Quantifying bladder outflow obstruction in men: A comparison of four approximation methods exploiting large data samples

Introduction: A pressure flow study (PFS), part of the International Continence Society standard urodynamic test, is regarded gold standard for the classification and quantification of the urethral resistance (UR), expressed in the bladder outflow obstruction (BOO). For men with benign prostatic hyperplasia, the minimum urethral opening pressure (p(muo) ), found at the end of the passive urethral resistance relation is considered the relevant parameter describing BOO. However, in clinical practice, direct measurements of p(muo) are easily confounded by terminal dribbling. For that reason, alternative methods were developed to derive p(muo) , and thereby assess BOO using the maximum urine flow rate (Q(max) ) and the corresponding pressure (p(detQmax) ) instead. These methods were never directly compared against a large data set. With the increasing variety of treatments becoming available more precise grading of UR may become of relevance. The current study compares four well-known methods to approximate p(muo) and examines the relation between p(muo) and p(detQmax) .Methods: In total, 1717 high-quality PFS of men referred with lower urinary tract symptoms between 2003 and 2020 without earlier lower urinary tract surgery were included. From these recordings, p(muo) was calculated according to three one-parameter methods. In addition, a three-parameter method (3PM) was used, based on a fit through the lowest pressure flank of the pressure-flow plot. The estimated p(muo) 's were compared with a precisely assessed p(muo) . A difference of <10 cmH(2)O between an estimate and the actual p(muo) was considered accurate. A comparison between the four approximation methods and the actual p(muo) was visualized using a Bland-Altman plot. The differences between the actual and the estimated slope were assessed and dependency on p(muo) was analyzed.Results: A total of 1717 studies were analyzed. In 55 (3.2%) PFS, 3PM analysis was impossible because all pressures after Q(max) were higher than p(detQmax) . The 3PM model was superior in predicting p(muo) , with 75.9% of the approximations within a range of +10 or -10 cmH(2)O of the actual p(muo) . Moreover, p(muo) according to urethral resistance A (URA) and linearized passive urethral resistance relation (linPURR) appear equally reliable. Bladder outflow obstruction index (BOOI) was significantly less accurate when compared to all others. Bland-Altman analysis showed a tendency of BOOI to overestimate p(muo) in men with higher grades of UR, while URA tended to underestimate p(muo) in those cases. The slope between p(muo) and p(detQmax) -Q(max) increased with larger p(muo) , as opposed to the constant relation proposed within BOOI. Although significant differences were found, the clinical relevance of those differences is not known.Conclusion: Of the four methods to estimate p(muo) and quantify BOO, 3PM was found the most accurate and BOOI the least accurate. As 3PM is not generally available and performance in lower quality PFS is unknown, linPURR is (for now) the most physiologically accurate.