Treatment of benign prostatic hyperplasia.

The treatment of benign prostatic hyperplasia includes a variety of options ranging from medication to open prostatectomy. Several newer technologies have been developed. Transurethral resection of the prostate remains the gold standard among surgical procedures for prostates less than 80 cc whereas enucleation and simple open prostatectomy are most documented for larger prostates. This review has focus on the status of treatment available in Denmark at the moment. Thorough evaluation of the patients before treatment and shared decision-making with regard to treatment options is essential.

Bladder Neck Contracture after Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Treated with a Thermo-Expandable Metal Stent (Memokath® 045).

Bladder neck contracture following transurethral resection of the prostate is a rare but feared complication. Treatment is often challenging with significant recurrence rates. In this report, we present a complicated case treated with a simple procedure. A 75-year-old male developed urinary retention due to bladder neck contracture after transurethral resection of the prostate. He was initially treated with several transurethral incisions, but the obstruction recurred few months after each incision. At urethroscopy, the bladder neck was completely obstructed. Using both retrograde and antegrade endoscopy, it was possible to place a through-and-through guidewire, after which the length of the stricture could be measured. Subsequently, the stricture was slightly dilated, and a double-cone thermo-expandable metal stent (Memokath 045) could be placed. The correct position was monitored with antegrade and retrograde endoscopy, securing the proximal cone expanded above the stricture and the distal cone above the sphincter. The patient was discharged the same day with spontaneous voiding and minimal residual urine. Twenty-one months after stent placement, the patient still had no complaints of his urination. Thus, the double-cone thermo-expandable metal stent, Memokath 045, may be a durable option for treatment of complicated bladder neck contracture after TURP for benign prostatic hyperplasia.

[Convalescence and sick leave following transurethral prostatectomy]. / Rekonvalescens og sygemelding efter transuretral prostatektomi.

Recovery after transurethral prostatectomy (TUR-P) is characterized by lower urinary tract symptoms (LUTS) and haematuria often affecting the patient's social life negatively. Procedure-specific information reduces the patient's anxiety postoperatively. When giving advice on level of activity during recovery, the risk of haematuria is the most important factor. Since bleeding ceases in 95% of cases within three weeks, patients should avoid hard physical activity for three weeks. Normal activity can be resumed immediately, although bothersome LUTS may be a limiting factor. Equivalent advice should be given with regard to the need for sick-leave.

Retrograde ureteroscopic holmium laser endopyelotomy in a selected population of patients with ureteropelvic junction obstruction.

OBJECTIVE: Significant controversy remains concerning the best way to treat ureteropelvic junction obstruction (UPJO). This study evaluates subjective and objective outcomes of retrograde holmium laser endopyelotomy in a selected population with UPJO. MATERIAL AND METHODS: Forty-seven patients with UPJO were referred to retrograde endopyelotomy between April 2004 and March 2007. Patients with a very large pelvis, a high insertion of the ureter, a renal split function below 20% or a long (>2 cm) stenosed ureteropelvic segment, and patients younger than 18 years were not selected for endopyelotomy, but subjected to laparoscopic pyeloplasty. Renal function was estimated on renal diuretic scan before and after surgery with a mean renographic follow-up of 35 weeks. Subjective results were based on questionnaires which were returned from 44 patients with primary (n=37) or secondary (n=7) obstruction (mean follow-up 110 weeks). Success criteria were defined as symptom relief and improved or preserved renal function. RESULTS: Twenty-nine patients (66%) experienced complete symptom resolution and 10 patients (23%) had significant symptom improvement (i.e. no need for pain-killing medication). Five patients (11%) had unchanged symptoms. No difference in postoperative renal function was observed between these three groups of patients. The differences between preoperative and postoperative renal function were non-significant in each group. No major complications were observed. Five patients (11%) were referred to retreatment owing to unchanged symptoms. CONCLUSION: Retrograde ureteroscopic endopyelotomy is a safe and effective treatment option in patients with primary and secondary UPJO when selected properly.

Endoluminal isoproterenol irrigation decreases renal pelvic pressure during flexible ureterorenoscopy: a clinical randomized, controlled study.

