• ETIOLOGY OF BPH
    • Βασικες αρχες και υποθεσεις για την αναπτυξη της ΚΥΠ
      • The observed increase in cell number may be due to epithelial and stromal proliferation or to impaired programmed cell death leading to cellular accumulation
      • Androgens not only are required for normal cell proliferation and differentiation in the prostate but also actively inhibit cell death
      • the aging process induces a block in this maturation process so that the progression to terminally differentiated cells is reduced, reducing the overall rate of cell death
    • ο ρολος των ανδρογονων
      • Although androgens do not cause BPH, the development of BPH requires the presence of testicular androgens during prostate development, puberty, and aging( McConnell, 1995 ; Marcelli and Cunningham, 1999 ). Patients castrated prior to puberty or who are affected by a variety of genetic diseases that impair androgen action or production do not develop BPH
      • Assuming normal ranges, there is no clear relationship between the concentration of circulating androgens and prostate size in aging men
      • the prostate, however, the nuclear membrane bound enzyme steroid 5α-reductase converts the hormone testosterone into DHT, the principal androgen in this tissue
      • DHT is a more potent androgen than testosterone because of its higher affinity for the AR. Moreover, the DHT-receptor complex may be more stable than the testosterone-receptor complex.
      • The hormone receptor then binds to specific DNA binding sites in the nucleus, which results in increased transcription of androgen-dependent genes and ultimately stimulation of protein synthesis.Conversely, androgen withdrawal from androgen-sensitive tissue results in a decrease in protein synthesis and tissue involution
      • Besides inactivation of key androgen-dependent genes (e.g., prostate-specific antigen), androgen withdrawal leads to the activation of specific genes involved in programmed cell death
      • Despite the importance of androgens in normal prostatic development and secretory physiology, there is no evidence that either testosterone or DHT serves as the direct mitogen for growth of the prostate in older men. Indeed, neither hormone is mitogenic to cultured prostatic epithelial cells ( McKeehan et al, 1984 ). In the rat ventral prostate, differential gene expression experiments failed to demonstrate direct activation of mitogenic pathways ( Wang et al, 1997 ). However, many growth factors and their receptors are regulated by androgens (see later). Thus, the action of testosterone and DHT in the prostate is mediated indirectly through autocrine and paracrine pathways.
    • Ποιος είναι ο ρολος του ανδρογονικου υποδοχέα (ή πως εξηγεις ότι με την ηλικια που μειωνεται η τεστοστερονη εχουμε υπερπλασια??)?
      • The prostate, unlike other androgen-dependent organs, maintains its ability to respond to androgens throughout life.
        • In the penis, AR expression decreases to negligible rates at the completion of puberty ( Roehrborn et al, 1987 ; Takane et al, 1991 ). Thus, despite high circulating levels of androgen, the adult penis loses its ability for androgen-dependent growth. If the penis maintained high levels of AR throughout life, presumably the organ would grow until the time of death.
      • Ινcontrast, AR levels in the prostate remain high throughout aging ( Barrack et al, 1983 ; Rennie et al, 1988
      • there is evidence to suggest that nuclear AR levels may be higher in hyperplastic tissue than in normal controls ( Barrack et al, 1983 ).
      • Age-related increases in estrogen, as well as other factors, may increase AR expression in the aging prostate, leading to further growth (or to a decrease in cell death), despite decreasing levels of androgen in the peripheral circulation and “normal” levels of DHT in the prostate.
    • Oρολος της διυδροτεστοστερονης και της 5ααναγωγασης
      • Intraprostatic DHT concentrations are maintained but not elevated in BPH
      • type 2 enzyme is critical to normal development of the prostate and hyperplastic growth later in life
      • Immunohistochemical studies with type 2 5α-reductase specific antibodies show primarily stromal cell localization of the enzyme
      • stromal cell plays a central role in androgen-dependent prostatic growth and that the type 2 5α-reductase enzyme within the stromal cell is the key androgenic amplification step
      • circulating DHT produced in the skin and liver may act on prostate epithelial cells in a true endocrine fashion
    • ο ρολος των οιστρογονων
      • estrogen appears to be involved in induction of the AR ( Moore et al, 1979 ). Estrogen may, in fact, “sensitize” the aging dog prostate to the effects of androgen
      • Serum estrogen levels increase in men with age, absolutely or relative to testosterone levels. There is also suggestive evidence that intraprostatic levels of estrogen are increased in men with BPH
    • ΠΑΘΟΦΥΣΙΟΛΟΓΙΑ
      • Τι γνωριζεις για την παθοφυσιολογια της ΚΥΠ?
        • Prostatic hyperplasia increases urethral resistance, resulting in compensatory changes in bladder function.However, the elevated detrusor pressure required to maintain urinary flow in the presence of increased outflow resistance occurs at the expense of normal bladder storage function. Obstruction-induced changes in detrusor function, compounded by age-related changes in both bladder and nervous system function, lead to urinary frequency, urgency, and nocturia, the most bothersome BPH-related complaints
        • BPH nodules develop either in the transition zone or in the periurethral region
        • One of the unique features of the human prostate is the presence of the prostatic capsule, which plays an important role in the development of LUTS( Caine and Schuger, 1987 ). In the dog, the only other species known to develop naturally occurring BPH, symptoms of bladder outlet obstruction and urinary symptoms rarely develop because the canine prostate lacks a capsule. Presumably the capsule transmits the “pressure” of tissue expansion to the urethra and leads to an increase in urethral resistance. Thus, the clinical symptoms of BPH in man may be due not only to age-related increases in prostatic size but also to the unique anatomic structure of the human gland. Clinical evidence of the importance of the capsule can be found in series that clearly document that incision of the prostatic capsule (transurethral incision of the prostate) results in a significant improvement in outflow obstruction, despite the fact that the volume of the prostate remains the same.
        • The size of the prostate does not correlate with the degree of obstruction
      • τι είναι και από πού προερχεται ο μεσος λοβος?
        • In some cases, predominant growth of periurethral nodules at the bladder neck gives rise to the “middle lobe” ( Fig. 86-4 ). The middle lobe must be of periurethral origin because there is no transition zone tissue in this area. It is not clear whether middle lobe growth occurs at random in men with BPH or whether there is an underlying genetic susceptibility to this pattern of enlargement.
      • Ποια είναι η σημασια των λειων μυικων ινων του προστατη?
        • both passive and active forces in prostatic tissue play a major role in the pathophysiology of BPH
        • stimulation of the adrenergic nervous system clearly results in a dynamic increase in prostatic urethral resistance. Blockade of this stimulation by α-receptor blockers clearly diminishes this response
        • Active smooth muscle tone in the human prostate is regulated by the adrenergic nervous system
        • Receptor binding studies clearly demonstrate that the α1A is the most abundant adrenoreceptor subtype present in the human prostate(Lepor et al, 1993a, 1993b [86] [87]; Price et al, 1993 ; Roehrborn and Schwinn, 2004 ). Moreover, the α1A receptor clearly mediates active tension in human prostatic smooth muscle
      • Τι γνωριζεις για την απαντηση του εξωστηρα στην αποφραξη?
        • Obstruction-induced changes in the bladder are of two basic types.
          • First, the changes that lead to detrusor instabilityor decreased complianceare clinically associated with symptoms of frequency and urgency( Andersson, 2003 ).
          • Second, the changes associated with decreased detrusor contractilityare associated with further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine,and (in a minority of cases) detrusor failure.
        • the major endoscopic detrusor change, trabeculation, is due to an increase in detrusor collagen
        • the initial response of the detrusor to obstruction is the development of smooth muscle hypertrophy(Levin et al, 1995, 2000 [89] [90]). It is likely that this increase in muscle mass, although an adaptive response to increased intravesical pressure and maintained flow, is associated with significant intra- and extracellular changes in the smooth muscle cell that lead to detrusor instability and in some cases impaired contractility
      • ποια είναι η σχεση μετξυ LUTS,BPH, BPOandBPE
        • Of all men older than 40, a certain proportion develop histologic hyperplasia of the prostate, that is, BPH. Of those, some but not all develop LUTS, and other may have LUTS for reasons other than BPH (e.g., urethral stricture, stones, inflammation). Prostate enlargement occurs in some but again not all men with histologic BPH and LUTS, and some men with enlarged glands may not have any symptoms at all. Lastly, urodynamically proven obstruction may be present in men who have either one, several, or all of histologic BPH, LUTS, and enlarged glands, yet others may have obstruction without having any evidence of BPH (e.g., urethral stricture, prostate cancer, primary bladder neck sclerosis). In addition to the mere enumeration of symptoms by frequency of occurrence, the bother associated with the symptoms, interference with activities of daily living, and the impact the symptoms have on quality of life are important distinguishing characteristics.
      • ΙΣΤΟΛΟΓΙΚΑ ΧΑΡΑΚΤΗΡΙΣΤΙΚΑ
        • Τι γνωριζεις για τα ιστολογικα χαρακτηριστικα της ΚΥΠ
          • BPH is a true hyperplastic Histologic studies document an increase in the cell number ( McNeal, 1990 ). In addition, thymidine uptake studies in the dog clearly indicate an increase in DNA synthesis in experimentally induced BPH ( Barrack and Berry, 1987 ). The term benign prostatic hypertrophyis pathologically incorrect
          • There is significant pleomorphism in stromal-epithelial ratios in resected tissue specimens. Studies from primarily small resected glands demonstrate a predominance of fibromuscular stroma( Shapiro et al, 1992b ). Larger glands, predominantly those removed by enucleation, demonstrate primarily epithelial nodules ( Franks, 1976 ). However, an increase in stromal-epithelial ratios does not necessarily indicate that this is a “stromal disease”; stromal proliferation may well be due to “epithelial disease
          •  
        • NATURAL HISTORY
          • Τι είναι το IPSS
            • seven-item American Urological Association (AUA) symptom index (also known as the International Prostate Symptom Score [I-PSS]) has been a pivotal event in the clinical research on LUTS and BPH(Barry et al, 1992a, 1992b, 1992c [214] [215] [216]; O’Leary et al, 1992 ). With the total score running from 0 to 35 points, patients scoring 0 to 7 points are classified as mildly symptomatic, those scoring from 8 to 19 points as moderately symptomatic, and those scoring 20 to 35 points as severely symptomatic
          • ποιο είναι το ποσοστ νυκτουριας σε ανδρες και γυναικες >70
            • πανω από 40%
          • ποιοι είναι οι πιο σημαντικοι παραγοντες εξελιξης της νοσου?
            • Age, symptom severity, flow rate, prostate size, and serum PSA are useful predictors of the risk of progression.
          • ποιους τυπους οξειας επισχεσης γνωριζεις και ποια η κλινικη σημασια τους?
            • From a clinical and prognostic point of view, spontaneous AUR should be separated from precipitated AUR, although this is by no means consistently done in the literature. Precipitated AUR refers to the inability to urinate following a triggering event such as non–prostate-related surgery, catheterization, anesthesia, or ingestion of medications with sympathomimetic or anticholinergic effects or antihistamines. All other AUR episodes are classified as spontaneous( Roehrborn et al, 2000a ).
            • Following spontaneous AUR, 15% of patients had another episode of spontaneous AUR and a total of 75% underwent surgery, whereas after precipitated AUR only 9% had an episode of spontaneous AUR and 26% underwent surgery
          • Ποιοι είναι οι παραγοντες κινδυνου για επισχεση ουρων?
