[Physician health: What makes us ill? What keeps us healthy?] / Arztgesundheit: Was macht uns krank ­ Was hält uns gesund?

The medical profession is a particular health risk. Internal reasons for this are the common practice of self-diagnosis and self-therapy, presenteeism (work despite illness), and increased risks of addiction and suicide. External reasons include infectious diseases, violence against health professionals, the increasingly difficult working conditions - due to economisation, among other things - and the posttraumatic stress syndrome. Therefore, it is increasingly important to proactively take care of one`s own health. Science has shown that the underlying mechanisms leading to this problem are the high self-demand and lack of self-care observed in medical professionals. These starting points and available programs (cognitive-emotional reflection, stress management, relaxation techniques, conflict resolution techniques, mindfulness, priming, framing, meditation, embodiment, etc.) to strengthen resilience offer instruments to optimise the salutogenesis of health professionals. This review article presents interdependencies and concepts aiming to strengthen the resilience of health professionals.

Bi-layer sandwich film for antibacterial catheters.

Background: Approximately one quarter of all nosocomial infections can be attributed to the urinary tract. The infections are supposed to be mainly caused by implantations of urethral catheters and stents. A new catheter design is introduced with the aim to lower the high number of nosocomial urethral infections. In order to avoid limitations to use, the design is first applied to conventional commercially available balloon catheters. Results: The main feature of the design is a sandwich layer on both sides of the catheter wall, which is composed of a fragmented base layer of silver capped by a thin film of poly(p-xylylene). This top layer is mainly designed to release a controlled amount of Ag+ ions, which is bactericidal, but not toxic to humans. Simultaneously, the lifetime is prolonged to at least one year. The base layer is electrolessly deposited applying Tollens' reagens, the cap layer is deposited by using chemical vapor deposition. Conclusion: The three main problems of this process, electroless deposition of a fragmented silver film on the surface of an electrically insulating organic polymer, irreproducible evaporation during heating of the precursor, and exponential decrease of the layer thickness along the capillary, have been solved trough the application of a simple electrochemical reaction and two standard principles of physics: Papin's pot and the principle of Le Chatelier.

Efficacy of silver/hydrophilic poly(p-xylylene) on preventing bacterial growth and biofilm formation in urinary catheters.

Catheter associated urinary tract infections (CAUTI), caused by several strains of bacteria, are a common complication for catheterized patients. This may eventually lead to a blockage of the catheter due to the formation of a crystalline or amorphous biofilm. Inhibiting bacteria should result in a longer application time free of complaints. This issue has been investigated using an innovative type of silver-coated catheter with a semipermeable cap layer to prevent CAUTI. In this work, two different types of silver catheters were investigated, both of which were capped with poly(p-xylylene) (PPX-N) and exhibited different surface properties that completely changed their wetting conduct with water. The contact angle of conventionally deposited PPX-N is approximately 80°. After O2 plasma treatment, the contact angle drops to approximately 30°. These two systems, Ag/PPX-N and Ag/PPX-N-O2, were tested in synthetic urine at a body temperature of 37 °C. First, the optical density and the inhibition zones of both bacteria strains (Escherichia coli and Staphylococcus cohnii) were examined to confirm the antibacterial effect of these silver-coated catheters. Afterward, the efficacy of silver catheters with different treatments of biofilm formed by E. coli and S. cohnii were tested with crystal violet staining assays. To estimate the life cycles of silver/PPX-catheters, the eluted amount of silver was assessed at several time intervals by anodic stripping voltammetry. The silver catheter with hydrophilic PPX-N coating limited bacterial growth in synthetic urine and prevented biofilm formation. The authors attribute the enhanced bacteriostatic effect to increased silver ion release detected under these conditions. With this extensive preparatory analytic work, the authors studied the ability of the two different cap layers (without silver), PPX-N and oxygen plasma treated PPX-N, to control the growth of a crystalline biofilm by measuring the concentrations of the Ca2+ and Mg2+ ions after exposure of the catheters to saturated urine for 24 h. The higher concentrations of Ca2+ and Mg2+ in the precipitates on the PPX-N catheters indicates that the hydrophilic PPX-N coating is superior to the simple PPX-N coating, with regard to the formation of a crystalline biofilm. Moreover, hydrophilic PPX-N as a cap layer may promote wettability and increase silver ion release rate and thus reduce the adhesion of suspended crystals to the catheter. Reduced bacterial growth and reduced adhesion may help to prevent CAUTI.

