[The microbiome in benign prostatic hyperplasia]. / Das Mikrobiom beim benignen Prostatasyndrom.

The advent of new high throughput sequencing technologies has paved the way for microbiome research, opening up entirely new perspectives on the complex and diverse ecosystems of the human body. One of the main findings was that it became clear that in contrast to the widely held dogma the urinary tract is not a sterile environment. As for all niches of the human body, a well-balanced microbiome is an essential part for the physiological functioning of the urinary tract and therefore it must be considered a prerequisite for health. The dysbalance of the microbiome is now seen as having a considerable impact on the pathogenesis of a plethora of diseases. Its role in benign disorders, such as interstitial cystitis, urinary urge incontinence and chronic prostatitis/chronic pelvic pain syndrome as well as participation in malignant conditions, such as prostate cancer has recently been revealed. The contribution of the urinary microbiome to the pathogenesis and progression of lower urinary tract symptoms due to benign prostatic obstruction are currently under investigation.

[Sophisticated surgical management of distinctive patients with benign prostatic hyperplasia (BPH)]. / Differenziertes operatives Management unterschiedlicher Patienten mit benignem Prostatasyndrom (BPS).

Herein we describe four clinical scenarios. For the standard patient (prostate volume 30-80 ml, life expectancy >10 years) transurethral resection of the prostate (TURP) remains the standard of care, while endoscopic enucleation is a valuable alternative. Patients with a relevant middle lobe profit most from TURP, endourological enucleation procedures, or laser vaporization. In the case of the absence or a moderate-sized middle lobe and the absence of severe bladder outlet obstruction (BOO), minimally invasive procedures such as Rezum®, UroLift® or prostate artery embolization (PAE) can be offered. Patients have to be informed that long-term data on this specific indication are lacking. Particularly younger men requiring BPH surgery are interested in preserving ejaculatory function. In the presence of severe BOO, ejaculatory-protective TURP or endoscopic enucleation by preserving the pericollicular region or aquablation are the methods of choice providing an antegrade ejaculation in 60-90% of cases. Rezum®, AquaBeam®, and UroLift® enable preservation of ejaculation in almost 100%; data on PAE with this respect are more controversial. For patients with a small prostate and significant post void residual, a thorough preoperative work-up, including urodynamics and bladder/detrusor wall thickness measurement, is of great importance. Desobstructive surgery provides satisfactory short- and midterm outcome, yet the long-term outcome is disappointing and remains to be determined in greater detail. The broad spectrum of therapeutic options enables today an individualized minimally invasive or surgical management of BPH considering patient wishes, anatomical factors or urodynamic factors. The time of a "one therapy fits all" strategy is definitely history.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]. / Einsatz von synthetischen Band- und Netzimplantaten bei der Behandlung von Belastungsinkontinenz und Descensus genitalis der Frau : Stellungnahme des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau der Akademie der Deutschen Gesellschaft für Urologie.

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]. / Diagnostik und Therapie der interstitiellen Zystitis (IC/BPS) : S2k-Leitlinie der Deutschen Gesellschaft für Urologie.

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

[Diagnostic procedures and diagnostic strategy for lower urinary tract symptoms/benign prostatic hyperplasia : An overview]. / Diagnostik und diagnostische Strategie beim benignen Prostatasyndrom : Ein Überblick.

BACKGROUND: Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) is the most common condition affecting the lower urinary tract of men. Evidence-based assessment is the basis for an ideal treatment approach. OBJECTIVES: To provide an overview of the current status of diagnostic measures for LUTS/BPH. MATERIALS AND METHODS: Descriptive review of the literature on the diagnosis of LUTS/BPH. RESULTS: A medical history inquiring about LUTS/BPH symptoms and burden as well as a standardized and validated symptom questionnaire such as the International Prostate Symptom Score (IPSS) are the basis of the assessment. A physical examination including a rectal exam and the ultrasonography of the lower and upper urinary tract are also part of the basic diagnostic workup. Prostate size is ideally measured by transrectal ultrasound. Serum prostate-specific antigen measurement may help to estimate the prostate size and the risk fo progression. It can also be helpful in the detection of prostate cancer. Urine dipstick or sediment is used to exclude urinary tract infection, hematuria, or glucosuria. Voiding dysfunction can be detected by uroflowmetry. In addition to the aforementioned examinations, further tests such as frequency-voiding charts, multichannel urodynamic evaluation, measurement of detrusor wall thickness and X­ray imaging of the upper urinary tract as well as a cystoscopy may be offered if needed. CONCLUSIONS: Diagnostics of LUTS/BPH consist of basic exams as well as optional exams and can be used to assess the progression risk, to identify complications and to offer the ideal treatment.