OBJECTIVES: Irrigation during ureterorenoscopic procedures causes increased pelvic pressure (PP), which may lead to intrarenal backflow with potential harmful consequences. This study aims to investigate PP response to intraluminal administration of isoproterenol (beta-agonist; ISO) during flexible ureterorenoscopy. METHODS: Twelve patients admitted for retrograde intrarenal stone surgery (RIRS) were included. Patients were randomized to (1) irrigation with saline (n=6) or (2) irrigation with ISO 0.1 microg/mL (n=6). Irrigation rate was standardized to 8 mL/min. A ureteral catheter was retrogradely placed in the renal pelvis for PP measurements. PP, heart rate (HR), and mean arterial pressure (MAP) were also measured. RESULTS: Baseline PP was 12.1+/-4mm Hg in the saline group and 10.3+/-4mm Hg in the ISO group (p=0.44). In the saline group, PP increased to a mean 33+/-12 mm Hg during ureterorenoscopy. In the ISO group, PP was a mean 19+/-3mm Hg (p=0.029). During endoscopy, PP peaks as high as 328 mm Hg were noted during saline irrigation. The number of pressure peaks above 50mm Hg was minimized dramatically during ISO irrigation (p=0.035). No systemic side effects to ISO irrigation were observed. CONCLUSION: For the first time, a randomized, controlled human study demonstrates that pharmacologic modulation of the ureter is possible during upper urinary tract endoscopy. The ability to relax ureteral tone during endoscopy may have clinical advantages.

[Surgical treatment of benign prostatic hyperplasia in Denmark--1993-2003]. / Kirurgisk behandling af benign prostatahyperplasi i Danmark 1993-2003.

INTRODUCTION: The treatment of BPH includes many possibilities, from medical treatment to open prostatectomy. During the last 20 years medical treatment has increasingly been used. Furthermore, new minimal invasive techniques have been developed. The aim of this study was to examine changes in the surgical treatment of BPH from 1993 to 2003. MATERIALS AND METHODS: Data were drawn from the National Patient Register and Statistics Denmark from 1993 to 2003. For each operation case, the diagnosis, region, age group in decades, and the year of the operation were registered. BPH-related cases include prostatic hypertrophia, benign prostatic neoplasm, bladder stone, urinary retention, hematuria, LUTS, and bladder neck stenosis. RESULTS: In the 10-year period 63,970 prostate operations were performed. 44,347 of these operations could be related to BPH. 21% fewer prostate operations were performed in 2003 than in 1993. Standard prostate operations constituted 93-97% of all operations during the entire period. The operation rate per 1,000 men older than 50 years was median 6.5 in 1993 and 4.5 in 2003. The rate differed considerably between regions. There was a large variation in the number of operations per region with the new techniques. The use of the new techniques has been constantly low during the entire period. CONCLUSION: In 2003 21% fewer prostate operations were performed than in 1993. Standard prostate operations constituted more than 90% of operations during the entire period. The use of the new techniques has been constantly low.

[Investigation of lower urinary tract symptoms among men in general practice and in hospitals]. / Udredning af maend med nedre urinvejssymptomer i almen praksis og på sygehuset.

Many men over 50 years of age have lower urinary tract symptoms (LUTS). It is therefore important that evaluation of symptoms and treatment decision is mainly taken care of by the family practitioner. A guideline for evaluation of LUTS is described, giving the family practitioner an adequate tool for evaluation and decision-making. The guidelines also describe which patients should be referred to an urologist and the extent of supplementary evaluation that should be performed in this setting.

Retrograde intrarenal stone surgery for extracorporeal shock-wave lithotripsy-resistant kidney stones.

OBJECTIVE: The newer flexible ureteroscopes, 150-200-microm holmium YAG laser fibres and superflexible Dormia baskets have made it possible to reach and treat stones in all parts of the kidney. The object of this evaluation was to study the outcome of retrograde intrarenal stone surgery (RIRS) for extracorporeal shock-wave lithotripsy (ESWL)-resistant kidney stones. MATERIAL AND METHODS: A total of 38 consecutive patients (18 males, 20 females) participated in the study. All patients had undergone ESWL prior to RIRS without success. In all cases the stones could be reached with the endoscope. Calculi ranged in size from 3 to 20 mm (mean 9 mm). In 32 cases the stones were fragmented using a holmium YAG laser and in six the stones could be extracted using zero-tip Dormia baskets without fragmentation. Sixteen patients had lower calyceal calculi and eight had an abnormal anatomy of the upper urinary tract. Intravenous pyelography was performed 6-8 weeks after the treatment. RESULTS: In all cases the stones could be reached and fragmented to some extent. After a single RIRS procedure, 22/38 patients (58%) were completely stone-free at follow-up, and four (11%) had residual fragments < or = 4 mm in size that were expected to pass spontaneously. Of the remaining 12 patients, who initially had larger stones (mean 11.3 mm), the residual fragments ranged in size from 5 to 15 mm. Three patients underwent an additional RIRS procedure, after which they were all completely stone-free, resulting in an overall success rate of 76%. There were no major complications. CONCLUSIONS: RIRS is a safe procedure with a high success rate and a low complication rate for ESWL-resistant renal stones. Patients with larger stones (> 10 mm), those with stones in the lower pole and those with an abnormal renal anatomy may require more than one procedure.