Assisted Reproductive Technology are medical and laboratory tecniques facilitating a pregnancy. BACKGROUND Benign prostatic hyperplasia (BPH) is a condition intimately related to ageing .
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Although it is not lifethreatening, its clinical manifestation as lower urinary tract symptoms (LUTS) reduces the patient's quality of life. Prevalence Although many epidemiological clinical studies have been conducted worldwide over the last 20 years, theprevalence of clinical BPH remains difficult to determine.
A standardized clinical definition of BPH is lacking, which makes it intrinsically difficult to perform adequate epidemiological studies. Among the published epidemiological studies, some include probability samples from an entire country, while others represent agestratified random samples or enroll participants from general practice, hospital populations or responders to selective screening programmes. There is also a lack of homogeneity among these studies in the way in which BPH is assessed, with different questionnaires and methods of administration. Histological BPH was not found in men under the age of 30 years but its incidence rose with age, reaching a peak in the ninth decade.
A palpable enlargement of the prostate has been found in up to 20% of males in their 60s and in 43% in their 80s; however, prostate enlargement is not always related to clinical symptoms .
By the age of 60 years, nearly 60% of the cohort of the Baltimore Longitudinal Study of Aging had some degree of clinical BPH. In the USA, results of the Olmstead County survey, in a sample of unselected Caucasian men aged 40-79 years, showed that moderate-to-severe symptoms can occur among 13% of men aged 40-49 years and among 28% of those older than 70 years. In Scotland and in the area of Maastricht, the Netherlands, the prevalence of symptoms increased from 14% of men in their 40s to 43% in their 60s. Depending on the sample, the prevalence of moderate-to-severe symptoms varies from 14% in France to 30% in the Netherlands.
Preliminary results of one of the most recent European epidemiological studies on the prevalence of LUTS show that approximately 30% of German males aged 50-80 years present with moderateto-severe symptoms according to the International Prostate Symptom Score (I-PSS > 7). A multicentre study performed in different countries in Asia showed that the age-specific percentages of men with moderate-to-severe symptoms were higher than those in America.
Curiously, the average weight of Japanese glands seemed to be smaller than those of their American counterparts. Despite methodological differences, some conclusions can be drawn from the studies mentioned above: · Mild urinary symptoms are very common among men aged 50 years and older · Mild symptoms are associated with little bother, while moderate and severe symptoms are associated with increasingly higher levels of inconvenience and interference with living activities · The same symptoms can cause different troublesome and daily living interference · The correlation between symptoms, prostate size and urinary flow rate is relatively low It must be stressed that there is still a need for an epidemiological definition of BPH and its true incidence has yet to be determined. Less commonly, changes in urodynamic variables and deterioration in disease-specific quality of life have been advocated.
It appears to be as good a predictor of progression as any of the variables mentioned above. Most instruments in current use conform to acceptable standards of validity, reliability and responsiveness; in other words they measure what they purport to measure, are stable over time and are able to reflect clinically important changes 1) International Prostate Symptom Score (I-PSS) By adding the scores (with equal weighting) to its constituent questions, a summary or index score is generated which has been shown to be an accurate reflection of a man's overall symptoms over the preceding month 2) Quality-of-life assessment It is a self-completed questionnaire used to measure general health status and quality of life. Secondly, it enhances the capacity to estimate prostate volume, and in this way may assist in choosing the right treatment, as prostate size has been shown to be a determining factor for certain treatment options. Flow rate machinery provides information on voided volume, maximum flow rate (Qmax), average flow (Qave) and time to Qmax, and this information should be interpreted by the physician to exclude artifacts.
Serial flows (two or more) with a voided volume exceeding 150 mL are recommended to get a representative flow rate.
Men with mild to moderate uncomplicated LUTS (causing no serious health threat), who are not too bothered by their symptoms, are suitable for a trial of WW Approximately 85% of men will be stable on WW at 1 year, deteriorating progressively to 65% at 5 years. Minor changes in lifestyle and behaviour can have a beneficial effect on symptoms and may prevent deterioration requiring medical or surgical treatment.
Controlled studies have shown that -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%.
Although these improvements take a few weeks to develop fully, statistically significant efficacy over placebo was demonstrated within hours to days.