Results of multiparametric transrectal ultrasound-based focal high-dose-rate dose escalation combined with supplementary external beam irradiation in intermediate- and high-risk localized prostate cancer patients.

PURPOSE: Clinical results of a biologic information-based focused dose escalation combined with dose de-escalation for the whole organ in external beam radiotherapy + high-dose-rate brachytherapy (HDR-BT) boost application for localized prostate cancer in a consecutively treated patient cohort. METHODS AND MATERIALS: One hundred thirty patients were treated with external beam radiotherapy (50 Gy) complementary to two multiparametric transrectal ultrasound-guided 15 Gy HDR-BT fractions. Real-time multiparametric transrectal ultrasound-based biologic planning for high-dose-rate boost dose planning used the summation of gray scale and Doppler sonography imaging + biopsy information. Target subvolumes received HDR-BT dose escalation up to 60 Gy/fraction. Dose-volume histogram parameters, organ at risks doses, and toxicity results were investigated. RESULTS: The median followup was 4.3 years, the median age was 68.62 years, and the mean initial prostate-specific antigen was 18.69 ng/mL. Low-, intermediate-, and high-risk constituted 69%, 21%, and 10% of the patients, respectively. The mean peripheral dose was 3.9 Gy per fraction. Prostate-specific antigen nadir was in 93% of the patients ≤1 ng/mL. Quality parameters were as follows: D90: 6.58 Gy, V100: 30.36%, V150: 9.96%, V200: 3.16%, uD0.1: 7.34 Gy, uD2: 9.34 Gy, rD01: 10.56 Gy, and rD2: 8.32 Gy, respectively. We observed G1, G2, G3 urinary toxicity in 17/130, 11/130, and 2/130 patients, respectively. Rectal toxicity: G1 and G2 occurred in 19/130 and 2/130 patients with mean dose values G1: 8.2 Gy and G2: 8.76 Gy. Analysis of variance test resulted in no correlation between toxicities and any other investigated factors. CONCLUSIONS: Focused extreme dose escalation with low prostate mean peripheral dose results in excellent long-term outcome data and very high focal boost doses and is causing no enhancement in late treatment toxicity.

Stone/tissue differentiation for Holmium laser lithotripsy using autofluorescence: Clinical proof of concept study.

BACKGROUND AND OBJECTIVES: Holmium laser lithotripsy is the gold standard for intracorporeal fragmentation of urinary calculi. Usually, a visible beam is superimposed on the IR treatment laser as an aiming beam to guide the surgeon. In vitro tests showed that this aiming beam (532 nm, power <1 mW) excites strong fluorescence on human calculi. Tissue, in contrast, emitted much weaker fluorescence. If this is verified in vivo, the fluorescence signal induced by the aiming beam could be used to implement a feedback loop, preventing the Holmium laser being fired on tissue. MATERIALS AND METHODS: Fluorescence signals of 67 tissue and 68 stone spots were measured in a clinical proof of concept study with eight patients. For this, a modulated excitation/detection scheme (lock-in technique) was implemented. A frequency-doubled, diode-pumped solid-state laser module (532 nm, modulation frequency 66 Hz, average power 0.3 mW) was coupled via a dichroic mirror with the Holmium lithotripsy laser into the treatment fiber. The fluorescence signal entering the treatment fiber was detected via another dichroic mirror with a photodiode and a lock-in amplifier. RESULTS: In most instances (94%), the calculus of a patient gave a signal which was at least twice the maximum signal of ureteral tissue. CONCLUSION: The results of our proof of concept study indicate that measuring the fluorescence signal of a green aiming beam could be used to implement a feedback loop for Holmium laser lithotripsy. Preventing the laser being fired on tissue, this would increase the safety of the procedure. Lasers Surg. Med. 49:361-365, 2017. © 2016 Wiley Periodicals, Inc.

First Clinical Experience with Extracorporeally Induced Destruction of Kidney Stones by Shock Waves.

We performed extracorporeally induced destruction of kidney stones on 72 patients. No complications have resulted from the tissue exposure to high energy shock waves. Clearance studies before and after the shock wave treatment indicate no changes in renal function. The method was used successfully in all patients with stones in the renal pelvis. In none of these patients was an open operation required. Two patients with ureteral stones also were treated with shock waves but had to be operated upon because of insufficient destruction of the stone.

Silver ions eluted from partially protected silver nanoparticles.

