[Urinary stress incontinence after radical prostatectomy in treatment reality : Results of a rehabilitation clinic-2009 compared to 2016]. / Belastungsharninkontinenz nach radikaler Prostatektomie in der Versorgungswirklichkeit : Ergebnisse einer Reha-Klinik 2009 und 2016.

PURPOSE: Based on the work of Lent et al., the aim of this study was to compare and to evaluate the 2009 outcomes of maintaining continence after radical prostatectomy (rp) with those of patients from 2016. PATIENTS AND METHODS: The data of all patients who underwent follow-up treatment 1 to 8 weeks after rp in 2016 (n = 1392) were evaluated by quantitative measuring all day incontinence under a defined graduation and compared to the results of 2009 (n = 1750). RESULTS: The basic data of the patients including age (p < 0.001), prostate-specific antigen (PSA) value (median 10.8/13.76 ng/ml in 2009/2016), cancer stage (p = 0.001) and Gleason score (p = 0.001) were significantly higher in 2016. Robot-assisted prostatectomy (RARP; 12% in 2009 to 45% in 2016) was performed much more often than radical retropubic prostatectomy. Laparoscopic and perineal prostatectomy were rarely performed. Significantly fewer patients achieved pad-free continence at discharge in 2016 (23%) vs. 33.9% in 2009; p ≤ 0.001. Within the same age group, there was a significant worsening of continence (p = 0.01). The results of maintaining continence did not significantly differ between patients with open retropubic prostatectomy and RARP (p = 0.078). The certification type of a clinic had no effect on continence preservation (p = 0.12). CONCLUSION: Incontinence rates after discharge from a rehabilitation clinic are high and have not improved over time or with new surgical techniques. The patient should be prepared for this in the patient information discussion prior to the surgery.

[Types and harms of medical errors in urology: results of reviews from 1999-2019]. / Fehlerarten und Fehlerschäden in der Urologie: Ergebnisse von Begutachtungen 1999­2019.

BACKGROUND AND OBJECTIVE: Medical errors are comprised of various problems. Influencing factors include the diseases and procedures involved, the types of errors and the consequential harms of the respective treatment processes. Their contribution is determined for the first time in an extended systematic analysis of errors ascertained by a professional commission. METHODS AND RESULTS: In all, 236 confirmed errors were analyzed based on 359 expert examinations by a professional commission from 1999 to 2019 regarding causes and consequences of errors. Errors occurring in a practice (103/43.6%) concerned diagnosis (69/29.3%) and therapy (34/14.4%). In contrast, errors occurring in a clinic (159/67.4%) concerned most often therapy (144/61.0%) and rarely diagnosis (15/6.4%). Some diseases and procedures were involved significantly more often than others, depending on their frequency and complexity or on the quality of treatment and the avoidance of errors. Types of errors were: diagnostics: inadequate examination (112/47.5%) or assessment (86/36.4%) of findings; indication: reason lacking (58/24.6%), disregarded or against (33/14.0%) intervention; information: inadequate explanation of risks (24/10.2%); therapy: inadequate performance of technique (59/25.0%), organization of treatment (16/6.8%), medication (6/5.5%); aftercare: inadequate follow-up (20/8.5%), information (15/6.3), management of complications (13/5.5%); documentation: inadequate (19/8.1%) and/or falsified (4/1.7%) records. Direct/primary harms of errors were: complications (126/54.7%), Clavien 3/4 (120/50.8%), Clavien 5 (death; 16/6.8%), unnecessary surgery (39/16.5%) or medication (40/16.9); surgical revision (83/35.2%), revision with intensive care (55/14.9%), error correction for mistake made elsewhere in a clinic (131/55.1%) or practice (13/5.5%). Indirect/secondary harms of errors were: delayed diagnosis/therapy (94/39.8%), functional or organic loss of kidney (6/2.5% or 7/3.0%), testis (2/0.8% or 22/9.3%), urinary sphincter (14/5.9%); extended/increased need of treatment (167/70.8%), prolonged suffering/diminished quality of life (173/73.3%), diminished chance of healing/prognosis (45/19.1%). CONCLUSION: Based on a systematic analysis of medical reviews over two decades, a summary is provided regarding types of diseases and procedures that are particularly prone to error in urology, the types of errors in the treatment process that give rise to direct and indirect medical error, and the that consequences have to be drawn.

