[Fatal complications after urological interventions-connection between error, damage and causality]. / Tödliche Komplikationen nach urologischen Eingriffen ­ ein Spannungsfeld: Fehler ­ Schaden ­ Kausalität.

Case studies from the clinic outline the connection between error, damage and causality. If the three "categories" mentioned are to be affirmed, recourse claims of the payers and the patients or their relatives are enforced in practice.

[Where do dangers lurk in informed consent and documentation and what are common technical mistakes?] / Wo lauern Gefahren bei Aufklärung und Dokumentation und was sind häufige handwerkliche Fehler?

In legal expert discussions, the following questions are usually raised: Is the procedure indicated? Have all diagnostic and therapeutic steps been carried out lege artis? Has sufficient informed consent been provided? Is there a diagnostic or treatment error? Did this cause any damage? Is the damage causally related to the error? Consideration of these fundamental questions in daily practice and good communication between patient-physician, physician-patient, and between physicians themselves is good protection in legal disputes.

[Prostate biopsy: Procedure in the clinical routine]. / Prostatabiopsie : Durchführung im klinischen Alltag.

Over the last decade there has been a 25% decrease in the mortality rates for prostate cancer. The reasons for this significant decrease are most likely associated with the application of urological screening tests. The main tools for early detection are currently increased public awareness of the disease, prostate-specific antigen (PSA) tests and transrectal ultrasound (TRUS) guided topographically assignable biopsy sampling. Together with the histopathological results these features provide essential information for risk stratification, diagnostics and therapy decisions. The evolution of prostate biopsy techniques as well as the use of PSA testing has led to an increased identification of asymptomatic men, where further clarification is necessary. Significant efforts and increased clinical research focus on determining the appropriate indications for a prostate biopsy and the optimal technique to achieve better detection rates. The most widely used imaging modality for the prostate is TRUS; however, there are no clearly defined standards for the clinical approach for each individual biopsy procedure, dealing with continuous technical optimization and in particular the developments in imaging. In this review the current principles, techniques, new approaches and instrumentation of prostate biopsy imaging control are presented within the framework of the structured educational approach.

[Economic implications of bedside communication errors]. / Ökonomische Implikationen fehlerhafter Kommunikation am Krankenbett.

Good communication can contribute significantly to avoiding expert disputes. An open and honest relationship in dealing with errors allows people to learn from them and avoid them in the future. This benefits both doctors and patients.

[Motivation and satisfaction of residents in urology]. / Assistentenmotivation und -zufriedenheit in der Urologie.

To address the increasing shortage of qualified residents, which leads to further discontent and additional on-call rotations for the remaining physicians, an analysis of the current situation was performed. Stress in the daily working routine, not enough free time, too little pay, or too little compensatory time off for overtime as well as inadequate options for continuing education were reported to be the main elements of dissatisfaction. The economic pressure of day-to-day work continues to define the physician's role and places demands on the medical staff by burdening them with nonmedical and administrative tasks.The major causes mentioned were staff shortage and lack of support provided by supervisors and the administration. For this reason, human resource development should be considered a strategic and central goal. This requires a normative, cross-functional approach at all levels of management and inclusion of personnel departments in the strategic processes of the hospital. The most important aspects for resident satisfaction were the work environment, acceptable work-life balance and remuneration, compensation for overtime, and quality of available continuing education, which is often rated as being insufficient.Effective strategies to improve the motivation of residents comprise offering opportunities for structured continuing education, optimizing the everyday work processes, and involving employees in social networks. The establishment of feedback strategies, including recognition of residents' achievements, will help to ensure their loyalty and identification with their clinic. This can serve as a preventive measure to offset any potential willingness to change jobs.

[Effects of the new further training regulations on the training behavior of assistant doctors]. / Auswirkungen der neuen Weiterbildungsordnung auf das Weiterbildungsverhalten der Assistenzärzte.

During the 106th "Deutschen Arztetag" (German Medical Assembly) in 2003 new model further training regulations were finalized. Further training was to be more clearly arranged and the targets more clearly defined. There are no uniform training regulations for Germany. The new training regulations promise more clarity: the numbers of the individual interventions and investigations are no longer specified. Instead operation groups which are connected with respect to content and organization in a defined minimum are to be identified. The new further training regulations are geared to a process orientation. For the first time trainers and trainees have the possibility to actively work together in the further training process. The joint logbook"Urological further training" from the GeSRU (German Society of Residents in Urology), DGU (German Society for Urology) and BDU (Professional Association of German Urologists) is a milestone in Germany. The further training will be continuously improved through constant evaluation.

[Bilateral intrauterine spermatic cord torsion with infarction]. / Beiderseitige intrauterine Hodentorsion mit Infarzierung.

Case report on an intrauterine torsion of the spermatic cord. The newborn was clinically in good condition, the enlarged and coarse scrotum being the only symptom. Surgery revealed necrosis of both testicles; their extirpation was mandatory. This is followed by a description of the diagnostic difficulties and by a comparative review of the literature.

Estimation of total PSA with a supersensitive PSA-assay during neo-adjuvant-chemotherapy of prostate cancer before radical resection of prostate.