            • the PhysiciansHealth Study, rates increased with age and baseline symptom severity (The sensation of incomplete bladder emptying, having to void again after less than 2 hours, and a weak urinary stream were the best independent symptom predictors)
            • The Olmsted County study: The relative risk increased for older men, men with moderate to severe symptoms (3.2-fold), those with a flow rate under 12 mL/sec (3.9-fold), and those with a prostate volume greater than 30 mL by TRUS (3.0-fold), all compared with a baseline risk of 1.0-fold for the corresponding groups
            • in PLESS, an observation that applies to both spontaneous and precipitated AUR( Roehrborn et al, 1999c ). The risk for both types of AUR increases with increasing serum PSA as well as prostate volume stratified by tertiles
          • ΔΙΑΓΝΩΣΗ
            • ΤΙ είναι μικροσκοπικη ΒΡΗ και ποια η συχνοτητα της?
              • Microscopic BPH describes a proliferative process of the stromal and epithelial elements of the prostate( Bartsch et al, 1979 ). The proliferative process originates in the transition zone and the periurethral glands
              • approximately 70% and 90% of males in their seventh and ninth decades of life, respectively.
            • Τι ονομαζουμε μακροσκοπικη ΒΠΗ και πως γιεται η διαγνωση?
              • Macroscopic BPH describes an “enlarged” prostate
              • Digital rectal examination (DRE) provides a relatively crude estimate of prostate size when compared with measurements using transrectal ultrasonography or magnetic resonance imaging (MRI)
              • There is no consensus regarding the extent of enlargement required to establish the diagnosis of macroscopic BPH; however, prostate volume between 20 and 30 mL may be regarded as normal
            • Ποιες είναι οι κλινικες εκδηλωσεις της ΒΡΗ?
              • The clinical manifestations of BPH include LUTS, poor bladder emptying, urinary retention, an overactive bladder, UTI, hematuria, and rarely now renal insufficiency
              • Παντωςonly weak relationships between prostate size, severity of BOO, and severity of symptoms
            • Ποια είναι η θεση της κρεατινινης στην εξεταση για lUTS
              • The recently published AUA guidelines on BPH no longer recommend routine creatinine measurement in the standard patient.However, it is well established that BPH patients with renal insufficiency haveincreased risk for postoperative complications. The risk is 25% for patients with renal insufficiency, compared with 17% for patients without the condition ( Mebust et al, 1989 ). Moreover, the mortality increases up to sixfold for BPH patients treated surgically if they have renal insufficiency
              • Elevated serum creatinine in a patient with BPH is an indication for imaging studies (ultrasound) to evaluate the upper urinary tract
            • Ποτε πρεπει να γινεται εξεταση PSAσε ασθενεις που εξεταζονται για ΒΡΗ?
              • Therefore, measurement of the serum PSA value should be performed in patients in whom the identification of cancer would clearly alter BPH management
              • In the absence of prostate cancer the PSA value can provide a guide to prostate volume and also provide an indication of the likelihood of response to pharmacotherapy with a 5α-reductase inhibitor
            • Ποιες είναι οι άλλες εξετασεις που συνιστονται από την internationalconsensous?
              • In the International Consensus recommendations, urinary flow rate and PVR are recommended tests
              • Both AHCPR and International Consensus Guidelines recommend surgery if the patient has refractory urinary retention (failing at least one attempt of catheter removal) or any of the following conditions clearly secondary to BPH: recurrent UTI, recurrent gross hematuria, bladder stones, renal insufficiency, or large bladder diverticula( McConnell et al, 1994 ; Denis et al, 1998 ).
              • Ιn this situation, the performance of further diagnostic testing is not necessary unless there is reason to suspect that the patient’s retention may be due to detrusor hypocontractility. In that case, urodynamic studies (e.g., filling cystometry) may be helpful. Pressure-flow urodynamic studies are not informative if the patient cannot urinate.
              • Cystoscopy is appropriate to consider before the operative procedure to help plan the most prudent approach. The presence of infection and hematuria in patients should prompt appropriate evaluation and therapy for these conditions before treatment of BPH.
            • Τι μας εδειξεμελετη του OelkeΣχετικα με τον ρολο του Qmaxστην διαγνωση της αποφραξης?
              • Σε 1`418 ασθενεις >40 ετων με Qmax<15 , PVR50 και LUTS
                • Περιπου 40% δεν εχε αποφραξη- περιπου 40% ειχαν αποφραξη
                • 20% δεν ειχει αποφραξη αλλα υπερλειτουργικο εξωστηρα
              • Ποιος είναι ο ρολος της ουροροομετριας με βαση την AHCPRGuidelinePanel?
                • Flow rate measurements are inaccurate if the voided volume is less than 125 to 150 mL.
                • Flow rate recording is the single best noninvasive urodynamic test to detect lower urinary tract obstruction. Current evidence, however, is insufficient to recommend a given “cutoff” value to document the appropriateness of therapy
                • The peak flow rate (PFR; Qmax) more specifically identifies patients with BPH than does the average flow rate (Qave).
                • Although Qmax decreases with advancing age and decreasing voided volume, no age or volume correction is currently recommended for clinical practice
                • Although considerable uncertainty exists, patients with a Qmax greater than 15 mL/s appear to have somewhat poorer treatment outcomes after prostatectomy than patients with a Qmax of less than 15 mL/s.
                • A Qmax of less than 15 mL/s does not differentiate between obstruction and bladder decompensation
              • Υπαρχει καποια συσχετιση μεταξυ της ουροομετριας / του IPSSκαι αποτελεσμα χειρουργειου?
                • Neither subjectively assessed symptoms nor quantified symptom-score analysis correlates strongly with uroflowmetry measurements; they are independent assessments.
                • Patients with a PFR greater than 15 mL/s may have somewhat poorer outcomes after surgery than those with a Qmax less than 15 mL/s (although the majority of patients still improve). Other investigators report similar findings for different Qmax cutoff values (e.g., 12 mL/s).
                • Patients with very bothersome symptoms suggestive of clinical BPH but having a Qmax greater than 15 mL/s may benefit from further urodynamic testing (i.e., pressure-flow studies) to reduce the number of surgical treatment failures.
                • A Qmax less than 15 mL/s does not differentiate between outflow obstruction and detrusor impairment. Apparently, no minimal threshold of Qmax reliably diagnoses detrusor failure or predicts a poor surgical outcome.
              • Ποια είναι τα βασικα σημεια που δειχνουν την θεση του υπολειμματο ςμετα ουρηση?
                • Residual urine volume measurement has significant intraindividual variability that limits its clinical usefulness
                • Residual urine volume does not correlate well with other signs or symptoms of clinical BPH
                • Large residual urine volumes may predict a slightly higher failure rate with a strategy of watchful waiting. However, the threshold volume defining a poorer outcome is uncertain
                • It is uncertain whether PVR urine volume predicts the outcome of surgical treatment.
                • It is uncertain whether PVR urine volume indicates impending bladder or renal damage
                • PVR urine volume can be measured with sufficient accuracy noninvasively by transabdominal ultrasonography. The measurement variation caused by the method is less than the biologic range of PVR variation.
                • Most clinical studies demonstrate minimal correlation between PVR urine volume and baseline measurements of symptoms, flow rate, or urodynamic measures of obstruction
                • PVR urine volume is best viewed as a “safety parameter.” Men with significant PVR amounts should certainly be monitored more closely if they elect nonsurgical therapy, particularly if antimuscarinic therapy is chosen.
              • Ποια είναι η θεση των μελετων πιεσης-ροης στην διαγνωση των ασθενων με LUTS?
                • Pressure-flow studies differentiate between patients with a low PFR secondary to obstruction and those whose low PFR is caused by impaired detrusor contractility.
                • These studies should be performed when the distinction between the two will affect therapeutic decisions. Patients with a history of neurologic diseases known to affect bladder or sphincteric functions, as well as patients with normal flow rates (PFR > 15 mL/sec) but bothersomesymptoms, may also benefit from urodynamic evaluation and especially if surgical therapy is contemplated
                • Με βαση την EAUεχει θεση σε:
                  • Μικρη ηλικια <50
                  • Μεγαλη ηλικια >80
                  • Αν εχει προηγηθει αλλαο χειρουγειο
                  • Αν υπολειμμα>300
                  • Αν χειρουργειο πυελο
                  • Υποψια νευρογενης κυστη
                • Ποια είναι η θεση της ουρηθροκυστεοσκοπησης στην εκτιμηση των ασθενων με LUTS?
                  • The test is recommended for men with LUTS who have a history of microscopic or gross hematuria, urethral stricture disease (or risk factors such as history of urethritis or urethral injury), bladder cancer or suspicion of carcinoma in-situ, or prior lower urinary tract surgery (especially prior TURP).
                  • Urethrocystoscopy may be considered in men with moderate to severe symptoms who have chosen (or require) surgical or other invasive therapy to help the surgeon determine the most appropriate technical approach. (TUIP or TURP or OPEN)
                • Ποια είναι η θεση των απεικονιστικων εξετάσεων του ανώτερου ουροποιητικού στην εκτιμηση ασθενων με LUTS?
                  • Upper urinary tract imaging is not recommended in the routine evaluation of men with LUTS unless they also have one or more of the following: hematuria, UTI, renal insufficiency (ultrasonography recommended), history of urolithiasis, or history of urinary tract surgery
                • ΠΑΡΑΚΟΛΟΥΘΗΣΗ-φυσικη εξελιξη νοσου
                  • Υπαρχουν ενδειξεις ότι η αυξηση του υπολειμματος μετα την ουρηση αθξανει τον κινδυνο λοιμωξης και ?
                    • There are no data clearly documenting that the incidence of UTI is related to the PVR urine volume
                  • Πως οριζετια και ποια είναι η θεση του υπερδαστηριου εξωστηρα στην εξελιξη της νοσου ενός ασθενους?
                    • The definition of bladder overactivity (detrusor instability) is the development of a detrusor contraction exceeding 15 cm H2O at a bladder volume less than 300 mL (Jepsen and Bruskewitz, 2000).
                    • The clinical significance of an overactive bladder (OAB) in men with BPH is unresolved.
                    • There is no evidence that men with detrusor instability electing watchful waiting are predisposed to develop disease progression.
                    • The presence of an OAB does not reliably predict response to medical or surgical treatment.
                    • Therefore improvement of an OAB is not a standard outcome measure in clinical trials.
                  • Εχουμε ενδειξεις βεβαιοτητας ότι η ουρολοιμωξη σε ηλικιωμενους σχετιζεται με υπολειμμα ή με υποκυστικο κωλυμμα?
                    • There is no convincing evidence that UTI in the aging male population is associated with either PVR urine or BOO.
                  • Μετα από ένα επεισοδιο επισχεσης ουρων- ποτε εχουμε τον κεγαλυτερο κινδυνο υποτροπης?
                    • Το 80% υποτροπιάζει στον 1οχρονο μετα από ένα επεισοδιο επισχεσης
                  •  
                  • ΘΕΡΑΠΕΙΑ
                    • Ποιοι είναι οι ασθενεις που δεν χρειαζονται θεραπεια για lUTS
                      • Όταν διαφορετικη υποκειμενη παθολογια
                      • Όταν χαμηλος κινδυνος εξελιξης της νοσου
                    • Ποσος είναι ο κινδυνος εξελιξης της νοσου
                      • Σε μελετη στο NEJMτο 80% των ασθενων με LUTSδεν παρουσιασαν εξελιξη της νοσου στα επομενα 5 χρονια
                    • Pποιες είναι οι ενδειξεις για χειρουργικη θεραπεια?
                      • Both AHCPR and International Consensus Guidelines recommend surgery if the patient has
                        • 1) refractory urinary retention (failing at least one attempt of catheter removal) or any of the following conditions clearly secondary to BPH:
                        • 2)recurrent UTI,
                        • 3) recurrent gross hematuria,
                        • 4) bladder stones,
                        • 5)renal insufficiency, or
                        • 6)large bladder diverticula
                      • WATCHFULL WAITING
                        • Σε ποιους ασθενεις μπορουμε να δοκιμασουμε συντηρητικη παρακολούθηση?