[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.

[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.

[Residents training in private practice : Conflicts between circumstances, willingness, and reality]. / Facharztweiterbildung in der Niederlassung : Im Spannungsfeld zwischen Rahmenbedingungen, Bereitschaft und Wirklichkeit.

BACKGROUND: The increasing average age of urologists in private practice and outpatient treatment needs means that there is an increased demand for young urologists to cover outpatient care. Due to the increasing range of treatments, residents lack the mediation of those treatment methods and medical conditions which are necessary to become competent in the complete field of urology. OBJECTIVES: To assess the willingness, the requirements, and the current implementation of residents training in private practice. MATERIALS AND METHODS: A 14-item online survey was sent to 1326 urologists in private practice to measure the willingness, the requirements, and the current implementation of residents training. RESULTS: Of the 219 (17 %) respondents, 25 % have already trained residents, 41 % were authorized to provide training to residents, and 87 % have taken the appointment of a trainee into consideration. The main reason for employing a trainee was the enjoyment of the teaching experience. The main reason against employing a trainee was the lack of financial compensation. CONCLUSIONS: Urologists in private practice are willing and able to participate in residents' training. An extended integration of urological training into private practice can contribute to ensure the teaching of a wide variety of diseases/procedures and influence structural changes in the field of urology. Residents, private practitioners, and clinicians should search for solutions together with those responsible in the health care system for better integration of private practice into urology residents training.

[Treatment errors involving diagnosis using prostate specific antigen. Decisions of the commission of experts for medical mistakes of treatment of the state medical board of North Rhine]. / Behandlungsfehler im Zusammenhang mit der Bestimmung des prostataspezifischen Antigens Entscheidungen der Gutachterkommission für ärztliche Behandlungsfehler bei der Arztekammer Nordrhein.

Advances in prostate specific antigen (PSA) diagnosis are accompanied by deficits in realization. The justification of claims by affected patients against their doctors are reviewed by commissions of experts and mediation by medical councils out of court, impartial and free of charge. The objectivity of the review is ensured by the independence of the commission and its members as well as the determination of facts and their assessment. Criteria are professional standards and required care. Since 1995, 21 requests by affected patients have been reviewed. In 15 cases (71.4%), treatment errors were ascertained. This involved either a delayed or an insufficient diagnosis (prostatic biopsy). In ten of the patients, a mostly early prostate cancer would have be diagnosed and treated at the time of the first finding of PSA values between 3.3 and 10.4 ng/ml. In ten of 13 patients, the tumor was diagnosed late, having PSA values between 6.8 and 1251 ng/ml with no chance of curative therapy. As in other life threatening diseases, time of recognition is most important for the diagnosis and treatment of patients with prostate cancer. Particularly for early recognition, PSA is much more sensitive then digital rectal examination, and in cases without a digital finding is the only parameter for early diagnoses. In men with suspicious PSA values (>4.0 ng/ml) suitable a diagnostic test (prostate biopsy) is required early, until cancer is detected or excluded.

[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.

[Economic importance of postoperative urinary incontinence]. / Volkswirtschaftliche Bedeutung der postoperativen Harninkontinenz.

In the 22,160 patients treated in Germany for prostate cancer by prostatectomy, the costs for direct and indirect sequelae as the result of postoperative urinary incontinence are estimated to be 71.8 million €. This greatly exceeds the costs of 69.8 million € for the operation itself. This additional economic burden can, however, be decisively influenced by using a surgical technique that preserves the integrity of the urethral sphincter.

[Experiences with a modified nephrostomy instrument kit in ultrasound-guided kidney fistulization]. / Erfahrungen mit einem modifizierten Nephrostomiebesteck bei ultraschallgeführter Nierenfistelung.

During a period of 24 months, ultrasound-guided percutaneous nephrostomies were performed in 51 patients in the Hospital at Köln-Merheim. The procedure was carried out with a modified nephrostomy instrument manufactured by Angiomed, Ettlingen, according to our own design. The procedure was successful in 49 patients. In one case it had to be abandoned because of lack of patient co-operation. In one patient a pyonephrosis was found and the patient was treated surgically.