[Fake News BPH - what is really true!] / Hartnäckige Mythen zum Thema BPS ­ und was davon wirklich stimmt!

BACKGROUND: Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is the fourth most common and the fifth most costly disease in men aged 50 years or older. Despite the high prevalence of LUTS/BPH in clinical practice and evidence-based guideline recommendations, there are still plenty of misconceptions on the terminology and pathophysiology of the disease, leading to false assumptions and malpractice. OBJECTIVES: Listing of commonly used false assumptions and clarification of the correct terminology and pathophysiology. MATERIALS AND METHODS: Critical reflection of 12 selected fake news based on PubMed search. RESULTS: Average prostate weight in healthy men is 20 g but varies between 8-40 g. The BPH-disease does not progress in stages; therefore, the BPH-classifications according Alken or Vahlensieck should not be used anymore. There is only a weak and inconsistent relationship between bladder outlet obstruction (BOO) and prostate size, diverticula/pseudo-diverticula, postvoid residual, urinary retention or renal insufficiency, which is too unreliable for BOO-diagnosis in the individual patient. Urethro-cystoscopy with grading of the degrees of occlusion of the prostatic urethra and bladder trabeculation is insufficient for BOO-diagnosis. There is no clinically relevant reduction of BOO with licensed BPH-drugs and no convincing data that prostate resection (TURP) has to be complete until the surgical capsule in order to obtain optimal results. CONCLUSIONS: The reasons for the persistent use of wrong terminology and pathophysiology are diverse. One reason is lack of implementation of evidence-based guidelines into clinical practice due to lack of knowledge, individual beliefs, costs, availability and reimbursement policies. Another reason is the increasing focus on oncology, coupled with underrepresented education and training on BPH.

[Influence of medical BPS treatment on sexual function]. / Einfluss medikamentöser BPS-Therapie auf die sexuelle Funktion.

BACKGROUND: Benign prostate syndrome is frequently associated with sexual dysfunction. The therapeutic options discussed in the S2e guideline may be able to improve existing sexual dysfunctions but can also worsen disorders or even trigger new ones. OBJECTIVES: What are the effects of therapeutic options as described in the S2e guideline on sexual function? METHODS: By selective literature search related to benign prostate syndrome and sexual dysfunction adverse effects of drugs mentioned in the S2e guideline have been evaluated. RESULTS: Serenoa repens extracts do not have adverse effects on sexual function; this is also true for muscarine receptor antagonists. 5α-Reductase inhibitors frequently worsen erectile function, libido and ejaculation; selective α1-blockers have an adverse effect on ejaculation. Phosphodiesterase (PDE)-5 inhibitors can improve sexual function. A combination of α1-blockers and 5α-reductase inhibitors worsens sexual functions significantly. CONCLUSIONS: A suitable therapy for benign prostate syndrome should be chosen jointly by the patient and the treating physician and should be adapted to personal needs. Effects on sexual functions have to be taken into consideration when choosing a therapy.

[Interstitial cystitis : Diagnosis and pharmacological and surgical therapy]. / Interstitielle Zystitis : Diagnostik, medikamentöse und operative Therapie.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic debilitating condition which generally has a severely negative impact on quality of life. An autoimmune genetic predisposition correlates with the theory of pathogenesis. Diagnosis requires history, diaries, physical examination, exclusion of other diseases, cystoscopy with or without hydrodistension and/or bladder biopsy. Novel biological markers are upcoming but not established. Behavioural, pharmacological oral and intravesical, interventional and surgical therapies with a wide range of reported success are available. A multimodal approach is recommended, although most of the therapeutic options lack a high degree of evidence.

