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To evaluate morphological changes in the hyperplastic prostate tissue following transurethral microwave thermotherapy and to investigate the dependence of the treatment outcome on structural and physiological features of the prostate.In this prospective study, 13 patients with chronic urinary retention due to benign prostatic hyperplasia (BPH) underwent Coretherm (ProstaLund, Lund, Sweden) microwave thermotherapy. Prior to the treatment and 1 week and 6 months after, the patients were examined with MRI using morphologic, contrast medium-enhanced perfusion and diffusion-weighted imaging. Such advanced MRI techniques permit an assessment of parameters that have a hypothetical influence on microwave thermotherapy (e.g. prostate blood perfusion, water content and prostate microstructure).Morphologic and perfusion MRI showed a clear prostatic tissue defect in all 13 patients after 1 week and in all 12 patients at 6 months' follow-up. The mean size of the defect was 22.5 cm(3) (27%) (range 3.7-47.3 cm(3)) and 4.1 cm(3) (1.1-10.1 cm(3)) at 1 week and 6 months, respectively. The cell kill volume was estimated to be 20.5+/-7.4 cm(3) and correlated significantly with the size assessed by MRI at 1 week (r=0.8; p=0.002) and 6 months (r=0.69; p=0.05). At 6 months, the mean decrease in prostate volume was 20.1 cm(3) (p0.0001). The microstructure of the prostate expressed as the apparent diffusion coefficient was shown to have a strong influence on the treatment process. All patients (n=12) were catheter-free at 6 months. Another patient experienced persistent obstruction and underwent transurethral resection of the prostate.Coretherm microwave treatment leads to significant intraprostatic necrosis, which is detectable with MRI even 6 months after the treatment. Diffusion-weighted MRI is capable of identifying structural features of the prostate that can predict the length of treatment and the amount of energy needed.

Objectives. To analyse the risk of afferent nipple valve stenosis and its consequences and management in patients with a Kock pouch for continent urinary diversion and to study the early results after using an alternative antireflux technique. Material and methods. Sixty patients consecutively operated on with a conventional Kock reservoir for continent cutaneous urinary diversion between 1988 and 2001 were analysed with regard to the occurrence of afferent nipple valve stenosis and its clinical characteristics. Sixteen patients operated on for continent urinary diversion during the period 2002-04 had the antireflux valve constructed according to the serous-lined extramural ileal valve technique. Results. Eight patients with a conventional Kock pouch developed true afferent nipple valve stenosis and the risk approached 30% after 15 years. Dilatation and stenting were usually successful. Conclusions. The high risk of afferent nipple valve stenosis when using the intussuscepted nipple valve in the construction of a Kock reservoir for continent cutaneous urinary diversion calls for an alternative method for anastomosing the ureters to the reservoir. Our early results with the combined Kock/T-pouch are promising.

To estimate the relationship between age and the values of different diagnostic tests in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic enlargement (BPE) and to compare prostate growth curves between the normal population sample, healthy men and men with LUTS.A series of 354 men (mean age 70.2 years; range 45-91 years) with LUTS due to BPE were stratified into seven age groups and reviewed retrospectively. All patients underwent a standard evaluation, involving determination of the International Prostate Symptom Score (IPSS), digital rectal examination, uroflowmetry, determination of the prostate-specific antigen (PSA) level and transrectal ultrasonography. Descriptive statistics were used to describe all the variables and Spearman's correlation test was used to evaluate the relationships between them.The mean prostate volume was 40.1 (+/-23.9) cm(3) and mean PSA concentration 3.9 (+/-4.2) ng/ml. Both values increased progressively from 27.5 ml and 1.5 ng/ml, respectively in the54 years age group to 48.2 ml and 5.4 ng/ml, respectively in the80 years age group. However, in the 75-79 years age group there was a decrease in both prostate volume and symptom score; PSA concentration remained unchanged and maximal flow rate increased slightly. A statistically significant but weak correlation was found between prostate volume and age (r = 0.25, p0.0001) and between PSA and age (r = 0.28, p0.0001). Prostate volume correlated positively with serum PSA (r = 0.54, p0.0001). The correlations between maximum flow rate and age, prostate volume, PSA and IPSS were r = -0.21, p0.0001; r = -0.18, p0.0006; r = -0.29, p0.0001; and r = 0.14, p0.0098, respectively.These data confirm that prostate volume and serum PSA concentration are significantly correlated and increase with advanced age. The correlations between uroflowmetry (Qmax) and age, prostate volume, serum PSA and IPSS were also significant. However, there was no relationship between symptoms and objective measures of BPE. The increase in different parameters of the severity of benign prostatic hyperplasia with advanced age is not continuous. The prostate volume alone is not useful in the estimation of disease severity.