                          • Σεασθενειςμεmild to moderate uncomplicated LUTS who are not too bother of their symptoms
                        • Ποιο είναι το ποσοστο ασθενων στους οποιους αν προσφερεις συντηρητικη παρακολουθηση θα παραμεινει σε συντηρητικη αγωγη στα επομενα 5 χρονια?
                          • Περιπου το 65% αλλα δυστυχως δεν γνωριζουμε ποιοι θα είναι αυτοι οι ασθενεις. Φαινετια ότι επειδεινωση των συμπτωματων και αυξηση του υπολειμμα μετα ουρηση είναι προγνωστικοι παραγοντες
                        • ΦΑΡΜΑΚΟΘΕΡΑΠΕΙΑ
                        • Ποια φαρμακα υπαρχουν για τα LUTS?
                          • Medical therapies extensively investigated for BPH include α-adrenergic blockers, 5α-reductase inhibitors, aromatase inhibitors, and numerous plant extracts. Newer therapies include antimuscarinic drugs and phosphodiesterase inhibitors (PDEIs) and several combinations of these agents.
                        • a adrenoceptor antagonist
                          • Ποια είναι τα συνιθισμενα φαρμακα και ποιος ο χρονος ημισειας ζωης?
                          •  
                          • Τι γνωριζεις για την αποτελεσματικοτητα τους
                            • all α-blockers have a similar efficacy in appropriate doses
                            • α-blockers typically reduce the International Prostate Symptom Score (IPSS), after a run-in period, by approximately 35-40% and increase the maximum urinary flow rate (Qmax) by approximately 20-25%
                            • σημαντικοόμωςναθυμομασταιότιIPSS improvement of up to 50% and Qmax increase of up to 40% were documented
                            • statistically significant efficacy over placebo was demonstrated within hours to days
                            • α-blockers seem to have a similar efficacy, expressed as a percent improvement in IPPS, in patients with mild, moderate and severe symptoms (6).
                            • α-blocker efficacy does not depend on prostate size (7) and is similar across age groups (6).
                            • α-blockers do not reduce prostate size and do not prevent acute urinary retention in long-term studies (8), so that eventually some patients will have to be surgically treated.
                            • the efficacy of α-blockers appears to be maintained over at least 4 years.
                          • με ποιο μηχανισμο δρουν οι ανταγωνιστες των α υποδοχεων και βοηθουν στην βελιτωση των συμπτωματων?
                            • Historically, it was assumed that α-blockers act by inhibiting the effect of endogenously released noradrenaline on prostate smooth muscle cells, thereby reducing prostate tone and bladder outlet obstruction. Contraction of the human prostate is mediated predominantly, if not exclusively, by α1A-adrenoceptors (1).
                            • However, it has been shown that α-blockers have little effect on urodynamically determined bladder outlet resistance (2) and treatment-associated improvement of LUTS is correlated only poorly with obstruction (3).
                              • Administration of an alpha-adrenoceptor blocking age nt results in a small reduction in BOO, although a decrease in urodynamic obstruction parameters of up to 50% has been shown.
                              • Patients with LUTS may all benefit from the use of alphablockers,whether they have severe BOO or not.
                              • There is an indication that unobstructed patients respond better to alpha-blockers with respect to symptoms and Qmax than do obstructed patients.
                              • Generally, there is no strong indication to perform urodynamic studies when prescribing alphablockers to relieve patients’ bothersome LUTS
                            • The contemporary alpha-blockers, such as alfuzosin, doxazosin, tamsulosin, and terazosin, appear to have a very similar therapeutic efficacy,producing a 20% to 30% increase in Qmax and a significant improvement in patients’ symptoms
                            • They have a rapid onset of action and are likely to be effective in many patients within days to weeks. This is in contrast to 5-alpha-reductase inhibitors,which take months to show a therapeutic result
                            • the improvement in symptoms ranged from 20% to 60%, without a clear difference between the different alpha-blockers
                            • the increase in Qmax was on average 2.9 mL/s (range _0.9 to 5.6)
                          • με ποιο μηχανισμο , η χορηγηση α ανταγωνιστων μειωνει τα συμπτωματα κατωτερου ουροποιητικου?
                            • It was felt that a1-adrenoceptor antagonists (a-blockers) relieve LUTS in elderlymales by relaxing prostatic smooth muscle and thereby reducing bladder outlet resistance.3 However, several lines of evidence have questioned whether these mechanisms can indeed explain LUTS in elderly maλεςFor example,
                              • LUTS can persist after effective deobstruction by transurethral resection of the prostate,4–6 and similar observations have also been made in experimental animal models of BOO.7
                              • studies with various a-blockers have consistently demonstrated good symptom reductions as assessed by the IPSS or similar scores, whereas improvements of free-flow Qmax typically are only moderate.8
                              • Accordingly, pressure-flow studies in elderly males with LUTS have not consistently shown reductions of bladder outlet resistance upon treatment with a-blockers.9
                              • Finally, a-blockers can relieve LUTS in experimental animals with surgically induced BOO, that is, under conditions where a reduction of bladder outlet resistance is impossible.3,10
                            • Thus, various lines of circumstantial evidence question the theory that the improvement of LUTS in elderly males upon a-blocker treatment is due to reductions of BOO, but direct evidence is missing.
                            • Από μελετη Barendrecht:
                              • In conclusion, our analysis confirms that IPSS, Qmax and BOOI represent different aspects of LUTS in elderly males which are only poorly related to each other. In extension of previous circumstantial evidence, our data show that a-blocker-induced improvements of IPSS are largely independent from those of BOOI. These data question the previous concept that the beneficial effects of a-blockers in elderly males with LUTS are predominantly or even exclusively due to relaxation of prostatic smooth muscle. They give further support to newer models in which the beneficial effects of a-blockers in elderly males with LUTS involve to a large extent action on extra-prostatic a1-adrenoceptors, for example, those in the spinal cord21,22 and/or the urinary bladder.23,24 The efficacy of tamsulosin in patients with neurogenic LUTS due to suprasacral spinal cord injury25 makes the former location an unlikely candidate. Given the scarcity of a1-adrenoceptors in the human detrusor,26 their recent discovery in the urothelium,27 however, provides an exciting avenue to positively identify the mechanism of action of a-blockers in elderly males with LUTS
                                • (ΑΝ ΑΥΤΟ ΣΥΜΒΑΙΝΕΙ ΤΙ ΘΑ ΣΥΜΒΕΙ ΑΝ ΔΩΣΟΥΜΕ Α ΑΝΑΣΤΟΛΕΙΣ ΣΕ ΑΣΘΕΝΕΙΣ ΠΟΥ ΕΧΟΥΝ ΚΑΝΕΙ ΔΙΟΥΡΗΘΡΙΚΗ ΠΡΟΣΤΑΤΕΚΤΟΜΗ???)
                              • Τι γνωριζεις για την ανεκτικοτητα, την ασφαλεια και τα adverseevents?
                                • the side-effect profile of alfuzosin is more similar to tamsulosin than to doxazosin and terazosin (δοξατωρα). The mechanisms underlying such differential tolerability are not fully understood, but may involve better distribution into lower urinary tract tissues by alfuzosin and tamsulosin
                                • s The most frequent side-effects of α-blockers are asthenia, dizziness and (orthostatic) hypotension
                                  • asthenia and dizziness do not appear to be associated with blood pressure reduction
                                  • πιοσυχναμεdoxazocin and terazocin
                                • h Vasodilating effects are most pronounced with doxazosin and terazosin, and are much less common for alfuzosin and tamsulosin
                                • patients with cardiovascular co-morbidity and/or vasoactive co-medication may be susceptible to α-blocker-induced vasodilatation
                                • intraoperative floppy iris syndrome (IFIS
                                  • discovered only recently in the context of cataract surgery
                                  • most reports have been related to tamsulosin
                                  • the occurrence of IFIS complicates cataract surgery and makes it technically more demanding
                                  • prudent not to initiate α-blocker treatment prior to cataract surgery while existing α-blocker treatment should be stopped (not clear how long)
                                • α-blockers do not adversely affect libido
                                • have a small beneficial effect on erectile function
                                • sometimes cause abnormal ejaculation (anejaculation or retrograde ejaculatin)
                                  • young age risk factor
                                  • more common with silidosin and tamsulosin
                                • ποτε χρειαζεται titration?
                                  • Μετοterazocin and doxazocin (not necessary with tamsulosin and alfulozin)
                                • Πωςοριζειτηναποφραξηηinternational continence society?
                                  • PdetQmax-2_ Qmax.
                                • 5 a reductase inhibitor
                                  • Πως δρουν αυτά τα φαρμακα?
                                    • Αναστελλουν την μετατροπη της τεστοστερονης σε διυδροτεστοστερονη (ενεργος μεταβολιτητς) μεσω της αναστολης της δρασης του μετατρετικου ενζυμου που λεγεται (αναστολεις της 5 α αναγωγασης). Αποτελεσμα υτης της αποστερησης είναι επιθηλιακα κυτταρα του προστατη να οδηγουνται σε αποπτωση
                                  • Ποσοι τυποι υπαρχουν
                                    • 2 τυποι
                                      • Τυπος 1 àηπαρ και δερμα
                                      • Τυπος 2àπροστατης και γεννητικα οργανα
                                    • Ποια η διαφορα της φιναστεριδης με την dutasteride?
                                      • HdutasterideΜπλοκαρει και τους 2 τυπους ενώ η φιναστεριδη μονο τον τυπο 2
                                    • Ποια είναι η αποτελεσματικοτητα τους
                                      • Μειωση του ογκου του προστατη κατά 15-25% σε 6 μηνες (
                                      • Το PSAστο μισο σε 12 μηνες
                                    • Πως μεταβολιζονται τα φαρμακα αυτά και ποια η φαρμακοκινητικη?
                                      •  
                                      • Στο ηπαρ και αποβαλλονται με τα κοπρανα
                                    • Τι γνωριζεις για την αποτελεσματικοτητα των φαρμακων αυτων?
                                      • Clinical effects relative to placebo are seen after minimum treatment duration of at least 6 to 12 months
                                      • After 2 to 4 years of treatment, 5α-reductase inhibitors
                                        • reduce LUTS (IPSS) by approximately 15-30%,
                                        • decrease prostate volume by approximately 18-28% and
                                        • increase Qmax of free uroflowmetry by approximately 1.5-2.0 mL/s in patients with LUTS due to prostate enlargement
                                      • Symptom reduction by finasteride depends on initial prostate size and may not be more efficacious than placebo in patients with prostates smaller than 40 mL
                                      • dutasteride and finasteride are equally effective in the treatment of LUTS
                                      • 5α-reductase inhibitors reduce symptoms more slowly and, for finasteride, less effectively
                                      • The greater the baseline prostate volume (serum PSA concentration), the faster and more pronounced the symptomatic benefit of dutasteride
                                      • 5α-reductase inhibitors, but not α-blockers, reduce the long-term (> 1 year) risk of acute urinary retention or need for surgery
                                      • The precise mechanism of action of 5α-reductase inhibitors in reducing disease progression remains to be determined, but it is most likely attributable to reduction of bladder outlet resistance
                                    • Ποιες είναι οι πιο συχνες και σημαντικες παρενεργειες?
                                      • Στυτιη δυσλειτουια
                                      • Μειωση της Libido
                                      • Διαταραχεςεκσπερματιση(retrogrqde, anejaculation, decreased semen volume, ejaculation failure)
                                      • Gynecomastia (1-2%)
                                      • ?? κινδυνος για χειορτερη μορφη καρκινου του προστατη??
