Activity-dependent plasticity occurs in the spinal cord throughout life. Driven by input from the periphery and the brain, this plasticity plays an important role in the acquisition and maintenance of motor skills and in the effects of spinal cord injury and other central nervous system disorders. The responses of the isolated spinal cord to sensory input display sensitization, long-term potentiation, and related phenomena that contribute to chronic pain syndromes; they can also be modified by both classical and operant conditioning protocols. In animals with transected spinal cords and in humans with spinal cord injuries, treadmill training gradually modifies the spinal cord so as to improve performance. These adaptations by the isolated spinal cord are specific to the training regimen and underlie new approaches to restoring function after spinal cord injury. Descending inputs from the brain that occur during normal development, as a result of supraspinal trauma, and during skill acquisition change the spinal cord. The early development of adult spinal cord reflex patterns is driven by descending activity; disorders that disrupt descending activity later in life gradually change spinal cord reflexes. Athletic training, such as that undertaken by ballet dancers, is associated with gradual alterations in spinal reflexes that appear to contribute to skill acquisition. Operant conditioning protocols in animals and humans can produce comparable reflex changes and are associated with functional and structural plasticity in the spinal cord, including changes in motoneuron firing threshold and axonal conduction velocity, and in synaptic terminals on motoneurons. The corticospinal tract has a key role in producing this plasticity. Behavioral changes produced by practice or injury reflect the combination of plasticity at multiple spinal cord and supraspinal sites. Plasticity at multiple sites is both necessary-to insure continued performance of previously acquired behaviors-and inevitable-due to the ubiquity of the capacity for activity-dependent plasticity in the central nervous system. Appropriate induction and guidance of activity-dependent plasticity in the spinal cord is an essential component of new therapeutic approaches aimed at maximizing function after spinal cord injury or restoring function to a newly regenerated spinal cord. Because plasticity in the spinal cord contributes to skill acquisition and because the spinal cord is relatively simple and accessible, this plasticity is a logical and practical starting point for studying the acquisition and maintenance of skilled behaviors.

Activity-dependent spinal cord plasticity in health and disease.

(WW) to holmium-laser resection (Table 1). RCTs with Introduction a follow-up of <6 months and with a substantial number of patients in urinary retention preoperatively were For decades TURP was the undisputed gold standard of therapy for patients with LUTS due to BPH; however, excluded. within the past 10 years this role has increasingly been challenged by the development of medical (5a reductase The current morbidity of TURP inhibitors, a1-receptor blockers) and less invasive interventional alternatives [1–8]. The main driving forces Mortality after TURP has decreased substantially during the past 30 years and is <0.25% in contemporary TURP behind this development were the high prevalence of the disease, an absolute indication for surgery in only 5–10% series [10–16]. Horninger et al. reported no postoperative deaths in a consecutive series of 1211 patients underof patients with symptomatic BPH, recent technical innovations and, most importantly, the apparently going TURP between 1988 and 1991 [16]. In the 29 RCTs reviewed, no patient died within the first 6 weeks unchanged high morbidity of TURP [9–16]. As a result, the number of prostatectomies decreased substantially after surgery, reflecting advances in anaesthesia achieved during the past two decades. [17,18], e.g. in the USA the number of TURPs for BPH was 253 000 within the US Medicare Program in 1987 The major intraoperative complication of TURP and fell to 145 000 in 1994, a reduction of 43% [17]. This trend is also demonstrable in Europe, although less Table 1 Pertinent characteristics of the 29 RCTs analysed pronounced in countries with very extensive public healthcare systems [18]. Enthusiastic reports on the No. of patients* in success of alternative treatment options in the lay and No. of urological press seemed to herald the end of TURP as Method studies Reference(s) TURP Control the gold standard, perhaps best reflected by Stamey’s Open 1 20 43 32 quote in 1993 that ‘TURP is now a therapy of history’ Prostatectomy [19]. TUIP 6 21–26† 285 270 The objective of this review is to determine the current TUVP 4 27–30 199 189 status of TURP with particular reference to less invasive Holmium Laser 1 31 11 23 procedures and recent developments of transurethral VLAP 7 32–38 351 416 electrosurgery. To reliably assess this issue, we reviewed ILC 2 39, 40 41 60 the recent urological literature and, specifically, all 29 TUNA 2 41, 42 107 117 TUMT 2.5 2 43, 44 61 61 randomized clinical trials (RCTs) published between IRFT 1 45 25 25 1986 and 1998 comparing less-invasive treatment TUMT 2.0 1 46 32 37 options directly with TURP (Table 1) [20–48]. These 29 BDP 2 26†, 47 45 46 RCTs contain clinical information for a total of 3032 WW 1 48 280 276 patients, 1480 being randomized to TURP, 1552 to lessTotal 29 148

