[Costs and benefits of quality management]. / Kosten und Nutzen eines Qualitätsmanagements.

The establishment of quality management (QM) has been mandatory for health care providers of the national health insurance since 2004; however, certification is so far only compulsory for rehabilitation clinics. The costs have so far only been quantified in a few medical studies, while they are widely known in business administration with a basic distinction made between planning, steering, auditing, and declaration costs. Another business economics approach differentiates between prevention, appraisal, and non-conformance costs. The benefits of QM relates to customers, employees, external service providers, and health insurance providers. Also important in our consideration of the patient as a customer is that they should not be considered a customer in the usual business sense because the patient is in an emergency situation and can not freely decide. Improvements in treatment quality and in reducing the rate of adverse events make up the largest portion of the benefits of QM. Furthermore, QM can have a positive influence on motivation and employee recruitment. In addition, the cost savings that result despite costs for QM must not be forgotten.

[New aspects of case law on andrological questions: what does this mean for physicians in private practice?]. / Neue Aspekte der Rechtsprechung bei andrologischen Fragestellungen : Was bedeutet dies für die niedergelassenen Kollegen?

In recent years there have been several Supreme Court adjudications concerning andrological issues. Among other things it was reconfirmed that drug therapy for erectile dysfunction does not have to be paid by compulsory health insurance providers. In contrast one Supreme Court decided that cryoconservation of ejaculates has to be paid by compulsory health insurance providers under certain circumstances.Vasectomy in men under guardianship is performed approximately 100 times per year in Germany. Before vasectomy is performed judicial authorisation has to be obtained in an extensive court proceeding.The Tissue Act regulates the implementation of the EG guideline 2004/23/EG into German law. This is only important for urologists who perform MESA/TESE procedures. Current case law does not allow use of the title Männerarzt as patients can confuse it with the official title andrologist.

[Surgical sperm retrieval]. / Operative Spermiengewinnung.

The introduction of intracytoplasmic sperm injection (ICSI) into the catalogue of assisted reproductive technologies in the mid-nineties has, for the first time, offered men who suffer from severe disorders of spermatogenesis and azoospermia the possibility of fathering a child. Different surgical techniques can be used to extract spermatozoa from these men from either the epididymis and/or the testis for ICSI. Surgical sperm retrieval offers a treatment for both patients with testicular or obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques that have been developed over the years, microsurgical epididymial sperm aspiration (MESA) and testicular sperm extraction (TESE) have become the most popular. By utilizing these techniques together with the cryopreservation of extracted spermatozoa, a single surgical intervention is able to provide spermatozoa for several ICSI attempts.

Evaluation of uridine metabolism in human and animal spermatozoa.

The objective of this study was to elucidate the role of uridine for spermatozoa, since this pyrimidine nucleoside was found in millimolar concentration in human seminal plasma. Here, the degradative activity of uridine-phosphorylase [EC 2.4.2.3] and the salvage activity of uridine kinase [EC 2.7.1.48] were detected in human spermatozoa. HPLC analysis depicted the uptake of exogeneous 14C-labelled adenine, but not of uridine and of hypoxanthine, into nucleotide pools of boar spermatozoa. On addition of uridine, the computer-assisted semen analysis (CASA) of human cells revealed a reduction of the percentage of motile spermatozoa in contrast to an elevation of some velocity parameters. It is concluded that exogeneous uridine could function as suppressor for early capacitation and as a substrate for phosphorolysis, if ribose is needed, rather than to satisfy a demand for intracellular pyrimidine nucleotides.

[Cost of fertility and erectile dysfunction therapy: who has to pay what in the GVK?]. / Kosten einer Fertilitäts- und ED-Therapie Wer zahlt was in der GKV?