[What treatment in kidney trauma? A critical evaluation treatment reports up to now based on a new classification]. / Welche Behandlung beim Nierentrauma? Eine kritische Bewertung bisheriger Behandlungsberichte anhand einer neuen Klassifikation.

The objective of treatment in renal injuries is to save the life of the traumatized patient, to maintain the function of the affected kidney(s) and to avoid later complications with their sequelae. It has not by any means been established what therapeutic measures (conservative or surgical) are appropriate to obtain the best results in certain traumas, e.g. penetrating injuries, 'moderately severe' parenchymal ruptures or obstructive vascular lesions, since 'conservative' does not automatically entail that there is no operation, and no operation does not automatically mean 'conservative'. According to my own analysis of treatment reports published up to now, inadequate classifications play a major role amongst the multivarious reasons for this. The results and complications are based on such heterogeneous criteria that valid comparisons are not possible. More differentiated measures with modern interventional and surgical techniques appropriate to each individual case can be used for a treatment enabling maximal preservation of the kidneys and which is as free of complications as possible. However, this presupposes a differentiated classification which takes all the relevant factors of renal trauma into consideration. Such a classification of the pathogenesis, location, extent and symptoms as prognostic factors is presented in a suggestion of my own in a gradual differentiation and a simple trauma formula. This enables therapies to be compared, and facilitates clinical decision-making, thereby improving the results of renal trauma treatment.

[Pseudotumor of the urinary bladder and intestino-vesical fistula in ileitis regionalis (Crohn's disease) and diverticulitis. Surgical tactic and technic]. / Harnblasen-Pseudotumor und Darm-Blasen-Fistel bei Ileitis regionalis (M. Crohn) und Divertikulitis. Operative Taktik und Technik.

Pseudotumor of the urinary bladder and intestino-vesical fistula caused by regional ileitis (Crohn's disease) and diverticulitis require radical en bloc resection. The authors present their own procedure.

[Transverse incision in ureterolithotomy]. / Die quere Ureterolithotomie.

Anatomical, physiological, physical and technical reasons support a transverse ureteral incision for stone removal. Its advantages are confirmed by early clinical and radiological results.

[Hemangioma of scrotum (author's transl)]. / Scrotalhämangiome.

We present a thirty years old man with a large scrotal cavernous hemangioma and discuss the diagnosis and the therapeutic problems.

[Adrenal gland cysts. Case reports and potential complications--review of the literature (author's transl)]. / Nebennierenzysten. Fallberichte und Komplikationsmöglichkeiten--Literaturübersicht

Adrenal cysts are rare, mostly harmless, processes, either congenital inborn or acquired by regression, bleeding, infection and tumor. In the case of endocrine dysfunction with arterial hypertension and local expansion with perforation into the retroperitoneal, peritoneal and pleural cavity, purulence, bleeding and vasal obstruction complications are serious. In the differential diagnosis carcinoma of the kidney and the adrenal gland should be excluded.

[Macrohematuria associated with ruptured abdominal aneurysm (author's transl)]. / Makrohämaturie bei rupturiertem Bauchaortenaneurysma

Macrohematuria associated with rupture abdominal aneurysm is caused by renal infarction due to renal arterial compression or dissection, by renal congestion due to renal venous perforation, by urinary bladder congestion due to aortocaval fistula, possibly by hydronephrosis due to ureteral obstruction, and by urinary bladder perforation. Also in the case of a simultaneous urologic finding treatment of the aneurysm is urgent.

[Cholesteatoma of the renal pelvis (author's transl)]. / Cholesteatom des Nierenbeckens.

A 63-year-old male experienced pain in the epigastric region and a septic fiver. X-ray examinations showed a tumor-like process in the lower part of the left kidney with some concrements. Upon operation a nodular inflammatory tumor was found, occupying more than two-thirds of the left kidney. Histologic examination revealed a typical cholesteatoma of the renal pelvis and calyces with some concrements among the abundant keratin material.