                                        • Φιναστεριδη
                                          • Μειωση 26% συνολικου κινδυνου εμφανισης καρκινου
                                          • Αυξηση κινδυνου για >8 gleasonscoreκαρκινους (1.8 εναντι 1.1%)
                                        • Δουταστεριδη
                                          • Μειωση 23% συνολικου κινδυνου
                                          • Αυξηση χαμηλου βαθμου (1% εναντι 0.5%)
                                        • Σε ποιους ασθενεις απευθυνεται κυριως
                                          • Σε ασθενεις με συμπτωματα κατωτερου ουροποιητικου ΚΑΙ μεγάλο προστάτη
                                        • Τι πρεπει να προσεχουμε σε αυτους τους ασθενεις
                                          • Ότι τα φαρμακα προκαλουν μειωση του PSAστο μισο περιπου και αρα προσοχη στις μελετες
                                        • ΑΝΤΙΜΟΥΣΚΑΡΙΝΙΚΑ ΦΑΡΜΑΚΑ
                                          • Ποιος εινια ο μηχανισμος δρασης?
                                            • The predominant neurotransmitter of the urinary bladder is acetylcholine that is able to stimulate muscarinic receptors (m-cholinoreceptors) on the surface of detrusor smooth muscle cells
                                            • muscarinic receptors are not only densely expressed on smooth muscle cells but also on other cell types, such as epithelial cells of the salivary glands, urothelial cells of the urinary bladder, or nerve cells of the peripheral or central nervous system
                                            • Five muscarinic receptor subtypes (M1-M5) have been described in humans, of which the M2 and M3 subtypes are predominantly expressed in the detrusor.
                                            • Although approximately 80% of these muscarinic receptors are M2 and 20% M3 subtypes, only M3 seems to be involved in bladder contractions in healthy humans (1,2).
                                            • The role of M2 subtypes remains unclear. However, in men with neurogenic bladder dysfunction and in experimental animals with neurogenic bladders or bladder outlet obstruction M2 receptors seem to be involved in smooth muscle contractions as well (
                                            • The detrusor is innervated by parasympathic nerves which have their origin in the lateral columns of sacral spinal cord on the level S2-S4 which itself is modulated by supraspinal micturition centres.
                                            • The sacralmicturition centre is connected with the urinary bladder by the pelvic nerves which release acetylcholine after depolarisation.
                                            • Acetylcholine stimulates postsynaptic muscarinic receptors leading to G-protein mediated calcium release in the sarcoplasmatic reticulum and opening of calcium channels of the cell membrane and,finally, smooth muscle contraction. Inhibition of muscarinic receptors by muscarinic receptor antagonists inhibit/decrease muscarinic receptor stimulation and, hence, reduce smooth muscle cell contractions of the bladder.
                                            • Antimuscarinic effects might also be induced or modulated by the urothelium of the bladder and/or by the central nervous system
                                          • Ποια φαρμακα υπαρχουν και ποια τα φαρμακοκινητικα χαρακτηριστικα τους?
                                            •  
                                          • Τι γνωριζεις για την αποτελεσματικοτητα των φαρμακων αυτων?
                                            • In an open-label study with α-blocker nonresponders, each answer of the IPSS questionnaire was improved during tolterodine treatment irrespective of storage or voiding symptoms (8).
                                            • Randomised, placebo-controlled trials demonstrated that tolterodine can significantly reduce urgency incontinence and daytime or 24-hour frequency compared to placebo. It was also demonstrated that urgency related voiding is significantly reduced by tolterodine
                                            • tolterodine significantly reduced daytime frequency, 24h voiding frequency and IPSS storage symptoms in those men with PSA concentrations below 1.3 ng/mL, which was not the case in men with PSA concentrations of 1.3 ng/mL or more indicating that men with smaller prostates might profit more from antimuscarinic drugs
                                          • τι γνωριζεις για την ανεκτικοτητα και την ασφαλεια των φαρμακων αυτων?
                                            • Muscarinic receptor antagonists are generally well tolerated and associated with approx. 3-10% study withdrawals which were not significantly different compared to placebo in most of the studies
                                            • Ποιο συχνες παρενεργειες
                                              • dry mouth (up to 16%),
                                              • constipation (up to 4%),
                                              • micturition difficulties (up to 2%)
                                              • nasopharyngitis (up to 3%), and
                                              • dizziness (up to 5%).
                                            • Αντιμουσκαρινικα και κινδυνος για επισχεση ουρων
                                              • In men with bladder outlet obstruction, antimuscarinic drugs are not recommended due to the theoretical decrease of bladder strength which might be associated with postvoid residual urine or urinary retention.
                                              • A 12-week placebo-controlled safety study dealing with men who had mild to moderate bladder outlet obstruction (median bladder outlet obstruction index, BOOI, in the placebo or tolterodine group 43 demonstrated that tolterodine significantly increased the amount of postvoid residual urine (49 vs. 16 mL) but was not associated with increased events of acute urinary retention (3% in both study arms) (15)
                                              • Urodynamic effects of tolterodine included significant larger bladder volumes to first detrusor contraction, higher maximum cystometric bladder capacity, and decreased bladder contractility index.Maximum urinary flow remained unchanged in both the tolterodine and placebo groups. This single trial indicated that the short-term treatment with antimuscarinic drugs in men with bladder outlet obstruction is safe.
                                            • Ποιος είναι ο ρολος της συνδυασμενης θεραπειας με α ανταγωνιστες και αντιμουσκαρινικά?
                                              • There is minimal available evidence on the long-term outcome of medical therapy of mixed OAB and BOO due to BPH.
                                              • The short-term data suggest that combination of antimuscarinic and α-adrenergic blocker therapy is safe with minimal risk of retention or AUR in carefully selected
                                              •  
                                              • It would seem advisable to avoid treating men with a substantialresidual urine (200 mL or more in the study), and men onthis therapy who are reporting increased hesitancy or showingsigns of increasing PVR or clinical evidence of retention should bewarned to stop the antimuscarinic element of the combination
                                              • therapy immediately.
                                              • Men with significant obstruction and large, persistent residual urine volumes should be considered for surgical therapy rather than the addition of antimuscarinic agents.
                                            • ANAΛΟΓΑ VASOPRESSIN-DESMOPRESSIN
                                              • Ποιος είναι ο μηχανισμος δρασης?
                                                • Η αντιδιουρητικη ορμονη αργινινη Vasopressinσυνδεεται με οτυς υποδοχεις V2 στο νεφρικο σωληναριο (renalcollectingducts) και προκαλεια αυξηση επαναρροφηση νερου, μειωση εκκρισης νερου, αυξησης ωσμοτικοτητας των ουρων και μειωση του ογκου ουρων.
                                                • Η vasopressinΌμως συνδεεται και με τους υποδοχεις V1 με αποτελεσμα να προκαλει αγγειοσυσπαση και υπερταση
                                                • Η ορμονοη όμως εχει πολύ μικρο χρονο ημισσεια ζωης και για αυτό δεν μπορει να χρησιμοποιηθει μα αυτην την μορφη για την αντιμετωπισης της νυκτερινης πολυουριας/νυκτουριας
                                                • ΕτσισημεραχρησιμοποιειταιτοDesmopressin acetate (desmopressin) (the only registered drug for antidiuretic treatment) is a synthetic analogue of AVP with high V2 receptor affinity and antidiuretic properties
                                                  • In contrast to AVP,desmopressin has no relevant V1 receptor affinity and hypertensive effects
                                                  • Desmopressin may be used by intravenous infusion, nasal spray, tablet, or MELT formulation.
                                                  • Nasally or orally administered desmopressin is rapidly absorbed and, later, excreted 55% unchanged by the kidneys
                                                  • After intake before sleeping, urine excretion during the night decreases and, therefore, the urge to void is postponed and the number of voids at night is reduced
                                                  •  
                                                  • The clinical effects – in terms of urine volume decrease and an increase in urine osmolality – last for approximately 8-12 hours
                                                • Ποια είναι η αποτελεσματιτκοτητα της θεραπειας με δεσμοπρεσσινη?
                                                  • drug is titrated from 0.1 to 0.4 mg according to the individual clinical response
                                                  • Desmopressin significantly reduced nocturnal diuresis by approximately 0.6-0.8 mL/min (-40%),
                                                  • decreased the number of nocturnal voids by approximately 0.8-1.3 (-40%) (-2 in the long-term open-label trial), and
                                                  • extended the time until the first nocturnal void by approximately 1.6 hours (-2.3 in the long-term open-label trial)
                                                  • significantly reduced night-time urine volume as well as the percentage of urine volume excreted at night
                                                  • he clinical effects more pronounced in patients with more severe nocturnal polyuria and bladder capacity within the normal range at baseline.
                                                  • The 24-hour diuresis remained unchanged during desmopressin treatment (6).
                                                  • The clinical effects were stable over a follow-up period of 10-12 months and returned to baseline values after trial discontinuation (12).
                                                  • A significantly higher proportion of patients felt fresh in the morning-time after desmopressin use
                                                • Tiγνωριζεις για την ασφαλεια της δεσμοπρεσσινης?
                                                  • Πιο συχνες παρενεργειες
                                                    • headache,
                                                    • nausea,
                                                    • diarrhoea,
                                                    • abdominal pain,
                                                    • dizziness,
                                                    • dry mouth, and
                                                    • hyponatraemia
                                                      • κυριως αντρες
                                                      • ηλικια>65
                                                      • περιπου στο 5%
                                                      • the treatment of men aged 65 years or older should not be initiated without monitoring theserum sodium concentration.
                                                      • At the time of treatment initiation or dose change, older men with normal valuesof serum sodium should be monitored by Na+ measurement at day 3 and day 7 of treatment as well as at 1month later.
                                                      • If serum sodium concentration has remained normal and no dose adjustment is intended, Na+should be monitored every 3-6 months thereafter (15).
                                                      • Furthermore, patients should be informed about theprodromal symptoms of hyponatraemia, such as headache, nausea, or insomnia
                                                    • Peripheral oedema (2%) and
                                                    • hypertension (5%)
                                                  • Πως χορηγειται η δεσμοπρεσσινη?
                                                    • Μια φορα την ημερα το βραδυ
                                                    • As the optimal dose differs between patients,desmopressin treatment should be initiated at a low dose (0.1 mg/day) and may be gradually increased every week until maximum efficacy is reached.
                                                    • The maximal daily dose recommended is 0.4 mg/day.
                                                    • Patients should avoid drinking fluids at least 1 hour before using desmopressin until 8 hours thereafter.
                                                    • In men aged 65 years or older, desmopressin should not be used if the serum sodium concentration is below the normal value.
                                                    • In all other men aged 65 years or older, serum sodium concentration should be measured at day 3 and 7 as well as after 1 month and, if serum sodium concentration has remained normal, every 3-6 months subsequently.
                                                  • ΣΥΝΔΥΑΣΜΕΝΗ ΘΕΡΑΠΕΙΑ α αναστολεις και ανταγωνσιστες της 5 α αναγωγασης
                                                    • Τι γνωριζεις για την συνδυασμενη θεραπεια?
                                                      • Αφορα συνδυασμο α αναστολεις (alfuzosin, doxazosin, tamsulosin, orterazosin)και ανταγωνιστες της 5 α αναγωγασης (dutasterideorfinasteride)
                                                      • Initial studieswith follow-up periods between 6 and 12 months used symptom (IPSS) change as their primary endpoint (1-3). These trials consistently demonstrated that the α-blocker was superior to finasteride in symptom reduction, whereas the combination treatment was not superior to the α-blocker alone
                                                      • More recently, 4-year data analysis from MTOPS (Medical Therapy of Prostatic Symptoms), as well as the 2- and 4-year results from the CombAT (Combination of Avodart® and Tamsulosin) trials, have been reported¨
                                                        • In contrast to earlier studies with only 6 to 12 months follow-up,long-term data have demonstrated that combination treatment is
                                                          • superior to either monotherapy with regard to symptom reduction and Qmax improvement (μετααπό9 μηνες) and
                                                          • superior to α-blocker in reducing the risk of acute urinary retention and the need for surgery (μετάαπό8 μήνες)
                                                        • παντως είναι χαρακτηριστικο ότι παρουσιαζονται διαφορετικα αποτελεσματα στις μεγαλες αυτές μελετες (ΜΤΟΡS) andCombAT. Δηλαδη
                                                          •  
                                                        • μπορεις να διακοψεις την χορηγηση ενός φαρμακου, και ποιου και ποτε?
