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.

[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.

[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.

[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.

Interstitial laser prostatectomy.

In an attempt to minimize the need for hospitalization and the associated perioperative and postoperative morbidity, alternatives to transurethral resection of the prostate (the standard treatment modality for benign prostatic hyperplasia) have been sought. Various types of laser prostatectomy have been proposed. Interstitial laser coagulation is performed by placing laser-diffusing fibers directly in the hyperplastic prostatic adenoma. The goal is to achieve coagulation necrosis within the adenoma, which causes the prostatic lobes to regress and thereby relieves the bladder outlet obstruction. Either the transurethral cystoscopic approach or the perineal approach can be used for laser application. Numerous published studies have shown that this laser procedure safely and effectively decreases symptoms of prostatism, increases the urinary flow rate, and reduces the volume of the prostate. Because of substantial tissue edema after treatment, catheter drainage may be necessary for 7 to 21 days. Although retrograde ejaculation has occurred occasionally (affecting from 0 to 11.9% of patients in reported studies) and uncomplicated urinary tract infections are common after interstitial laser coagulation, no cases of impotence or sustained incontinence have been described. Because interstitial laser coagulation is not associated with blood loss or intravascular fluid shifts and, if necessary, can be performed with a combination of local anesthesia and intravenous sedation, even high-risk patients are candidates for this procedure.

The optimization of laser prostatectomy. Part I: Free beam side fire coagulation.

OBJECTIVES: To study laser-tissue interaction and develop unifying principles for the optimization of free beam side fire neodymium:yttrium-aluminum-garnet (Nd:YAG) laser coagulation prostatectomy. METHODS: The heating patterns and coagulation volumes created by different right angle deflecting fibers were studied at different wattages and times in potato and canine models. RESULTS: In the potato, higher wattage resulted in deeper and more rapid heating. The high power density fibers created lesions of smaller volume which increased less with rising wattage than those fibers of lower power density. In the canine model, carbonization decreased heat penetration, and "popcorn" decreased superficial temperature without altering lesion size as long as it occurred without carbonization. As lasing progressed, smaller incremental increases in coagulation depth were achieved. CONCLUSIONS: To optimize coagulation laser prostatectomy, the surgeon should operate at the highest wattage which does not cause carbonization. The visualized intraoperative laser-tissue interaction allows the adjustment of laser power during the case as needed.

The optimization of laser prostatectomy. Part II: Other lasing techniques.

OBJECTIVES: To evaluate the laser-tissue interaction during neodymium:yttrium-aluminum-garnet (Nd:YAG) irradiation using right angle firing fibers in motion, contact vaporization applicators, and interstitial lightguides. METHODS: The heating patterns and coagulation volumes created during right angle firing fiber pulling and painting, contact tip vaporization, and interstitial thermotherapy were studied in potato and canine models. RESULTS: High power density right angle firing fibers can be used in motion to create coagulation lesions at 40 and 60 watts (W). The depth of such lesions was less than that obtained during fixed free beam side fire coagulation. Contact vaporization applicators caused tissue vaporization without creating concurrent coagulation lesions. Interstitial lightguide thermotherapy created coagulation lesions without carbonization using A step power reduction approach during irradiation. CONCLUSIONS: Each of the investigated methods had the ability to destroy prostate tissue, and therefore may have a role in the evolution of laser prostatectomy.

Electrosurgical vaporization of the prostate in the canine model.

OBJECTIVES: To investigate the histopathologic changes and heating patterns caused by electrosurgical vaporization of the prostate in the living canine model. METHODS: Prostate electrosurgical vaporization was undertaken in the canine model. Temperatures within and near the prostate and of the irrigation fluid were measured during a single pass and during the creation of a vaporized cavity. The prostate and adjacent tissues were examined by gross and microscopic pathology. RESULTS: Coagulation occurred deep to the vaporization zone for 1.38 to 1.44 mm for a single pass of the rolling cylinder and up to 2.52 mm for multiple passes. Thermometry revealed temperature increases of only 4 degrees C 5 mm away from the vaporization site. The largest temperature increases were found in the irrigation fluid as it passed through the prostatic fossa. Microscopic pathology revealed no damage to adjacent tissues. CONCLUSIONS: Electrosurgical vaporization creates minimal deep heating and coagulation beyond the vaporized cavity. The majority of the heat is removed by the irrigation fluid.

