[S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia]. / S2e-Leitlinie der Deutschen Urologen : Konservative und medikamentöse Therapie des benignen Prostatasyndroms.

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]. / S2e-Leitlinie der Deutschen Urologen : Instrumentelle Therapie des benignen Prostatasyndroms.

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

[Transurethral resection of the prostate and current modifications (bipolar, electrovaporization)]. / Transurethrale Resektion der Prostata und Modifikationen (bipolar, Elektrovaporisation).

Transurethral resection of the prostate (TURP) is the surgical standard which is truly minimally invasive by using a natural orifice and is also of durable efficacy. The use of TURP removes tissue from benign prostatic hyperplasia (BPH) and leads to clinically relevant improvement in symptoms and quality of life as well as in micturition parameters and obstruction. Tissue is removed by high frequency (HF) current with synchronous hemostasis. Many modifications of TURP, such as the use of video, have become generally accepted and improved the standard. Other modifications were developed because the balance between cutting and hemostasis needed improvement in favor of hemostasis. Several modifications of TURP, such as modulation of HF pulses, band loops and bipolar resection and new procedures, such as vaporization and enucleation showed improved hemostasis. These modifications and procedures, however, have not yet replaced standard TURP but have become established as additional options.

[Operative therapy of benign prostatic hyperplasia: enucleation procedures (HoLEP and ThuVEP)]. / Operative Therapie der benignen Prostatahyperplasie : Enukleierende Verfahren (HoLEP und ThuVEP).

Open simple prostatectomy is not only the oldest but also the most effective treatment option for benign prostatic obstruction. Laser enucleation has been established as a transurethral minimally invasive alternative especially but not exclusively for large volume prostates. To date two laser systems, holmium:YAG laser enucleation of the prostate (HoLEP) and thulium:YAG laser vapoenucleation of the prostate (ThuVEP) have been established. Both treatment modalities have similarities in terms of wavelength and surgical technique but differ in the type of energy released (pulsed versus continuous wave). The HoLEP and ThuVEP procedures lead to a significant improvement in symptoms, quality of life, urinary flow and post-void residual urine. Surgery-related morbidity, especially bleeding complications is significantly reduced with laser enucleation. For HoLEP the durability of the results was shown for a follow-up interval of up to 10 years while for ThuVEP the follow-up interval reached 18 months due to the shorter time since clinical implementation of this method.

The use of mannitol in partial and live donor nephrectomy: an international survey.

PURPOSE: Animal studies have shown the potential benefits of mannitol as renoprotective during warm ischemia; it may have antioxidant and anti-inflammatory properties and is sometimes used during partial nephrectomy (PN) and live donor nephrectomy (LDN). Despite this, a prospective study on mannitol has never been performed. The aim of this study is to document patterns of mannitol use during PN and LDN. MATERIALS AND METHODS: A survey on the use of mannitol during PN and LDN was sent to 92 high surgical volume urological centers. Questions included use of mannitol, indications for use, physician responsible for administration, dosage, timing and other renoprotective measures. RESULTS: Mannitol was used in 78 and 64 % of centers performing PN and LDN, respectively. The indication for use was as antioxidant (21 %), as diuretic (5 %) and as a combination of the two (74 %). For PN, the most common dosages were 12.5 g (30 %) and 25 g (49 %). For LDN, the most common doses were 12.5 g (36.3 %) and 25 g (63.7 %). Overall, 83 % of centers utilized mannitol, and two (percent or centers??) utilized furosemide for renoprotection. CONCLUSIONS: A large majority of high-volume centers performing PN and LDN use mannitol for renoprotection. Since there are no data proving its value nor standardized indication and usage, this survey may provide information for a randomized prospective study.

[Local treatment of prostate cancer using thermal-ablative energy]. / Die Lokaltherapie des Prostatakarzinoms mit thermisch ablativer Energie.

Thermal and thermal-ablative procedures for treating prostate cancer have been investigated systematically since approximately 1980 (apart from some historical predecessors), and numerous experimental and clinical reports have been published on this subject. Various technologies have been used, including transurethral ablation of prostatic tissue using laser or microwave energy, interstitial application of laser or microwave energy, and inductive heating of previously implanted thermoseeds or injected magnetic nanoparticles in a magnetic field. For all of these procedures, clinical studies with a total of some 350 patients have been performed. However, the results cannot be judged correctly because of a lack of adequate control parameters for the older studies and inadequately short follow-up of all studies. Conclusions regarding treatment-related morbidity seem to be possible, with a generally positive impression and low rates of adverse effects. But before such results can be generalized, patient selection bias and the technology standards that existed when the studies were performed must be taken into consideration. Various papers are reviewed and summarized. In the author's opinion, the different options for thermal and thermal-ablative treatment of prostate cancer are very promising, but in light of the existing standard procedures, feasibility must not overrule reasonableness.

