Partnerships between Medical Centres and General Hospitals Providing Normal Care Standards in Gynaecology and Obstetrics in Germany.

Hospital managers and the heads of medical departments are nowadays being faced with ever increasing demands. It is becoming difficult for some small hospitals to find highly experienced or even experienced medical staff, to provide specific health-care services at break-even prices and to maintain their position in competition with other hospitals. On the other hand, large hospitals are facing enormous pressure in the investment and costs fields. Cooperation could provide a solution for these problems. For an optimal strategic exploitation of the hospitals, their direction could be placed in the hands of a joint medical director. However, the directorship of two hospitals is associated both with opportunities and with risks. The present article illustrates the widely differing aspects of the cooperation between a medical centre and a general hospital providing standard care from both a theoretical point of view and on the basis of practical experience with an actual cooperation of this type in Heidelberg.

Change of aesthetic and functional outcome over time and their relationship to quality of life after breast conserving therapy.

PURPOSE: We analyzed changes in aesthetic and functional outcome over time after breast conserving therapy. Our special interest resides in the question of whether these aspects gain or loose their influence on quality of life (QoL) with temporal progress. PATIENTS AND METHODS: This prospective single centre cohort study included 138 patients, treated with breast conserving surgery and consecutive radiotherapy. Patients completed two questionnaires one week and one year after surgery: the BCTOS (Breast Cancer Treatment Outcome Scale) to measure Functional, Aesthetic, and Breast Sensitivity Status and the EORTC (European Organisation for Research and Treatment of Cancer) C30-BR23 to assess QoL. We applied correlation and multiple regression analysis as statistical methods. RESULTS: Aesthetic and Functional Status did not change significantly over one year, whereas Breast Sensitivity Status and several QoL subscales showed significant improvement (p < 0.0001). Correlations between BCTOS scales and EORTC subscales remain similar over time. Functional and Aesthetic Status kept a strong impact on global health (Spearman's Rho = -0.28 to -0.45 depending on time of assessment). Increasing age and poorer Functional Status shortly after surgery are predictors of a decline in global health over one year (p < 0.001). CONCLUSION: Functional and aesthetic outcome after breast conserving surgery maintain their impact on QoL over a one year follow-up period and are valuable predictors of QoL.

[The value of laparoscopic and laser-assisted techniques in reconstruction of distal fallopian tube pathology]. / Die Wertigkeit laparoskopischer bzw. laser-assistierter Techniken zur Rekonstruktion bei distaler Tubenpathologie.

In an overall study population (3 different study designs) of n = 285 patients the role of laparoscopic resp. laser-assisted techniques was evaluated on the basis of the results of distal tubal reconstruction. An interventional comparison of a laparoscopic (n = 150) with a retrospective microsurgical (n = 135) group of patients with distal tubal pathology showed a significantly higher baby-take-home rate in the laparoscopically treated patients (38% vs. 22.2%, p < 0.05), but detailed critical analysis of indication revealed a certain selection effect in the laparoscopic group. A prospective study on laser (n = 100) and non-laser techniques for salpingostomy showed in no significant differences between the two groups, as results were concerned (delivery 35% in the laser, 44% in the non-laser cohort). In a prospective randomized subgroup laparoscopic fimbrial eversion with the laser was compared to suture eversion (n = 20). In both groups the reocclusion rate was of 20%. On may thus conclude, that the most important surgical approaches for treatment of a tuboperitoneal sterility: micro-surgery and endoscopy, resp. the various surgical techniques: laser and non-laser, should not be regarded as competing procedures, but as components of a multimodal strategy. The indication, however, must be critically viewed in every particular case. Of major importance being strict scientific evaluation criteria to prevent misinterpretations, e.g. based on indication-specific selection.

[Abdominal colposuspension: a synopsis of various approaches and techniques including endoscopic modifications]. / Die abdominale Kolposuspension: Eine Synopsis der verschiedenen Zugangswege und Techniken incl. endoskopischer Modifikationen.

Though abdominal colposuspension is an established operative procedure in the therapeutic spectrum of female urinary stress incontinence, there is controversy concerning new access routes and fixation techniques. On the basis of a comparison between results of a "feasibility" study at our department concerning the trans- and extra-peritoneal endoscopic access as well as suspension techniques with alloplastic material and suturing vs. stapler application, and al literature survey, a synoptic concept is being evaluated. In case of critically made indication, first trends show that results of laparoscopically and retziusscopically assisted techniques are comparable to those of conventional procedures. However, the lack of long-term results as well as an initially prolonged operation time have to be considered. In the meantime an extraperitoneal transumbilical colposuspension was attempted in 2 patients, already unsuccessfully operated upon (conventional Burch) previously. Due to extensive perivesical adhesions a laparotomy had to be performed. The limits of the endoscopic approach seen to be reached in these cases.

[Endoscopic colposuspension ("retziusscopy" versus laparoscopy). An effective extension of the surgical spectrum of stress incontinence?]. / Endoskopische Kolposuspension ("Retziusskopie" versus Laparoskopie). Eine sinnvolle Erweiterung des Operationsspektrums der Stressinkontinenz?

Within the framework of "minimal access surgery" a prospective randomised study was initiated at the Dept. of Obstetrics and Gynaecology of Heidelberg University to examine the feasibility of endoscopical abdominal Burch colposuspension for stress incontinence (II-III), at laparoscopy and "retziusscopy". Further, also prospectively randomised, two suspension techniques: needle suspension and suspension by means of alloplastic material with stapler fixation, were compared, irrespective of the endoscopic approach chosen, especially because long-term results of our study population on colposuspension with fibrin glue which are now available, are below expectations, worse than those obtained with conventional techniques. Except for a bladder lesion (during laparoscopic dissection of the space of Retzius) no intra- or postoperative complications occurred in the pilot study group of 20 patients. Both types of endoscopic access proved technically feasible, and presented the typical advantages of minimal access surgery such as short hospitalization and rapid recovery. Short-term follow-up (2-12 months) showed subjective and objective results (continence in 18/20 patients), comparable to conventional abdominal procedures at laparotomy. Detailed evaluation of subgroups is not yet possible, since the number of patients it still too small and follow-up too short.

Endoscopic retropubic colposuspension: "Retziusscopy" versus laparoscopy--a reasonable enlargement of the operative spectrum in the management of recurrent stress incontinence?

The technical feasibility of the laparoscopic and extraperitoneal approach to the Burch colposuspension for treatment of grade II and III (moderate to severe) stress incontinence was examined in a randomised prospective study. Irrespective of the endoscopic access, two suspension techniques, namely conventional suture and stapler fixation of alloplastic materials, were compared. A total of 20 patients entered this preliminary evaluation. Three complications occurred; a bladder perforation (during laparoscopic dissection of the space of Retzius), a postoperative detrusor instability and transient urinary retention. Both the endoscopic approaches and the suspension procedures employed proved feasible and safe, and presented the advantages of a "minimal access" procedure, with short hospitalisation and rapid recovery. Short-term follow-up (6-12 months) showed subjective and objective results comparable to those of the conventional abdominal Burch colposuspension. Detailed evaluation of the subgroups is not yet feasible, as the number of patients in this preliminary evaluation was too small and follow-up too short. Final evaluation of the entire study population and long-term follow-up will be necessary before these procedures can be generally offered as a therapeutic alternative.