Initial human clinical experience with diode laser interstitial treatment of benign prostatic hyperplasia.

OBJECTIVES: To report the initial results of treatment of outlet obstruction induced by benign prostatic hyperplasia (BPH) using interstitial laser coagulation performed with the Indigo 830 nm diode laser system. METHODS: A group of 112 men with lower urinary tract symptoms caused by BPH underwent treatment with the Indigo 830 nm laser system between October 1994 and November 1995. Patients were assessed prior to treatment and at specified post-treatment intervals for symptom score, uroflow, postvoid residual, and prostate volume. Adverse events and changes in laboratory parameters were monitored at each post-treatment visit to investigate safety of the procedure. RESULTS: Symptom score decreased from 20.9 at initial measurement to 9.6 at 3 months after procedure and 7.9 at 6 months. Uroflow rate increased from 8.0 mL/s initially to 15.2 and 14.2 mL/s at 3 and 6 months, respectively. Residual bladder volumes decreased from 105 mL initially to 59 and 38 mL at 3 and 6 months, respectively. There were no major complications (impotence, sustained incontinence, significant blood loss). Minor complications occurred in a small number of patients but were generally associated with urinary tract infection in patients with catheters. Three patients (2.7%) required retreatment and underwent transurethral resection of the prostate. CONCLUSIONS: Interstitial laser coagulation using an 830-nm diode laser system appears to be a promising new treatment, with substantial improvements in objective and subjective parameters of obstruction and a favorable side-effect profile.

Interstitial laser therapy outcomes in benign prostatic hyperplasia.

Two hundred thirty-nine patients with benign prostatic hyperplasia (BPH) were treated using interstitial laser coagulation (ILC or LITT; laser-induced interstitial thermotherapy), and the long-term results were determined. In this minimally invasive procedure, special laser light guides were inserted into the adenoma tissue in order to achieve primary large-volume coagulation necrosis and secondary shrinking, leaving the urethra intact. The AUA Symptom Scores improved markedly, from an average of 25 pretreatment to an average of 6 at 1 year. Peak urine flow rates improved commensurably, from 8 mL/sec pretreatment to 18 mL/sec at 1 year. Postoperative irritative symptoms occurred occasionally, affecting only 12% of patients. Significant complications were rare, with 4% of patients suffering strictures and 7% retrograde ejaculation. No patients suffered impotence or incontinence. Only 9.6% of patients required retreatment for BPH during 12 months of follow-up. Twelve patients were treated with subsequent transurethral laser incision of the bladder neck in order to shorten the time required for improvement of voiding function.

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.

[Gynaecomastia and mammography (author's transl)]. / Gynäkomastie im Mammogramm.

The term gynaecomastia indicates an increase in the mass of the normally rudimentary male breast; morphologically there is hyperplasia and differentiation of the epithelial and mesenchymal breast components. Gynaecomastia is not a disease in itself, but a symptom of some underlying disease or the result of drugs. Of 2895 breast operations performed at the surgical clinic of the University of Göttingen, 2.97% were operations on men with gynaecomastia. Amongst 79222 mammograms in the Radiological Clinic of the University, there were 900 mammograms (1.14%) of 392 men with gynaecomastia. Most benign and malignant conditions in men are retromammary in localisation. For this reason clinical evaluation is frequently wrong. The use of mammography as an additional diagnostic method in men is therefore more important than it is in women. Systematic analysis of the mammograms performed on men has made possible a classification of gynaecomastia according to the radiological appearances: I Septal linear structures (8.5%), II Opacities of varying density and size (26.5%), III Circular, usually inhomogenous shadows (15.5%), IV Homogeneous, demarcated foci of varying size (35.5%), V Soft-tissue hyperplasia-pseudo-gynaecomastia (10%).