[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.

[Priapism: Current diagnostics and therapy]. / Priapismus : Aktuelle Diagnostik und Therapie.

Priapism is characterized by involuntary persistent penile erection after or independent of sexual stimulation. The diagnostic clarification, including patient history, physical findings, duplex ultrasonography and analysis of blood gases is decisive for the underlying pathophysiology and the appropriate therapeutic procedure. Non-hypoxic and non-acidotic blood gas parameters enable a conservative approach, hypoxic, hypercarbic and acidotic parameters may lead to fibrosis of the corpora cavernosa and, in turn, to a loss of penile function. Low-flow or ischemic (veno-occlusive) priapism is an emergency situation and can lead to irreversible erectile dysfunction within 4 h. Treatment consists of blood aspiration and possibly intracavernosal injection of sympathomimetic drugs. A distal shunt is necessary in the case of treatment failure (in rare cases a proximal shunt). Management of recurrent priapism (stuttering) includes self-injection of sympathomimetic drugs and preventive long-term administration of erection inhibitory and erection promoting substances. This concept still needs to be validated. High-flow or non-ischemic priapism does not necessitate immediate treatment measures and should be kept under observation. In cases of a detectable fistula selective artery embolization is often a successful option.

[Use of botulinum toxin type A in non-neurogenic overactive bladder. Recommendations of the Working Group Urological Functional Diagnostics and Urology in Women]. / Botulinumtoxin Typ A bei der nicht-neurogenen überaktiven Blase. Empfehlungen des Arbeitskreises "Urologische Funktionsdiagnostik und Urologie der Frau".

The use of botulinum toxin for the treatment of neurogenic detrusor overactivity was first described in 2000 and thereafter botulinum toxin has also been used in non-neurogenic overactive bladder. In current guidelines intravesical injection of onabotulinumtoxin A in refractory patients is recommended. Our aim is to provide some clinically relevant recommendations from the Working Group Urologische Funktionsdiagnostik und Urologie der Frau for diagnostics and treatment with onabotulinumtoxin A of patients with non-neurogenic overactive bladder.

[Natural orifice transluminal endoscopic surgery in urology: feasability of a transrectal, flexible retroperitoneoscopy in a porcine model]. / "Natural orifice transluminal endoscopic surgery" in der Urologie : Machbarkeit einer transrektalen, flexiblen Retroperitoneoskopie im Schweinemodell.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) in urology is becoming more and more interesting due to technical innovations. One of those innovations is the HybridKnife®, a multifunctional sonde that combines high-frequency electrosurgery and water jet surgery. The aim of this study was to establish a transrectal, flexible endoscopic retroperitoneoscopy in a porcine model by means of the HybridKnife® for further development of a transrectal retroperitoneal NOTES lymphadenectomy (NOTES-RLA). MATERIAL AND METHODS: Five female pigs (25-30 kg body mass) were anesthetized and placed in a supine position. The rectal mucosa was opened 3-5 cm cranially of the linea dentata. After submucosal tunneling, the retrorectal space was opened. We performed a flexible endoscopic retroperitoneoscopy by means of a double-channel gastroscope 13.806 PKS (Karl Storz-Endoskope, Tuttlingen, Germany) and the HybridKnife® I-type (ERBE Elektromedizin, Tübingen, Germany). RESULTS: Transrectal access was safe and feasible without any difficulties. Using the HybridKnife® water jet technology, the retroperitoneal space could be distended which enabled safe access to the iliacal vessels, the bifurcation of the aorta/vena cava, and the pre- and paraaortal/-caval space up to the renal vessels. The water jet did not lacerate or injure blood vessels, nerves, or lymph vessels in any of the surgical procedures. CONCLUSIONS: By means of the HybridKnife®, transrectal access into the retrorectal space is safe and easily feasible. The water jet technology combined with electrosurgery prevented injuries of blood vessels, nerves, and lymph vessels and enabled transrectal flexible endoscopic retroperitoneoscopy as a precondition for further establishment of a transrectal NOTES-RLA.

