[Stress incontinence after prostatectomy in treatment reality: results from a rehabilitation clinic]. / Belastungsinkontinenz nach Prostatektomie in der Versorgungswirklichkeit : Ergebnisse einer Reha-Klinik.

BACKGROUND: In the current discussion on the operative therapy of prostate cancer, not only"if" but also"how" play a major role. Both questions are closely related as, e.g. a possible excessive therapy will result in additional suffering due to stress incontinence. For the most common, troublesome and expensive consequences of prostatectomy it is of interest to know which factors play a role in treatment reality and which could possibly be avoided. PATIENTS AND METHODS: The hospital records of all patients who underwent follow-up treatment after prostatectomy in 2009 at the clinic in the spa park in Bad Wildungen-Reinhardshausen were evaluated with respect to relevant data on outcome and clinical endpoints. RESULTS: Of the 1,750 patients 405 (23.1 %) were continent on admission and discharge and a further 189 (10.8 %) were continent on discharge so that a total of 594 patients (33.9 %) were continent on discharge. Of the 1,155 patients (66.0 %) who were incontinent on admission and discharge, this remained the same during the rehabilitation period for 727 (62.9 %) who were diurnally incontinent and 659 (57.1 %) who were nocturnally incontinent. For 387 patients (33.5 %) the incontinence decreased during the day and for 370 (32.0 %) during the night, for 34 (3.4 %) the incontinence increased during the day and for 45 (3.9 %) during the night. An age < 60 years was advantageous for maintaining continence and in contrast > 70 years was disadvantageous. Retention of nerves showed a significant effect on maintaining continence. Statistically significant differences between the results of operative procedures and the results of the type of clinic (KKP communal, confessional and private or UK university clinic) were not observed. However, the results of maintaining continence (up to termination of rehabilitation treatment) for the 594 patients (33.9 %) was only achieved by 94 (51 %) of all 183 clinics, i.e. 78 (49.7 %) of the KKP clinics and 14 (53.9 %) of UK clinics. For the certified prostate centers of KKP and UK clinics this amounted to 17 (81 %) and 5 (83.3 %), respectively. CONCLUSIONS: In treatment reality of follow-up treatment of patients after prostatectomy in rehabilitation clinics approximately one third (33.9 %) achieved retention of continence up to discharge. An age < 60 years was advantageous and > 70 years disadvantageous. Bilateral and unilateral retention of nerves significantly improved retention of continence. The operative procedure and type of clinic did not significantly affect the results. However, in approximately one third of patients (33.9 %) retention of continence was achieved by only approximately one half (51.4 %) of all clinics. This shows that in treatment reality, stress incontinence following prostatectomy is avoidably underdeveloped and can be demonstrably increased by suitable operative techniques for sphincter protection.

[Differential indications in hydrocele operations - a contribution to prophylaxis for recurrent hydrocele]. / Differenzialindikationen bei Hydrozelenoperationen - ein Beitrag zur Prophylaxe einer Rezidivhydrozele.

BACKGROUND: In the operative treatment of idiopathic hydroceles the available techniques are frequently not selected as indicated according to the different expansions of hydroceles but rather the accustomed procedures are used. MATERIAL AND METHODS: In a retrospective analysis the methods and complications of hydrocele operations were evaluated. RESULTS: From 1988 to 2008 195  hydroceles in 191  patients were operated upon: 22 (11.3 %) by eversion (according to Jaboulay), 27 (13.8 %) by resection (according to von Bergmann) and 146 (74.9 %) by a combination of resection and eversion (according to Kocher) of the tunica vaginalis communis. In 14 (7.2 %) patients the operation was indicated by a recurrent hydrocele, either after an eversion alone (n = 7) or after an insufficient resection (n = 7) of the tunica vaginalis communis. As complications of the operation an abscess occurred in 4 (21 %) cases, a haematoma in 5 (2.6 %) cases and a combination of both had to be reoperated in 2 (1.0 %) cases. CONCLUSIONS: In order to prevent recurrent hydroceles the available methods for the operative treatment of idiopathic hydrocele should be selected according to the different expansions of the hydroceles and as such consequently executed.

[Urologic errors in surgical procedures]. / Urologische Behandlungsfehler bei chirurgischen Eingriffen.

BACKGROUND: In the examinations of the appraisal commission of Northern Rhine the third most frequent urologic errors are ascertained after surgical procedures. In order to prevent them, it is adequate to evaluate their causes. MATERIAL AND METHODS: Urologic claims were examined that came before the appraisal commission for treatment errors of the Northern Rhine Physicians' Authority between 1975 and 2005. The results of the first 23 years were compared with those of the last 7 years. The judgment criteria were professional standards and required care. RESULTS: Ninety-five treatment errors were registered in 1975-2005. From 1975 to 1998 there were 60 such errors (2.6 per year) and from 1999 to 2005 there were 35 (5.0 per year). These errors concerned diagnosis in 14.7% of cases (mainly testicular torsion), indication in 7.5%, and explanations of the surgery in 2.1%. About half the cases (46.3%) applied to surgical technique, especially for injuries to the spermatic cord, urinary bladder, ureter, or urethra. In nearly one third of cases (29.4%), errors were found in postoperative care, concerning especially lesions of the spermatic cord and ureter. CONCLUSIONS: There is considerable risk of misjudging or even causing urologic disorders in abdominal and vascular surgery. This applies most strongly to diagnosis, above all for testicular torsion. Hernia surgery and colon resection are the treatments leading to the highest number of injuries to testicular vessels, ureter, bladder, and/or urethra. Such occurrences cannot be tolerated if they can be avoided or, if unavoidable, not recognized promptly and adequately managed.

