[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.

[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.

[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.

[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.·

[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.

[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.

[Stress incontinence after prostatectomy in treatment reality: results from a rehabilitation clinic]. / Belastungsinkontinenz nach Prostatektomie in der Versorgungswirklichkeit : Ergebnisse einer Reha-Klinik.

BACKGROUND: In the current discussion on the operative therapy of prostate cancer, not only"if" but also"how" play a major role. Both questions are closely related as, e.g. a possible excessive therapy will result in additional suffering due to stress incontinence. For the most common, troublesome and expensive consequences of prostatectomy it is of interest to know which factors play a role in treatment reality and which could possibly be avoided. PATIENTS AND METHODS: The hospital records of all patients who underwent follow-up treatment after prostatectomy in 2009 at the clinic in the spa park in Bad Wildungen-Reinhardshausen were evaluated with respect to relevant data on outcome and clinical endpoints. RESULTS: Of the 1,750 patients 405 (23.1 %) were continent on admission and discharge and a further 189 (10.8 %) were continent on discharge so that a total of 594 patients (33.9 %) were continent on discharge. Of the 1,155 patients (66.0 %) who were incontinent on admission and discharge, this remained the same during the rehabilitation period for 727 (62.9 %) who were diurnally incontinent and 659 (57.1 %) who were nocturnally incontinent. For 387 patients (33.5 %) the incontinence decreased during the day and for 370 (32.0 %) during the night, for 34 (3.4 %) the incontinence increased during the day and for 45 (3.9 %) during the night. An age < 60 years was advantageous for maintaining continence and in contrast > 70 years was disadvantageous. Retention of nerves showed a significant effect on maintaining continence. Statistically significant differences between the results of operative procedures and the results of the type of clinic (KKP communal, confessional and private or UK university clinic) were not observed. However, the results of maintaining continence (up to termination of rehabilitation treatment) for the 594 patients (33.9 %) was only achieved by 94 (51 %) of all 183 clinics, i.e. 78 (49.7 %) of the KKP clinics and 14 (53.9 %) of UK clinics. For the certified prostate centers of KKP and UK clinics this amounted to 17 (81 %) and 5 (83.3 %), respectively. CONCLUSIONS: In treatment reality of follow-up treatment of patients after prostatectomy in rehabilitation clinics approximately one third (33.9 %) achieved retention of continence up to discharge. An age < 60 years was advantageous and > 70 years disadvantageous. Bilateral and unilateral retention of nerves significantly improved retention of continence. The operative procedure and type of clinic did not significantly affect the results. However, in approximately one third of patients (33.9 %) retention of continence was achieved by only approximately one half (51.4 %) of all clinics. This shows that in treatment reality, stress incontinence following prostatectomy is avoidably underdeveloped and can be demonstrably increased by suitable operative techniques for sphincter protection.

[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.

[Baron Dominique-Jean Larrey: the founder of urological traumatology]. / Baron Dominique-Jean Larrey: Der Begründer der urologischen Traumatologie.

Dominique-Jean Larrey (1766-1842) was Surgeon-in-Chief of the Grande Army under Napoleon Bonaparte (1769-1821) and personal physician of the Emperor. Against the opposition of the traditionalists he introduced the "ambulances volantes", the so-called flying ambulances. The aim was the medical treatment of the injured soldiers immediately on the battlefield. This revolutionary treatment led to a benefit not only for the own soldiers, but also for the wounded enemies. His innovation in the field of immediate assistance of wounded persons, together with Larreys' outstanding medical competence, saved thousands of soldiers lives on the battlefield of the Napoleonic wars. His memories concerning the military campaigns, have been even up to the 20th century one of the standard works of modern military surgery. He had as well great interest in urolological injuries of the urinary system and their conservative and operative care. Up to these days, his work shows a surprising actuality and perfect anatomic understanding. In a time without anaesthetics, antibiotics and under primitive circumstances, Larrey and his collegues accomplished surgical feats. Larreys flying ambulances were copied by many different countries. The American Mobile Army Surgical Hospital (M.A.S.H) is clearly based on his thoughts and ideals. In our opinion he is the father of the modern war surgery as well the urological traumatology.

[Criteria for errors in prostate-specific antigen diagnostics]. / Fehlerkriterien bei der PSA-Diagnostik.