Many different treatments for lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) are available today. To select the most suitable method for each patient is therefore a delicate task. The aim of this study has been to use a standardised systematic investigation schedule including pressure flow studies (pQS) in order to try to use graded treatment according to obstruction.Ninety-nine patients were systematically examined with routine investigations and pQS to select between 3 treatment options, TURP, TUMT 2.0 (low energy) and watchful waiting (WW). Patients with severe BOO were recommended TURP, patients with moderate BOO were treated with TUMT and patients with no or minor BOO were recommended WW.TURP produced the best improvement in maximum free flow (Q-max), IPS-score and PVR, but only TURP had serious complications. TUMT treatment produced a more moderate improvement in flow rate, IPS-score and PVR, and all of the complications were minor. WW did not improve PVR or Q-max but the IPS-score decreased significantly. One UTI was the only complication in the WW group.pQS can be used to allocate patients with LUTS due to suspected BOO into different treatment arms; TURP, TUMT, WW, all with known different effects of BOO and with different severity of complications. Good symptomatic effect in Q-max, PVR and IPS-score with less serious complications and at low failure rate can thereby be obtained.

OBJECTIVE: To compare costs of transurethral prostatic resection (TURP) and transurethral microwave thermotherapy (TUMT) for symptomatic benign prostatic hyperplasia (BPH) in a randomized, controlled trial. METHODS: In 70 BPH patients all costs were calculated for management, including complications and repeat treatment, during TURP or TUMT and 24-month follow-up. Clinical outcome was judged from Madsen-Iversen symptom score, peak urinary flow and residual urine. The effect of changes in some critical variables was assessed by sensitivity analysis. A cost-effectiveness analysis was carried out to compare the two methods. RESULTS: Symptom reduction after 2 years was 92% in the TURP group and 83% in the TUMT group. The total costs over 2 years were SEK 24,234 and 14,830 in the respective groups. Costs for retreatments were higher after TUMT, while complication costs were higher in the TURP group. TUMT costs depend on the investment for the equipment, including disposable probes, and the degree of its utilization. TUMT was more cost-effective than TURP in relieving BPH-related symptoms during the 2-year follow-up. CONCLUSIONS: Primary treatment costs were lower for TUMT than for TURP. Complication costs were higher in the trial's TURP arm, while retreatment costs were greater in the TUMT arm. TUMT costs depend on investment in and utilization of the equipment and reuse of treatment probes. TUMT was more cost-effective than TURP in the 2-year study period.

In this study we have investigated 70 men fulfilling the usual criteria accepted for transurethral resection of the prostate (TURP). The anamnestic evaluation included the Madsen-Iversen symptom score and a quality of life questionnaire. The clinical examination included suprapubic pressure flow measurement, free urinary flow, the determination of residual urine and the ultrasound evaluation of the size of the prostate. The clinical data were correlated with the grade of obstruction according to Schäfer calculated from the pressure/flow studies. No correlation was found between the grade of obstruction and anamnestic symptom data, the size of the prostate or residual urine. A slight correlation was found between the Schäfer grade of obstruction and the flow curve pattern or peak flow.

