[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.

Integrating risk profiles for disease progression in the treatment choice for patients with lower urinary tract symptoms/benign prostatic hyperplasia: a combined analysis of external evidence and clinical expertise.

The RAND appropriateness method was used to explore the relevance of risk factors for disease progression in the treatment choice for patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). A total of, 12 international experts assessed the appropriateness of various treatments for 243 risk profiles. Highest appropriateness rates were found for alpha1-adrenoceptor antagonists (68% of profiles) and combination therapy (46%). A large prostate volume was the dominant argument in favour of 5alpha-reductase inhibitors and combination therapy, but was irrelevant for the choice of surgery. Considerable postvoid residual, severe symptoms and poor maximum flow rate were the most important factors in favour of surgery.

Risk factors for disease progression in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH): a systematic analysis of expert opinion.

Disease progression has become an important issue for the management of lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). Although several risk factors have been identified, no specific patient risk profiles have been established that can be useful in the day-to-day management of LUTS/BPH. In this study, an international panel of urologists developed a risk classification based on the attribution of a risk score to 243 unique patient profiles. From the perspective of clinical decision making, it was concluded that postvoid residual, symptom severity and maximum flow rate are the most relevant determinants of the risk of disease progression.

[Phytotherapy for BPS. Which products can still be prescribed?]. / Phytotherapie bei BPS. Welche Präparate können heute noch verschrieben werden?

For decades, plant extracts have been amongst to the most popular drugs for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)/benign prostatic enlargement (BPE). Only a few of the many published studies meet the criteria of the WHO-BPH consensus conference. The few placebo-controlled, long-term (>/=6 months) studies suggest a positive effect of some extracts (saw palmetto, beta-sitosterol, urtica, rye-grass, saw palmetto/urtica combination) on LUTS; an effect on uroflow, post-void residual volume, prostate volume and PSA was not consistently demonstrable. Randomised trials against an active comparator (alpha1-blocker, 5alpha-reductase inhibitors) are difficult to interpret. Due to the lack of prospective studies, several meta-analyses have been published that can not, however, replace prospective studies. None of the BPH-guidelines currently recommend plant extracts, yet universally conclude that this is an interesting approach. Further prospective studies using WHO standards are required to reliably determine the role of such extracts in the management of elderly men with LUTS due to BPH/BPE.

Lack of correlation between apoptosis and DNA single-strand breaks in X-irradiated human peripheral blood mononuclear cells in the course of ageing.

The dependence on age of both the basal and the X-radiation-induced levels of apoptosis was examined in human peripheral blood mononuclear cells (PBMC). In the same samples, the base value and the extent of induced DNA single-strand breaks were determined, using a sensitive and fast microplate assay. PBMC were isolated from blood of donors of various age groups (20-30, 40-60 and > 70 years of age) and X-irradiated ex vivo using a 6 MV linear accelerator to give a total exposure of 4 Gy. The mean basal levels of apoptosis in PBMC from donors in the 40-60 year age group and the > 70 year age group were found to be only slightly higher (by 20-10%) compared to that of the 20-30 year age group, whereas the extent of DNA damage strongly and significantly (P < 0.01) increased with age by up to 2-fold. In contrast to the extent of induced DNA damage, which steadily increased in the course of ageing by up to 1.8-fold, there was only a transient increase in the level of induced apoptosis to 1.5-fold in PBMC from X-irradiated blood (4 Gy photons) from donors aged 40-60 followed by a decrease to 0.9-fold in PBMC from old donors (>70), compared to age group 20-30. The results show that X-ray-induced apoptosis and DNA damage in PBMC are not correlated during ageing.

Assessment of plasma neopterin in clinical kidney transplantation.

