[Experiences of an Initiative Qualitätsmedizin reviewer]. / Erfahrung eines Peer Reviewers der Initiative Qualitätsmedizin.

BACKGROUND: The quality of medical care is on a high level in hospitals, yet variations in quality as well as room for improvement can often be identified. This potential can be made visible by active error management. The Initiative Qualitätsmedizin (IQM) carries out a quality measurement based on routine data. Furthermore, it commits to the transparency of the results by publication. Other means for quality improvement include peer review. METHODS: Peer reviews serve to clarify statistical abnormalities with the applied quality indicators without using reprisals. Reviews take place following accepted analysis criteria and are subject to explicit rules concerning the process. The peer teams are comprised of members from several providers. Each review is ended with a summarized record including a proposed solution as well as a time frame. It is essential that all participants are satisfied after finishing the peer review. The subsequent implementation is the responsibility of the head of medicine. CONCLUSION: It is a challenge, especially in the field of medicine, to change long-standing learned and practised processes. To bring one's daily actions to the attention by others publicly might yet be another and even bigger challenge. The willingness to undergo such a process and to accept the resulting criticism is being experienced and accepted very differently.

[The role of contrast-enhanced pulse inversion harmonic imaging (CEUS) and contrast-enhanced computed tomography (CECT) in the preoperative diagnosis of renal lesions]. / Die Rolle von kontrastmittelverstärktem "pulse inversion harmonic imaging" (CEUS) und kontrastmittelverstärkter Computertomographie (CECT) bei der präoperativen Diagnose von renalen Raumforderungen.

OBJECTIVE: The preoperative assessment of structural and functional changes in renal tumors using contrast-enhanced pulse inversion harmonic imaging (CEUS) and contrast-enhanced computed tomography (CECT). MATERIALS AND METHODS: All consecutive patients referred to two tertiary hospitals for surgery on suspicion of a malignant renal lesion, who had been examined under the predefined study protocol using CEUS and CECT, were prospectively included in the study. All renal lesions suspected of being malignant were subjected to histopathological examination. Lesions expected to be benign were followed up according to the study protocol. The accuracy of CEUS and CECT with the final histology or follow-up results and the statistically significant difference between the two imaging techniques was calculated. RESULTS: Over a period of 3 years (2008-2011), 68 of 93 patients examined met the study criteria. The prevalence of malignant tumors in the study was 72%. Fifty four (79%) patients underwent surgery and had a histologically confirmed renal tumor (clear cell carcinoma 45, urothelial papillocarcinoma 4, angiomyolipoma 1, oncytoma 3, xanthogranulomatous pyelonephritis 1) and 14 (21%) patients underwent regular follow-up. Specificity, sensitivity and area under the curve (AUC) reached 57.9%, 98% and 0.779 for CEUS and 52.6%, 98% and 0.753 for CECT. CONCLUSION: The results show that both imaging methods can reliably rule out malignant disease due to absence of enhancement. Taking into consideration that CEUS can be carried out without severe risk or discomfort, it is time to reconsider CEUS as the method of choice for diagnosis, while CECT should be reserved for staging.

Morbidity and mortality after surgery for lower urinary tract symptoms: a study of 95 577 cases from a nationwide German health insurance database.

BACKGROUND: Little real-world data is available on the comparison of different methods in surgery for lower urinary tract symptoms due to benign prostatic obstruction in terms of complications. The objective was to evaluate the proportions of TURP, open prostatectomy (OP) and laser-based surgical approaches over time and to analyse the effect of approach on complication rates. METHODS: Using data of the German local healthcare funds (Allgemeine Ortskrankenkassen (AOK)), we identified 95 577 cases with a primary diagnosis of hyperplasia of prostate who received TURP, laser vaporisation (LVP), laser enucleation (LEP) of the prostate or OP between 2008 and 2013. Univariable logistic regression was used to analyse proportions of surgical approach over time, and the effect of surgical method on outcomes was analysed by means of multivariable logistic regression. RESULTS: The proportion of TURP decreased from 83.4% in 2008 to 78.7% in 2013 (P<0.001). Relative to TURP and adjusting for age, co-morbidities, AOK hospital volume, year of surgery and antithrombotic medication, OP had increased mortality (odds ratio (OR) 1.47, P<0.05), transfusions (OR 5.20, P<0.001) and adverse events (OR 2.17, P<0.001), and lower re-interventions for bleeding (OR 0.75, P<0.001) and long-term re-interventions (OR 0.55, P<0.001). LVP carried a lower risk of transfusions (OR 0.57, P<0.001) and re-interventions for bleeding (OR 0.76, P<0.001), but a higher risk of long-term re-interventions (OR 1.43, P<0.001). LEP had increased re-interventions for bleeding (OR 1.35, P<0.01). Complications were also dependent on age and co-morbidity. Limitations include the lack of clinical information and functional results. CONCLUSIONS: OP has the greatest risks of complication despite a low re-intervention rate. LVP demonstrated favourable results for transfusion and bleeding, but increased long-term re-interventions compared with TURP, while LEP showed increased re-interventions for bleeding. Findings support a careful indication and choice of method for surgery for LUTS, taking age and co-morbidities into account.