From 1 January 2004 new legislation changed the liability of the public health insurance regarding diagnostic and therapy both of erectile dysfunction and infertility. Before 2004 medical therapy of erectile dysfunction (autoinjection therapy, PDE5 inhibitors) was included in the coverage of the general health insurance; however, it is now excluded by law. Before 2004 sterilization was covered by public health insurance only if medically indicated. The costs of vasovasostomy or artificial fertilization after sterilization were only covered by health insurance if the sterilization was carried out for medical reasons. In the field of infertility the liability of statutory health insurance has only been restricted concerning artificial fertilization. Since 2004 there have been restrictions concerning the age of the insured person, and 50% of the costs have to be payed by the patient herself. Moreover, for the different methods of artificial fertilization, the number of trials and the indications have been defined by the Federal Committee. The statutory health insurance is not liable if the number of trials exceeds the limit.

Influence of autogenous leucocytes and Escherichia coli on sperm motility parameters in vitro.

Urogenital infections are considered important factors in male infertility. In this in vitro study we have evaluated the impact of leucocytes in association with an artificial infection with Escherichia coli on the motility of human spermatozoa. Ejaculates and blood samples were obtained from healthy donors with normal semen parameters. Ejaculates were prepared by swim-up technique and five fractions were isolated for incubation. Leucocyte subtypes were separated from blood samples by gradient centrifugation. Purified sperm suspensions were adjusted to a concentration of 20 x 106 ml-1 and incubated with lymphocytes/ monocytes, polymorphonuclear granulocytes (PMN), and E. coli. Samples were incubated for up to 6 h at 37 degrees C. Motility analysis was performed using a computer-assisted sperm analyzer (CASA). Spermatozoa incubated with 3 x 106 PMN ml-1 revealed a significant (P=0.003) decrease in progressive motility after 2 h. This decrease remained weakly significant (P=0.024) after 4 and 6 h. Lymphocytes and monocytes had no effect on sperm motility. Spermatozoa incubated with granulocytes and E. coli demonstrated highly significant alterations in motility after 4 and 6 h of incubation (P < 0.001). The PMN indicate an effect on motility of spermatozoa under experimental conditions. However, the results suggest that bacteria are the primary agents that interfere with sperm motility.

Vasovasostomy.

Vasovasostomy after sterilisation vasectomy is the most frequently performed microsurgical intervention in refertilizing surgery. Causes for obstruction other than vasectomy such as juvenile hernia repair and other kinds of surgery affecting the seminal cord appear to be rare. The pre-operative diagnostic approach follows the rules of conventional diagnostics in male infertility. The significance of the intra-operative evaluation of aspirates from the duct and its role in surgical decision-making is controversely debated in the literature. Similar controversies are evident concerning the microsurgical technique that is applied. In particular, the advantages of the two-layered technique (gold standard) of the anastomosis versus the single-layered technique are discussed. Other techniques such as laser applications and fibrin glue are not routinely used in humans. Even difficult microsurgical problems in cases with extended obstructions and cases of re-vasovasostomy can nowadays be managed and have significant success rates. Important prognostic factors appear to be the interval of obstruction, sperm granulomas, and length of the testicular end of the duct. High success rates accompanied by a lower profile in cost make the microsurgical approach (refertilization) superior versus the primary use of ART techniques such as ICSI.

Long-term results of Essed-Schroeder plication by the use of non-absorbable Goretex sutures for correcting congenital penile curvature.

This study evaluated the long-term outcome of the Essed-Schroeder procedure for correcting congenital penile curvature using non-absorbable Goretex sutures. The Essed-Schroeder procedure was performed in 35 patients with congenital ventral penile curvature (minimum 30 degrees ). Follow-up included a standardized interview with measurement of angulation. Twenty-three of 35 patients were available for complete long-term follow-up (average 34.3 months). The mean preoperative ventral curvature was 54 degrees. In 17/23 patients, the penis remained straightened. Recurrent curvature (average 23 degrees ) was observed in six of 23 patients. Fifteen of 23 patients complained of penile shortening (average 1.8 cm). Two of 23 patients reported disturbing side effects that were caused by plication nodes. In most cases, the results of penile straightening by the Essed-Schroeder procedure are excellent with a high grade of subjective satisfaction. Regarding the main problem, that is recurrent curvature, there is no decisive advantage of applying Goretex sutures. Discomfort caused by plication nodes can be reduced to a minimum by using a combination of soft Goretex sutures with the 'inverting stitch-technique'.