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1464-410x.1999.00908.x

Is transurethral resection of the prostate still justified

http://www.klinikum.uni-muenchen.de/Urologische-Klinik-und-Poliklinik/download/de/eurur/reich_2006.pdf

Techniques and Long-Term Results of Surgical Procedures for BPH

Objectives To determine the clinical effectiveness and cost utility of procedures alternative to TURP (transurethral resection of the prostate) for benign prostatic enlargement (BPE) unresponsive to expectant, non-surgical treatments. Data sources Electronic searches of 13 databases to identify relevant randomised controlled trials (RCTs). Review methods Two reviewers independently assessed study quality and extracted data. The International Prostate Symptom Score/American Urological Association (IPSS/AUA) symptom score was the primary outcome; others included quality of life, peak urine flow rate and adverse effects. Cost-effectiveness was assessed using a Markov model reflecting likely care pathways. Results 156 reports describing 88 RCTs were included. Most had fewer than 100 participants (range 12–234). TURP provided consistent, high-level, long-term symptomatic improvement. Minimally invasive procedures resulted in less marked improvement. Ablative procedures gave improvements equivalent to TURP. Holmium laser enucleation of the prostate (HoLEP) additionally resulted in greater improvement in flow rate. HoLEP is unique amongst the newer technologies in offering an advantage in urodynamic outcomes over TURP, although long-term follow-up data are lacking. Severe blood loss was more common following TURP. Rates of incontinence were similar across all interventions other than transurethral needle ablation (TUNA) and laser coagulation, for which lower rates were reported. Acute retention and reoperation were commoner with newer technologies, especially minimally invasive interventions. The economic model suggested that minimally invasive procedures were unlikely to be cost-effective compared with TURP. Transurethral vaporisation of the prostate (TUVP) was both less costly and less effective than TURP. HoLEP was estimated to be more cost-effective than a single TURP but less effective than a strategy involving repeat TURP if necessary. The base-case analysis suggested an 80% chance that TUVP, followed by HoLEP if required, would be cost-effective at a threshold of £20,000 per quality-adjusted life-year. At a £50,000 threshold, TUVP, followed by TURP as required, would be cost-effective, although considerable uncertainty surrounds this finding. The main limitations are the quantity and quality of the data available, in the context of multiple comparisons. Conclusions In the absence of strong evidence in favour of newer methods, the standard – TURP – remains both clinically effective and cost-effective. There is a need for further research to establish (i) how many years of medical treatment are necessary to offset the cost of treatment with a minimally invasive or ablative intervention; (ii) more cost-effective alternatives to TURP; and (iii) strategies to improve outcomes after TURP.

/pdf/systematic-review-and-economic-modelling-of-effectiveness-t9z6ifq698.pdf

Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement

Management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO)

Objective: To evaluate bladder emptying methods and urinary tract problems five years after spinal cord injury (SCI). Material and methods: Neurological level, method of bladder emptying and urological investigations were retrieved from the records for all 165 patients admitted to our Centre for Spinal Cord Injured with a traumatic SCI sustained from 1984 to 1988. Results: A total of 77 patients with completed 5-year control were included in the final analyses. We found that 64% had suprasacral bladder dysfunction, while 23% had infrasacral bladder dysfunction. Plasma-creatinine was normal, both at the initial examination and the 5-year control. From the time in the SCI centre to the 5-year control a trend towards less intermittent catheterization and more use of abdominal pressure was observed. During the follow-up period nine patients (12%) experienced urinary calculi. Six bladder stones were removed endoscopically. Five had kidney stones; three were left untreated, one was removed by extracorporeal sho...