Serial plasma samples of 172 kidney transplant recipients and 42 chronic dialysis patients were evaluated retrospectively in a radioimmunoassay to determine the clinical relevance of plasma neopterin levels. Dialysis patients had a higher neopterin level 196 +/- 82 nmol/L (mean +/- SD) than 70 healthy controls (7 +/- 4 nmol/L). In 45 patients with a completely uneventful postoperative course, elevated pretransplant neopterin levels dropped rapidly within a week to a mean of 30 nmol/L and remained stable thereafter. In 22 outpatients with stable graft function there was a highly significant correlation between 170 paired serum creatinine and plasma neopterin values (r = 0.94). A group of 13 patients had experienced delayed graft function (ATN) without rejection. Their one-week mean neopterin level was 100 nmol/L and continued to drop in parallel with the serum creatinine. Another 15 patients rejected their kidneys irreversibly within 3 weeks-6 of them had extremely high neopterin levels during the rejection process (range 500-1000 nmol/L) that were not seen in other patients. A total of 169 rejection episodes in 43 patients were treated with bolus-dose cortisone. On the day of bolus therapy, both serum creatinine (P less than 0.002) and neopterin (P less than 0.005) were elevated. At 24 hours prior to bolus cortisone therapy, creatinine levels were not significantly elevated, whereas there was a significant rise in plasma neopterin (P less than 0.01). The overall sensitivity of neopterin increase was 86% with a 17% probability of false positives, and the sensitivity was 95% in biopsy-proved rejections. Plasma neopterin appears to be a useful marker for early detection of rejection and for identifying severe rejections that are not responsive to treatment.

Posture-induced disturbance of pertechnetate flow and I-123 iodohippurate transport in some renal graft recipients with hypertension.

Iodohippurate renography and rapid serial scintigrams with pertechnetate were done in 27 allograft recipients in supine and standing positions. Posture-dependent iodohippurate transport and/or disturbance of pertechnetate flow pattern was found in nine of those examined. Patients demonstrating these abnormalities were found to be hypertensive. We suggest a causal relationship between posttransplant hypertension and the described posture-induced alterations of tracer transit.

Renal graft evaluation with pertechnetate and I-131 Hippuran. A comparative clinical study.

This retrospective study compared standard clinical and biochemical data from 50 graft recipients against 533 I-131 Hippuran sequential scintigrams and 515 [99mTc]pertechnetate serial scintigrams. All grafts included in this study are cadaver kidneys. The majority of the studies were made during the early posttransplantation period. Anuria or oliguria of at least 4 days duration was seen in 18 patients. The study spans 574 days of oliguria during which 136 dual-tracer studies were made. I-131 Hippuran renography of functioning grafts was carried out 397 times, and the Tc-99m sequential scintigraphy 379 times. In all, 47 espisodes of actue rejection were registered clinically in functioning gfafrs, 36 of which were recognized during Hippuran renography and 38 with the pertechnetate study. False-positive errors were seen 12 times during renography. The study also demonstrated that furosemide will significantly and predictably influence renography and the pertechnetate study. This seems noteworthy since furosemide is extensively used in posttransplant management.

[Contribution of digital subtraction angiography to the diagnosis of rejection reactions after kidney transplantation]. / Beitrag der digitalen Subtraktionsangiographie zur Diagnostik von Abstossungsreaktionen nach Nierentransplantation.

The ability to diagnose rejection changes in renal transplants using DSA was evaluated retrospectively taking intrarenal vascular changes into consideration. The findings obtained with DSA were compared to those of scintigraphy in 26 graft recipients, on whom both methods had been performed within a narrow time period for evaluation of hypertensive disease. The scintigraphic diagnosis was based on function and perfusion studies. The intrarenal vascular tree was demonstrated on DSA better by intraarterial than by intravenous contrast media injection, however both techniques delivered useful diagnostic information. The status of the graft was evaluated with comparable results by DSA and scintigraphy in 73% of the cases. In our experience, functional effects produced by morphological changes demonstrated by DSA, can be defined better with the help of scintigraphy. On the other hand, by performing DSA it is possible to clarify morphologically functional findings, which may be detected by scintigraphy but often are diagnostically nonspecific. The availability of both morphological and functional data increases the diagnostic accuracy which can be obtained with these two low invasive procedures in the assessment of vascular changes in renal transplants.

HBV DNA and other hepatitis B virus markers in sera from long-term hemodialysis and kidney transplant patients.

