Werner Hochreiter

Zusammenfassung   Die zunehmende Inzidenz asymptomatischer Bakteriurien, aber auch symptomatischer Harnwegsinfekte beim alternden Menschen macht eine differenzierte Betrachtung dieser Problematik unter Beachtung altersspezifischer medizinischer und sozialer Risikofaktoren notwendig. Im Vordergrund stehen dabei die zunehmende Pflegebedürftigkeit, alters-, aber auch geschlechtsspezifische komplizierende Faktoren wie subvesikale Obstruktion, Adnexinfektionen und Inkontinenz, sowie die Notwendigkeit der Katheterisierung. Auch spezifische Alterserkrankungen wie Diabetes mellitus, die veränderte Pharmakodynamik

PurposeThe holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined

Specific mechanisms underlying chronic pelvic pain syndrome have yet to be identified. However, the disorder has features common to other chronic pain syndromes, such as fibromyalgia and chronic pelvic pain in women. Like other chronic pain patients, men presenting with chronic prostatitis may meet diagnostic criteria for other functional pain syndromes as well as affective disorders, which should be screened

Symptomatic cystic epididymis in a 21-year-old man led to the detection of several genital malformations, including a partially obstructing pelvic cyst, prostatic and bilateral testicular atrophy and penoscrotal hypospadias. These malformations are probably due to a deficiency of either testosterone or müllerian inhibiting hormone (MIH). Development of the male genitalia is influenced by testosterone secreted in the Leydig cells during weeks 8-16 of gestation, while regression of the müllerian ducts is induced by MIH secreted in the Sertoli cells from weeks 9-12 of gestation.

The first step in adopting a practical approach to the management of patients with prostatitis lies in the realization that the etiology of the symptoms often remains unclear and the traditional etiologically based classification system is part of the problem and not the solution. This problem was recognized in 1995 by the National Institutes of Health Consensus Conference on prostatitis. It was suggested that the classification of this disease be changed. The traditional categories "chronic nonbacterial prostatitis" and "prostatodynia" were replaced by the new category "chronic pelvic pain syndrome." The introduction of the term "syndrome" reflects two issues: despite lack of evidence for bacterial involvement based on conventional methods, nonbacterial prostatitis may indeed still be an infectious disease, and the etiology of the symptoms may be caused by a disorder not related to the prostate gland alone.

Annual incidences of kidney stones are about 0.1-0.4% of the population, and lifetime prevalences in the USA and Europe range between 8 and 15%. Kidney stones occur more frequently with increasing age and among men. Within ten years, the disease usually recurs in more than 50% of patients. Nowadays, about 85% of all kidney stones contain calcium salts (calcium oxalate and/or calcium phosphate) as their main crystalline components. Because human urine is commonly supersaturated with respect to calcium salts as well as to uric acid, crystalluria is very common, i.e. healthy people excrete up to ten millions of microcrystals every day. Recurrent stone formers appear to excrete lower amounts or structurally defective forms of crystallization inhibitors which allows for the formation of large crystal aggregates as precursors of stones. Alternatively, crystal adhesion to urothelial surfaces may be enhanced in stone formers. Medical treatment of renal colic is based on nonsteroidal antiinflammatory drugs, because prostaglandins appear to play a crucial role in the pathophysiology of pain during ureteral obstruction. In addition, centrally acting analgesics such as pethidine-HCl may be required in many cases. The administration of high amounts (3-4 liters/day) of intravenous fluids should be abandoned, since it may raise intraureteral pressure whereby pain increases and kidney pelvis or fornices may rupture. All first-stone formers should undergo a simple basic evaluation, including stone analysis (x-ray diffraction or infrared spectrometry), serum values of ionized calcium (alternatively: total calcium and albumin) and creatinine, urinalysis and repeated measurements of fasting urine pH in order to detect urinary acidification disorders or low urine pH. In high-risk patients with as first stone episode (i.e. strongly positive family history, inflammatory bowel disease, short-bowel syndrome, nephrocalcinosis, bilateral stones, hypercalcemia, renal tubular acidosis, airline pilots) as well as in all recurrent stone formers, an extended metabolic evaluation should be performed. Two 24-hurines should be collected on free-choice diet not prior to three months after stone passage or urological intervention. Analysis includes measurements of volume, creatinine, calcium, oxalate, uric acid and citrate; sodium and urea as markers of salt and protein consumption are optional but clinically very helpful. Since hypercalciuria is of much less importance than increases in urinary oxalate, therapeutic efforts should primarily focus on lowering urinary oxalate excretion. Sufficient calcium intake, i.e. 1200 mg per day, is crucial, because it allows for binding of oxalate at the intestinal level whereby increases of urinary oxalate (reciprocal hyperoxaluria) can be avoided. Excess intake of flesh protein (meat, fish, poultry) is lithogenic since it increases urinary calcium, oxalate and uric acid, and lower citrate. On the other hand, a diet rich in alkali (vegetables, fruit) is associated with a lower risk of stone formation. A "common sense diet" containing sufficient amounts of fluids, 1200 mg of calcium per day and reduced amounts of flesh protein as well as salt is able to reduce the 5-year stone recurrence rate in calcium stone formers by 50%. The scientific evidence for drug treatment (thiazides, alkali citrate) is rather poor: the most widely quoted randomized thiazide trial included only 42 patients of whom 36% left the protocol prematurely, whereas 36-48% of patients included in three randomized studies with alkali citrate suffered from undesirable side-effects; nevertheless, citrate therapy reduced the stone recurrence rate by 38%, compared with 22% in patients on placebo treatment (p < 0.0005).