The most prominent character of a new type of antibacterial urological catheters is the zebra-stripe pattern of a silver film, which is plated electroless on their interior wall and capped by a very thin semipermeable layer of parylene. This design effectively controls the release rate of Ag(+) ions in artificial urine, which has been measured as function of time with optical emission spectroscopy. By evaluating the minimum inhibitory concentration against certain strains of bacteria with solutions of AgNO3 of known concentration with the method of optical density and applying this analysis to the silver-eluting catheters, it was shown that this moderation prolongs the period of their application significantly. But to act as antibacterial agent in chlorine-containing solutions, as in urine, the presence of urea is required to avoid precipitation of AgCl and to meet or even exceed the minimum inhibitory concentration of Ag(+). The quality of the silver depot layer was further determined by the deposition rate and its morphology, which revealed that the film consisted of grains with a mean size of 150 nm.

Self-adjuvanted mRNA vaccination in advanced prostate cancer patients: a first-in-man phase I/IIa study.

BACKGROUND: CV9103 is a prostate-cancer vaccine containing self-adjuvanted mRNA (RNActive®) encoding the antigens PSA, PSCA, PSMA, and STEAP1. This phase I/IIa study evaluated safety and immunogenicity of CV9103 in patients with advanced castration-resistant prostate-cancer. METHODS: 44 Patients received up to 5 intra-dermal vaccinations. Three dose levels of total mRNA were tested in Phase I in cohorts of 3-6 patients to determine a recommended dose. In phase II, 32 additional patients were treated at the recommended dose. The primary endpoint was safety and tolerability, the secondary endpoint was induction of antigen specific immune responses monitored at baseline and at weeks 5, 9 and 17. RESULTS: The most frequent adverse events were grade 1/2 injection site erythema, injection site reactions, fatigue, pyrexia, chills and influenza-like illness. Possibly treatment related urinary retention occurred in 3 patients. The recommended dose was 1280 µg. A total of 26/33 evaluable patients treated at 1280 µg developed an immune response, directed against multiple antigens in 15 out of 33 patients. One patient showed a confirmed PSA response. In the subgroup of 36 metastatic patients, the Kaplan-Meier estimate of median overall survival was 31.4 months [95 % CI: 21.2; n.a]. CONCLUSIONS: The self-adjuvanted RNActive® vaccine CV9103 was well tolerated and immunogenic. The technology is a versatile, fast and cost-effective platform allowing for creation of vaccines. The follow-up vaccine CV9104 including the additional antigens prostatic acid phosphatase (PAP) and Muc1 is currently being tested in a randomized phase IIb trial to assess the clinical benefit induced by this new vaccination approach. TRIAL REGISTRATION: EU Clinical Trials Register: EudraCT number 2008-003967-37, registered 27 Jan 2009.

Stone/tissue differentiation during intracorporeal lithotripsy using diffuse white light reflectance spectroscopy: In vitro and clinical measurements.

BACKGROUND AND OBJECTIVE: Holmium laser lithotripsy is the 'gold standard' for intracorporeal fragmentation of stones. However, there is a risk of damaging and perforating the ureter wall when the laser is accidentally fired while the fiber is in contact with tissue. The aim of this study was to evaluate if white illumination light, diffusely reflected back into the treatment fiber and spectrally analyzed, can be used for differentiating between stone and tissue. STUDY DESIGN/MATERIALS AND METHODS: Firstly, in vitro reflectance spectra (Xenon light source, wavelength range λ = 350-850 nm) of 38 human kidney stones, porcine renal calix and ureter tissue were collected. Secondly, in an in vivo study with 8 patients, 72 ureter and 49 stone reflectance signals were recorded during endourological interventions. The spectra were analyzed to discriminate between stone and tissue by the absence or presence of minima due to hemoglobin absorption at λ1 = 542nm and λ3 = 576nm. RESULTS: In vitro, all stone and tissue signals could correctly be identified by calculating the ratio R = I (λ1 = 542 nm)/I (λ2 = 475 nm): Because of the hemoglobin absorption at λ1 , R is smaller for tissue than for calculi. In vivo, only 75% tissue spots could correctly be identified utilizing this method. Using the more sophisticated evaluation of looking for minima in the diffuse reflectance spectra at λ1 = 542 nm and λ3 = 576 nm, 62 out of 64 tissue spots were correctly identified (sensitivity 96.9%). This was also the case for 39 out of 43 stone spots. Taking into account the number of measured spectra, a tissue detection probability of 91% and a stone detection probability of 77% was achieved (significance level 5%). CONCLUSION: White light diffusely reflected off the treatment zone into the fiber can be used to strongly improve the safety of Holmium laser lithotripsy by implementing an automatic feedback control algorithm that averts mispositioning the fiber.