                                                          • Ναι όπωςε φαινεται από μελετη, μετα από διακοπη μετα από 6 μηνες θεραπειας, χειροτερευης των συμπτωματων παρατηρηθηκε στο ¼ των ασθενων
                                                          • Σε πιο προσφατη μελετη μετα από 9 μηνες αγωγη συνδυασμενη θεραπεια, δεν παρατηρειται χειροτερευση συμπτωματων μετα από 3 και 9 μηνες
                                                        • Σε συνδυασμενη θεραπεια υπαρχει αυξηση των παρενεργειων?
                                                          • Ναι, αν και τα ειδη παρενεργειων είναι τα ιδιαστις μελετες φαινεται ότι η συχνοτητα εμφάνισης τιους είναι αυξημένη
                                                        • Ποτε λοιπον πρεπει να προτεινεται συνδυασμενη θεραπεια?
                                                          • Σε ασθενεις με μετρια προς σοβαρου βαθμου LUTS, με κινδυνο εξέλιξης (πχ επισχεσης/ ψηλο PSA, μεγαλος προστατης, προχωρημένη ηλικία) και μονο στην περιπτωση που προγραμματιζεται μακροχρονια θεραπεια (>12 μηνες)
                                                        • ΣΥΝΔΥΑΣΜΕΝΗ ΘΕΡΑΠΕΙΑ (α αναστολεις και αντιμουσκαρινικα φαρμακα)
                                                          • Τι γνωριζεις για την αποτελεσματικοτητα και την ασφαλεια του συνδυασμου αυτου?
                                                            • Τα αποτελεσματα από 9 κλινικες μελετες μεχρι σημερα αποδεικνυουν ότι σε σχεση με το Placeboή τους α blockers, ο συνδυασμος α blockerwithantimusxarinicπροσφερει στατιστικά σημαντική μείωση
                                                              • της συχνουρίας,
                                                              • της νυκτουρίας
                                                              • Επιτακτικότητας
                                                              • Επιτακτικής ακράτειας
                                                              • του IPSS
                                                              • Και αυξηση της ποιοτητας ζωής
                                                            • 3 άλλες μελετες έδειξαν ότι σε ασθενείς που ήδη βρίσκονται υπο α αναστολεις, η προσθήκη αντιμουσκαρινικών μειώνει σημαντικά τα LUTS(κυριως αν συνυπαρχει υπερσραστηριος εξωστηρας)
                                                            • Παντως πρεπει να γνωρίζουμε ότι ο συνδυασμός αυτός οδηγεί σε αύξηση της συχνότητας των επιπλοκών (κυριοτερα της ξηροστομίας και της διαταραχής εκσπερμάτισης) και επισης πολύ σημαντικό, αύξηση του υπολείμματος μετά ούρηση και της συχνότητας επίσχεσης ούρων- αν και παραμε΄νει άγνωστο το ποιο ασθενείς θα παρουσίασουθν επίσχεση ουρων – για τον λογο αυτό θα πρεπει οι ασθενεις που αντιμετωπιζονται με συνδυασμενη θεραπιε να υποβλαλοονται σε συχνες μετρησεις του υπολειμματος μετα ουρηση
                                                            • Και θα πρεπει να αποφευγονται σε ασθενεις που εχουν υποκυστικο κωλυμα
                                                          • ΑΛΛΕΣ ΦΑΡΜΑΚΕΥΤΙΚΕΣ ΘΕΡΑΠΕΙΕΣ (αναστολεις της 5 φψσφψδιαστερασης)
                                                            • Τι είναι και ποιος omhxanismosδρασης των αναστολέων της 5 φωσφωδιεστεράσης στην αντιμετωπιση της ΚΥΠ?
                                                              • Το μονοξείδιο του αζώτου (ΝΟ) παρασκευαζεται από την Lαργινινη μεσω των ενζύμων ΝΟ συνθάσεις (NOsynthase).
                                                              • ΝΟsynthases: classified based on their original tissues of detection as neuronal (nNOS), endothelial (eNOS), and immune cells (inducible NOS, iNOS).
                                                              • NOàactivation of guanilate cyclaseàproduction of cGMPàactivation of protein kinases, ion channels, and cGMP-binding phosphodiesterases (PDEs)àdepletion of intracellular Ca2+ and desensitisation of contractile proteinsàof smooth muscle cell relaxation
                                                              • The effects of cGMP are terminated by PDE isoenzymes catalysing the hydrolysis of cGMP to an inactive form.
                                                              • PDE inhibitors increase the concentration and prolong the activity of intracellular cGMP, hereby reducing smooth muscle tone of the detrusor, prostate, and urethra
                                                              • NO might also be involved in the micturition cycle by inhibiting reflex pathways in the spinal cord and neurotransmission in the urethra, prostate, or bladder
                                                              • Three selective oral PDE5 inhibitors (sildenafil citrate [sildenafil], tadalafil, and vardenafil hcl [vardenafil]) have been licensed in Europe for the treatment of erectile dysfunction or pulmonary arterial hypertension (sildenafil and tadalafil), but these drugs have not yet been officially registered for the treatment of male LUTS
                                                              • PDE5 inhibitors are taken on-demand by patients with erectile dysfunction but tadalafil is also registered for daily use in lower dose (5 mg) than for on-demand use
                                                            • Ποιος είναι ο ρολος των φαρμακων στην αντιμετωπιση των LUTS
                                                              • ΗαρχικηπαρατηρησηότιταφαρμακααυτάθαμπορουσανναεχουνκαποιορολοσταLUTS βασιζειταισεμιαpost-hoc analysis of patients with erectile dysfunction treated with sildenafil initially showed that the PDE5 inhibitor was capable of significantly reducing concomitant LUTS and increasing bladder symptoms-related QoL, as measured by the IPSS questionnaire
                                                              • LUTS improvement was found to be independent of improvement of erectile function.
                                                              • Randomised, placebo-controlled trials on the efficacy of all three available oral PDE5 inhibitors have been published during the last years ταοποιαεδειξανότιολοιοιPDE5
                                                                • significantly and consistently reduced IPSS (both storage and voiding symptoms) by approximately 17-35%
                                                                • unchanged post void residual urinv
                                                                • increase Qmax in a dose-dependent fashion-BUT NOT DIFFERENT FROM PLACEBO
                                                                • significantly improved QoL compared to placebo-treated patients
                                                              • τι λενε οι μελετες για την συγχωρηγηση α αναστολεων με PDE5 inh?
                                                                • The drug combination improved IPSS, Qmax, and postvoid residual urine to a greater extent than the single drug alone of each class (Table 14), although the difference compared to PDE5 inhibitor or α-blocker alone was only statistically significant in one of the three trials
                                                              • Ποιες είναι οι πιο συχνες παρενεργειες των PDE5 inh?
                                                                • headache,
                                                                • flushing,
                                                                • dizziness,
                                                                • dyspepsia,
                                                                • nasal congestion,
                                                                • myalgia,
                                                                • hypotension,
                                                                • syncope,
                                                                • tinnitus,
                                                                • conjunctivitis, or
                                                                • altered vision (blurred, discoloration
                                                              • Ποιες είναι οι αντενδειξεις των PDE5inh?
                                                                • patients using
                                                                  • nitrates or
                                                                  • the potassium channel opener,nicorandil,
                                                                    • due to additional vasodilatation, which might cause hypotension, myocardial ischaemia in patients with coronary artery disease, or cerebrovascular strokes (5).
                                                                  • patients who are taking the α-blockers doxazosin or terazosin,
                                                                  • unstable angina pectoris,
                                                                  • have had a recent myocardial infarction (previous 3 months) or stroke (previous 6 months),
                                                                  • myocardial insufficiency NYHA> 2,
                                                                  • hypotension,
                                                                  • poorly controlled blood pressure,
                                                                  • significant hepatic or renal insufficiency,
                                                                  • or if non-arteritic anterior ischemic optic neuropathy (NAION) with sudden loss of vision is known or has appeared after previoususe of PDE5 inhibitors.
                                                                  • Sildenafil and vardenafil are also contraindicated in patients with retinitis pigmentosa.
                                                                  • Caution is advised if PDE5 inhibitors are used together with other drugs which are metabolised by the same hepatic elimination pathway (CYP3A4), which is associated with an increased serum concentration of the PDE5 inhibitor.
                                                                • Ποτε μπορουμε να δωσουμε PDE5inhγια να αντιμετωπισουμε LUTSκαι μονο?
                                                                  • Στα πλαισια κλινικής δοκιμής
                                                                • SURGICAL TREATMENT
                                                                  • Με βαση την ευρωπαικη ουλογικηεταιρεια, ποτε συστηνουμε χειρουργειο/
                                                                    • ΣΕ ασθενεις με mildtomoderatelutsπου δεν απαντανε στην φαρμακοθεραπεια
                                                                    • Σε ασθενεις που δεν θελουν να παρουν φαρμακα
                                                                    • Όταν υπαρχει ισχυρη ενδειξη για χειρουργειο
                                                                  • Με βαση την EAU, ποιες είναι οι βασικες ενδειξεις για χειρουργικη θεραπεια
                                                                    • 1 υποτροπιαζουσα επεισοδια οξειας επισχεση
                                                                    • 2 υποτροπιαζουσες ουρολοιμωξεις
                                                                    • 3 υποτροπιαζουσα επεισοδια αιματουριας που ανθιστανται στην αναστολεις 5 α αναγωγασης
                                                                    • 4 λιθοι κυσδτεως]
                                                                    • 5 νεφρικη ανεπαρκεια
                                                                  • Στην κλινικη πρακτικη, σε ποιους ασθενεις θα πρεπει να προτεινουμε γρηγοροτερα χειορουργειο?
                                                                    • Στους ασθενεις με μεγαλυτερο κινδυνο εξελιξης της νοσου δηλαδη
                                                                      • Μεγαλυτερο ογκο προστατου
                                                                      • Υψηλοτερο PSA
                                                                      • Μεγαλυτερο υπολειμμα
                                                                      • Χαμηλοτερο Qmax
                                                                      • Ενδοκυστικη προβολη
                                                                      • Χειροτερευση υπο αγωγη
                                                                    • Ποιοι είναι οι 2 μεχανισμοι με τους οποιους πετυχαινουμε την αφαιρεση του αδενωματος ή υπαρχει η αντιδραση με τον ιστο (ΠΟΙΟΙ ΕΙΝΑΙ ΟΙ ΘΕΡΑΠΕΥΤΙΚΟΙ ΜΗΧΑΝΙΣΜΟΙ)?
                                                                      •  
                                                                    • Γενικοτερα ποια είναι τα αποτελεσματα της χειρουργικης θεραπειας της ΚΥΠ
                                                                      • TURP
                                                                        • Luts improvement 90%
                                                                        • Qmax 88%
                                                                        • Morbidity 53%
                                                                        • Patient dissatisfaction 16%
                                                                        • Failure rate 4.6%
                                                                      • Open
                                                                        • Luts 87%
                                                                        • Qmax 175%
                                                                        • Morbidity 68%
                                                                        • Dissatisfaction 9%
                                                                        • Failure rate 0%
                                                                      • Ποια είναι η αποτελεσματικοτητα της TURP?