Permanent low-dose-rate brachytherapy (BT) with iodine 125 is an established curative treatment for localized prostate cancer. After treatment, prostate-specific antigen (PSA) kinetics may show a transient rise (PSA bounce). Our aim was to investigate the association of PSA bounce with biochemical control. Patients treated with BT in Switzerland were registered in a prospective database. Only patients with a follow-up of at least 2 years were included in our analysis. Clinical follow-up and PSA measurements were assessed after 1.5, 3, 6, and 12 months, and annually thereafter. If PSA increased, additional follow-up visits were scheduled. Cases of PSA bounce were defined as a rise of at least 0.2 ng/ml above the initial PSA nadir with a subsequent decline to or below the initial nadir without treatment. Biochemical failure was defined as a rise to nadir + 2 ng/ml. Between March 2001 and November 2010, 713 patients with prostate cancer undergoing BT with at least 2 years of follow-up ...

Permanent low-dose-rate brachytherapy (BT) with iodine 125 is an established curative treatment for localized prostate cancer. After treatment, prostate-specific antigen (PSA) kinetics may show a transient rise (PSA bounce). Our aim was to investigate the association of PSA bounce with biochemical control. Patients treated with BT in Switzerland were registered in a prospective database. Only patients with a follow-up of at least 2 years were included in our analysis. Clinical follow-up and PSA measurements were assessed after 1.5, 3, 6, and 12 months, and annually thereafter. If PSA increased, additional follow-up visits were scheduled. Cases of PSA bounce were defined as a rise of at least 0.2 ng/ml above the initial PSA nadir with a subsequent decline to or below the initial nadir without treatment. Biochemical failure was defined as a rise to nadir + 2 ng/ml. Between March 2001 and November 2010, 713 patients with prostate cancer undergoing BT with at least 2 years of follow-up were registered. Median follow-up time was 41 months. Biochemical failure occurred in 28 patients (3.9 %). PSA bounce occurred in 173 (24.3 %) patients; only three (1.7 %) patients with PSA bounce developed biochemical failure, in contrast to 25 (4.6 %) patients without previous bounce (p < 0.05). The median time to bounce was 12 months, the median time to biochemical failure was 30 months. The median bounce increase was 0.78 ng/ml. Twenty-eight patients with bounce (16.5 %) had a transient PSA rise of + 2 ng/ml above the nadir. In most cases, an early increase in PSA after BT indicates PSA bounce and is associated with a lower risk of biochemical failure.

Neben den Kalziumsteinen stellen Harnsäure- und Infektsteine mit Häufigkeiten von etwa 10 resp. 8% die zweit- und dritthäufigsten Nierensteinarten dar, während Steine aus Zystin oder 2,8-Dihydroxy-Adenin in 1–2% vorkommen. Als Infektstein bezeichnet man nicht einen infizierten «metabolischen» Stein (z.B. Kalziumoxalat), sondern die Steinbildung durch einen Infekt mit harnstoff-spaltenden Keimen (meist Proteus mirabilis). Die Harnstoffspaltung führt zu starker Alkalinisierung des Urins, was die Kristallisation der Infektsteinkomponenten Struvit und Karbonatapatit begünstigt. Infektsteine bilden den weitaus größten Teil der sogenannten «Ausgusskonkremente», die im Extremfall das gesamte Nierenbeckenkelchsystem ausfüllen können. Die Symptome des Infektsteinleidens sind variabel und reichen von der akuten Flankenkolik bis hin zum asymptomatischen Verlauf. Die bildgebende Diagnostik bedient sich der herkömmlichen radiologischen Methoden. Infektsteine können nur durch radikale Entfernung ...

