[The MDK Reform Act and its effect on outpatient potential : Risk or opportunity for urology?] / Das MDK-Reformgesetz und seine Auswirkungen auf das ambulante Potenzial : Risiko oder Chance für die Urologie?

BACKGROUND: With the introduction of the MDK (Medizinischer Dienst der Krankenversicherung) Reform Act, there have been multiple new regulations for hospitals, some of which are confusing and interact with one another. A major focus of the legal changes is directly or indirectly on expanding the provision of outpatient services. OBJECTIVES: It can be assumed that-as a result of the new version of the framework conditions and the AOP catalog-the relevant OPS list will be expanded in the future. With the revision of the AOP catalog and the effects of the MDK Reform Act, the number of cases with outpatient potential will increase. Can the effects and challenges for hospitals and especially urology be identified? METHODS: Evaluation of official statistics of inpatient and outpatient treatments. Focusing on the problem based on a fictitious practical example from urology. RESULTS: A strategy is developed for dealing with cases with outpatient potential and identification of different solutions to compensate for this shift in services and enabling an increase in performance or a deliberate reduction in the provision of services. CONCLUSIONS: The choice of the type of service provision is increasingly no longer an issue, and the short-term inpatient treatment of many urological cases is coming under considerable pressure due to political measures such as the MDK Reform Act and the demands of health insurance companies. The reduction of different parts of the inpatient reimbursement for special patient groups must be anticipated. Individual strategies will range from simply not providing outpatient services to complex models of cooperation. This change also means opportunities for hospitals!

[Geocoding of routine data. Where are my referring physicians and what are my competitors doing?]. / Geocoding von Routinedaten. Wo sind meine Zuweiser und was machen meine Mitbewerber?

Modern methods of reporting include the visualization of data concerning patients and referring doctor's residence and other clinical data with geographical reference. Thus, static and dynamic information about catchment areas and their changes can be visualized as well as answers to the important question for your main referring practicing physicians and possible changes in their behavior. Apart from the purely operational significance for the hospital, we also find important strategic aspects that include issues concerning hospital perspectives and possibilities, e.g., for the planning of collaborations. Overall, the method represents a useful addition to conservative forms of controlling reports in the hospital.

[Amendments to the German diagnosis-related groups (G-DRG) system for urology in 2012]. / Veränderungen des G-DRG-Systems für die Urologie im Jahre 2012.

The remuneration system of German diagnosis-related groups (G-DRG) is updated every year in a clearly defined process. This article presents all changes relevant for urologists in 2012.

[Complexity level simulation in the German diagnosis-related groups system: the financial effect of coding of comorbidity diagnostics in urology]. / Schweregradsimulation im G-DRG-System : Die finanziellen Auswirkungen der Nebendiagnosenkodierung in der Urologie.

BACKGROUND: Precise and complete coding of diagnoses and procedures is of value for optimizing revenues within the German diagnosis-related groups (G-DRG) system. The implementation of effective structures for coding is cost-intensive. The aim of this study was to prove whether higher costs can be refunded by complete acquisition of comorbidities and complications. METHODS: Calculations were based on DRG data of the Department of Urology, University Hospital of Münster, Germany, covering all patients treated in 2009. The data were regrouped and subjected to a process of simulation (increase and decrease of patient clinical complexity levels, PCCL) with the help of recently developed software. RESULTS: In urology a strong dependency of quantity and quality of coding of secondary diagnoses on PCCL and subsequent profits was found. Departmental budgetary procedures can be optimized when coding is effective. The new simulation tool can be a valuable aid to improve profits available for distribution. Nevertheless, calculation of time use and financial needs by this procedure are subject to specific departmental terms and conditions. CONCLUSIONS: Completeness of coding of (secondary) diagnoses must be the ultimate administrative goal of patient case documentation in urology.

High-dose chemotherapy with autologous PBSC transplantation for poor prognosis germ cell tumors: a retrospective monocenter analysis of 44 cases.