Testicular sperm extraction in a patient with metachronous bilateral testicular cancer.

A new indication for testicular tissue cryopreservation is demonstrated in a patient with metachronous bilateral testicular tumours and azoospermia. At the age of 18 (1982) the patient underwent left orchidectomy and radical retroperitoneal lymphadenectomy for a testicular teratoma (pT1N0M0). Semen samples were not cryopreserved because of absence of motile spermatozoa after thawing. Seventeen years after the primary testicular cancer, a seminoma of the contralateral right testis was diagnosed (pT1N0M0). Since the patient was azoospermic, no semen samples could be cryopreserved. However, spermatozoa were detected in testicular biopsy material of the right testis and were cryopreserved for ICSI. Since all spermatozoa were dead after thawing, testicular sperm extraction (TESE) was performed in the remaining tissue samples at the time of ICSI treatment. Only spermatids could be extracted from frozen-thawed samples due to the inhomogeneous distribution of spermatogenic activity in the testicular tissue. Although one oocyte was fertilized with these spermatids, a clinical pregnancy was not achieved. Despite the disappointing results of ICSI in the couple presented here, this case report demonstrates that cryopreservation of testicular tissue and TESE should be considered in patients with bilateral testicular tumours and azoospermia, if frozen semen samples are not available.

Extracorporal shock wave therapy in the treatment of Peyronie's disease. First results of a case-controlled approach.

OBJECTIVE: To test whether extracorporal shock wave therapy (ESWT) has an effect in the treatment of Peyronie's disease. METHODS: 22 patients with Peyronie's disease and previous unsuccessful oral drug therapy were treated with ESWT in a prospective design with a follow-up of at least 3 months; 23 age-matched patients without previous therapy received oral placebo drug for 6 months daily as control. The standard follow-up included palpation, ultrasound, autophotography and evaluation of symptomatology based on a symptom score. The shock waves were applied under ultrasound guidance using the 'Storz Minilith SL1' lithotripter. RESULTS: The results show a significant decrease in penile curvature in the patients treated with ESWT. Concerning the decrease in pain, subjective improvement and improvement in the quality of sexual intercourse, there was no significant difference to the case-control group. The inhomogeneity of the 2 groups may influence these results due to the questionable varying natural history. CONCLUSIONS: A prospective, controlled multicenter study with standardized parameters (concerning technique and patients) is urgently required to test the effect of ESWT.

Microsurgical epididymal sperm aspiration: aspirate analysis and straws available after cryopreservation in patients with non-reconstructable obstructive azoospermia. MESA/TESE Group Giessen.

Microsurgical epididymal sperm aspiration (MESA) combined with intracytoplasmic sperm injection (ICSI) represents a great advance in the therapy of non-reconstructable obstructive azoospermia. For procedure synchronization, a great number of organizational facilities are needed. Intentional cryopreservation of the aspirate may reduce these problems, therefore the aim of this study was to analyse the amount and quality of aspirate fluid obtained by means of MESA and the quality of the vials after thawing. Furthermore, the available cryopreserved straws were calculated. A total of 93 consecutive MESA procedures were performed and epididymal spermatozoa were obtained in 88 patients. Mean sperm concentration was 40.9 x 10(6) spermatozoa/ml. Global and progressive motility were 24.8 and 7.5% respectively. In one-third of the aspirates, no progressive motile spermatozoa were found. The mean number of straws available was 7.6. In 33 ICSI cycles with frozen-thawed epididymal spermatozoa, a pregnancy rate of 42.4% was achieved. In conclusion, these data show that enough spermatozoa are available for various ICSI cycles following a single MESA procedure in men with non-reconstructable obstructive azoospermia. Furthermore, ICSI with cryopreserved spermatozoa leads to excellent pregnancy rates

Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach.