Alfa-blocker efficacy does not depend on prostate size and is similar across age groups and they do not reduce prostate size.
Two isoforms of this enzyme exist: · 5alfa-reductase type 1, with minor expression and activity in the prostate but predominant activity in extraprostatic tissues, such as skin and liver · 5 alfa-reductase type 2, with predominant expression and activity in the prostate.
Their effect on the serum PSA concentration needs to be considered for prostate cancer screening.
However, 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.


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 sacral micturition 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. It remains controversial which components of the extracts are responsible for symptom relief in male LUTS. In vitro studies have shown that plant extracts: · have anti-inflammatory, antiandrogenic, or oestrogenic effects · decrease sexual hormone binding globulin (SHBG) · inhibit aromatase, lipoxygenase, growth-factor stimulated proliferation of prostatic cells, alfa-adrenoceptors, 5 alfa-reductase, muscarinic cholinoceptors, dihydropyridine receptors, or vanilloid receptors · improve detrusor function · neutralize free radicals However, most in vitro effects have not been confirmed in vivo and the precise mechanisms of action of plant extracts remain unclear. The extracts of the same plant produced by different companies do not necessarily have the same biological or clinical effects so that the effects of one brand cannot be extrapolated to others . To complicate matters, even two different batches of the same producer might contain different concentrations of active ingredients and cause different biological effects.Thus, the pharmacokinetic properties can differ significantly between different plant extracts Tolerability and safety Side-effects during phytotherapy are generally mild and comparable to placebo with regard to severity and frequency.
Hence, meta-analyses of extracts of the same plant do not seem to be justified and results of these analyses have to be interpreted with caution.
These, and other, reports documented the fact that prostatic tissue ablation could be achieved using the Nd:YAG laser.
In subsequent years, the TULIPTM device was abandoned and other authors experimented with even greater prostatic tissue ablation using a much simpler side-firing Nd:YAG laser delivery system. This consisted of a gold-plated mirror affixed to the distal end of a standard, flexible, silica-glass, laser transmission fibre (UrolaseTM fibre) Operative technique Side-firing laser prostatectomy is performed using Nd:YAG laser light at 1064 nm and relatively high power settings (typically between 40 and 80 W), delivered via an optical fibre equipped with a distal reflecting mechanism. This fibre fits through standard cystoscopes and all laser applications are performed transurethrally under the direct visual control of the surgeon.
The operation may be performed under general or regional anaesthesia, or under local peri-prostatic block as described by Leach et al..
Optimal tissue ablation is achieved using long-duration (60-90 seconds) Nd:YAG laser applications to fixed spots along the prostatic urethra.
These laser applications are repeated systematically and with considerable overlap until all visible obstructing prostatic tissue has been coagulated Interstitial Laser Coagulation (ILC) ILC as a therapy for BPH was first mentioned by Hofstetter in 1991.
Since then, several variations and technical and procedural developments have been introduced and tested in clinical trials. The objective of ILC of BPH is to achieve marked volume reduction and to decrease urethral obstruction and symptoms.
As the applicator can be inserted as deeply and as often as necessary, it is possible to coagulate any amount of tissue at any desired location. Post-procedure, the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes rather than sloughing of necrotic tissue. A continuous flow resectoscope is required with a working element; normal saline is used as the irrigant. The basic principle of the technique consists of retrograde enucleation of the prostate and fragmentation of the enucleated tissue to allow its elimination through the operating channel of the resectoscope .
If the site-intensity is set below the tissue cavitation threshold, the predominant therapeutic effect is the induction of heat. The source for HIFU is a piezoceramic transducer, which has the property of changing its thickness in response to an applied voltage. Theoretically the prostate can be ablated by HIFU via a transabdominal or transrectal route.
In clinical use, however, only transrectal HIFU devices are applied for the indication of BPH. It results in an improvement of urinary symptoms in the range 50-60% and Qmax increases by a mean of 50-70%. The main difference between the devices available is the design of the urethral applicator. Apart from differences in the construction of the catheter, the characteristics of the applicators differ, significantly affecting the heating profile.
The similarity in catheter construction consists of the presence of a microwave antenna positioned in the tip of the catheter just below the balloon. Also incorporated in the catheter are one or more temperature sensors that differ in the way in which they measure temperature.



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