[Auricular acupuncture in patients with detrusor overactivity: a pilot study]. / Ohrakupunktur bei Detrusorhyperaktivität : Eine Pilotstudie.

BACKGROUND: Patients suffering from overactive bladder/detrusor overactivity (OAB/DO) seem to benefit from body acupuncture. The study was carried out to test if auricular acupuncture (AAP), which is supposed to show an immediate effect, can also cause urodynamic changes. PATIENTS AND METHODS: The OAB/DO condition was verified by means of cystometry in 14 patients. These patients were subjected to bilateral AAP after cystometry, a second cystometry was performed 20-30 min later and data were analyzed using the Wilcoxon rank-sum test. RESULTS: None of the patients showed local or systemic complications but DO persisted in all patients and urge urinary incontinence (UUI) persisted in 85 % (11/13) of patients. Intravesical pressure decreased after AAP but without reaching statistical significance. In 22 % (2/9) of patients residual volume (RV) disappeared completely while 78 % (7/9) of patients showed significant reduction of RV. CONCLUSIONS: This study could not prove a significant influence of AAP on DO or UUI; therefore an immediate effect of AAP in patients suffering from OAB/DO seems to be unlikely. Further studies are necessary to evaluate the effect of repeated AAP sessions on urodynamic changes.

Acute epididymitis in ultrasound: results of a prospective study with baseline and follow-up investigations in 134 patients.

OBJECTIVES: To perform a comprehensive follow-up analysis of ultrasonographic scrotal features and associated signs in patients with acute epididymitis. METHODS: Between 2007 and 2012, 134 adults (median age 54 years) with acute epididymitis underwent scrotal ultrasonography and palpation at first presentation and after 2 weeks and 3 months. RESULTS: At first presentation, 61 patients (45.5%) had hydrocele, 63 (47.0%) concomitant orchitis, and 8 (5.9%) epididymal abscess. Epididymitis was predominantly located in 24 cases (17.9%) in the head, 52 cases (38.8%) in the tail, and 58 cases (43.3%) in both. On the affected side, testicular volume was 16.9 ± 6.8 ml and peak systolic velocity of the testicular artery was 23.7 ± 7.5 cm/s, compared to the healthy side with 12.3 ± 4.4 ml and 9.5 ± 3.6 cm/s respectively (P<0.001). Concomitant orchitis was associated with hydrocele, testicular enlargement and pain (P<0.01). Orchiectomy due to secondary testicular infarction was necessary in four cases, while in all other patients ultrasound parameters normalized. Only 16/90 patients (17.8%) showed a persistent epididymal swelling after 3 months. CONCLUSIONS: Common ultrasound features include hydrocele, epididymal enlargement, hyperperfusion, and testicular involvement. Under conservative treatment, ultrasound parameters normalize without evidence of testicular atrophy even in patients with epididymal abscess or concomitant orchitis.

[Overactive bladder in the elderly]. / Blasenüberaktivität im Alter.

The prevalence of overactive bladder syndrome (OAB) increases with age and is associated with a clear reduction in patient quality of life. Age-related alterations of the urinary bladder as well as increased occurrence of neurological and non-neurological diseases with age contribute to the onset of OAB. Antimuscarinic drugs are the medication of choice; however, restricted tolerability and polypharmacotherapy limit administration in the elderly. Extended release preparations are to be favored as constant intake of medication is more feasible and adverse effects occur less often compared to immediate release formulations. With respect to cognitive impairment newly introduced substances and quaternary amines seem to be advantageous. However, constipation remains a notable side effect in older patients. Intravesical botulinum toxin type A (BoNT/A) injections are an alternative and a therapeutic escalation in patients suffering from OAB. Adverse events are very rare and drug interactions are unknown; however, injections can result in hypercontinence causing the necessity for artificial urine drainage.