[Eduard Lent (1831-1911): founder and supporter of public health care, social institutions, and physician self-management]. / Eduard Lent (1831-1911) : Begründer und Förderer öffentlicher Gesundheitspflege, sozialer Einrichtungen und ärztlicher Selbstverwaltung.

Modern urology owes much to our predecessors. Researchers in the 20th century were able to develop their specialist techniques and their professional independence on the basis of the fundamental studies and measures carried out by their predecessors in the 19th century. As a medical practitioner, Eduard Lent provided pioneering solutions to the three major sociomedical problems of his time, namely wide-spread epidemics like cholera, social inequalities, and lack of organization of the medical profession. His answer are to be found in the organization of public healthcare, establishment of suitable social institutions, and the promotion of self-government of the medical profession. These achievements have left their imprint on many fields, including urology.

[Ureteroarterial fistula - pathogenesis, diagnostics, and therapeutic outcome]. / Die uretero-arterielle Fistel - Ursachen, Diagnostik und Therapieergebnisse.

Although ureteroarterial fistulas are rare, they result in a high mortality because of the massive urogenital haemorrhage. The diagnosis is often difficult even when invasive measures are applied. Including the ureteroarterial fistula in the diagnostic process in cases of macrohaematuria with a positive medical history can be helpful. A ureteroarterial fistula typically develops in pa-tients who have undergone pelvic surgery and radiation as well as after long-term ureteral stents. Patients are usually multimorbid. The treatment of choice consists of fistula exclusion by stent graft deployment in the iliac artery and application of a ureteral stent or a ureterostomy. The significance of surgical treatment is diminishing. The long-term results of endovascular treatment, however, are inconsistent because of stent infections and recurrent bleeding. Therefore, close patient surveillance and cooperation among the treating specialists is necessary.·

[Eversion orchidopexy as prophylaxis for recurrence of testicular torsion]. / Die Umwendungsorchidopexie zur Rezidivprophylaxe einer Hodentorsion.

BACKGROUND: In patients with torsion of the testis, in addition to the urgency of early recognition and immediate operation, it is questionable which method should be used to prevent renewed torsion of the affected and/or contralateral testis with the least damage and most enduring results. Direct suturing or indirect adhesion fixation are recommended as alternative methods. A review of the literature has shown, however, that recurrence of testicular torsion can occur in many cases and that in some cases this leads to complete anatomical or functional loss of the testis. PATIENTS AND METHODS: As a logical continuation of a successful pilot study, it was retrospectively investigated by means of a structured questionnaire whether the known eversion operations according to Jaboulay or Kocher for the treatment of idiopathic hydrocele of the testis were also suitable as organ-sparing and enduring procedures for the prophylaxis of recurrent testicular torsion. RESULTS: In 53 out of 76 patients who were treated exclusively for testicular torsion by means of eversion orchidopexy between 1988 and 2008, no evidence of any subsequent recurrent testicular torsion or any other testicular disease was found by means of a structured questionnaire 1-21 years later. Occasional cicatricial symptoms that were of no clinical significance were found in only 5 cases (9.4%). CONCLUSIONS: On the basis of these results it may be concluded that eversion orchidopexy can be considered to be a safe and effective method for the prophylaxis of recurrent testicular torsion in comparison to alternative methods.

[Medical reviews of claims for damages and errors in urology]. / Ärztliche Begutachtung bei Vorwürfen von Behandlungsfehlern in der Urologie.

In liability law, a medical review is considered to be an expert opinion that is provided at the request of those involved (patient or physician) of a course of treatment. It must be carried out according to defined criteria with the aim of providing a plausible basis for arbitration. This is achieved by means of an objective determination of the facts, a reasonable assessment of the error(s) and (where appropriate) a realistic description of the injury involved. The following fields should be covered in a concise review: conditions and procedures applied to the review, criteria to be used in the review, types of error that are possible during the treatment, assessment of the treatment errors committed, possible treatment errors that can occur in urology, conclusions to be drawn from the review. In summary, a medical assessment carried out in the course of claims for damages should provide a balanced assessment that takes into account the confidential relationship between the physician and patient. This means that the review procedure must be performed under the best possible conditions for professional standards and care.