[Laser treatment of benign prostatic hyperplasia]. / Laserbehandlung der benignen Prostatahyperplasie.

This review article describes the different methods of laser treatment of benign prostatic hyperplasia and their development. Published treatment results are compared with our own results obtained with different procedures. The aim of therapy is to reduce the volume of the gland by coagulation, with subsequent secondary ablation or primary vaporization. Due to the desired volume effects Nd:-YAG lasers are used almost exclusively. The technique most frequently used is transurethral laser coagulation of the prostate. Radiation is done in the non-contact mode with beam-detecting applicators, with either direct vision (VLAP) or ultrasound guidance (TULIP). In interstitial laser coagulation of the prostate (ILC) laser energy is applied by light guides inserted into the tissue either transurethrally or transperineally. Contact lasers are used for incision of the prostate or superficial ablation.

[Laser applications in condylomata acuminata]. / Laseranwendung bei Condylomata acuminata.

Condylomata acuminata are benign epidermal proliferations caused by human papillomavirus (HPV). Recent epidemiological data have shown that HPV infection is the most common sexually transmitted disease. Some HPV types are considered to be potentially oncogenic. Therefore, effective examinations and treatment of both sexual partners are important in all cases. The CO2 laser and the Nd:-YAG laser have gained widespread acceptance in the treatment of HPV efflorescences. CO2 lasers are characterized by surface absorption; the Nd:-YAG laser effect depends on volume absorption; depth of coagulation can be controlled by laser power, spot size and exposure time. Both of these fundamentally different laser effects lead to excellent cosmetic results and high cure rates. Our follow-up examinations revealed recurrences in 22%.

[Interstitial laser-induced coagulation of the prostate for therapy of benign hyperplasia]. / Die interstitielle laserinduzierte Koagulation (ILK) der Prostata zur Therapie der benignen Hyperplasie (BPH).

Interstitial laser-induced coagulation (ILC) is a new, minimally invasive, procedure for the treatment of benign prostatic hyperplasia (BPH). It is based on the placement of special light guides in the prostatic tissue, either transurethrally or perineally. The radiation source is a Nd-YAG laser, which is active for 3 or 5 min per fiber placement, respectively, with the power reduced stepwise. The coagulation necroses caused shrink during follow-up, leading to a decrease in the obstruction. In 239 patients treated in this way the mean I-PSS-Score fell from 25.4 to 8.1 points and the quality of life index from 4.1 to 1.6, the urinary peak flow rate increased from 7.7 to 16.3 ml/s, the residual urine volume fell from 151 to 32 ml, and the mean prostate volume declined from 47.4 to 32.2 ml in the first 3 months of follow up; 9.2% of the patients required further treatment within 1 year because of persistent obstruction. The complication rate was low. Statistical analysis showed no factors allowing prediction of the outcome. ILC is an effective method with few side effects and complications, and it has a wide range of indications for all BPH patients.

[Interstitial laser coagulation of benign prostatic hyperplasia]. / Die interstitielle Laserkoagulation der benignen Prostatahyperplasie.

We report on the new method of interstitial laser coagulation for the treatment of benign prostatic hyperplasia (BPH). The procedure is based on the interstitial application of Nd:YAG laser irradiation, delivered through a new light guide system. Such light applicators coagulate constant tissue volumes in a homogeneous manner, as proven by in vitro studies in different tissues, including surgically removed prostate adenoma. The extent of the coagulation is determined by laser power and irradiation time. At 5 W, for example, and during a 10-min period, this zone reached a diameter of up to 20 mm. Temperatures generated in the process were over 100 degrees C, as measured by time/space resolution. These results were confirmed by in vivo studies in canine prostates. In the course of 7 weeks, the coagulated areas formed scars with degeneration and fibrosis, accompanied by marked shrinking. Neighbouring organs were not affected. The method was successfully transferred to clinical practice. The application of the light guides to the lateral lobes was performed percutaneously from the perineum under transrectal ultrasound guidance. The median lobe was punctured transurethrally under direct vision. Twenty-seven patients with an average age of 67.7 years were treated between July 1991 and March 1992. At the time of evaluation 15 patients had a follow-up of more than 2 months. They experienced a mean increase of peak flow rate from 6.6 to 15.2 ml/s and a mean decrease of residual volume from 206 to 38 ml. This was accompanied by a marked lessening of symptoms. The average prostate weight decreased from 63 to 44 g. Sexually active patients did not experience retrograde ejaculation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laser lithotripsy of ureteral calculi]. / Laserlithotripsie von Harnleitersteinen.