43 patients with untreated and clinically localised prostate carcinoma (cT1-3NoM0) were submitted to neo-adjuvant complete androgen deprivation treatment and radical prostatectomy. Hormonal treatment was given until PSA (supersensitive Immulite 3rd generation assay) reached a value of < 0.1 ng/ml or the nadir value. The resultant mean duration of treatment was 6 months (3-22 months). 93% of our patients reached a PSA value of 0.1 ng/ml or below. The nadir of 6 patients was between 0.1-0.3 ng/ml. In one case it remained above 0.3 ng/ml. 82% had a measurable hypoechoic lesion on initial transrectal ultrasound. 84% of these became smaller, 7.5% remained unchanged and 8.5% increased. Of the patients with cT1-2 tumours 2% had a positive margin and in 28% of the specimens no tumour tissue could be detected at the time of prostatectomy. Of the initial patients with epithelial cells in bone marrow only 14% remained positive after controlled induction and all of them had fewer cells than before. Five patients relapsed showing raising PSA values > 0.1 ng/ml in the follow-up. In this group the mean PSA and the time of nadir was significantly higher (0.15 ng/ml) than the mean PSA at the time of nadir of the rest of the group (0.06 ng/ml). Supersensitive PSA assays like Immulite 3rd generation offer a valuable tool to collect data for clinical evaluation to optimise therapy of prostate carcinomas.

Supersensitive PSA-monitored neoadjuvant hormone treatment of clinically localized prostate cancer: effects on positive margins, tumor detection and epithelial cells in bone marrow.

OBJECTIVE: The present study was done to investigate the effects of supersensitive PSA-controlled inductive treatment on positive margins, detection of tumor and epithelial cells in bone marrow of 101 patients with untreated and clinically localized prostatic carcinoma (cT1-3N0M0). METHODS: Hormonal treatment was given until PSA (DPD Immulite(R) third-generation assay) reached <0.1 ng/ml or the nadir value, as shown by two consecutive measurements at monthly intervals. RESULTS: The resultant median duration of treatment was 6 months (range 3-22). Ninety-three (93%) of our patients reached a PSA value <0.1 ng/ml. The nadir of 6 patients (6%) was between 0.1 and 0.3 ng/ml, and it remained >0.3 ng/ml in only 1 case. Of the 101 patients, 82 had a measurable hypoic lesion on initial transrectal ultrasound. 84% of these became smaller, 7.5% remained unchanged and 8.5% increased. Of the 101 prostatectomy specimens, 20 (20%) were margin-positive. The incidence of affected margins was relatively high (35% from 55 patients) with cT3 tumors, but almost negligible (2% from 46 patients) in cT1-2 tumor. Our pathologists, despite their great experience in evaluating hormonally treated prostates (>500 cases) and using immunohistochemical staining, were unable to detect carcinoma in 15 (15%) specimens. Whereas only 2 (4%) of the 55 cT3 specimens were without detectable tumor, this incidence rised to 28% (13 of 46 prostates) in patients with cT1-2 tumors. Of the initial 29 patients with epithelial cells in bone marrow, only 4 (14%) remained positive after controlled induction and all of them had fewer cells than before. CONCLUSION: Endocrine induction controlled by a supersensitive PSA assay and continued until reaching PSA nadir is highly effective in clearing surgical margins and eliminating tumor cells from bone marrow. It seems to be clearly superior to the conventional 3 months of pretreatment at least in cT1-2 tumors in respect to surgical margins and detectability of tumor in the resected prostate. A definitive statement about the value of endocrine induction can only be given by prospective randomized studies, with optimal drugs, doses and treatment time. But the conventional 3 months of pretreatment are far from exploiting the possibilities of this therapeutic option.

Immunocytochemical monitoring of micrometastatic disease: reduction of prostate cancer cells in bone marrow by androgen deprivation.

Occult dissemination of tumor cells mainly determines the prognosis of patients with primary prostate cancer. The effect of androgen deprivation on micrometastatic tumor cells in these patients is currently unknown. We therefore used an immunocytochemical assay with monoclonal antibodies (MAbs) directed against epithelial cytoskeleton proteins (i.e., cytokeratins) to monitor the concentration of isolated tumor cells in the bone marrow of 36 prostate cancer patients (stage C), who underwent hormonal androgen deprivation with Flutamide and Leuprorelin acetate. Tumor cells in cytologic bone marrow preparations were detected using an assay that employed the MAb CK2 directed against cytokeratin (CK) 18 and the alkaline anti-alkaline phosphatase staining method. Prior to therapy, we detected between 1 and 38 CK-positive cells per sample of 2 x 10(6) nucleated cells in 21 patients, while the remaining 15 patients displayed tumor-free marrow samples. There was no significant correlation between the concentration of CK-positive cells and the volume of hypo-echogenic lesions as an indicator of the primary tumor volume or the serum level of prostate-specific antigen (PSA). After androgen deprivation, 20 of the 21 initially positive patients either became negative (n = 16) or showed at least a reduction in the concentration of CK-positive cells (n = 4). Moreover, only 2 of the 15 patients with negative pre-treatment findings became positive. All of the 7 patients with remaining tumor cells in the bone marrow after therapy showed no detectable amounts of PSA in their serum. Our findings suggest that serum PSA concentration is no indicator of micrometastatic disease in bone marrow. Neoadjuvant androgen deprivation appears to eliminate disseminated CK-positive tumor cells present in bone marrow, a preferred site of overt metastasis in prostate cancer patients.