THERAPEUTISCHE UMSCHAU最新文献

The Complexity in Fall Prevention and Mobility in Older Persons Abstract: Falls have often far-reaching consequences for the older person. In contrast to the positive development in fall prevention over the last 20 years, the number of falls is still increasing in the older population worldwide. In addition, the fall risk varies between different settings, as for the community-dwelling older population fall rates of about 33% are reported whereas in the long-term care setting rates of about 60% are described. In the hospital setting fall rates are also higher than in community-dwelling older persons. Falls are seldom caused by just one single risk factor. The complexity of the interacting risk factors ranges from biological, socioeconomical, environmental, and behavioral risk factors. The following article will address the complexity and the dynamic interaction of these risk factors. Special interest will be given to the behavioral and environmental risk factors, as well as an effective screening and assessment, which are also presented in the new recommendations by the World Falls Guidelines (WFG).

Nutrition and Dementia - Dementia and Nutrition Abstract: Nutritional aspects play an important role both in the prevention of dementia and in its course. There is a mutual relationship between cognitive impairment and nutrition. In terms of prevention, nutrition is one of the potentially modifiable risk factors for the development of the disease, since it can influence both the structures and the functionality of the brain in a variety of ways. A food selection based on the traditional Mediterranean diet or on a generally healthy diet also seems to be advantageous for maintaining cognitive function. In the course of dementia, various symptoms of the disease sooner or later lead to nutritional problems, which make it difficult to achieve a varied, needs-based diet and are associated with an increased risk of a qualitatively and quantitatively inadequate nutrition. In order to maintain a good nutritional status in people with dementia for as long as possible, early detection of nutritional problems is fundamental. Strategies for the prevention and treatment include the elimination of potential causes of malnutrition and various supportive measures to promote adequate eating. The diet itself can be supported by an attractive, varied range of food, additional snacks, enrichment of the food with energy and nutrients and by oral nutritional supplements. Enteral or parenteral administration of nutrients, on the other hand, should be reserved for justified exceptional cases.

Benign Prostate Hyperplasia - Current Medical Therapy, New Developments, and Side Effects Abstract: Lower urinary tract symptoms (LUTS) consist of both voiding and storage symptoms. Urethral obstruction leading to voiding symptoms is most commonly attributed to benign prostatic hyperplasia (BPH), where hyperplastic growth and increased smooth muscle tone in the hyperplastic prostate may lead to benign prostate obstruction (BPO). Spontaneous contractions of the detrusor muscle may cause storage symptoms, which are referred to as overactive bladder (OAB). With a considerable proportion of patients suffering from "mixed LUTS", a combination of voiding and storage symptoms, LUTS affect a large portion of the population worldwide, with major impact on quality of life (QoL). A demographic shift in society, will lead to higher incidence and prevalence of LUTS, with a growing economic burden. Standard-of-care medical treatment for LUTS/BPO includes α₁-adrenoceptor antagonists and phosphodiesterase-5 (PDE-5) inhibitors, for reduction of prostate smooth muscle tone, and 5α-reductase inhibitors (5-ARI) to slow down disease progression. Medical therapy for LUTS/OAB includes muscarinic receptor antagonists, and β₃-agonists for relief of spontaneous bladder contractions. When left untreated, LUTS may cause considerable adverse events, ranging from acute urinary retention with kidney failure, and recurring infections, to social withdrawal, and depression.

Minimally Invasive Treatment of Benign Prostate Enlargement Abstract: Minimally invasive techniques are becoming increasingly important treatment options for benign prostate enlargement. With regard to the available evidence, UroLift has a high level of evidence with two prospective randomized studies compared to sham surgery or TUR-P (Transurethral resection of the prostate). The technique is characterized by a significantly higher rate of ejaculation preservation compared to TUR-P, while the improvement in objective voiding parameters is inferior to TUR-P. With regard to Rezum water vapor ablation of the prostate, data from a randomized study compared to sham surgery and several cohort studies are available, which show a significant improvement in urinary symptoms with a high rate of sexual function preservation. The iTIND (temporary implantable nitinol device) procedure has the least amount of evidence, with only one randomized study versus sham surgery with a follow-up of one year. This technique also shows a significant improvement in urinary symptoms with a low rate of comorbidities. Prostatic stents have been on the market for many years, but data from randomized trials are still lacking. When selecting minimally invasive techniques, one should balance the wishes and expectations of the patient with respect to less comorbidities and impact on sexual function against potentially inferior improvement of symptoms and micturition parameters compared to standard techniques.

Aquablation Treatment for Benign Prostatic Obstruction Abstract: The surgical BPH treatment is one of the most common urological procedures. With our reference methods: transurethral resection of the prostate (TUR-P), open surgical adenomenucleation over a transabdominal access, and also modern laser procedures. Various effective surgical options are available. However, the quality of the surgical outcome is highly dependent on the surgeons' experience. At the same time, all of the above-mentioned reference methods are associated with a high rate of sexual dysfunction, especially postoperative anejaculation, a symptom complex which is relevant for men, regardless of age [1]. Robotic Aquablation^® was developed with the goal to reduce the dependency of the surgical outcome on the expertise of the surgeon, but at the same time achieving a comparable outcome and reduced morbidity. After the "first in human treatment" by Peter Gilling in 2013, the Aquabeam^® robot has been used in its current form in clinical studies since 2015 (Water, Water II and Open Water Study) and finally was introduced in clinical routine in August 2017 by Thorsten Bach in Hamburg. The safety and effectiveness of Aquablation^® therapy has been proven in various studies and in everyday clinical practice.