Performing radical cystectomy and urinary diversion in regional anesthesia: potential risk reduction in the treatment of bladder cancer.

OBJECTIVE: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. MATERIALS AND METHODS: In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. RESULTS: All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. CONCLUSIONS: Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.

[Rage against the machine -- necessity of robotic assisted prostatectomy]. / Die Macht der Maschinen - Notwendigkeit der roboterassistierten Prostatektomie.

During the last decade urologists have faced a dramatic increase in robotic surgery. Despite the exceptional acceptance of this technique there is a complete lack of evidence for the equi-efficacy or superiority of this technique compared to open or laparoscopic prostatectomy. There is now an increasing body of evidence for the evaluation of robotic assisted prostatectomy. Robotic assisted prostatectomy is a safe procedure. The rate of technical failure is small. The rate of surgical complications is comparable with that of open or conventional laparoscopic prostatectomy. Similar to the conventional laparoscopic prostatectomy there is a trend for a minor blood loss and a smaller transfusion rate compared to the retropubic approach. In recent meta-analyses there is no advatage regarding the oncological or functional outcome for robotic prostatectomy. Neither the rate of positive surgical margins nor the rate of biochemical recurrence favours robotic prostatectomy. Regarding functional outcome some publications describe better results for urinary and sexual function for robotic surgery. Careful evaluation of these data reveals a low level of evidence due to a strong bias in favour of robotic surgery. In contrast, recent analysis of "Medicare" data reveal a considerable poorer urinary function after robotic prostatectomy compared to open retropubic prostatectomy. The Urological Board of the Helios Hospital Group does not recommend the use of a robotic device for radical prostatectomy.

Cystectomy and urinary diversion in the treatment of bladder cancer without artificial respiration.

PURPOSE: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA). MATERIALS AND METHODS: In 2011 radical cystectomy with extended pelvic and iliac lymphadenectomy was performed on 14 patients using urinary diversion without applying general anesthesia. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Postoperatively, pain management took three days with the remaining epidural catheter before oral analgesics were administered. Mobilization and diet restoration were carried out according to the fast-track concept. Outcome measurements included operative time, blood loss, beginning of oral nutrition, beginning of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), length of hospital stay. RESULTS: All surgical procedures were performed without any complications. The absence of general anesthesia did not result in any relevant disadvantages. The postoperative progress was normal in all patients. Particularly, cardiopulmonary complications and enteroparesis did not occur. The provided palliative care proved sufficient (NAS max. 3-4). Discharge followed 10 to 22 days after surgery. At the time of discharge, the patients described the procedure to be relatively positive. CONCLUSIONS: Our data show that CSTEA is an effective technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes, and complications of CSTEA.

Cystectomy and urinary diversion in the treatment of bladder cancer without artificial respiration

PURPOSE: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA). MATERIALS AND METHODS: In 2011 radical cystectomy with extended pelvic and iliac lymphadenectomy was performed on 14 patients using urinary diversion without applying general anesthesia. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Postoperatively, pain management took three days with the remaining epidural catheter before oral analgesics were administered. Mobilization and diet restoration were carried out according to the fast-track concept. Outcome measurements included operative time, blood loss, beginning of oral nutrition, beginning of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), length of hospital stay. RESULTS: All surgical procedures were performed without any complications. The absence of general anesthesia did not result in any relevant disadvantages. The postoperative progress was normal in all patients. Particularly, cardiopulmonary complications and enteroparesis did not occur. The provided palliative care proved sufficient (NAS max. 3-4). Discharge followed 10 to 22 days after surgery. At the time of discharge, the patients described the procedure to be relatively positive. CONCLUSIONS: Our data show that CSTEA is an effective technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes, and complications of CSTEA.

[Primary and secondary prevention of erectile dysfunction]. / Primäre und sekundäre Prävention der erektilen Dysfunktion.