                                                                        • A study in 577 men who underwent TURP reported excellent functional outcomes with
                                                                          • a mean IPSS of 4.9 and
                                                                          • a mean QOL score of 1.2 after 10 years of followup
                                                                          • (9). A meta-analysis of 29 RCTs reported a mean LUTS improvement of 70.6%
                                                                        • Ποια είναι τα ποσοστα επανεπεμβασης tURP?
                                                                          • 9%, 5.8% and 7.4% at 1, 5, and 8 years of follow-up
                                                                          • Retreatmentrate2% peryear(δηλαδη στα 5 χρονια 10% θα χρειαστουν επανεπεμβαση)
                                                                        • Ποιος είναι ο μηχανισμος (φυσικη ιδιοτητα) της TURP?
                                                                          • vaporarization
                                                                        • με ποιους τροπους ?
                                                                          • Vaporization and coagulation
                                                                        • Ποιαείναιηδιαφοραcoagulation and hemostasis?
                                                                          • Coagulation is the denaturation of the protein and hemostasis is stop the bleeding
                                                                        • Ποια είναι η θνητοτητα και νοσηροτητα της TURP?
                                                                          • Θνητότητα 0.25%
                                                                          • TUR συνδρομο 1.1%
                                                                            • Παραγοντες κινδυνου
                                                                              • Αιμοραγια
                                                                              • Μεγαλος προστατης
                                                                              • Μεγαλη διαρκεια χειρουργειου
                                                                              • Past or present nicotine abuse
                                                                            • Blood transfusion rate 2.9-8%
                                                                          •  
                                                                          • Υπαρχει συσχετιση διουρηθρικης με κινδυνο θανατου αργοτερα?
                                                                            • Όχι. (υπηρξε μια τετοια υποθεση που δεν επιβεβαιωθηκε)
                                                                          • Κυριοτερες επιπλοκες και ποσοστα αυτων μετα από TURP
                                                                            • Oυρολοιμωξη 6%
                                                                            • Ιεγχειρητικες επιπλοπκες 3%
                                                                            • Επιτακτικοτητα μετεγχειρητια15%
                                                                            • Επανεπεμβαση 5%
                                                                            • Παλινδρομη εκσπερματιση 65%
                                                                            • Στυτικη δυσλειοτυργια 10%
                                                                            • Μεταγγιση 8%
                                                                          • Ποιες είναι οι κυριοτερες μακροχρονιες επιπλοκες?
                                                                            • Ακρατεια 2%
                                                                            • Επισχεση ουρων
                                                                            • λοιμωξεις
                                                                            • Στενωμα ουρηθρας (στενωμα κυστικου αυχενα)4%
                                                                            • Παλινδρομη εκσπερματιση 65%
                                                                            • Στυτικη δυσλειτουργια (? Μεγαλος προβληματισμος για το αν ισχυει/ καποιοι αναφερουν 65%)
                                                                          • Ποτε καλυτερα TUIP than TURP
                                                                            • Προστατης<30ml
                                                                          • Ποια είναι τα πλεονεκτηματα της TURPεναντι TUIP?
                                                                            • Reduced bleeding incidents,
                                                                            • shorter operation time,
                                                                            • avoidance of TUR syndrome,
                                                                            • minimal and shorter post-operative
                                                                            • bladder irrigation,
                                                                            • low risk of retrograde ejaculation, and
                                                                            • shorter times for catheterisation and hospitalisation.
                                                                            • Με μειονεκτημα την συχνη αναγκη για επανεπεμβαση
                                                                          • Τι είναι η διπολικη διουρηθρικη προστατεκτομή
                                                                            • Μηχανισμος λειτουργιας
                                                                              • In contrast to monopolar TURP, B-TURP uses a specialized resectoscope loop, which incorporates both the active and return electrodes. It permits electrosurgical tissue cutting in a conductive saline medium. After activation of the high frequency current, the physiological saline around the loop is heated up to the boiling point. The resulting bubbles create an environment with high electrical resistance; the voltage between electrode and saline solution spikes forms an arc. The tissue is heated indirectly by the heat of the ignition of the arc; this enables both resection and coagulation.
                                                                            • Ποσαdevice Υπαρχουν σημερα
                                                                              • the plasmakinetic (PK) system (Gyrus),
                                                                              • Vista Coblation/CTR (controlled tissue resection) system (ACMI) [withdrawn],
                                                                              • transurethral
                                                                              • resection in saline (TURis) system (Olympus),
                                                                              • Karl Storz, and
                                                                              • Wolf
                                                                            • Σε σχεση με την μονοπολικη, ποια είναι η
                                                                              • Αποτελεσματικοτητα
                                                                                • Short term studies: Identical outcomes regarding Qmax and IPSS improvement
                                                                                • Long term results are still awaited
                                                                              • Ασφαλεια
                                                                                • The overall rate of adverse events was significantly lower with B-TURP compared to monopolar TURP (28.6%vs. 15.5%) (23).
                                                                                • Main advantages of B-TURP include (trends and not statistically significant differences)
                                                                                  • reduced blood loss
                                                                                  • decreased incidences of postoperative clot retention
                                                                                  • reduced blood transfusions.
                                                                                  • Reduced post-operative catheterisation and hospitalization
                                                                                  • reduced Post-operative storage symptoms, particularly dysuria,
                                                                                  • no TUR syndrome due to the use of saline and reduced fuid absorption
                                                                                • ANOIXTHΠΡΟΣΤΑΤΕΚΤΟΜΗ
                                                                                  • Ποιες είναι οι ενδειξεις για προστατεκτομη?
                                                                                    • LUTS πουανθειστανταιστηνφαρμακοθεραπεια/LUTS refractory to medical management
                                                                                    • Υποτροπιαζουσεςουρολοιμωξεις/recurrent urinary infection
                                                                                    • Υποτροπιαζουσες?? επισχεσης/refractory urinary retention
                                                                                    • Υποτροπιαζουσαεπεισοδιααιματουριαςπουανθστανατιστηνθεραπειαμεαναστωλειςτης5 ααναγωγασης/recurrent haematuria refractory to medical treatment with 5-alpha reductase inhibitors
                                                                                    • Λιθοι κυστης/bladder stones.
                                                                                    • ΝεφρικηανεπαρκειαεξαιτιαςBPO/BPE /renal insufficiency due to BPE/BPO
                                                                                    •  
                                                                                  • Ποιοι είναι οι παραγοντες που προδιαθετουν σε επιτυχια μετα από χειρουργικη επεμβαση?
                                                                                    • Η σοβαροτητα των συμπτωματων
                                                                                    • Ο βαθμος ενοχλησης
                                                                                    • Η παρουσια αποφραξη
                                                                                  • Ποια ειδη ανοιχτης προστατεκτομης γνωριζεις?
                                                                                    • την Millin και την Freyer
                                                                                      • Freyer
                                                                                        • Διακυστικη προστατεκτομη
                                                                                        • A transverse incision is made in the anterior bladder wall.
                                                                                        • The index finger is then placed in the urethra and with forward pressure towards the symphysis, the urethral mucosa is broken, and the plane between the surgical capsule and the adenomas is defined.
                                                                                        • The prostatic adenomas are then bluntly separated from the capsule with the finger.
                                                                                        • Special care must be taken when dividing the urethra at the apex in order not to harm the urethral sphincter.
                                                                                        • Haemostatic sutures are placed in the posterior corners of the cavity and the posterior margin, taking care not to include the ureteral orifices.
                                                                                        • Post-operative haemostasis might be obtained using gauze packing and/or traction on a large balloon catheter.
                                                                                        • For sufficient drainage, both a transurethral and a suprapubic catheter are placed.
                                                                                      • Millint prostatectomy
                                                                                        • A transverse incision is made in the anterior prostatic capsule and the adenomas freed bluntly with a scissor and the index finger.
                                                                                        • Care is taken when dividing the urethra.
                                                                                        • Many surgeons will resect the posterior bladder neck to avoid late bladder neck stricture.
                                                                                        • The prostatic capsule is closed after insertion of a transurethral balloon catheter for drainage
                                                                                      • Ποια είναι τα αποτελεσματα της ανοιχτης προστατεκτομης
                                                                                        • Βελτιωση LUTS 65%
                                                                                        • Αυξηση Qmax 300%
                                                                                        • Reduction PVR 90%
                                                                                      • Morbidity and Complications
                                                                                        • Ιανατος <0.25%
                                                                                        • Μεταγγιση 7-14%
                                                                                        • Ακρατεια 10%
                                                                                        • Συγκλειση αυχενα 6%
                                                                                        • Στενωμα ουρηθρας 6%
                                                                                      • Ποτε εχει ενδειξη η ανοιχτη προστατεκτομη?
                                                                                        • Σε μεγαλους προστατες >80, ανθεκτικους στην θεραπεια και σε απουσια Holmiumlaser
                                                                                      • TUMT(transurerthral microwave therapy)
                                                                                        • Tι είναι και πως δουλευει και ποια η αποτελεσματικοτητα
                                                                                          • emition microwave radiation through an intra-urethral antenna in order to deliver heat into the prostate.
                                                                                          • Tissue is destroyed by being heated at temperatures above cytotoxic thresholds (> 45°C) (coagulation necrosis).
                                                                                          • Heat is mainly produced by electrical dipoles (water molecules) oscillating in the microwave field and electric charge carriers (ions) moving back and forth in the microwave field.
                                                                                          • All TUMT devices consist of a treatment module that contains the microwave generator with a temperature measurement system and a cooling system
                                                                                          • Τα αποτελεσματα μιας ανασκοπησης εδειξαν ότι η ΤUMTείναι λιγοτερο αποελεσματικη ενατντι της TURPόσο αφορα το Qmaxενώ φαινεται να εχει πολύ χαμηλα ποσοστα οσο αφορα την διαρκεια της θεραπειας με περιοπου 30% επανεπεμβασης
                                                                                          • ΟσοαφορατηνασφαλειαàCatheterization time, incidence of dysuria/urgency and urinary retention were significantly less with TURP, while the incidence of hospitalisation, haematuria, clot retention, transfusions, transurethral resection (TUR) syndrome, and urethral strictures were significantly less for TUMT
                                                                                        • Ποια είναι η θεση της ΤUMT?
                                                                                          •  
                                                                                          •  
                                                                                          • Reported low morbidity and the absence of any need for anaesthesia (spinal or general) make TUMT a true outpatient procedure, providing an excellent option for older patients with co-morbidities at high operative risk and, therefore, unsuitable for invasive treatment
                                                                                        • TUNA (transurethral needle ablation of the prostate)
                                                                                          • Ποιος ο μηχανισμος δρασης και ποια η αποτελεσματικοτητα?
                                                                                            • Το μηχανημα TUNAδινει χαμηλης εντασης ενεργεια ραδιοσυχνοτητας στον προστατη που οδηγει σε νεκρωση (coagulativenecrosis) της μεταβατικης χωνης που οδηγει σε ινωση και τελικα σε μειωση ΒΡΟ
                                                                                            • A recent report with 5 years’ follow-up in 188 patients demonstrated symptomatic improvement in 58% and improved flow in 41%. However, 21.2% of patients required additionaltreatment
                                                                                            • ΣυγκρισημεταξυTUNA and TURPàTURP produced greater symptom improvement and a better quality of life than TUNA™, as well as a significant improvement in Qmax after TUNA™
                                                                                            • A recent French report described a failure rate (incorporating re-treatment) of up to 50% over a 20-month period
                                                                                          • Ποιος είναι ο ρολος στην θεραπεια
                                                                                            • Δ
                                                                                          • LASER
                                                                                            • Holmium laser enucleation (HoLEP) and holmium resection of the prostate (HoLRP)
                                                                                              • Τι είναι, βασικα χαρακτηριστικα και κυριοτερα αποτελεσματα
                                                                                                • holmium:yttrium-aluminum-garnet (Ho:YAG) laser (2140 nm) is a pulsed, solid-state laser
                                                                                                • The wavelength of the Ho:YAG laser is strongly absorbed by water.