Zusammenfassung Das Ziel der radikalen Zystektomie mit nachfolgender Harnableitung ist es, ein sicheres onkologisches Ergebnis mit einem zufrieden stellenden funktionellen Ergebnis zu kombinieren. Rezente Erkenntnisse zur Anatomie, Physiologie und Innervation der Beckenorgane haben zu einer modifizierten, nerverhaltenden Operationstechnik geführt. Eine Vielzahl von Studien konnten zeigen, dass das onkologische Ergebnis, insbesondere die Rate an Lokalrezidiven, nach nerverhaltender Zystektomie im Vergleich zur

Anthony J Schaeffer a Corresponding Author Information 1 email address, Wolfgang Weidner b Corresponding Author Information 2 email address, George A Barbalias c, Henri Botto d, Truls E. Bjerklund Johansen e, Werner W Hochreiter f, John N Krieger g, Bernard ...

The term "prostatitis" includes several entities ranging from the acute bacterial inflammation of the prostate gland to the chronic pelvic pain syndrome. Since both acute and chronic bacterial prostatitis are clearly defined by the documented detection of microbial agents, a standardised antimicrobial treatment eventually leads to a predictable rate of cure. However, the most common type is the chronic abacterial prostatitis, called "chronic pelvic pain syndrome" (CPPS) which is subdivided into an inflammatory and a noninflammatory form. CPPS affects men of all ages and is the most common urological diagnosis in men younger than 50 years. Chronic prostatitis/CPPS shares features with other chronic pain syndromes, including a poorly understood etiology, low correspondance of symptoms and objective findings, application of various treatments and frequent failure to be alleviated by medical treatment. Due to the intricacy of the syndrome a thorough clinical evaluati...

In the recent past, several endoscopic procedures using laser technology have evolved for the treatment of benign prostatic hyperplasia. The term "laser treatment of the prostate" comprises a variety of different application systems, different laser wavelengths, and different surgical techniques to eliminate bladder outlet obstruction. The aim of laser prostatectomy is to be less invasive than transurethral electroresection, but equally effective. Promising short-term results led to a booming laser decade in the 1990s, stimulating the development of several devices. However, the emergence of medium-term data has shown that some of these techniques did not stand the test of time due to the lack of long-term efficacy, unacceptable morbidity, and high retreatment rates. Nevertheless, the results of transurethral resection of the prostate are challenged by some of the newer laser devices, putting the so-called "gold standard" into question.

Chronic prostatitis/chronic pelvic pain syndrome is a disease that is mainly characterized by three parameters: pain in the suprapubic and pelvic area, presence or absence of white blood cells in expressed prostatic secretions, and voiding disorders of various degrees. The causative factors underlying this very common condition are poorly understood. Therapeutic options (ie, antimicrobial treatment) often are based on the presence of an inflammatory reaction in the expressed prostatic secretions, but the benefit of recurring or prolonged courses of antimicrobial agents is highly variable. Observations have been made regarding functional and structural changes in the lower urinary tract that are suggestive to have an impact on the pathogenesis of chronic pelvic pain syndrome.

The aim of radical cystectomy with subsequent urinary diversion is to combine a safe oncological outcome with a satisfactory lower urinary tract function. Recent findings on the anatomy, physiology and nerve supply of the pelvis have resulted in a modified nerve-sparing cystectomy technique. A number of studies have shown that the oncological outcome is not compromised by such a technique; in particular the rate of local recurrences is not enhanced. Nerve-sparing cystectomy is of importance for the lower urinary tract function, including continence status after orthotopic bladder substitution and erectile function. Prerequisites for a nerve-sparing technique are a profound knowledge on the nerve supply of the pelvic organs and a subtle surgical technique. Recent surgical developments, for example in prostate and seminal vesicle sparing cystectomy techniques, indicate that it will be feasible to restore lower urinary tract and also sexual function after radical cystectomy and orthoto...