Erectile dysfunction has an incidence of up to 75% in men aged 80, thus making primary prevention really important. Aetiologically multiple reasons are responsible for erectile dysfunction; therefore, recommendations for primary prevention contain different parts. The first one is to maintain a healthy arterial system and prevent atherosclerosis. Besides that diabetes, neurogenic disturbances or mental distress should be avoided. Physical activity, balanced nutrition, nonsmoking, unsaturated fatty acids and moderate alcohol consumption are preventive. Regular erections cause oxygenation of the cavernous body and prevent fibrosis which could lead to an insufficient occlusion of the cavernous veins. If the patient already suffers from coronary heart disease or diabetes, blood pressure, pulse, blood lipids and blood sugar should be as normal as possible. Erectile dysfunction might be the primary symptom of coronary heart disease; therefore, consideration should be given to a cardiac examination in the diagnostic setting.

[Quality assurance in andrological surgery]. / Qualitätssicherung bei andrologischen Operationen.

Total quality management in andrology does exist for different lab diagnostics and endocrinology, not however for andrological surgery. Scientific investigations and comparisons to determine the efficiency and effectiveness of certain procedures as well as advanced training courses held by professional societies are commendable, but do not reach the level of modern high-class total quality management. Case-related procedures based on routine data or case-covering, on routine data of the health insurance schemes based procedures are also conceivable for andrological surgery, but since andrological surgery accounts for about 1.5% of all urological surgery this is not the main point of interest.

[SILS, LESS, NOS, and Co. for minimally invasive kidney treatment: is less more?]. / SILS, LESS, NOS & Co. bei minimalinvasiven Niereneingriffen : Ist weniger mehr?

BACKGROUND: Single-port surgery (LESS) is a new method of minimally invasive laparoscopic urology. These modern methods reduce the tissue trauma of the patient; however, high demands are placed on the surgeon. We report our initial clinical experience. MATERIAL AND METHODS: Eight patients with different pathologies in the abdomen and retroperitoneum (nephrectomy, renal cyst resection) were treated with an abdominal LESS access and two patients with vaginal NOS (natural orifice surgery) access. Previously, we obtained extensive experience with the setup and implementation in animal studies. The port placements were realized by various single-port systems in the paraumbilical region. RESULTS: All procedures were performed without conversion to an open surgical procedure. Two additional trocars were needed in the first single-port operation. The intra- and postoperative follow-up was uneventful in all patients. The average age of the patients was 58.9 years, the average operating time 131 min, the mean blood loss 70 ml, and the median body mass index 27. The postoperative evaluation of patient satisfaction revealed that all patients were perfectly satisfied. CONCLUSIONS: With appropriate experience and training of the whole team, single-port surgery is a safe and appropriate method for selected renal surgery.

[Testosterone replacement: application and surveillance]. / Testosteronsubstitution : Applikation und Kontrollen.

Male hypogonadism is based on an insufficient gonadal function, especially testosterone deficiency. The decreased endogenous production of testosterone can be acquired or congenital. The lack of testosterone results in typical clinical symptoms which give initial indications for testosterone replacement therapy. Nevertheless, less than 10% of the affected patients receive an adequate treatment. Presently different preparations and application forms are available for the therapy of hypogonadism with testosterone. Intramuscular, peroral, transdermal, sublingual and subcutaneous preparations show differences in pharmacodynamics, pharmacokinetics, price and handling. Therefore these formulations should be applied individually. Regular clinical and chemical controls of effect, side effects and contraindications are essential along with long-term substitution.

[Follow-up at 24 months after treatment of overactive bladder with 0.2 % sodium chondroitin sulfate]. / Zwei-Jahres-Follow-up nach Einsatz von 0,2 % Natrium-Chondroitinsulfat bei der Behandlung der "Uberaktiven Blase".

AIM: A retrospective study was performed to investigate whether the improvement of symptoms achieved with 0.2 % sodium chondroitin sulfate in treating overactive bladder (OAB) persists after 24 months. MATERIALS AND METHODS: Two years ago, a total of 82 patients with chronic OAB were randomly assigned to receive either anticholinergic treatment (Tolterodin; group A, n = 41) or 0.2 % sodium chondroitin sulfate (Gepan instill; group B, n = 41). Diagnostic assessment included a gynecological examination and history, urodynamic test-ing, introital ultrasound, and cystoscopy. Duration of treatment was 12 months. The patients underwent repeat follow-up after 24 months and the findings were compared with the results at 12 months. RESULTS: In group A, 15 / 35 (43 %) women reported an improvement of symptoms after 12 months as opposed to only 5 / 35 (14 %) after 24 months. In group B, there was an improvement in 23 / 32 (72 %) at 12 months and in 18 / 32 (56 %) after 24 months (p = 0.001). The subjective results were corroborated by means of urodynamic test-ing, pad counts, voiding frequency and nycturia (voiding diary). CONCLUSION: Our findings suggest that instillation treatment with 0.2 % sodium chondroitin sulfate results in a more sustained improvement or cure of the symptoms of overactive bladder due to development of a glycosaminoglycan layer. Long-term results are needed for confirmation.