                                                                                                • This means that the area of tissue coagulation and the resulting tissue necrosis is limited to 3-4 mm, which is enough to obtain adequate haemostasis (2).
                                                                                                • Resection is usually performed when the prostate is smaller than 60 mL, while enucleation is used for larger glands.
                                                                                                  • ΕκπυρηνησηàMimicking open prostatectomy, the prostatic lobes are completely enucleated and pushed into the bladder, before being fragmented and aspirated afterwards by a morcellator
                                                                                                • this technique includes a 550 μm, end-firing, quartz fibre and an 80 W Ho:YAG laser.
                                                                                                • HoLEP versus TURPà
                                                                                                  • Efficacy is comparabvle between the 2 treatments
                                                                                                  • meta-analyses found that HoLEP resulted in a significantly shorter catheterization time and hospital stay, reduced blood loss and fewer blood transfusions, but had a longer operation time than TURP
                                                                                                  • Dysuria is common peri-operative complication with an incidence of approximately 10%
                                                                                                • 523 nm (“Greenlight”) laser vaporization of the prostate
                                                                                                  • Vaporization of prostatic tissue is achieved by a sudden increase in tissue temperature from 50°C to 100°C following the application of laser energy.
                                                                                                  • A rapid increase in tissue temperature results in intracellular vacuoles (bubbles), followed by an increase in intracellular cell pressureàOnce the cell pressure exceeds that compatible with cellular integrity, the vacuoles are released, as can be seen during the procedure.
                                                                                                  • Because of the way in which tissue interacts with oxyhaemoglobin, laser vaporization is increased within a wavelength range from 500-580 nm.
                                                                                                  • Because of the green light emitted (=532 nm), this laser procedure is known as ‘Greenlight’ laser vaporization.
                                                                                                  • It is important to include the wavelength or crystal used to produce the laser energy when describing the type of laser vaporization used.
                                                                                                  • Laser vaporization of the prostate using an 80 W, 532 nm laser is performed by using a 600 μm side-firing laser fibre with a 70°-deflecting laser beam and a 30°-deflecting laser cystoscope
                                                                                                  • Greenlight versus TURPà
                                                                                                    • The longest available follow-up of a RCT is only 12 months; this trial indicated that 532 nm laser vaporization was equivalent to TURP in symptom improvement
                                                                                                    • Regarding intra-operative safety, 532 nm laser vaporization was reported to be superior to TURP in non-randomised trials (21,22).
                                                                                                    • It is also an effective technique when compared to TURP, producing equivalent improvements in flow rates and IPSS with the advantages of markedly reduced length of hospital stay, duration of catheterisation, and adverse events in a randomized trial.
                                                                                                  • Ποια είναι οι οδηγιες της EAUgforlaser?
                                                                                                    • dd
                                                                                                    • d
                                                                                                    • d
                                                                                                    • d
                                                                                                  • PROSTATIC STENTS
                                                                                                    • Τι είναι και σε ποιους απευθυνονται?
                                                                                                      •  
                                                                                                      • A prostatic stent requires a functioning detrusor, so that the bladder still has the ability to empty itself. This is in contrast to an indwelling catheter, which drains the bladder passively (4).
                                                                                                      • Stents can be temporary or permanent.
                                                                                                        • Permanent stents are biocompatible, allowing epithelialisation, so that eventually they become embedded in the urethra.
                                                                                                        • Temporary stents do not epithelialize and may be either biostable or biodegradable.
                                                                                                      • Temporary stents can provide short-term relief from BPO in patients temporarily unfit for surgery or after minimally invasive treatment
                                                                                                      • Prior to stent insertion, the length of the prostatic urethra is measured to determine the stent length.
                                                                                                      • It is important that the stent is not positioned inside the external urethral sphincter as it may cause stress urinary incontinence
                                                                                                      • To confirm proper positioning, abdominal ultrasonography or cystoscopy is performed.
                                                                                                      • Removal of a temporary stent is achieved by pulling the retrieval suture, until the stent is completely retracted, or by using graspers under endoscopic guidance. It can be difficult to remove permanent stents in cases of stent migration, stent encrustation or epithelial in-growth, and general anaesthesia is usually needed
                                                                                                    • ΠΑΡΑΚΟΛΟΥΘΗΣΗ
                                                                                                      • Κάθε ποτε πρεπει να εξαταζονται οι ασθενεις και με ποιες εξετασεις?
                                                                                                        • Αν
                                                                                                          • wathcfull waiting àat 6 months and then annually, provided there is no deterioration of symptoms or development of absolute indications for surgical treatment
                                                                                                          • α-blockers, muscarinic receptor antagonists, or the combination of α-blockers with 5α-reductase inhibitors or muscarinic receptor antagonists should be reviewed 4 to 6 weeks after drug initiation in order to determine treatment response. If patients gain symptomatic relief in the absence of troublesome adverse events, drug therapy may be continued
                                                                                                          • Patients receiving 5α-reductase inhibitors should be reviewed after 12 weeks and 6 months to determine their response and adverse events
                                                                                                        • following are recommended at follow-up visits:
                                                                                                          • I-PSS
                                                                                                          • Uro-flowmetry and post-void residual urine volume.
                                                                                                        • Patients receiving desmopressin, serum sodium concentration should be measured at day 3 and 7 as well as after 1 month and, if serum sodium concentration has remained normal, every 3 months subsequently.
                                                                                                          • The following tests are recommended at follow-up visits:
                                                                                                            • Serum-sodium concentration
                                                                                                            • Frequency-volume chart
                                                                                                          • Patients after prostate surgery should be reviewed 4 to 6 weeks after catheter removal in order to evaluate treatment response and adverse events.
                                                                                                            • If patients have symptomatic relief and are without adverse events no further re-assessment is necessary.
                                                                                                            • The following tests are recommended at follow-up visit after 4 to 6 weeks:
                                                                                                              • I-PSS
                                                                                                              • Uroflowmetry and post-void residual urine volume
                                                                                                            • LASER PROSTATECTOMY
                                                                                                              • Ποια είναι η αρχη λειτορυγιας των laser?
                                                                                                                • Οι ακτινες laserπαραγονται μετα απο μια πηγη παραγωγη ενεργειας (πχ τοξο ξενου, φωτεινη ή ηλετκτρικη ενεργεια) που βομβαρδιζει δραστικο αριθμο ατομων (ατομα CO2, αργου Nd:YAG)
                                                                                                                • Toαποτελεσμα του βομβαρδισμου είναι η διεγερση των ηλεκτρονιων των ατομων που με την επιστροφη τουςστην βασικη στοιβαδα εκπεμπουν φωτονια
                                                                                                                • Τα φωτονια προσκουουν σε αλλα ηλεκτρονια και παραγονται καινουργια φωτονια σε μια διαδικασια που ονομαζεται ενισχυση φωτος
                                                                                                                • Στον χωρο υπαρχει ένα ημιδιαπερατο κατοπτρο που επιτρεπει την εξοδο μονο των φωτονιων που εχουν το ιδιο μηκος κυματοςàετσι η εξερχομενη δεσμη είναι σχεδον παραλληλη, μονοχρωματικη, με πολύ υψηλη ισχυ σε σχεση με την διαμετρο της και εχει την ιδιοτητα μνα μη μειωνεται η ισχυς της λογω διαχυσης και αποκλεισης
                                                                                                                • Αναλογα με την παραγωγη της μπορουμε να εχουμε παλμικο ή συνεχες κυμα laser
                                                                                                                  • Παλμικοàπαρεχομενο φως εινα μεγαλυς εντασης και παρεχεται για μικρη διαρκεια
                                                                                                                  • Συνεχεςàενταση παραμενει σταθερη
                                                                                                                • Όταν η ακτινα συναντηθει με τους ιστους
                                                                                                                  • ένα μερος απορρογφαται (σε ποσοστο που εξαρταται από την περιεκτικοτητα του ιστου σε χρωστικες όπως αιμοσφαιρινη . μελανινη και από την πυκνοτητα του)
                                                                                                                  • ένα μερος αντανακλαται (αναλογα με την ομαλοτητα της επιφανειας)
                                                                                                                  • ένα μικρο μερος διαχεεται
                                                                                                                • η θεραπευτικη δραση οφειλεται στον μετασχηματισμος της φωτεινης ενεργειας σε θερμικη
                                                                                                                • η αξιοποιηση τους βασιζεται στην απορροφητικοτητα και την κατακρατηση τους στους ιστουςà
                                                                                                                  • <60 όχι μονιμες βλαβες
                                                                                                                  • 60-100 πηκτικη νεκρωση
                                                                                                                  • 100 βρασμος ενδοκυτταριου υδατος
                                                                                                                  • >200 απανθρακωση ιστου
                                                                                                                • Ποιες είναι οι βασικες φυσικες ιδιοτητες των laser?
                                                                                                                  • Coherence
                                                                                                                  • Collimation
                                                                                                                  • monochromacity
                                                                                                                • Ποια είναι τα σημαντικοτερα χαρακτηριστικα των laser?
                                                                                                                  • Reflection (αντανακλαση)
                                                                                                                    • Όταν μια δεσμη laserσυναντα ένα ιστο, ένα μερος της δεσμης αντανακλα στου γειτονικους ιστους στους οποιου μπορει να προκαλεσει θερμανση και βλαβη
                                                                                                                    • Η αντανακλαση εξαρταται αποκλειστικα από τον ιστο και το irrigantμεσο(αρα δεν την λαβανουμε υποψιν όταν μιλαμε για μηκος κυματοςσε συναρτηση γιαχειρουργικο σκοπο)
                                                                                                                  • Scattering(διασπορα)
                                                                                                                    • The heterogeneous composition of tissue causes an intruding laser beam to scatter.
                                                                                                                    • Scattering diverts part of the laser beam away from its intended direction and therefore its intended purpose.
                                                                                                                    • The amount of scattering depends on the size of the particles and the wavelength of the laser.–> Shorter wavelengths are scattered to a much higher degree than longer wavelengths, i.e. blue laser radiation is scattered more than green, green more than red, and red more than infrared
                                                                                                                  • Απορρόφηση (absorption)
                                                                                                                    • Intensity of the laser beam decreases exponentially as the absorbing medium increases in density.
                                                                                                                    • Absorbed laser radiation is converted into heat, causing a local rise in temperature.
                                                                                                                    • Depending on the amount of heat produced, tissue will coagulate or even vaporise.
                                                                                                                    • Heat is more likely to be generated next to the tissue surface than further below because of the exponential decrease in beam intensity as it passes into the tissue and the immediate action of the absorption process.
                                                                                                                    • However, absorption can only occur in the presence of a chromophore. Chromophores are chemical groups capable of absorbing light at a particular frequency and thereby imparting colour to a molecule. Examples of body chromophores are melanin, blood and water.
                                                                                                                    • Figure 1 shows the wavelength dependence and absorption length of a laser beam. The absorption length defines the optical pathway, along which 63% of incident laser energy is absorbed.
                                                                                                                  • Μηκος εξάλειψης
                                                                                                                    • The extinction length defines the depth of tissue up to which 90% of the incident laser beam is absorbed and converted into heat.
                                                                                                                    • An extinction length is equal to 2.3 absorption lengths.
                                                                                                                    • Haemoglobin and water are widely used as chromophores for surgical lasers
                                                                                                                    • It is important to match the achieved effect along the extinction length with the intended surgical effect. At the same power wattage, a laser wavelength with a long extinction length may create a deep necrosis, whereas alaser wavelength with a much shorter extinction length will produce an increase in temperature above boiling point and immediate vaporisation of tissue
                                                                                                                  • Ποια ειδη laserστον προστατη?