BACKGROUND: The widespread use of prostate-specific antigen (PSA) determination in the diagnosis of prostate cancer has proved to be generally beneficial; however, as a result expert commissions, arbitration committees and the courts have had to deal with an increased number of suspected treatment errors. As a follow-up to the previous report on the decisions made by expert commissions, this paper deals with recent developments and their assessment. METHODS: The procedures followed for assessment have been extensively described in the previous paper. The criteria for assessment of disputed treatment were and are the accepted standards (i.e. the standards applicable to medical specialists) and the quality of care applied in accordance with the pertinent definitions. RESULTS: In the period from 2005 to 2011 (i.e. 7 years) errors in medical treatment were determined in connection with PSA determinations in 22 out of the 37 cases reviewed, i.e. 71%. These were subdivided into 3 cases from general practitioners, 5 cases from specialists in internal medicine and 15 cases from urologists (in 1 case 2 different doctors were involved). They were faulted for omitting a follow-up biopsy of the prostate. In 12 cases this involved PSA values above the recommended cut-off level without suspicious palpation results, in 7 cases raised PSA levels with suspicious palpation findings, in 2 cases suspicious palpation findings without raised PSA and in 1 case the omission of both palpation and PSA determination. An error in treatment was negated if the PSA value was below the recommended cut-off value or had fallen below it again subsequently (two cases each), if follow-up prostate biopsy was recommended and documented following the determination of raised PSA and/or suspicious palpation findings (three cases) or if follow-up treatment was rejected in spite of a documented recommendation (one case). CONCLUSIONS: Treatment errors in association with PSA determinations can therefore be uniformly and plausibly assessed using objective criteria and can thus be avoided.

[The Importance of De- /Vascularisation of the Ureter during Reconstruction after Trauma]. / Die Bedeutung der De-/Vaskularisation des Harnleiters bei der Rekonstruktion nach Verletzungen.

BACKGROUND: Serious errors may occur in the reconstruction of injured ureters if the degree of -devascularisation is not taken in account. MATERIAL AND METHODS: The problems involved in ureter reconstruction after traumatic reconstruction are presented by means of two case -studies reviewed by the Expert Committee for Re-viewing Errors in Medical Treatment of the Ärztekammer Nordrhein. RESULTS: In a 55-year-old man there was a persistent drainage disorder of the left kidney following implantation of a Y-prosthesis with "lateralisation of the ureter". Following renewed splint-ing of the ureter and percutaneous nephrostomy, operative ureterolysis with partial resection of the ureter and end-to-end anastomosis resulted in anastomostic necrosis with a ureter-skin fistula. Fol-lowing a renewed nephrostomy, the left kidney had to be removed because of considerable loss in function. In a 66-year-old woman with right-sided salpingo-oophorectomy and right-sided -colonectomy there was extensive devascularisation of the right ureter with complete -severance in the lower third. An emergency uretero-uretero anastomosis led to scar-induced stenosis of the anastomosed segment of the ureter. Following unsuccessful attemps at splinting, the ureter was reimplanted using the psoas hitch procedure. Because of a fistula to the small intestine, relaparotomy with segmental resection of the small intestine and opening of an abscess -because of wound infection were necessary. A satisfactory final result was obtained after about nine months. CONCLUSIONS: When reconstructing damaged -ureters, numerous factors must be taken into account, e. g., the type, extent and location of the -damage to the ureter(s), the time of detection, the duration and severity of the sequelae for the kidney(s), the patient's concomitant condition and the suitability of the reconstruction procedure. Further-more, the degree of de- / vascularisation is of decisive impor-tance.

[Differential indications in hydrocele operations - a contribution to prophylaxis for recurrent hydrocele]. / Differenzialindikationen bei Hydrozelenoperationen - ein Beitrag zur Prophylaxe einer Rezidivhydrozele.

BACKGROUND: In the operative treatment of idiopathic hydroceles the available techniques are frequently not selected as indicated according to the different expansions of hydroceles but rather the accustomed procedures are used. MATERIAL AND METHODS: In a retrospective analysis the methods and complications of hydrocele operations were evaluated. RESULTS: From 1988 to 2008 195  hydroceles in 191  patients were operated upon: 22 (11.3 %) by eversion (according to Jaboulay), 27 (13.8 %) by resection (according to von Bergmann) and 146 (74.9 %) by a combination of resection and eversion (according to Kocher) of the tunica vaginalis communis. In 14 (7.2 %) patients the operation was indicated by a recurrent hydrocele, either after an eversion alone (n = 7) or after an insufficient resection (n = 7) of the tunica vaginalis communis. As complications of the operation an abscess occurred in 4 (21 %) cases, a haematoma in 5 (2.6 %) cases and a combination of both had to be reoperated in 2 (1.0 %) cases. CONCLUSIONS: In order to prevent recurrent hydroceles the available methods for the operative treatment of idiopathic hydrocele should be selected according to the different expansions of the hydroceles and as such consequently executed.