[Current aspects of surgical restoration of fertility]. / Aktuelle Aspekte der Refertilisierungsoperationen.

Obstruction of the seminal ducts is the cause of infertility in about 5% of patients. It can be congenital or arise as the result of secondary changes. The reconstruction of the duct undertaken depends on the site of the obstruction. The introduction of microsurgical techniques has revolutionized the treatment of male infertility.A tubulovasostomy is carried out if the obstruction lies in the region of the epididymis. Such an anastomosis requires, owing to the minute anatomical relationships involved, a microsurgical procedure. For an obstruction of the vas deferens a vasovasostomy is required. Many investigations have shown that microsurgical techniques are also necessary for this procedure if a satisfactory success rate is to be achieved. The double-layer technique is the standard method for vasovasostomy. Transurethral resection of the ejaculatory ducts (TURED) is required for the very rare obstruction in this region, and men with an obstruction here cannot be regarded as forming a homogeneous group.Before advising an infertile couple it is necessary to investigate the individual conditions and possibilities. Because of the high success rate obtainable today by surgical reconstruction of the seminal ducts, this must constitute the first type of treatment to be considered, before any of the procedures of reproductive medicine are undertaken.

[Germ cell tumors - documentation of diagnosis and therapy by means of a web-based modular database system]. / Keimzelltumoren - Dokumentation von Diagnostik und Therapie mittels Web-basierten modularen Dokumentationssystems.

PROBLEM: Health telematics is gaining ground worldwide as it promises the bridging of distances in space and time as well as a highly effective use of financial and other resources. In Germany the development and introduction of a national telematic platform is in the foreground at present. However, there are a number of more specialised projects already in existence. The aim of this study was to develop an internet platform to document the quality of individual sections of treatment for patients with germ cell tumours in Berlin and to improve the therapy in conformity with the S2 guidelines. MATERIAL AND METHODS: As a pilot project, a web-based modular database system (WBMDS) was developed, which can be used by any physician involved in the treatment of germ cell tumour patients from any computer connected to the internet. RESULTS: The WBMDS proved to be a practicable system of documentation. Data protection was ensured by pseudonyms as well as symmetrical and asymmetrical coding. The size of the extended documentation mask that had initially seemed to be necessary for valid documentation appeared to be too user-unfriendly with its 833 items. To meet the requirements of the user as well as of the documentation, a compact variant with 496 input fields was designed. On a random basis, treatment not in conformity with the guidelines could be detected in 20 % of 151 patients with the help of this system. CONCLUSION: For the successful use of an oncological database the following showed to be essential:[nl]Queries clearly defined for later statistical evaluation,[nl]clear separation between the phases of planning and implementation,[nl]a size of the database that does not make excessive demands on the user,[nl]intensive training of the users.[nl]The modular database system established proved to be well suitable for a quality-ensuring longitudinal case documentation, which can also be applied to other tumour entities.

[Management of female stress urinary incontinence. Endoscopic extraperitoneal artificial urinary sphincter--early experience]. / Therapie der weiblichen Belastungsinkontinenz. Endoskopische extraperitoneale Implantation des artifiziellen Blasenhalssphinkters--erste Erfahrungen.

Implantation of an artificial urinary sphincter (AUS) is an established surgical option for treating female stress urinary incontinence due to internal sphincter deficiency (ISD). However, this operation is often performed as an open surgical procedure. Here, we introduce an endoscopic extraperitoneal approach for implanting an artificial urinary sphincter. Two women (ages 22 and 79 years) underwent endoscopic extraperitoneal implantation of the AMS 800 artificial sphincter. In both cases, neurogenic bladder disease was the underlying cause of ISD. The endoscopic extraperitoneal approach allowed excellent preparation and mobilisation of the bladder neck and implantation of the AUS. The overall operating time was <120 min. Both patients were mobilised on the same day and could be discharged from the hospital after 5-6 days. The AUS were activated after 6-9 weeks. However, after an average of 6 months, total continence was achieved in both patients. Laparoscopic extraperitoneal implantation of AUS in women with moderate to severe stress urinary incontinence is safe and might be less traumatic to neighbouring organs than the open operation. However, more implantations are needed to evaluate the long-term feasibility of this method.