Sera from 191 long-term hemodialysis patients and from 115 renal transplant patients were studied for the presence of HBsAg and other HBV markers. In 19.1% of the hemodialysis patients and 28.7% of the transplant patients, the sera were positive for HBeAg.HBV DNA in sera was detected by molecular hybridization. HBV DNA was present in the sera of 15 out of 16 hemodialysis patients positive for HBeAg, and in one hemodialysis patient positive for anti-HBe. All renal transplant patients positive for HBeAg were also positive for HBV DNA. Twelve transplant patients were positive for HBV DNA, but negative for both HBeAg and anti-HBe. Determination of HBV DNA was the most sensitive marker of infectivity in patients with end-stage renal disease, and in renal transplant patients.

[Obstructive uropathy by perirenal lymphocele, a rare complication after renal transplantation (author's transl)]. / Harnabflussstörung durch perirenale Lymphozele, eine seltene Komplikation nach Nierentransplantation

One lymphocele was observed in 151 renal transplants. Ureteral compression led to obstructive uropathy with decreased renal function. The clinical symptomatology, diagnostic procedures and management of lymphoceles is described and discussed. Lymphoceles can mimic the clinical pattern of rejection. The most important data of 21 lymphoceles reported in the literature are reviewed. The formation of lymphoceles may be prevented by careful ligation of all lymphatics transected during dissection of the recipient vessels. Intraperitoneal marsupialization is the therapy of choice in case of persistent lymph leakage and recurrency.

[Indications for transplant nephrectomy with reference to possible complications]. / Indikationen zur Transplantatnephrektomie unter Berücksichtigung der möglichen Komplikationen.

Mortality rates of 1.2-38% and morbidity rates up to 68% following transplant nephrectomy (TPL-X) have been reported in the literature. From 1988 to 1995, 40 TPL-X were performed in the transplant centre in Bremen. In 15 cases the organs were removed within the first 6 weeks after renal transplantation. The indications were infarction in 10 cases, hyperacute/acute rejection in 3 cases, and repeated rejections with irreversible functional disorder in 2 cases. In the 25 patients in whom TPL-X was performed later than 6 weeks after transplantation the indication was chronic rejection associated with clinical findings in every case. The overall mortality rate was zero in the first 6 weeks after TPL-X, and the morbidity rate, 20%. TPL-X is a re-operation in patients with chronic disease. From this point of view the complication rate with a subtle technique is acceptable. The indications for TPL-X have not been well defined in the literature, so that the decision as to whether or not TPL-X is indicated is made on the basis of the individual situation. TPL-X seems not to be necessary in all cases of transplant failure.

[Current status of renoprotective procedures in the surgery of impaired kidneys]. / Aktueller Stand renoprotektiver Massnahmen bei Operationen an der insuffizienten Niere.

Renoprotective measures are of utmost importance for the preservation of renal function and prevention of acute renal failure of kidneys with impaired function subjected to operative procedures. Preoperatively a thorough nephrological work-up and preparation of the patient has to be performed. Potentially nephrotoxic drugs should be avoided. Examinations with radio contrast agents may lead to a deterioration of renal function, especially if risk factors are present. Hydration is an important part of preoperative renoprotection. Intraoperative renoprotective measures include atraumatic surgical techniques with preservation of renal parenchyma, the administration of diuretics and dopamine as well as a balanced substitution of blood and fluid loss. If the renal circulation has to be interrupted hypothermia should be applied. Controversy exists concerning the beneficial effect of membrane stabilisers, metabolic inhibitors and nucleotid precursors. For the prevention resp. treatment of postoperative acute renal failure balanced hydration, diuretics, dopamine and parenteral hyperalimentation have proven to be useful. The use of prophylactic dialysis leads to a reduction of the complications associated with acute renal failure.

[Technique of multiple organ procurement. Is involvement of urology indicated?]. / Technik der Multiorganentnahme. Ist die Beteiligung der Urologie sinnvoll?

Today the organ donor operation in brain dead donors is mostly projected as multiple organ procurement (MOP). Not only the kidneys, but heart and liver or additionally lungs and pancreas are removed in MOP. A good synchronization between the collaborating transplantation groups (thoracic and abdominal surgeon, urologist) is essential to prevent loss of an organ because of technical problems. In Germany urologists perform more than 40% of kidney transplantations. These urologic institutions perform the cadaver kidney retrievals and participate on MOP. If possible, an urologist experienced in renal transplantation should contribute to the care for quality of the kidneys. Since 1987 the transplant center of Bremen obtained 390 donor registrations. 202 organ donor operations have been performed (106 MOP and 96 exclusive kidney retrievals). 398 donor kidneys have been collected and 382 could be transplanted.