[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.

[Consistency and change of medical errors in urology]. / Konstanz und Wandel von Behandlungsfehlern in der Urologie.

BACKGROUND: Whether and how far the ascertainment of medical errors is influenced by advances in medicine is a matter of question. MATERIAL AND METHODS: The cases of the Expert Committee for Medical Malpractice Claims of the Medical Association of North Rhine were reviewed from 1975 to 2005. The results of the first 23 years were compared with the last 7 ones. Underlying criteria were the professional standards and required care. RESULTS: The number of claims and medical errors increased. The rate of medical errors remained approximately constant. The spectrum of medical errors remained constant to a large extent. Frequent errors were more frequently ascertained. Several errors decreased or increased according to medical progress. CONCLUSIONS: To avoid medical errors individual cases should be published for learning purposes. Each treatment should be undertaken with utmost competence and care.

[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.

[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.

Management of bleeding, transfusion requirement and removal of catheters in transurethral prostate resection.

OBJECTIVE: The objective of the present study was to establish the therapeutic value of early coagulation of severe postoperative bleeding after transurethral prostate resection in unselected patients. PATIENTS AND METHODS: In a prospective study of 772 prostate resections carried out in 617 patients, bleeding complications, hemostatic measures, blood transfusions, catheter removals, and catheter-related and general complications were registered, and the factors influencing them were analyzed. RESULTS: Severe postoperative bleeding was coagulated endoscopically on the day of the operation in 70 resections (9.1%), and after removing the catheter in a further 19 cases (2.7%). Blood was transfused perioperatively in 14 patients (2.3%): in 11 patients (2.0%) because of preoperative anemia, and in 3 patients (0.3%) because of postoperative hemorrhage. In 96.3% of the resections, the catheter was removed on the first postoperative day, and in the last year of the study in 99.3% of the cases. Neither additional hemostasis nor early catheter removal had disadvantageous consequences. CONCLUSIONS: Transurethral prostate resections can be performed without any blood transfusion in more than 99.0% of patients without preexisting risk when severe postoperative hemorrhage is coagulated at an early stage. Moreover, this enables early catheter removal, after 24 h at the latest, in more than 99.0% of the cases.

What classification is appropriate in renal trauma?

OBJECTIVE: The objective of this paper is to attain an adequate consideration of the relevant factors in conventional classifications of renal trauma and to work out a differentiated classification with a simple trauma formula suitable for both scientific purposes and for clinical decision-making. METHOD: Previous classifications of renal trauma were evaluated retrospectively to establish whether and to what extent all criteria have been considered which may be important for the outcome of kidney trauma. The pathogenesis, the locations and the symptoms of the injuries with their degrees served as principal parameters. RESULTS: From 1950 to 1991, a minimum of 24 classifications of renal trauma with different criteria has been used. In 54.2% of these, blunt and perforating injuries were not distinguished. Injuries of the renal pelvis or the vascular system were not considered in 62.9 and 8.3% of these, respectively. The degrees of severity ranged from 2 to 6 (on average, 3.5). In 87.5%, there was a combination with the injury location (renal pelvis, vascular system). Finally, of 29 definable criteria, an average of only 9.6 was specified, i.e. most were not evaluated at all. CONCLUSION: It is concluded that most of the previous classifications of renal trauma neither clearly distinguish between nor adequately differentiate their individual factors. This may be a major reason for the persistence of controversies with regard to concepts of therapy, since they are based on inadequate definitions of comparative studies. A more differentiated PLS classification is proposed comprising the following elements: the pathogenesis P1 (blunt injuries), P2 (perforating injuries), the locations of the injuries LA (parenchyma), LB (renal pelvis), LC (vascular system) with their degrees of injury LA 0-7, LB 0-2, LC 0-9, and the symptoms of injury SA (hemorrhage), SB (extravasation of urine), SC (kidney damage) with their degrees of severity SA 0-3, SB 0-3, SC 0-3 as prognostic factors. The new classification incorporated in a simple trauma formula may enable more precise scientific investigation and also facilitate clinical decisions, so that patients with kidney trauma can be treated more specifically.