Germ cell cancer (GCC) is curable in metastatic stages. The International Germ Cell Cancer Collaborative Group (IGCCCG) reports a poor prognosis subgroup with a 5-year survival of 48%. High-dose chemotherapy with PBSC transplantation (HD-PBSCT) in these patients showed promising results in phase II, but failed to show significant advantage in randomized trials. We report our monocenter series of all poor and selected intermediate prognosis germ cell tumor patients treated with multiple-course HD-PBSCT and secondary surgery of remaining tissue. We performed a retrospective analysis of our complete series of 44 patients (40 poor prognosis and 4 intermediate prognosis) treated by HD-PBSCT as part of first-line therapy from 1999 to 2010. The CR rate after up to four cycles of HD-PBSCT and radical resection of residual manifestations was 73%. The 3-year survival rate was 79.5% (median follow-up of 51.5 months; range: 7-143 months). Disease-related death rate was 16%. HD-PBSCT-related death did not occur. One patient died postsurgery. Multiple courses of HD-PBSCT with radical secondary surgery is safe and effective in poor prognosis metastatic GCC. Despite disappointing phase III studies it is of high interest to further study this field.

Sequential therapies with sorafenib and sunitinib in advanced or metastatic renal cell carcinoma.

PURPOSE: To investigate whether patients with metastatic renal cell carcinoma benefit from sequential therapies with the tyrosine kinase inhibitors (TKIs) sorafenib and sunitinib. PATIENTS AND METHODS: A total of 89 patients were treated in nine German centres between 2002 and 2009. The TKI sequence started as first-, second- or third-line therapy after prior chemo- or immunotherapy. When progression was diagnosed, treatment was switched to the second TKI until further progression. RESULTS: Overall progression-free survival (PFS) of patients receiving sunitinib followed by sorafenib shows no statistically significant difference to patients receiving sorafenib followed by sunitinib (15.4 months vs. 12.1 months). The secondary use of sorafenib resulted in a median PFS of 3.8 months if the TKI sequence had been started as a first-line treatment and of 3.5 months if the TKI sequence had been started second-line treatment. The secondary use of sunitinib resulted in a median PFS of 3.4 and 4.0 months, respectively. OS was 28.8 months for all patients, without a statistically significant difference between the two groups. CONCLUSIONS: This study endorses the notion of a clinical benefit of the sequential use of sorafenib and sunitinib and supports observations from previous studies. In terms of the optimal succession of the two TKIs, the study does not allow a definite answer.

Testosterone deficiency in testicular germ-cell cancer patients is not influenced by oncological treatment.

The aim of the study was to investigate prospectively the prevalence of testosterone deficiency (TD) in patients with testicular germ-cell cancer (TGCC) using longitudinal data. A total of 376 TGCC patients were evaluated for serum testosterone levels before, during and after the following therapies: cisplatin-based polychemotherapy, carboplatin monotherapy, radiotherapy or surgery only. Complete serial hormone analyses were performed on 160 patients (age: 33.8±9.1years, mean±SD). All patients received treatment according to the guidelines of the 'German Testicular Cancer Study Group' and the 'European Germ Cell Cancer Consensus Group' or within studies performed by the 'European Organisation for Research and Treatment of Cancer' and the 'Deutsche Krebsgesellschaft'. Main outcome measurements were sexual hormone profiles over time. Statistical analysis of 1831 testosterone serum levels over time revealed a persistent TD in 23.9% of seminoma and 26.2% of non-seminoma patients. TD was associated with subnormal residual testicular volumes (<12mL). In conclusion, TD rates are high in testis cancer patients. This is present at primary diagnosis and most likely related to testicular dysgenesis or atrophy. Our longitudinal evaluation indicates that treatment modalities have minor influence and effect on the persistently high rates of TD in TGCC patients.

[Adjustment of the German DRG system in 2009]. / G-DRG-Systemanpassung 2009.

BACKGROUND: The 2009 version of the German DRG system brought significant changes for urology concerning coding of diagnoses, medical procedures and the DRG structure. In view of the political situation and considerable economic pressure, a critical analysis of the 2009 German DRG system is warranted. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The relevant diagnoses, medical procedures and German DRGs in the versions 2008 and 2009 were analysed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focus on the development of the DRG structure, DRG validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. CONCLUSION: The German DRG system again gained complexity. High demands are made on correct and complete coding of complex urology cases. The quality of case allocation in the German DRG system was improved. On the one hand some of the old problems (e.g. enterostomata) still persist, while on the other hand new problems evolved out of the attempt to improve the case allocation of highly complex and expensive cases. Time will tell whether the increase in highly specialized DRG with low case numbers will continue to endure and reach acceptable rates of annual fluctuations.