[Reconstruction of tissue defects on the glans penis by transplantation of buccal mucosa]. / Wiederherstellung von Gewebedefekten der Glans penis mittels Mundschleimhauttransplantation.

OBJECTIVES: The purpose of the present communication is the presentation of a surgical method for treating tissue defects of the glans penis through free transplantation of a piece of the patient's buccal mucosa. Defects of the glans penis are most frequently formed from excision of a primary tumour or benign lesions through partial or total glansectomy. METHODS: During a 2-year period (2004-2005), at the Clinic of Urology of the Medical University, Sofia, 10 patients having penile cancer were diagnosed and treated. Out of these, 6 (60%) were found to be in T1 N0 M0 stage. In 5 (50%) of the said cases, a free mucosa transplant was used to cover the tissue defect remaining after partial or total glansectomy. In 4 (80%) cases buccal mucosa was used, and in 1 (20%) lower lip mucosa. RESULTS: The histological results from the operations performed confirmed the staging of the disease, with 4 flat-cell and 1 verrucosa cancer. Within the early post-operative period, no surgical complications were noted, not only at the site of extraction of the transplant, but also at the site of its transplantation. Late complications and relapses have not been observed. CONCLUSIONS: Our initial experience utilising the free transplantation of mucosa extracted from the oscular cavity for replacement of a surgical defect after partial or complete glansectomy has proven to be an alternative to the available treatment methods. Buccosa is more suitable in the case of a partial glansectomy because it has a thicker wall.

[Consistency and change of medical errors in urology]. / Konstanz und Wandel von Behandlungsfehlern in der Urologie.

BACKGROUND: Whether and how far the ascertainment of medical errors is influenced by advances in medicine is a matter of question. MATERIAL AND METHODS: The cases of the Expert Committee for Medical Malpractice Claims of the Medical Association of North Rhine were reviewed from 1975 to 2005. The results of the first 23 years were compared with the last 7 ones. Underlying criteria were the professional standards and required care. RESULTS: The number of claims and medical errors increased. The rate of medical errors remained approximately constant. The spectrum of medical errors remained constant to a large extent. Frequent errors were more frequently ascertained. Several errors decreased or increased according to medical progress. CONCLUSIONS: To avoid medical errors individual cases should be published for learning purposes. Each treatment should be undertaken with utmost competence and care.

[Treatment errors involving diagnosis of and therapy for prostate carcinoma]. / Behandlungsfehler bei der Diagnostik und Therapie des Prostatakarzinoms.

PURPOSE: In patients with prostate carcinoma diagnosis and therapy often present problems that are difficult to solve. Perfect results can only be reached by the highest level of professional expertise and required care. In cases of unwanted results and incidences it is asked whether claims of patients against their doctors are justified or not. METHODS: Claims of patients were reviewed by the commission of experts for medical mistakes of treatment of the state medical board of North Rhine based on objective criteria, out of court and free of charge. RESULTS: From 1975 to 1998 only 4 treatment errors were ascertained in patients with prostate carcinoma, 3 concerning the diagnosis and 1 concerning an operation. From 1999 to 2005 the errors of treatment increased by 6S-fold to 26. Mistakes concerned the diagnosis in 18 cases, the indication for operation in 1, the operative technique in 2 and the postoperative care in 5 cases. CONCLUSIONS: In comparison with the about 50,000 patients in whom a prostate carcinoma is diagnosed and treated in Germany every year the presented cases seem to be singular incidences. However, in the view of the experts, these are the tips of icebergs, since reviews most often are requested when professional disappointment and loss of confidence come together. This can only be avoided when the professionality and carefulness of the doctors is apparent and combined with their sympathy for their patients.

[Uterovesical fistula]. / Gebärmutter-Harnblasenfistel.

INTRODUCTION: Uterovesical fistulas belong to the least common types of urogenital fistulas. Although uncommon, they cannot be considered a rarity in view of about 800 published cases in the literature. They are most frequently caused by repeated caesarean sections, which are increasing, and their complications can be expected to increase as well. CASE REPORT: During the second caesarean section of a 31-year-old woman, the urinary bladder was opened and subsequently closed by a urologic surgeon. In the following weeks and months, the patient suffers from urinary incontinence in response to bladder filling, cyclic hematuria (menouria) and recurrent cystitis. After multiple examinations without establishing a diagnosis, an uterovesical fistula was suggested by cystoscopy and confirmed by cystography. The fistula, which measured 2 cm in diameter, was successfully closed by transperitoneal approach without interposition of omentum. CONCLUSION: Uterovesical fistulas are to be expected to increase due to an increasing rate of repeated caesarean sections. They can be suggested by their typical symptoms, easily diagnosed by imaging examinations and successfully treated by transperitoneal closure.