[Laser therapy for benign prostate hyperplasia]. / Lasertherapie der benignen Prostatahyperplasie.

Various procedures operating with different laser systems and application techniques are available for laser treatment of benign prostate hyperplasia (BPH). They generate differing qualitative and quantitative effects in tissue such as coagulation, vaporisation or, respectively, ablation as well as incisions leading according to technique to a resection or enucleation. Since these procedures are considered as alternatives to transurethral resection of the prostate (TURP), the objective of laser therapy is not only to achieve, in comparison to TURP, an equivalent improvement of the symptoms and quality of life but also a maximal urinary flow strength or, respectively, a reduction of obstruction to bladder emptying with lower accompanying morbidity and shorter hospitalisation. Most of the published case control and randomised studies on laser therapy for BPH show heterogeneous results both with regard to the improvement of subjective and objective urination parameters as well to complications. This is due, on the one hand, to the laser or its qualitative action and, on the other hand, to the operator and the resulting specific quantitative effect. The biophysical relationships between the laser parameters and the tissue effects are a topic of current discussion. The biological effect depends not only on the depth of penetration and the scattering but also on other parameters of the laser. For the generation of voluminous coagulation necrosis with a laser in the ca. 800 to 1100 nm wavelength region, a carbonisation of the surface must be avoided. For thermal vaporisation, for example, the Nd:YAG laser with contract-free application or contact tips as well as diode lasers of varying wavelengths are suitable. Especially suitable are the potassium titanyl phosphate (KTP) laser and the lithium triboride (LBO) laser. Ablation is also possible with the Ho:YAG laser. An incision and thus resection or enucleation is also possible with various laser systems including thermal ones, but is more effective with a continuous beam laser of ca. 2000 nm. The Ho:YAG laser achieves an athermal incision the quality of which depends on the pulse energy and the time behaviour of the laser impulse.

[Transurethral enucleation of the prostate with the holmium: YAG laser system: how much power is necessary?]. / Transurethrale Laserenukleation der Prostata mit dem Holmiumlaser : Wie viel Leistung ist notwendig?

PURPOSE: To evaluate the efficacy and safety of an intermediate power (50 W) holmium:YAG laser system for transurethral enucleation of the prostate (TULP) with the use of a new mechanical morcellator. Our results are compared with the results of high-powered holmium laser enucleation (HoLEP) presented in the literature. MATERIAL AND METHODS: From December 2003 to January 2008, 129 patients with benign prostatic hyperplasia were treated by TULP. In 45 cases (group A; 2.0, 12 Hz) we used a bipolar resectoscope (VISTA/ACMI) for morcellation, whereas after that morcellation was accomplished with a modified endoscopic shaver (Wolf). Thirty-nine patients were treated using 25 W (group B; 2.0 J, 12 Hz), and 45 patients were treated using 40 W (group C; 2.2 J 18 Hz), who were compared with 45 matched-pair patients who received transurethral resection of the prostate (TURP; group D). Finally, the literature on HoLEP was reviewed. RESULTS: Bipolar morcellation significantly prolonged the operating time (135 vs. 131 vs. 96 min). The morcellation speed averaged 2.8 (range 1.3-5.2) g/min with no complications. The resection speed (retrieval rate) of 40-W TULP was comparable to that for TURP (0.71 vs. 0.76 g/min). The transfusion rate was lower than for TURP (8% vs. 12%), with a smaller Hb difference (3.1 vs. 3.8 mg/dl). Catheter times (3.4 vs. 4.1 days) were similar; however, hospital stay was significantly shorter after TULP (5.2 vs. 6.8 days). The complication rate was significantly lower (6.6% vs. 13.3%). The efficacy of HoLEP significantly improved with introduction of the morcellator: Resection speed increased from 0.34-0.61 g/min to 0.48-0.82 g/min. HoLEP was better than 40-W TULP regarding transfusion rate (0-4% vs. 8%) and catheter time (1.1-1.5 vs. 3.4 days). Complications and functional results were similar. CONCLUSION[UBERSCHRIFT]: The intermediate-power 50-W holmium laser together with the new morcellator enable safe transurethral enucleation of the prostate. As with HoLEP, the procedure has a significant learning curve. The retrieval times of TULP are similar to those for HoLEP, but the risk of bleeding is higher. New modifications (i.e., thullium laser) will further improve the technique of laser enucleation.

[Surgical and instrumental management of benign prostatic hyperplasia]. / Operative und instrumentelle Therapie bei BPH/BPS.