Laser Techniques in the Treatment of Benign Prostatic Syndrome Abstract: Lasers have a wide range of applications in endourological therapy. Not only in the treatment of stones, but also in the treatment of benign prostatic syndrome (BPS), their importance continues to grow. The endourological treatment of BPH with different laser techniques will be discussed in more detail in the following. The physical differences between the individual lasers will be explained first, followed by the treatment options that can be performed with a laser. The main focus will be on the concrete comparison of the treatment methods, especially in clinical contexts. In particular, the duration of surgery, length of hospitalisation, risk of post-operative bleeding, catheterisation duration, risk of urinary retention and risk of post-operative complications such as retrograde ejaculation, bladder neck sclerosis, urethra stricture and adenoma recurrence will be listed and compared for the most important methods. Nevertheless, the distribution of TURP to laser is still 30:1 in favour for TURP [1].

Prostatic Artery Embolization (PAE) - Endo-vascular Treatment of Lower Urinary Tract Symptoms Presumed Secondary to Benign Prostatic Obstruction Abstract: Based on the available evidence on efficacy and safety in the short to midterm, Prostatic Artery Embolization (PAE) is now endorsed by international evidence-based guidelines as a treatment of lower urinary tract symptoms presumed secondary to benign prostatic obstruction (LUTS/BPO) for selected patients. As PAE has a unique treatment approach (i.e., endovascular instead of transurethral), its profile and ideal application differ clearly from other treatments of LUTS/BPO, which must be considered for patient selection. Performance in local anesthesia with ongoing anticoagulation and no upper prostate size limitation represent advantages of the technique. Limited availability, an inferior relief of obstruction associated with higher retreatment rates and inferior outcomes in small prostates represent disadvantages. This should be considered for patient selection and counselling.

Pathology and Pathophysiology of BPH and Relevant Incidental Findings in TUR-P Abstract: Benign prostatic hyperplasia (BPH) is defined as nodular prostate enlargement due to cellular proliferation of prostate glands and stroma. Beside adenocarcinoma, BPH is one of the most common diseases in the prostate. Transurethral resection of the prostate (TURP) is surgical treatment of choice for BPH. Resected tissue fragments are examined in the pathology and belong to the most commonly submitted urologic specimens. Up to date, pathophysiology of BPH is not yet completely understood. Different hormones such as androgens, dihydrotestosterone, estrogens as well as growth factors, inflammation, and environmental influences are important in the process. The diagnosis of BPH is usually straightforward. In this context, it is important to mention incidental findings, which may come along as "bad surprises" while examining TURP tissue fragments. Prostatic intraepithelial neoplasia (PIN) or incidental acinar adenocarcinoma of the prostate as well as the potential preneoplastic atypical adenomatoid hyperplasia (AAH) represent a few examples. According to literature, the histologic examination of TURP tissue reveals a high-grade PIN in up to 5%. Incidental adenocarcinoma is encountered in 5-13%. These frequencies justify a relatively laborious examination of the entire or majority resected TURP tissue.

Male Incontinence - An Overview and its Relationship to Benign Prostatic Enlargement Abstract: Male urinary incontinence is a common disease in elderly men and can lead to a significantly reduced quality of life. Reported prevalence of urinary incontinence increases up to 32% in men over 85 years. Risk factors for urinary incontinence are prostate surgery, advanced age, immobility, urinary tract infections, diabetes mellitus, cognitive disorders, and neurological disease. Urinary incontinence is divided into three subtypes: stress urinary incontinence, urge urinary incontinence, and mixed urinary incontinence. Benign prostatic obstruction can lead to a detrusor overactivity and a further urge incontinence. However, iatrogenic injury or a preexisting weakness of the external urinary sphincter are more common and can lead to stress urinary incontinence in men following prostate surgery. A correct treatment can significantly improve symptoms in men suffering from urinary incontinence. Though, every treatment plan must be tailored to the individual patient.

Robot-assisted Simple Prostatectomy (RASP) Abstract: Surgical treatment of large adenomas of the prostate (> 80g) in men suffering from symptomatic prostate hyperplasia is challenging. Transurethral resection of the prostate (TUR-P), known as the operative gold standard, is not a safe option in large adenomas due to prolonged resection time and the consecutive increased complication rate. For decades, large adenomas were surgically treated by open enucleation. Although the procedure has still its role in surgical treatment of large glands, the perioperative morbidity and complications can be severe. In view of this fact, several new and minimal invasive techniques such as transurethral procedures, mainly using laser technologies (Holmiun-Laser Enucleation, HoLEP and KTP-Laser vaporization, Greenlight™ Laser), have been invented. In addition, the traditional open enucleation of the prostate was performed and evaluated by using conventional laparoscopy and finally by robot-assisted laparoscopy. Meanwhile robot-assisted simple prostatectomy (RASP) and especially its modification with an extraperitoneal extravesical access and intraprostatic reconstruction of the prostatic urethra in order to exclude the prostatic wound bed from the urinary tract with consecutive lower perioperative complication rates are well established procedures to treat large adenomas.