Damage of stone baskets by endourologic lithotripters: a laboratory study of 5 lithotripters and 4 basket types.

Background. In some cases, the ureteral stone is simultaneously stabilized by a stone basket when endourologic lithotripsy is performed. This stabilization can be either on purpose or by accident. By accident means that an impaction in the ureter occurs by an extraction of a stone with a basket. A stabilization on purpose means to avoid a retropulsion of the stone into the kidney during lithotripsy. At this part of the operation, stone baskets have been frequently damaged. This severing of wires can lead to ureteral trauma because of hook formation. Material and Methods. In a laboratory setting, the time and the pulse numbers were measured until breaking the wires from four different nitinol stone baskets by using five different lithotripsy devices. The endpoint was gross visibledamage to the wire and loss of electric conduction. Results. The Ho:YAG laser and the ultrasonic device were able to destroy almost all the wires. The ballistic devices and the electrohydraulic device were able to destroy thin wires. Conclusion. The operating surgeon should know the risk of damagefor every lithotripter. The Ho:YAG-laser and the ultrasonic device should be classified as dangerous for the basket wire with all adverse effects to the patient.

Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data.

BACKGROUND: Studies on hexaminolevulinate (HAL) cystoscopy report improved detection of bladder tumours. However, recent meta-analyses report conflicting effects on recurrence. OBJECTIVE: To assess available clinical data for blue light (BL) HAL cystoscopy on the detection of Ta/T1 and carcinoma in situ (CIS) tumours, and on tumour recurrence. DESIGN, SETTING, AND PARTICIPANTS: This meta-analysis reviewed raw data from prospective studies on 1345 patients with known or suspected non-muscle-invasive bladder cancer (NMIBC). INTERVENTION: A single application of HAL cystoscopy was used as an adjunct to white light (WL) cystoscopy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We studied the detection of NMIBC (intention to treat [ITT]: n=831; six studies) and recurrence (per protocol: n=634; three studies) up to 1 yr. DerSimonian and Laird's random-effects model was used to obtain pooled relative risks (RRs) and associated 95% confidence intervals (CIs) for outcomes for detection. RESULTS AND LIMITATIONS: BL cystoscopy detected significantly more Ta tumours (14.7%; p<0.001; odds ratio [OR]: 4.898; 95% CI, 1.937-12.390) and CIS lesions (40.8%; p<0.001; OR: 12.372; 95% CI, 6.343-24.133) than WL. There were 24.9% patients with at least one additional Ta/T1 tumour seen with BL (p<0.001), significant also in patients with primary (20.7%; p<0.001) and recurrent cancer (27.7%; p<0.001), and in patients at high risk (27.0%; p<0.001) and intermediate risk (35.7%; p=0.004). In 26.7% of patients, CIS was detected only by BL (p<0.001) and was also significant in patients with primary (28.0%; p<0.001) and recurrent cancer (25.0%; p<0.001). Recurrence rates up to 12 mo were significantly lower overall with BL, 34.5% versus 45.4% (p=0.006; RR: 0.761 [0.627-0.924]), and lower in patients with T1 or CIS (p=0.052; RR: 0.696 [0.482-1.003]), Ta (p=0.040; RR: 0.804 [0.653-0.991]), and in high-risk (p=0.050) and low-risk (p=0.029) subgroups. Some subgroups had too few patients to allow statistically meaningful analysis. Heterogeneity was minimised by the statistical analysis method used. CONCLUSIONS: This meta-analysis confirms that HAL BL cystoscopy significantly improves the detection of bladder tumours leading to a reduction of recurrence at 9-12 mo. The benefit is independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer.

Application of an interstitial and biodegradable balloon system for prostate-rectum separation during prostate cancer radiotherapy: a prospective multi-center study.