[Relevance of hospitals participating in the DRG calculation for the development of the G-DRG system]. / Die Bedeutung der Kalkulationshäuser für die Weiterentwicklung des G-DRG-Systems.

Since the G-DRG system was established for remuneration of inpatient treatment, hospitals may offer the cost data of their cases as a database for the calculation of new DRGs. Therefore, the DRGs will be only as good as the cost data offered. These hospitals must be interested in offering perfect data, since this is the only option to optimize the DRG system.

[The German diagnosis-related groups in urology: reproducibility and quality of coding]. / G-DRG-System für die Urologie : Reproduzierbarkeit und Kodierqualität.

BACKGROUND: The German diagnosis-related group (G-DRG) system is based on the belief that there is only one specific coding for each case. The aim of this study was to compare coding results of identical cases coded by different coding specialists. MATERIAL AND METHODS: Charts of six anonymous cases -- except final letter and coding -- were sent to 20 German departments of urology. They were asked to let their coding specialists do a DRG coding of these cases. The response rate was 90%. RESULTS: Each case was coded in a different way by each coding specialist. The DRG refunding varied by 6-23%. The coding differences were caused by different interpretations of definitions in the DRG system and also by inaccurate chart analysis. CONCLUSION: The present DRG system allows a wide range of interpretation, leading to aggravation of the ongoing disputes between hospitals and insurance companies.

[Changes to diagnosis-related groups in urology in 2007. Urology in the G-DRG-System 2007]. / DRG-Veränderungen 2007 im Fachgebiet Urologie. Urologie G-DRGs 2007.

BACKGROUND: The German DRG (dose-related groups) system is updated each year by the institution dealing with the remuneration in hospitals (InEK). Once again, the German Spcoety for Urology has supported the adjustment process in a constructive manner. Analysis of the changes and their implications is highly significant for urology. This article describes and discusses the main changes in the system for the specialty of urology insofar as they concern the structure of the DRG system and the catalogues of diagnoses (ICD) and of procedures (OPS). RESULTS: The 2007 edition of the DRG system leads to numerous changes for urology. There are new OPS codes for partial resection of the kidney, treatment of urinary incontinence and radical resection in the pelvis minor. Additional payment for implantation of a prosthetic penis is divided with reference to the type of prosthesis. At DRG level, new DRG splits are found depending on the PCCL and patient age. Combination operations on the bladder and bowel and on the male genitalia are assigned to newly established DRGs. CONCLUSIONS: The changes described enhance the professional accuracy of the representations of urological care provision. New strategies designed to solve problems in representation have been established (e.g. multi-step interventions). Various problems persist, e.g. those of operations on the penis (DRG M03Z) and the need for more finely defined representation of laser treatment in urology. In the short term practicable solutions to the problem of improving the quality of representation are needed.

Blockage of urine by intravesical ejaculate in cynomolgus monkeys.

BACKGROUND: The present communication reports intravesical semen coagulation and formation of a larger precipitate in two Cynomolgus monkeys. METHODS: Ultrasound of the urinary bladder and light microscopy of intravesical coagulates. RESULTS: These monkeys suffered from complete blockage of urine output and surgery was required to remove the sperm mass. Microscopic examination of the urine revealed millions of sperm as a cause of the mass and the blockage of urine output. CONCLUSIONS: Retrograde ejaculation of sperm may cause coagulation of ejaculates in the bladder of the cynomolgus monkey Macaca fascicularis. However, involvement of sperm mass in blockage of urine passage has not been described in this species.

[Haemorrhoidal suffering]. / Das Hämorrhoidalleiden.

Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Conservative treatment consists of dietary and lifestyle modifications. Standard interventional procedures in outpatient treatment are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows shorter convalescence but may have a higher recurrence rate and needs further long-term evaluation.

[Internal quality management: use of a patient questionnaire in a urological university clinic. Results of a pilot project]. / Internes Qualitätsmanagement: Patientenbefragung in einer urologischen Universitätsklinik. Ergebnisse eines Pilotprojektes.