Urological situation five years after spinal cord injury.

In a prospective, randomized study 60 patients with prostatism caused by small prostate glands (estimated weight < 20 g) had either transurethral prostatectomy (TURP, n = 31) or transurethral incision of the prostate (TUI, n = 29). Operating time and blood loss were significantly less in the group that underwent TUI. There were no differences between the groups in number of days with an indwelling catheter or days in hospital after operation. Eight patients in the TUI group required further operation, as did four in the TURP group, one of whom was discharged with a permanent indwelling catheter. In addition one patient developed a urethral stricture. Nine of the failures of treatment occurred within the first month. Fifty-one patients were followed up at 3 months and 47 were also seen at 12 months. Both operations significantly improved symptom scores and maximum flow rates compared with preoperatively, but the improvement in maximum flow rate was significantly better in the TURP group than in the TUI group. At 12 months TURP had also improved micturition time and voided volume, which TUI had not. Neither operation caused any significant change in sexual activity or erective potency postoperatively. Retrograde ejaculation was, however, seen in more than half of the patients in the TURP group, and only one in the TUI group. We recommend TUI for the treatment of prostatism caused by small prostate glands in patients who want to preserve normal ejaculation or are at poor surgical risk.

Transurethral Prostatectomy Compared with Incision of the Prostate in the Treatment of Prostatism Caused by Small Benign Prostate Glands

To evaluate influence of age on symptomatology and objective parameters in benign prostatic hypertrophy, preoperative findings in 199 unselected patients during one year were analysed. Symptoms of bladder instability increased with age, as did incidence of uninhibited detrusor contractions and bladder trabeculation, whereas maximum urine flow and obstructive complaints decreased, although prostatic size was the same. In the oldest age groups only was increasing prostatic size associated with increasing bladder trabeculation. Age related changes in neurological control and in the structure of the bladder may be involved, and the present results suggest age to be an important factor in the interpretation of symptoms and objective findings in prostatic hypertrophy.

The significance of age on symptoms and urodynamic- and cystoscopic findings in benign prostatic hypertrophy.

Transurethral Prostatectomy or Incision of tie Prostate in the Treatment of Prostatism Caused by Small Benign Prostates

In a prospective, randomized study 21 patients with prostatism caused by small prostates (estimated weight less than 20 gram) had a transurethral prostatectomy (TURP), and 17 patients a transurethral incision of the prostate (TUI). In the TUI group operation time and blood loss was significantly less than in the TURP group, while there was no intergroup difference in postoperative fever greater than 38 degrees C, antibiotic treatment, number of days with indwelling catheter or days of hospitalization after surgery. Three patients in the TUI group had repeated surgery. In the TURP group one patient underwent reoperation and one was discharged with a permanent indwelling catheter. Thirty-three patients had a follow-up of 3 months. Both surgical procedures significantly improved symptoms and maximum flow rates, and there was no intergroup difference of the surgical outcome. Forty-five per cent in the TURP group developed retrograde ejaculation versus none in the TUI group. In this preliminary report TUI was as effective as TURP in relieving bladder outlet obstruction caused by small prostates.

Torben Dørflinger

Papers

Urological situation five years after spinal cord injury.

Transurethral Prostatectomy Compared with Incision of the Prostate in the Treatment of Prostatism Caused by Small Benign Prostate Glands

The significance of age on symptoms and urodynamic- and cystoscopic findings in benign prostatic hypertrophy.

Transurethral Prostatectomy or Incision of tie Prostate in the Treatment of Prostatism Caused by Small Benign Prostates

Transurethral prostatectomy or incision of the prostate in the treatment of prostatism caused by small benign prostates.