Reconstruction of seminal ducts in obstructive azoospermia.

Depending on the localization of the obstruction of the seminal ducts, either a microsurgical reconstruction (tubulovasostomy, vasovasostomy) or a transurethral resection of the ejaculatory ducts is carried out. We have compared the effectiveness and economic advantages of reconstructive microsurgery of the epididymis and vas deferens with standard procedures in animal experiments. Microsurgical invagination techniques in tubulovasostomy are equal to the standard procedure from the point of view of the patency and fertility rates. They are also easier to learn and carry out. Less time is required for the invagination technique, and also less microsurgical suture material. The double-layer technique in vasovasostomy is equal to the one-layer microsurgical technique from the point of view of patency and fertility rates. The one-layer technique requires less time and suture material. It seems that the discrepancy between the patency and the fertility rate is related to immunological processes after reconstruction of the seminal ducts. In cases of obstructive azoospermia it is necessary to investigate the individual conditions and possibilities of the infertile couple. As a result of the high success rate obtainable today by surgical reconstruction of the seminal ducts, this must constitute the first type of treatment to be considered, before any of the procedures of reproductive medicine are undertaken.

Use of cryostat sections from snap-frozen nervous tissue for combining stereological estimates with histological, cellular, or molecular analyses on adjacent sections.

Adequate tissue preparation is essential for both modern stereological and immunohistochemical investigations. However, combining these methodologies in a single study presents a number of obstacles pertaining to optimal histological preparation. Tissue shrinkage and loss of nuclei/nucleoli from the unprotected section surfaces of unembedded tissue used for immunohistochemistry may be problematic with regard to adequate stereological design. In this study, frozen cryostat sections from hippocampal and cerebellar regions of two rat strains and cerebellar and cerebral regions from a human brain were analyzed to determine the potential impact of these factors on estimates of neuron number obtained using the optical disector. Neuronal nuclei and nucleoli were clearly present in thin sections of snap-frozen rat (3 microm) and human (6 microm) tissue, indicating that neuronal nuclei/nucleoli are not unavoidably lost from unprotected section surfaces of unembedded tissue. In order to quantify the potential impact of any nuclear loss, optical fractionator estimates of rat hippocampal pyramidal cells in areas CA1-3 and cerebellar granule and Purkinje cells were made using minimal (1 microm) upper guard zones. Estimates did not differ from data reported previously in the literature. This data indicates that cryostat sections of snap-frozen nervous tissue may successfully be used for estimating total neuronal numbers using optical disectors.

Intravesical administration of 5-aminolevulinic acid (5-ALA). Safety and pharmacokinetics of 5-ALA and its metabolite protoporphyrin IX.

OBJECTIVE: In an open study, the local and systemic side effects and pharmacokinetics of 5-aminolevulinic acid (5-ALA) and the fluorescent metabolite protoporphyrin IX (PPIX) were investigated after intravesical administration for the fluorescent photodetection of superficial bladder carcinoma. PATIENTS AND METHODS: In 20 patients with confirmed bladder carcinoma, 5-ALA was introduced into the bladder 2 h (15 patients) and 4 h (5 patients) before an elective endoscopic resection. The 5-ALA and PPIX levels in the plasma were determined before and up to 10 h after application, and in the urine 2 h or 4 h after application. RESULTS: The plasma level of 5-ALA rose rapidly, the maximal concentration (340 ng/ml) being reached in 0.55 h (2 h) or 0.62 h (4 h). The elimination half-life of 5-ALA amounted to 0.74 h (2 h) or 0.79 h (4 h). In five of the patients, there was a measurable plasma concentration which ranged from the detection limit of 4.3 ng/ml to 14 ng/ml between 2 h and 5 h after application, and then fell below the detection limit after 9 h. Absorption of 5-ALA by the bladder was low, i.e. less than 1% of the total amount applied. During a period of observation of 96 h, no 5-ALA-specific side effects appeared. CONCLUSION: Because of the small quantity of 5-ALA resorbed following its intravesical administration, only minimal concentrations of PPIX that are responsible for producing side effects can be metabolised in the plasma. Therefore, no systemic side effects are to be expected after the intravesical administration of 5-ALA.