In recent decades, several various interventional procedures for the treatment of symptomatic benign prostatic hyperplasia (BPH) have been developed. Most of them were considered potential alternatives to prostatic surgery such as open prostatectomy, transurethral resection of the prostate (TURP), or transurethral incision of the prostate (TUIP). Despite good results observed in the initial clinical studies, most concepts and procedures were never generally accepted. However, they contributed considerably to general knowledge regarding the treatment of symptomatic and obstructive BPH. Only a few procedures could stand the test of time and became part of the urological armamentarium. Currently, interventional therapies are classified by their effects on prostate tissue: procedures with immediate tissue ablation (open prostatectomy, TURP, vaporization techniques, laser resection techniques), thermal coagulating procedures with delayed tissue ablation (transurethral high-energy microwave thermotherapy, transurethral needle ablation, interstitial laser coagulation), and other procedures (TUIP, stents) with deobstruction effects without tissue ablation. The analysis of clinical studies shows a great variety of different results. The main reason for this fact is that the design of past and present studies ignored the pathophysiological aspects of BPS, especially the obstructive component, and the fact that the outcome of most procedures more or less depends on the operator/user.

Present practice and treatment strategies in endourological stone management: results of a survey of the European Society of Uro-technology (ESUT).

OBJECTIVES: The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trends between urologists with regard to the application of endourological stone management to identify trends and differences in treatment strategies among urologists. METHODS: A total of 695 certified urologists and urological residents answered the ESUT Endourological Stone Management Questionnaire. There were 136 (28.7%) chief urologists, 240 (50.6%) staff urologists and 98 (20.7%) residents. The respondents were classified according to both the geographical origin (in four groups: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE) and Outside Europe (OE)), and department size (number of urological beds per department: small < or = 25, medium 26-50 beds, large > 50 beds) in order to identify any differences in the replies. RESULTS: On average, 40.1 newly diagnosed patients and 73.6 revisits with urolithiasis are seen a month per department. According to the replies, there are no significant differences in total numbers of treatments in ESWL and/or endourological stone managements amongst the geographically based groups. Monthly, on average 68.5 ESWL treatments and 23.0 URS are performed per department. A significant majority of surveyed urologists performs URS with a rigid or semi-rigid instrument (79%) instead of a flexible instrument (21%, p = 0.003). URS is more frequently performed outside Europe (p = 0.02) with a more frequent use of dormia catheters (p < 0.001). On average, 20.9 double g-stents are placed monthly in each department, most commonly before or after endourological procedures (p < 0.001). Percutaneous procedures are performed by 69.6% of the respondents with a mean of 16.8 PNL procedures a month. PNL for stone management is mainly performed in Eastern Europe and non-European countries (p = 0.017). Nephrostomy tubes are used by 77.7% of the responding urologists. Monthly, 13.1 nephrostomy tubes are placed, mostly during PNL or after endourological procedures (40.7%). CONCLUSION: The data obtained from the 695 urologists and residents provides information on the performed procedures and the use of material. In general, respondents from different geographical locations perform similar procedures and use identical material; however URS and PNL are performed more frequently outside of Europe, whereas laser lithotripsy is frequently used in Northern European counties.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]. / Gemcitabin/Cisplatin vs. MVAC. 5-Jahres-Ergebnisse der Phase-III-Studie zur Chemotherapie des fortgeschrittenen Urothelkarzinoms in Deutschland.

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

Present practice and development of minimally invasive techniques, imaging and training in European urology: results of a survey of the European Society of Uro-Technology (ESUT).

OBJECTIVES: The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trend between European urologists with regard to the application of new technologies in BPH, stone disease and imaging and to identify differences amongst urologists. MATERIAL AND METHODS: A total of 854 certified urologists and residents coming from European countries answered the ESUT survey during the XVIth Annual EAU Meeting in Geneva in 2001. The respondents were classified according to the geographical origin (Eastern, Southern and Northern Europe), year of certification (before 1980, and every 5 years hereafter) and power of the department in beds (less than 25, 26-50, and more than 50) in order to identify any differences in the replies mainly due to economical reasons, national or hospital policy and personal attitudes. RESULTS: According to the replies, in Eastern Europe more procedures related to BPH and stones are performed comparing to Northern and Southern Europe (165.8 versus 77.1 and 100.6/month/department, respectively). However, the Northern European urologists have access to every type of lithotriptor and most of the different minimally invasive treatments for BPH in a higher percentage, followed by the Southern and the Eastern European urologists. The most widespread intracorporeal lithotriptor is the pneumatic and the most common alternative minimally invasive BPH treatment is electrovaporization (80.7% and 45.6%, respectively). Holmium laser is the most frequent choice (40.1%) when the surveyed urologists were asked to choose which of the minimally invasive techniques would like to have access to. In total 79.4% (54.1% alone and 25.3% in collaboration with the radiologists) of the respondents perform the ultrasound studies while the remaining 20.6% declare that only the radiologists do the studies. Of the surveyed urologists, 92.8%, 89.6% and 94.9% are interested in hands-on courses, simulators and live surgery, respectively. CONCLUSIONS: The data obtained from the 854 surveyed European urologists and residents can be used as a tool to highlight the disparity between European countries and to advance training of European urologists.