INTRODUCTION AND OBJECTIVE: In order to support the introduction of quality management, a systematic patient questionnaire was used in the Urology Clinic of the University Hospital of Münster and in another comparable clinic. The aim was to distinguish between well established areas and areas needing improvement. METHODS: A multidimensional questionnaire with emphasis on items involving patient satisfaction was developed and handed out to the patients before they left the clinic. The questionnaire could be sent back with an enclosed envelop free of charge. RESULTS: Hospital hygiene was rated as most important factor by the patients, followed by professionalism of the physicians and nurses. Patients were dissatisfied with hospital hygiene, making this an issue for improvement. Physicians and nurses were rated positively in both clinics. Furthermore, a high proportion of patients (82%) said that they had no pain after surgery. Overall, patients were very satisfied with their hospital stay in both clinics. CONCLUSIONS: After analyzing the questionnaires, we could identify areas in need of improvement and areas of high performance. In particular, hospital hygiene needs to be improved. In order to reach more patients, the inquiries need to be performed in all departments of the University Hospital of Münster.

[Bilateral renal angiomyolipomas with a thrombus in the inferior caval vein. Rare growth pattern of a benign tumor]. / Bilaterale renale Angiomyolipome mit Thrombus in der Vena cava inferior. Seltenes Wachstumsverhalten eines benignen Tumors.

Renal angiomyolipomas are mesenchymal tumors that are composed of fat tissue, smooth muscle cells and vessels. These are benign tumors, but in rare cases they show a more aggressive growth pattern with invasion into the venous system but without revealing any signs of malignancy. We report a new case of bilateral renal angiomyolipomas with a caval thrombus in a 36 year old female patient with tuberous sclerosis, and give a brief review of the related literature.

[Intra- and peri-renal gas formation. Bilateral emphysematous pyelonephritis]. / Intra- und perirenale Gasbildung. Bilaterale emphysematöse Pyelonephritis.

Bilateral emphysematous pyelonephritis is an extremely rare, rapidly progressive and life-threatening intrarenal and perirenal infection. It is associated with diabetes mellitus, obstruction of the upper urinary tract and the presence of gas-forming coliform bacteria. As it presents as a severe acute pyelonephritis, a high index of suspicion and computer-tomographic imaging are essential to make the diagnosis. Only immediate combined medical and (bilateral) surgical therapy can reduce the high patient mortality. Postoperatively, computer-tomographic monitoring is recommended to follow the response to therapy.

High loading and low maintenance doses of a gonadotropin-releasing hormone antagonist effectively suppress serum luteinizing hormone, follicle-stimulating hormone, and testosterone in normal men.

The GnRH antagonist cetrorelix effectively suppresses serum LH, FSH, and testosterone (T) in normal men without major side-effects. However, as with other available GnRH antagonists, relatively high doses of 10 mg/day were required for sustained reduction of T levels during 1-week administration in normal men. Therefore, we investigated whether a suppression of LH, FSH, and T achieved by initial high dose cetrorelix can be maintained by continued low dose injections. Sixteen young male volunteers were randomly assigned to four study groups (n = 4/group). Twelve men were injected s.c. with 10 mg cetrorelix at 0800 h for 5 days, followed by injections of 2 mg/day (group I), 2 x 1 mg/day (group II), and 1 mg/day (group III) up to the end of the 3-week injection period. For the control, group IV was given daily placebo injections for 3 weeks. Morning and evening blood samples were obtained daily for 4 weeks and then at increasing time intervals up to week 13. Initial injections of 10 mg/day cetrorelix suppressed LH, FSH, and T effectively. This initial reduction of serum levels was maintained during the following low dose maintenance injections in all groups. In comparison to the initial suppression, significantly lower levels of LH, FSH, and T near the assay detection limits were measured during study weeks 2 and 3. The results show that compared to previous long term studies, much lower daily doses of the GnRH antagonist are sufficient for effective suppression of LH, FSH, and T after initial high loading dose injections. In addition to competitive receptor blockage, other mechanisms of GnRH antagonist action, such as receptor down-regulation, appear to be involved during long term administration in men.