In severe oligozoospermia or azoospermia, low ejaculate volume, low ejaculate pH and little or no fructose in seminal plasma suggest an obstruction of the seminal pathways at the level of the prostate gland, when vasal aplasia and ejaculatory disorders are excluded. We report on our standardized surgical approach in 16 consecutive patients with this condition after clinical evaluation, semen analysis, endocrine assessment, testicular biopsy and transrectal ultrasonography. Pre-operatively, sperm analysis demonstrated typical low-volume ejaculates with azoospermia in 12 and severe oligozoospermia in four cases. Ultrasonography demonstrated seven central (Müllerian) and five lateral cystic lesions. Four cases with central obstruction revealed no ultrasonographic pathology. After intra-operative vasopuncture and vasography for definite localization of the level of obstruction, transurethral incision and/or resection of ejaculatory ducts (TURED) was performed. Patency was proven in 15 out of 16 cases by 'intra-operative chromotubation'. In nine out of 12 patients, spermatozoa could be harvested intra-operatively from the vas. During the follow-up of 12 months, post-operative ejaculates showed persistent patency in six out of seven Müllerian cysts with concomitant improvement of sperm quality. Only three of the other nine cases remained patent with the worst results in lateral cystic lesions. Only two of the patients with Müllerian cysts have fathered a child so far. The data provide evidence for the effectiveness of surgical treatment of ejaculatory duct obstruction, especially in the case of central cystic lesions. The combination of surgery, cryostoring of spermatozoa retrieved intra-operatively and the possible storage of ejaculated spermatozoa post-operatively creates the possibility of subsequently using reproductive techniques if pregnancy is not achieved.

Clinical findings in congenital absence of the vasa deferentia.

In a clinical study, 105 patients with congenital bilateral absence of the vas deferens (CBAVD) and 18 with congenital unilateral absence of the vas deferens (CUAVD) were investigated. CUAVD was observed on the left side in 66%. Renal agenesis was more frequent in CUAVD (73.7%) than in CBAVD (11.8%). The leading signs of CBAVD are low pH level (average 6.5) and low volume of the ejaculate (average 0.95 ml). Testicular biopsies of 52 patients revealed normal spermatogenesis or hypospermatogenesis (33% in CBAVD; 45% in CUAVD). Genetic probing and counselling concerning cystic fibrosis are necessary if extracorporal micro-fertilization is considered. The absence of the vas deferens was often overlooked by the first investigator, the average time until correct diagnosis being 4.3 years. As artificial reproduction technology becomes more common, detection of vasal agenesis will certainly be made earlier and more frequently in the future. In order to assure compatibility of subsequent prospective studies about CBAVD and CUAVD, the following investigations are considered to be necessary: (i) semen analysis (pH, volume); (ii) renal ultrasonography or excretory urogram (screening for renal agenesis); (iii) genetic cystic fibrosis screening.

Comparison of expressed prostatic secretions with urine after prostatic massage--a means to diagnose chronic prostatitis/inflammatory chronic pelvic pain syndrome.

OBJECTIVES: To compare the analysis of urine after prostatic massage (VB3) with expressed prostatic secretions (EPS) to assess the significance of leukocyte analysis in VB3 and to give a first hint of the diagnosis of inflammatory chronic pelvic pain syndrome (CPPS) when EPS cannot be obtained. METHODS: Three hundred twenty-eight men (mean age 38 years, range 18 to 70) with expressible prostatic secretions were investigated. EPS were stained using the Papanicolaou stain and analyzed for leukocytes per high power field (HPF) (x1000). Additionally, identical aliquots of first voided urine (VB1), midstream urine (VB2), and VB3 were centrifuged, stained (Papanicolaou), and analyzed for leukocytes (x400). Patients with increased numbers of leukocytes in VB1 and VB2 (2 or more per x400) were excluded. For statistical analysis, Spearman's correlation coefficient for nonparametric tests was used. RESULTS: Of 180 men with less than 10 leukocytes per HPF in EPS, 178 (98.9%) had less than 10 leukocytes per view field in VB3. In 148 men with 10 or more leukocytes per HPF in EPS, 136 (91.9%) also had elevated leukocyte counts in VB3. The presence of elevated leukocytes in VB3 predicted the presence of increased leukocytes in EPS with a high certainty: 91.9% sensitivity, 98.9% specificity, and 95.7% accuracy, with a positive and negative predictive value of 98.6% and 93.7%, respectively. CONCLUSIONS: We conclude that the determination of leukocytes in VB3 is a feasible and reliable method compared with the analysis of EPS. However, although this association does not directly prove the significance of VB3 in those patients from whom no EPS can be obtained, we suggest this method be taken into account as an indirect indicator in the diagnosis of inflammation.

