reported170 men with urodynamically conrmed BOO.19 BWT by Kessler et al21 revealed similar sensitivity andwas measured at a single lling volume of 150 ml. A specicity to that reported by Oelke et al.2022 Morevalue of 5 mm appeared to be the best cutoff to diag- recently a study of 155 Turkish men reported anose BOO with 88 of patients with BWT 5 mm or statistical difference in BWT in those with a maxi-greater conrmed as obstructed on PFS. mum uroow rate of 10 ml per second or less mean Based on preliminary data revealing an effect of BWT 4.44 1.18 mm compared to those with a ratelling volume on DWT in healthy volunteers Oelke greater than 10 ml per second mean BWT 3.85et al assessed DWT at bladder capacity in men with 0.76 mm.23 Measurements were taken at bladderBOO.20 DWT increased incrementally in relation to volumes between 150 and 200 ml.the degree of obstruction. On PFS mean DWT was Although a consistent trend between BWT/DWT1.33 1.62 2.4 and greater than 3 mm in unob- and BOO can be appreciated no denitive referencestructed equivocal obstructed and severely ob- ranges have been established. It is likely that con-structed patients respectively g. 2. Comparable founding differences among tests for example mea-results were reported in a similar study of DWT at surements at different lling volumes are to blame.lling capacity in 102 men with LUTS.21 Median Blatt et al observed no difference in mean DWT be-DWT was 1.7 1.8 and 2.7 mm in the unobstructed tween patients with and without proven obstructionequivocal and obstructed groups respectively with 2.1 vs 2 mm respectively.18 The single measurementa DWT of 2.9 mm or greater shown to be the best at a lling volume of 200 ml used in this study maycutoff to diagnose BOO positive predictive value have resulted in underestimation of DWT.17100 specicity 100 AUC 0.88. In both of thesestudies the difference in DWT between unobstructed Ultrasound Estimated Bladder Weightand obstructed patients was statistically signicant. BWT/DWT is affected by lling volume. Therefore More recently a DWT of 2 mm or greater was its usefulness as a clinical tool becomes limited inreported in 94 of men with BOO conrmed on UDS everyday practice. Kojima et al attempted to resolveat a lling volume of 250 ml or greater.22 Compared this problem by calculating bladder weight.24 TAUSto other clinical parameters DWT was the best test measurements of intravesical volume and BWTFigure 2. BWT red arrow and DWT yellow arrow measurements in 4 men A to D with BPH-LUTS at bladder lling volume of 250ml. Patient A had LUTS but no obstruction Schfer grade 1. Patient.