                                                                                                                    •  
                                                                                                                    • Neodymium: Ytrimu-Aluminum-Garnet (Nd:YAG)
                                                                                                                      • Μηκος κυματος 1064 nm
                                                                                                                      • Ενεργομεσο: ατομαneodymium in a yttrium-aluminum-garnet rod
                                                                                                                      • Μεγαλη διυσδειτικοτητα (περιπου 5 χιλ) με μικρη απορροφηση από νερο και χρωστικεςàαυτό επιτρεπει θερμοπηξια μεγαλων ιστικων μαζων
                                                                                                                      • Πιο συχνα χρησιμοποιουμενο Laserαν και πλεον δεν χρησιμοποιειται
                                                                                                                      •  
                                                                                                                    • Potassium-titanyl-phosphate(KTPlaser)/KTP(kaliumtitanylphosphate, KTP:Nd:YAG[SHG] andLBO(lithiumborat,LBO:Nd:YAG[SHG]) lasers
                                                                                                                      • Κρυσταλλος φωσφωρικου-τιτανικου καλιου (oυσιαστικά είναι ένα Nd:Yagστο οποιο έβαλαν ένα κρυσταλο ΚΤΡ) με αποτελεσμα την μειωση του μηκου κυματος από 1064 σε 532
                                                                                                                      • Πρασινη δεσμη μηκος κυματος 532 (greenlight)
                                                                                                                      • Continuous wave
                                                                                                                      • Intense vaporization at high power
                                                                                                                      • Minimal coagulation beyond
                                                                                                                      • Μεγαλη απορροφηση από αιμοσφαιρινη
                                                                                                                      • Διυσδειτικοτητα1-2 χιλ(The resultant laser has a short extinction lengthand penetrates vascular tissue by only a few micrometres)
                                                                                                                      • Σε σχεση με το Nd:YAGεχει μικροτερη ικανοτητα θερμοπηξιας αλλα εχει μεγαλυτερη ενεργεια για μοναδα ιστου και παραγει αυξημενη ικανοτητα για εξαχνωση (vaporization and dessication)
                                                                                                                        • Για τον λογο αυτό
                                                                                                                      • Καληαιμοσταση επιφανειακα αγγεια
                                                                                                                      • Κυριως εξω γεννητικα οργανα
                                                                                                                      • In red, well-circulated tissue, the density of absorbed power is high and immediately raises the tissue temperature above the boiling point (Figure 1)àThis causes tissue to vaporise, leaving behind a coagulated seam(ραφηπηξης?) where the increased tissue temperature has resulted in haemostasis (3).–> In this seam, haemoglobin is bleached but not vaporised. The applied laser energy must travel through the coagulated seam, where the laser beam experiences mainly scattering. The lack of absorption in coagulated tissue impairs its removal, while the scattering of the green wavelength reduces the laser beam’s intensity, impairing its vaporising effect on the next tissue layer
                                                                                                                      • bleeding rate for the 80 W KTP laser of 0.21 g/min (In contrast, TURP is associated with a much higher bleeding rate of 20.14 g/min (p < 0.05))
                                                                                                                      • γιατιλεγεταηPhotoselective Vaporization of the Prostate (PVP) ηπροστατεκτομημετοΚΤΡ?
                                                                                                                        • In the absence ofan haemoglobin molecule, the extinction length increases dramatically and the beam penetrates deeply into irrigant and/or tissue. This technique is described as the photoselective vaporisation of prostate (PVP) (9).
                                                                                                                      • Πως είναι η τεχνικη?
                                                                                                                        • Laser energy is directed towards prostatic tissue using a 70° 600 μm side-firing probe.
                                                                                                                        • Under direct vision,vaporisation is performed with a fibre-sweeping technique, starting at the bladder neck and continuing with thelateral lobes and the apex. The prostate gland is vaporised from inside the gland to its outer layers. This alsooccurs with TURP, but in contrast to TURP, no tissue remains for histopathological evaluation
                                                                                                                      • Ποια είναι τα ουσιαστικα συμπερασματα της EAU2012 για το PVP?
                                                                                                                        •  
                                                                                                                      • Ηοlmium: Yttrium-Aluminum-Garnet Laser
                                                                                                                        • Μηκος κυματος 2100
                                                                                                                        • Ενεργο μεσο το Holmium
                                                                                                                        •  
                                                                                                                        • Έντονη απορροφηση από το νερο και εκρηκτικη εξατμιση και διατομη ιστων
                                                                                                                        • Υπολειπεται του Neodymiumστις αιμοστατικες ιδιοτητες
                                                                                                                        • Holmium laser radiation has a short extinctionlength in tissue due to strong absorption of the water molecule around 2140 nm (Figure 1). At this wavelength,the depth of penetration is approximately 400 μm. The density of absorbed power in irrigant and/or in tissue is high and results in an immediate increase of temperature above the boiling point
                                                                                                                        • All holmium laser techniques are based on vaporisation. The energy is delivered to the prostate through an end-firing laser fibre with a diameter of about 500-600 μm.
                                                                                                                        • Holmium laser techniques evolved from holmium laser ablation of the prostate (HoLAP) (21) to holmium laser resecting techniques (HoLRP) (22) and, finally with the introduction of the tissue morcelator, to the holmium laser enuclation technique (HoLEP) (23).
                                                                                                                        • A later modification combined HoLEP with electrocautery resection of the enucleated lobe, while still attached at the bladder neck
                                                                                                                        • in comparison to TURP and OP, patients undergoing HoLEP have a shorter catheterisation time and hospital stay, reduced blood loss and a smaller likelihood of blood transfusions, but comparable functional outcomes
                                                                                                                        • Although the literature has mainly focused on HoLEP, both HoLAP and HoLRP are suitable as alternatives for vaporising (HoLAP) or resecting (HoLRP) approaches in the treatment of BOO and BPE. One issue for both techniques that needs to be considered is the longer ablation or resection time. HoLEP is the most studied novel minimal therapy approach and is a real alternative to TURP for medium- and large-sized prostates for OP. However, the excellent early results obtained with HoLEP, as the prototype for transurethral laser enucleation, have not been matched by the wider use of this technique
                                                                                                                        •  
                                                                                                                      • Diode laser
                                                                                                                        • Μηκος κυματος 830nm
                                                                                                                        • The 830 nm (Indigo) diode laser has been extensively used in interstitial laser coagulation
                                                                                                                        • For the 940 nm diode laser, 60 W resulted in a bleeding rate of 0.21 g/min
                                                                                                                        • Compared with 80 W KTP, the coagulation capacity in the porcine kidney model for diode lasers was 7.7 to 8.7 times deeper
                                                                                                                        • Ιδιοτητες ομοιες με NdYAG
                                                                                                                        • Πλεονεκτημα τροφοδοσια χωρις ειδικη ηλεκρικη εγκατασταση και ευκολη μεταφορα της συσκευης και χαμηλο κοστος
                                                                                                                          • The term diode laser refers to the method of laser beam generation. Laser light can be generated by a resonator or a diode. The main advantages of diode lasers compared with Nd:YAG lasers are a smaller box size and a much higher wall-plug efficiency (i.e. how much of the mains supply is converted into laser power). These differences arise out of the technical principles behind the generation of laser radiation and energy.
                                                                                                                          • Depending on the type of laser generator, the efficiency of diode lasers is more than one order of magnitude better.
                                                                                                                          • Furthermore, the thermal power loss of diode lasers is much less and therefore they can be operated from a standard wall mounted power outlet.
                                                                                                                        • As with KTO and LBO lasers,procedures executed with diode lasers use side-firing techniques to ensure better direct visual control ofthe surgeon on the point of impact of the laser beam on the tissue
                                                                                                                        • Because laser penetration levels are deeper and the coagulation zone is wider (3,7,13), some authors have suggested power should be reduced when treating the apex with the underlying sphincter region
                                                                                                                        • In view of the available data on the use of the diode laser, it should not be a standard treatment option for BPE. The literature show a retreatment rate of up to 35%.
                                                                                                                        • Transitory and permanent incontinence (9%) seem to be higher than for alternative treatments.
                                                                                                                        • This treatment may offer a high inter-operative control of bleeding for patients on anticoagulative drugs.
                                                                                                                        •  
                                                                                                                      • Thulium:YAG
                                                                                                                        • Laser energy is emitted at a wavelength of about 2000 nm in a continuous-wave fashion
                                                                                                                        • Although a thulium laser has the same absorption characteristics as a holmium laser in water and tissue, it has superior properties in soft tissue surgery because of the continuous-wave output.
                                                                                                                        • Due to the slightly shorter wavelength, the depth of penetration is decreased to 250 μm.
                                                                                                                        • The wavelength is close to the absorptionpeak of water and, together with the short penetration depth, this results in a high-energy density leading to rapid vaporisation of water and tissue.
                                                                                                                        • Instead of the tearing action on tissue caused by the pulsed emission of Ho:YAG, the continuous-wave output of Tm:YAG allows smooth incision and vaporisation of tissue with excellent haemostasis.
                                                                                                                        • The tissue left behind after each laser pass is covered by a coagulated seam of tissue, which provides haemostasis.
                                                                                                                        • It still contains sufficient water for efficient absorption of the following laser pass. Thus the laser tissue effect remains unchanged and effective throughout the entire surgical procedure.
                                                                                                                        • In contrast to the pulsed emission mode of Ho:YAG, the continuous emission does not allow lithotripsy
                                                                                                                        • the bleeding rate for the cw 70 W
                                                                                                                        • Thulium laser reached 0.16 } 0.07 g/min, compared to 0.21 } 0.07 g/min for the 80 W KTP laser. In contrast, TURP showed a significantly increased bleeding rate of 20.14 g/min (p < 0.05)
                                                                                                                        • Four different technical approaches have been described so far:
                                                                                                                          • 1) Tm:YAG vaporisation of the prostate (ThuVaR);
                                                                                                                          • 2) Tm:YAG vaporesection (ThuVARP);
                                                                                                                          • 3) Tm:YAG vapoenucleation (ThuVEP);
                                                                                                                          • 4) Tm:YAG laser enucleation of the prostate (ThuLEP)
                                                                                                                        • ThuVARP showed equivalent effectivity when compared to TURP in one RCT and one nonrandomized prospective controlled trial with small and medium volume glands. Tm:YAG treated patient showed shorter catheterisation time and shorter hospitalisation time.
                                                                                                                        • Adverse events were significantly lower than in TURP (intra-operative and post-operative bleeding).1b
                                                                                                                        • Currently, only one RCT with a short follow-up has compared ThuVEP to HoLEP. Nevertheless, threeprospective cohort studies with a follow-up of 18 months demonstrated efficacy for ThUVEP, as wellas low perioperative complications and retreatment rates.
                                                                                                                        • Study data are awaited comparing ThuVEP and ThuLEP to HoLEP. HoLEP is the most extensivelystudied transurethral enucleation technique to date and long-term anatomical data are of particularinterest.
                                                                                                                        •  
                                                                                                                      • Ποια είναι τα αποτελεσματα της εφαρμογης των laser
                                                                                                                        • 2 ΕΙΔΩΝ
                                                                                                                          • α) την πήξη, με θέρμανση των ιστών κάτω από το σημείο ζέσεως/εξατμίσεως, αλλά πάνω από το κατώτατο όριο θερμοκρασίας για μετουσίωση πρωτεϊνών και
                                                                                                                          • β) την εξάχνωση, με άμεση αφαίρεση ιστού λόγω θέρμανσης σε θερμοκρασία πάνω από το σημείο εξατμίσεως/ζέσεως
                                                                                                                        • το τι από τα 2 θα συμβει εξαρταται από 3 παραγοντες
                                                                                                                          • 1)power density of laser beam itself
                                                                                                                          • 2) συνολικη ενεργεια που αποδιδεται
                                                                                                                          • 3) από τον χρονο που αυτή η ενεργεια εφαρμοζεται