Perioperative prediction by MRI of prostate volume six to twelve months after laser-induced thermotherapy of benign prostatic hyperplasia.

The purpose of this study was to predict prostate volume outcome 6-12 months after interstitial, laser-induced thermotherapy (LITT) for benign prostatic hyperplasia (BPH) on the basis of prostate magnetic resonance (MR) images obtained within 48 hours before and after LITT. Twenty patients (age, 64.2 +/- 7.4 years) with symptomatic BPH had LITT of the transitional zone of the prostate. MRI was performed within 48 hours before and after LITT, and 6-12 months after LITT (late follow-up). MRI included axial and sagittal T2-weighted fast spin-echo (FSE) images and contrast-enhanced, axial T1-weighted images. Volumes of different prostatic compartments (total prostate, transitional zone, peripheral zone, LITT lesions) were measured by planimetry. Subtraction of LITT lesion volume less than 48 hours after LITT from total and transitional zone volume before LITT, respectively, predicted respective prostatic volumes at late follow-up. Pearson correlations of predicted and measured total prostate and transitional zone volumes were 0.972 and 0.975, respectively. Total prostate volume at late follow-up was accurately predicted (difference, -0.5 +/- 5.7 cc; P = 0.6981, two-tailed paired t-test). Transitional zone volume was underestimated (difference, -3.1 +/- 4.7 cc; P = 0.0075). Peripheral zone volume was overestimated (difference, 2.6 +/- 3.5 cc; P = 0.0034). Perioperative MRI allows accurate prediction of prostate volume 6-12 months after LITT for BPH. Underestimation of transitional zone volume may be due to ongoing growth of BPH. LITT appears to affect peripheral zone tissue outside the target region. J. Magn. Reson. Imaging 2001;13:64-68.

Lasers for median lobe hyperplasia.

Laser treatment encompases a variety of techniques using different laser wavelengths, application systems, and surgical techniques to achieve contrasting tissue effects such as incision, resection, vaporization, or coagulation. Many studies have proven the clinical efficacy of the various laser techniques for the treatment of benign prostatiuc hyperplasia, including randomized studies versus transurethral prostatectomy (TURP). Recently, long-term follow-up of up to 5 years has demonstrated the durability of the results, although in some of the studies, retreatment rates were higher than after TURP. Median lobes were never seen as a contraindication for treatment in the laser based procedures. Technically, laser treatment techniques such as side-firing transurethral coagulation, contact- and free-beam laser vaporization, interstitial laser coagulation, and the holmium laser-based resection and enucleation are fully suitable for treatment of median lobes. Surprisingly, no studies focussing specifically on laser treatment of median lobes have been published.

Water-induced thermotherapy for benign prostatic hyperplasia.

Water-induced thermotherapy (WIT), administered by the Thermoflex System, represents a novel minimally invasive technique for the treatment of benign prostatic hyperplasia (BPH). The Thermoflex System consists of an extracorporeal heat source and a proprietary closed-loop catheter system. Water, heated to 60 degrees C, is continuously circulated through the catheter to a treatment balloon, which conducts thermal energy to targeted prostatic tissue. The combination of heat and compression reduces the heat sink effect of the circulating blood, thus enhancing the thermal energy transfer to the compressed tissue. WIT treatment is performed using only topical urethral anesthetic, in a single 45-minute session. The 2-year follow-up data from a European multicenter study consisting of 125 patients showed an improvement in peak urine flow of 87.4% (from baseline 8.7 +/- 1.9 to 16.3 +/- 9.1 mL/s) and in the International Prostate Symptom Score (IPSS) of -54.2% (from baseline 24 +/- 5 to 11 +/- 5). Patient tolerance of WIT was rated as "excellent" or "good" in 91.8% of the procedures. WIT is efficacious, simple, and inexpensive, has few side effects, and does not need special probes to monitor prostate or rectum temperature; thus, it can be used in hospitals, outpatient clinics, and doctors' offices.

Microwave thermotherapy: historical overview.

The application of heat with curative aim is an old and very well-known principle in medicine. A review of the history of heat use in the treatment of prostatic disease is presented. The article is based on bibliographic research (MEDLINE Search and PubMed) and focuses on treatment of benign prostatic hyperplasia (BPH) since the first clinical documentation of transrectal hyperthermia for this condition. Then, in a chronological sequence, not only the evolution toward thermotherapy but also enhancements of the latest techniques are presented. The new advances in the field of patient selection, indications, and outcome predictors, as well as new trends in treatment are briefly considered.