BACKGROUND AND PURPOSE: Rectal toxicity presents a significant limiting factor in prostate radiotherapy regimens. This study evaluated the safety and efficacy of an implantable and biodegradable balloon specifically designed to protect rectal tissue during radiotherapy by increasing the prostate-rectum interspace. PATIENTS AND METHODS: Balloons were transperineally implanted, under transrectal ultrasound guidance, into the prostate-rectum interspace in 27 patients with localized prostate cancer scheduled to undergo radiotherapy. Patients underwent two simulations for radiotherapy planning--the first simulation before implant, and the second simulation seven days post implant. The balloon position, the dimensions of the prostate, and the distance between the prostate and rectum were evaluated by CT/US examinations 1 week after the implant, weekly during the radiotherapy period, and at 3 and 6 months post implant. Dose-volume histograms of pre and post implantation were compared. Adverse events were recorded throughout the study period. RESULTS: Four of 27 patients were excluded from the evaluation. One was excluded due to a technical failure during implant, and three patients were excluded because the balloon prematurely deflated. The balloon status was evaluated for the duration of the radiotherapy period in 23 patients. With the balloon implant, the distance between the prostate and rectum increased 10-fold, from a mean 0.22 ± 0.2 cm to 2.47 ± 0.47 cm. During the radiotherapy period the balloon length changed from 4.25 ± 0.49 cm to 3.81 ± 0.84 cm and the balloon height from 1.86 ± 0.24 cm to 1.67 ± 0.22 cm. But the prostate-rectum interspace distance remained constant from beginning to end of radiotherapy: 2.47 ± 0.47 cm and 2.41 ± 0.43 cm, respectively. A significant mean reduction in calculated rectal radiation exposure was achieved. The implant procedure was well tolerated. The adverse events included mild pain at the perineal skin and in the anus. Three patients experienced acute urinary retention which resolved in a few hours following conservative treatment. No infections or thromboembolic events occurred during the implant procedure or during the radiotherapy period. CONCLUSION: The transperineal implantation of the biodegradable balloon in patients scheduled to receive radiotherapy was safe and achieved a significant and constant gap between the prostate and rectum. This separation resulted in an important reduction in the rectal radiation dose. A prospective study to evaluate the acute and late rectal toxicity is needed.

Interstitial biodegradable balloon for reduced rectal dose during prostate radiotherapy: results of a virtual planning investigation based on the pre- and post-implant imaging data of an international multicenter study.

PURPOSE: To evaluate dose reduction caused by the implantation of an interstitial inflatable and biodegradable balloon device aiming to achieve lower rectal doses with virtual 3D conformal external beam radiation treatment. MATERIALS AND METHODS: An inflatable balloon device was placed, interstitially and under transrectal ultrasound guidance, into the rectal-prostate interspace prior treatment initiation of 26 patients with localized prostate cancer, who elected to be treated with radiotherapy (3D CRT or IMRT). The pre- and post-implant CT imaging data of twenty two patients were collected (44 images) for the purpose of the 3D conformal virtual planning presented herein. RESULTS: The dorsal prostate-ventral rectal wall separation resulted in an average reduction of the rectal V70% by 55.3% (± 16.8%), V80% by 64.0% (± 17.7%), V90% by 72.0% (± 17.1%), and V100% by 82.3% (± 24.1%). In parallel, rectal D2 ml and D0.1 ml were reduced by 15.8% (± 11.4%) and 3.9% (± 6.4%), respectively. CONCLUSIONS: Insertion of the biodegradable balloon into the prostate-rectum interspace is similar to other published invasive procedures. In this virtual dose distribution analysis, the balloon insertion resulted in a remarkable reduction of rectal volume exposed to high radiation doses. This effect has the potential to keep the rectal dose lower especially when higher than usual prostate dose escalation protocols or hypo-fractionated regimes are used. Further prospective clinical investigations on larger cohorts and more conformal radiation techniques will be necessary to define the clinical advantage of the biodegradable interstitial tissue separation device.

Could titanium oxide coating from a sol-gel process make stone baskets more resistant to laser radiation at 2.1 µm?

BACKGROUND: Stone baskets could be easily destroyed by Holmium:YAG-laser at an endourologic treatment, with respect to this, we try to improve the resistance by coating them with a titanium oxide layer. The layer was established by a sol-gel-process. MATERIALS AND METHODS: Six new baskets (Equadus, Opi Med, Ettlingen, Germany) were used: 1.8 Ch. with 4 wires (diameter 0.127 mm). Three baskets were coated with a layer of titanium oxide established by a sol-gel process at the BioCerEntwicklungs GmbH in Bayreuth (~100 nanometres thickness). The lithotripter was a Holmium:YAG laser (Auriga XL, Starmedtec, Starnberg, Germany). 10 uncoated and 10 coated wires were tested with 610 mJ (the minimal clinical setting) and 2 uncoated and 2 coated wires were tested with 110 mJ. The wires were locked in a special holding instrument under water and the laser incident angle was 90°. The endpoint was gross visible damage to the wire and loss of electric conduction. RESULTS: Only two coated wires resisted two pulses (one in the 610 mJ and one in the 110 mJ setting). All other wires were destroyed after one pulse. CONCLUSION: This was the first attempt at making stone baskets more resistant to a Holmium:YAG laser beam. Titanium oxide deposited by a sol-gel-process on a titanium-nickel alloy did not result in better resistance to laser injuries.