We compared patient opinions concerning reservoir/bladder function as well as quality of life (QOL) after cystectomy for bladder carcinoma and continent cutaneous urinary diversion or orthotopic bladder reconstruction.Fifteen patients with Kock reservoirs (11 females, 4 males) and 11 men with orthotopic bladders answered the European Organization for Research and Treatment of Cancer quality-of-life questionnaire-C30 as well as specially constructed questions concerning reservoir/bladder function. The glomerular filtration rate (GFR) was determined using Cr-EDTA or iohexol clearance.Functioning and global health/QOL scales did not differ between the two groups of operated patients or between diverted patients and gender- and age-matched groups from the general population. The majority of the patients were satisfied/very satisfied with their diversion but more patients were troubled by leakage in the orthotopic bladder group than in the Kock reservoir group. The GFR was similar in the two groups.Continent cutaneous urinary diversion is associated with fewer leakage problems than orthotopic bladder reconstruction after cystectomy for bladder carcinoma.

An essential part of investigation of the lower urinary tract is pressure/flow studies (pQS). In fact, pQS is the only way of diagnosing bladder outlet obstruction. There is controversy regarding whether or not prophylactic antibiotic treatment is necessary. This prospective study was carried out in order to determine the frequency of infections and/or distress after pQS performed without the use of antibiotic prophylaxis.One hundred and twenty-three patients were included in the present study, all males. They were requested to answer a questionnaire I week after pQS. Questions were asked concerning symptoms of voiding disorders, dysuria, hematuria, incidence of fever and the patient's acceptance of the investigation after the pQS procedure. Urine was obtained for culture immediately before the investigation and 3 and 7 days after the pQS.Forty-six per cent of the patients experienced some degree of transient dysuria after pQS. and 18.5% experienced voiding problems of varying nature. Five per cent of the patients had hematuria and 2.5% reported fever. Fifty per cent of the patients experienced some degree of discomfort during the pQS investigation, and 4.1% had positive culture and symptoms of UTI requiring antibiotic treatment.PQS is well accepted by the patients and the regular use of propylactic antibiotics is not indicated. We recommend, though, that patients at risk for serious complications from infections (e.g. those with prosthetic heart valves) should receive prophylactic antibiotics.

One of the most common "treatment" alternatives in suspected outflow obstruction due to bladder outlet obstruction (BOO) is watchful waiting (WW). The aim of this study was to see whether there were any differences in outcome between patients with slight, moderate or severe obstruction due to BOO as classified by transrectal ultrasound (TRUS) and urodynamics.Thirty-seven men with lower urinary tract symptoms (LUTS) and suspected BOO were included. All of the patients were investigated by a routine investigation schedule, including TRUS and urodynamics with pressure-flow measurement (pQS) at baseline. Patients with cancer in the urinary tract, prostatitis, history of detrusor hyperreflexia (peripheral or central diseases or trauma to the nervous system affecting the bladder) and serious systemic diseases were excluded. Patients were examined at baseline, then checked again after 1 year and 4 years. Patients who did not want to continue with WW were listed as treatment failures.At baseline, 43.2% of the patients were urodynamically severely obstructed and 32.3% were moderately obstructed. Thirty-five per cent of the patients were found to have previously unknown detrusor hyperactivity/overactivity. The prevalence of detrusor hyperactivity/overactivity increased with BOO. After 1 year, IPSS had decreased at unchanged Qmax and postresidual volume. These findings persisted at 4 years. The failure rate increased in the more obstructed patients and was significantly higher with more severe obstruction. Complications were found in 13.5%, with no significant differences between patients with minor BOO [Detrusor Adjusted Mean PURR Factor (DAMPF) scale42], moderate BOO (DAMPF 42-65) and severe BOO (DAMPF65).In patients with severe BOO, the LUTS and failure rate increase over time. The percentage of patients with detrusor hyperactivity/overactivity was higher in the severely obstructed group. By including full urodynamics when investigating patients with BOO, it seems possible to predict the failure rate according to the patients' obstruction grade. This gives an opportunity to treat the patient with minimal invasion, and to give the individual patient a more precise prognosis if WW is preferred.