A total of 149 patients with 152 ureteral stones were treated with intraureteral lithotripsy by Dye-laser (83.55%), Alexandrite-laser (41.27%), electrohydraulic lithotripsy adapted for use in the ureter (25.16%) or neodymium: YAG laser with optomechanic coupling (3.2%). The Dye-laser has an automatic pulse shut-off mechanism with spectral analysis of the reflected laser beam, so that effective laser pulses can only be released by contact with a stone. Most (127 of 83.5%) of the stones could be completely fragmented, so that no further treatment was necessary. In 16 cases (10.5%) the stone was too hard for fragmentation and had to be removed by alternative techniques. Intraureteral lithotripsy is a save and effective method of treating ureteral stones that cannot be reached or have not been treated successfully by shockwave lithotripsy. No significant differences in outcome were found between the different lasers or electrohydraulic lithotripsy. In selected cases endoscopic treatment may be recommended as treatment of first choice.

[Diverticular calculi of the kidney calices--extracorporeal shockwave lithotripsy, percutaneous extraction or open surgery]. / Kelchdivertikelsteine--ESWL, perkutane Litholapaxie oder offene Operation.

The incidence of caliceal diverticula, mostly found on routine excretory urography, is very low. The indications for treatment include chronic or recurrent pyelonephritis, pain, gross hematuria and renal damage. There is controversy as to which treatment is best: extracorporeal shock-wave lithotripsy (ESWL), percutaneous techniques, or traditional open surgery. Since 1984, 27 patients with 28 caliceal diverticula calculi have been treated. Ten patients underwent ESWL, 13 patients percutaneous treatment, and 4 patients open surgery. The success rates as far as a stone-free status is concerned were: 1 patient (ESWL), 10 (percutaneous), and 4 (open surgery). There were no complications due to ESWL or open surgical treatment. Direct traumata such as severe bleeding in two and hydrothorax in one patient occurred during the training phase of the percutaneous techniques. Due to the low complication rate, non-invasive ESWL treatment should be tried first. The indications for percutaneous removal of calculi in caliceal diverticula depend on two aspects: it should be possible to puncture the caliceal diverticula via by a short parenchymal route coaxial to the axis of the calix and, if the intercostal approach is used, a pleural lesion must be excluded. If these requirements cannot be fulfilled, open surgical treatment should be performed, especially if the diverticula are located in the upper and anterior part of the kidney.

[Laser lithotripsy with automatic shut-off on tissue contact]. / Laserlithotripsie mit automatischer Abschaltung bei Gewebekontakt.

A group of 88 patients with 89 ureteral calculi were treated with the pulsed dye-laser. Visual control was carried out through 8.5-F or 9.5-F ureteroscopes. The laser has automatic shut-off via spectrum analysis of back-scatter laser light. Effective laser pulses can therefore only be induced in the case of contact with the stone. Of the 89 stones 58 (65.2%) were completely fragmented by laser lithotripsy, 15 (16.8%) by laser lithotripsy in combination with ESWL and 9 (10.1%) by other ureteroscopic techniques. Ureterolithotomy was necessary only in 1 case (1%). There were 5 calculi (5.6%) that were too hard for fragmentation. The pulsed dye-laser is a safe and effective treatment modality for ureteral calculi that are not accessible for ESWL or in which ESWL has been unsuccessful. Further experimental and clinical trials will have to show whether miniature probes for electrohydraulic lithotripsy, dye-laser with automatic shut-off, or alexandrite laser will be the method of choice for lithotripsy of ureteral calculi.