[Status of phytotherapeutic drugs in treatment of benign prostatic hyperplasia]. / Stellenwert von Phytotherapeutika bei der Behandlung der benignen Prostatahyperplasie (BPH).

Phytotherapeutic preparations are still commonly used for the treatment of symptomatic benign prostate hyperplasia (BPH) in Germany; in recent years there has even been an increase in their use, so that sales now amount to more than DM 220 millions per year. The preparations most frequently used are extracts of Hypoxis rooperi, the roots of the stinging nettle, the fruits of the saw palmetto, pumpkin seeds and rye pollen. The suggested mechanisms of action have not been documented by scientific observation. This applies especially to the blocking effect on 5 alpha-reductase postulated with the doses used. Moreover, a critical analysis of the data available suggests that the effects of phytotherapy are no better than those of placebo treatment. Further studies are urgently needed, to compare the effects of phytotherapy with those of chemically defined drugs (alpha 1-receptor antagonists, 5 alpha-reductase blocker) that seem to have a beneficial influence on the pathomechanism underlying symptomatic BPH.

[Surgical-urologic complications after kidney transplantation]. / Chirurgisch-urologische Komplikationen nach Nierentransplantation.

The incidence, pathogenesis, diagnostic procedures and management of surgical and urological complications observed in 437 consecutive renal transplantations are described. Urinary fistulas (4.3%) and ureteral obstructions (1.8%) are the most important urological complications. Prompt diagnosis and correction are mandatory to prevent graft loss and death of the recipient, especially if these complications are associated with infection. A high incidence of reflux into the graft (37.6%) was detected by routine cysto-urethrogram. For the first time a correlation between the incidence of reflux and the number of rejection episodes could be demonstrated, suggesting immunological alterations of the transplant ureter as the main pathogenetic factor of reflux after renal transplantation. However, reflux does not seem to be deleterious to graft prognosis, provided there is no subvesical obstruction. The main surgical complications after renal transplantation are lyymphoceles (8.2%), renal artery stenoses (6.7%), and spontaneous graft ruptures (4.3%), while wound infections (1.8%) and arterial thromboses resp. ruptures (0.7% resp. 0.5%) are rare complications. Urological and surgical complications can be kept to a minimum by strict adherence to certain principles in pretransplant recipient evaluation, donor nephrectomy (in situ perfusion, en bloc nephrectomy) and the technique of graft implantation. The extravesical technique of uretero-neocystostomy is the procedure of choice for the reconstruction of the urinary tract in renal transplantation.

[Current immunologic aspects of kidney transplantation]. / Aktuelle immunologische Aspekte der Nierentransplantation.

The results of clinical kidney transplantation are mainly dependent on immunologic factors many of which are unknown or of unspecified importance. Blood transfusions have a favorable effect on graft prognosis, although our knowledge about optimal transfusion protocols and transfusion-induced mechanisms is still incomplete. The value of HLA-typing is controversial: whereas compatibility of the "classical" HLA-A,B,C antigens improves graft survival only moderately, HLA-DR typing, routinely performed for the last 3 years only, might be of greater importance. In addition, non-HLA systems, such as endothelial/monocytic antigens or the Lewis blood group system, appear to play a role in graft rejection. The individual immune reactivity a recipient to a large extent determines the fate of a graft. The multifactorial dependence of graft prognosis is discussed in this report.

[Hypertension following renal transplantation (author's transl)]. / Hochdruck nach Nierentransplantation.

Hypertension is more frequent in transplant recipients than in the general population. The two most frequent causes are reduced function of the transplant and the presence of the recipient's own kidneys. Beyond the immediate postoperative period, administration of glucocorticoids appears to have little influence on blood pressure. The various forms of arterial stenosis of the transplant are infrequent, but clinically important, because they are susceptible to surgical correction or arterial dilatation. The pathogenetic mechanisms and diagnostic problems of the various forms of posttransplant-hypertension are discussed in this review.