According to the National Institutes of Health classification system, chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CPPS) is subdivided into an inflammatory (category IIIa) and a non-inflammatory (category IIIb) form. The difference is based on the presence or absence of white blood cells in expressed prostatic secretions, urine after prostatic massage, or semen. This is the only criterion which allows a differentiation between the IIIa and IIIb forms. The symptoms, i.e. pain and urinary complaints of various degrees, are thought to be similar in both forms. These symptoms can be assessed with the Chronic Prostatitis Symptom Index (CPSI) and the International Prostate Symptom Score (IPSS), which are both available in a validated German translation. One hundred and six patients with CPPS were evaluated with CPSI and IPSS. Urinary symptoms troubled all patients. Men with category IIIa had significantly more urinary symptoms when compared to men with category IIIb. Th...

The increasing incidence of asymptomatic bacteriuria and symptomatic urinary tract infections in the elderly requires a detailed consideration of this problem including age-specific medical and social risk factors. The increasing need for care, age- and gender-related complicating factors such as subvesical obstruction, adnexal infections, and incontinence, and the need for catheterization are predominant. Specific age-related diseases such as diabetes mellitus, pharmacodynamic alterations of antimicrobial substances, and changes in the vaginal colonization make increased demands on therapeutic strategies. Urologic implications resulting from this set of difficulties have not yet been investigated sufficiently and need further evidence-based work-up.

Painful micturition is one of the most common symptoms of urological diseases. The term "dysuria" is descriptive for micturition which the patient perceives as unpleasant. Usually, dysuria is combined with other symptoms such as pollakisuria (increased frequency of micturition) and urge (non suppressible compulsion of micturition). The symptoms may arise acutely or progress slowly and are often strictly linked to the act of micturition. The patients frequently complain of a burning pain at the beginning or during micturition. Therefore the anamnesis may already give the first clue for localization of the disease. The most common cause of painful micturition is an inflammation of the lower urinary tract. However, tumours, obstructive conditions and other less common urologic diseases must also be considered Basic diagnostics with urine analysis and culture can easily be done by almost all general practitioners. In doubtful cases, however, a special urologic examination is m...

Summary After the initial enthusiasm subsided lasercoagulation of the prostate has been criticized because the extent of tissue destruction cannot be controlled and many patients may be expected to have significant postoperative obstructive as well as irritative voiding ...

The terms andropause, partial androgen deficiency of the aging male (PADAM) or late-onset hypogonadism (LOH) describe a clinical entity which has been defined as a syndrome associated with advanced age. This syndrome is characterised by a deficiency in serum testosterone levels that may result in significant alterations in the quality of life and adversely affect the function of multiple organ systems. Whereas in classic primary and secondary hypogonadism, the clinical picture of testosterone deficiency is clearly defined, the clinical diagnosis of PADAM might escape detection for various reasons: not all signs and symptoms necessarily present together; they often progress slowly and are subtle in nature; the non-specific signs and symptoms might not be discernible from the unavoidable process of aging itself. However, PADAM features many potentially serious consequences that can be avoided or treated, and is, therefore, clinically relevant. Testosterone substitution may be an effec...

Urinary tract infection is an old problem that continues to present new challenges. The purpose of this special edition is to pull together new basic scientific information regarding the pathogenesis of infection and to review the state of the art in the evaluation and treatment of urinary tract infection in some of the more complex or challenging clinical settings. The

We assessed factors influencing urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. Of 381 consecutive men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution between April 1985 and June 2003, 331 (87%) met the inclusion criteria and were enrolled in the analysis. Kaplan-Meier models and multivariate analysis applying Cox regression were used to evaluate factors influencing postoperative urinary continence and erectile function. In univariate analysis, attempted nerve sparing and age younger than 65 years were significantly associated with better daytime (p = 0.002 and p = 0.007, respectively) and nighttime continence (p = 0.036 and p = 0.005, respectively). In multivariate analysis the rate of daytime continence was significantly higher in patients with attempted nerve sparing (hazards ratio [HR] 1.4, 95% confidence interval [CI] 1.05-1.87) and nighttime continence was significantly better in patients younger than 65 years (HR 1.39, 95% CI 1.07-1.8). Daytime continence was significantly better (p <0.0001) and was achieved more quickly than nighttime continence (p <0.0001). The time to achieve daytime continence was shorter for patients with attempted nerve sparing (p = 0.012). In multivariate analysis erectile function recovered significantly more often in patients with attempted nerve sparing (HR 2.59, 95% CI 1.24-5.39) and in those younger than 65 years (HR 2.98, 95% CI 1.83-4.85). After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.