Treatment-related stresses and depression in couples undergoing assisted reproductive treatment by IVF or ICSI.

The purposes of the study were to compare treatment-related stresses of couples undergoing IVF or ICSI treatment (ejaculated, epididymal or testicular spermatozoa) and to identify sex differences and risk factors for depression. A one-year cohort of couples was retrospectively sent questionnaires on infertility and treatment-related distress and depression (Depression Scale, D-S). Two hundred and eighty-one women and 281 men (61% of those eligible) were included. As determined by analysis of the medical charts, successful couples were more likely to participate. Treatment-related distress was generally higher for women than for men. Treatment by ICSI carried additional burdens for the men: they reported a greater subjective responsibility for the infertility, impact of childlessness on daily life, treatment-related stresses (particularly for MESA/TESE) and time demands. Even when clinical differences between treatments (e.g. age, previous treatments) were controlled statistically, depression scores did not differ. Independent of the treatment, women were significantly more depressed than their age-matched female controls from the general population and their husbands. The men only reported marginally elevated depression scores compared to their controls. Meaningful characteristics were identified that could guide clinicians to give psychological support to those couples at risk for depression, e.g. an unsuccessful treatment outcome, repeated treatment cycles, a low socioeconomic status, foreign nationality, or, for women, a lack of partner support.

Diagnosis and therapeutic management of 18 patients with prostatic abscess.

OBJECTIVES: Our retrospective study aimed to analyze the findings and therapeutic strategies in 18 men who were admitted to our department as outpatient emergency cases with prostatic abscess. METHODS: During the period 1985 to 1997, prostatic abscess was diagnosed in 18 patients (mean age 48 years, range 20 to 68) on the basis of evidence of fluctuation at digital rectal examination and transrectal ultrasound (TRUS) findings. Diagnostic workup included analysis of midstream urine and abscess fluid for leukocytes and pathogens. Therapeutic options were conservative treatment and/or draining procedures. RESULTS: Predisposing diseases were found in 13 men. Fluctuation at digitorectal palpation was present in 15 patients. In 3 patients, diagnosis was based on TRUS. All men demonstrated leukocytes in their midstream urine. Causative pathogens in midstream urine were found in 11 patients. In 3 men, additional microbiologic evaluation of abscess fluid revealed uncommon pathogens. All patients received antibiotic treatment. Nine men with monofocal abscess less than 1 cm in diameter were treated with antibiotic therapy and a suprapubic catheter. Surgical drainage (transperineal or transrectal puncture, partly guided by TRUS, or transurethral unroofing) was performed in 12 patients and included 3 patients in whom conservative treatment failed. CONCLUSIONS: Our data confirm the importance of predisposing factors in the pathogenesis of prostatic abscess. Medical history and analysis of midstream urine indicated a diagnosis that was confirmed by digital palpation. In some cases, TRUS may improve diagnosis and treatment. Although both operative and conservative therapy strategies appear feasible, prostatic abscess chiefly requires individually selected drainage procedures.

New aspects in Peyronie's disease--a mini-review.

There have been several advances in elucidation of the pathogenesis of Peyronie's disease. Transforming growth factor beta 1 seems to play a major role in this disease, while the importance of penile trauma is a matter of debate. High-resolution ultrasound sonography is the method of choice in detecting penile plaques, while magnetic resonance imaging is useful in the evaluation of actively inflamed plaques. There are still differences of opinion on the best drug therapy in noncalcified plaques. The results on tamoxifen or interferon therapy vary between useless and useful. Potassium-para-aminobenzoate seems to have a significant effect in decreasing plaque size and deviation angle. The operative strategy for big plaques or complex deviation has changed to the 'small incision' graft, leading to far lower post-operative impotence rates. Iontophoresis seems to be worthy of further trials, while the results of extracorporal shock wave therapy have to be discussed critically.