Investigation of bladder deformability within the development process of the artificial urinary diversion system - a pilot study.

PURPOSE: The purpose of this pilot study was to investigate changes in the dimensions of human bladders in different body positions to determine the required deformability of an artificial urinary diversion system (AUDS). This entirely artificial organ is comparable in size to the maximum capacity of natural bladders and is a replacement for diseased bladders, such those damaged by cancer. METHODS: The full bladders (determined by the individual's perception) of 5 healthy adult volunteers were imaged using a fully opened magnetic resonance imaging (MRI) device in different body positions: standing, maximum flexion, and seated. Dimensional changes were measured in four directions (ventral, dorsal, cranial and caudal) using a custom graphical method based on midsagittal images; the standing position was used as the reference position. RESULTS: The maximum flexed position was compared to the reference position, and the largest change was found in the cranial extension of the bladders: 6±4.2 mm (mean±SD). The seated and reference positions were compared; the maximum change was in the cranial extension and was measured to be 18±2.8 mm. CONCLUSIONS: The results indicate the requirement for a highly deformable artificial bladder in specific directions, such as the cranial and dorsal directions, which influences the positions of the technical components within the artificial organ. In a future development stage, artificial bladders will be designed using a computer-aided design system based on the results from this study and possibly a subsequent similar study.

Destruction of stone extraction basket during an in vitro lithotripsy--a comparison of four lithotripters.

BACKGROUND: Various techniques are available for intracorporeal disintegration of renal and ureteral stones, among them ballistic lithotripsy, ultrasonic lithotripsy and laser lithotripsy. The therapeutic effectiveness of these devices has been sufficiently studied and compared. This does not apply, however, to the risk of destroying the stone basket. MATERIALS AND METHODS: The time until destruction of the wires of various baskets with use of four different lithotripsy devices (LithoClast, EMS; LithoRapid, Olympus; Calcuson 27610029, Storz; Vera Pulse, Coherent) was measured in a model closely aligned with the clinic. RESULTS: As expected, the direct application of laser pulses (wavelength 2.1 µm) irrespective of thickness and shape led to a melting of all wires of the stone extraction basket in less than 50 seconds (pulse energy: 800 mJ, pulse repetition rate: 8 hertz; fiber diameter: 365 µm). The purely kinetic functioning lithotripters (electrokinetic-ballistic and pneumatic-ballistic) were not able to destroy any wire within the set time limit of one minute. The sonotrode of the ultrasonic device, which is considered to be very tissue-conserving, separated all wires of baskets with a diameter of 1.8F (4 wires), 75% of baskets with a diameter of 2.5F (9 of 12), but only 8.3% of baskets with a diameter of 3.5F (1 of 12). Plaited wires demonstrated a good resistance (0 of 4) in comparison with the sonotrode. CONCLUSION: Our study consequently shows that in addition to the laser, the ultrasonic probe can also easily destroy nitinol (nickel titanium) baskets.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Results of secondary ureteral implantation after kidney transplantation.

BACKGROUND: We reviewed our experience with ureteral complications and secondary ureteral implantation after kidney transplantation. METHODS: Between 1997 and 2005, 636 patients underwent kidney transplantation at our transplant center. Ureteral implantation was performed in the Lich-Gregoire technique. Thirty-one patients with ureteral complications after kidney transplantation and subsequent secondary ureteral implantation were analyzed for operative parameters and long-term transplant function. RESULTS: Twenty-seven patients had a ureteral stenosis and 4 patients a ureteral leakage. In 25 patients (81%), a resection of the distal transplant ureter followed by secondary ureteral implantation was performed. In 4 cases (13%), the native ureter was anastomosed to the transplant pelvis and in the remaining 2 cases (6%) to the transplant ureter. Three major complications occurred. At median follow-up of 5 years, 18/30 patients (60%) had a good transplant function and 12/30 patients (40%) had returned to dialysis. One patient with depression died from suicide. CONCLUSIONS: Secondary ureteral implantation can be performed with acceptable morbidity and good long-term transplant outcome.