[New aspects of case law on andrological questions: what does this mean for physicians in private practice?]. / Neue Aspekte der Rechtsprechung bei andrologischen Fragestellungen : Was bedeutet dies für die niedergelassenen Kollegen?

In recent years there have been several Supreme Court adjudications concerning andrological issues. Among other things it was reconfirmed that drug therapy for erectile dysfunction does not have to be paid by compulsory health insurance providers. In contrast one Supreme Court decided that cryoconservation of ejaculates has to be paid by compulsory health insurance providers under certain circumstances.Vasectomy in men under guardianship is performed approximately 100 times per year in Germany. Before vasectomy is performed judicial authorisation has to be obtained in an extensive court proceeding.The Tissue Act regulates the implementation of the EG guideline 2004/23/EG into German law. This is only important for urologists who perform MESA/TESE procedures. Current case law does not allow use of the title Männerarzt as patients can confuse it with the official title andrologist.

[Surgical sperm retrieval]. / Operative Spermiengewinnung.

The introduction of intracytoplasmic sperm injection (ICSI) into the catalogue of assisted reproductive technologies in the mid-nineties has, for the first time, offered men who suffer from severe disorders of spermatogenesis and azoospermia the possibility of fathering a child. Different surgical techniques can be used to extract spermatozoa from these men from either the epididymis and/or the testis for ICSI. Surgical sperm retrieval offers a treatment for both patients with testicular or obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques that have been developed over the years, microsurgical epididymial sperm aspiration (MESA) and testicular sperm extraction (TESE) have become the most popular. By utilizing these techniques together with the cryopreservation of extracted spermatozoa, a single surgical intervention is able to provide spermatozoa for several ICSI attempts.

Evaluation of uridine metabolism in human and animal spermatozoa.

The objective of this study was to elucidate the role of uridine for spermatozoa, since this pyrimidine nucleoside was found in millimolar concentration in human seminal plasma. Here, the degradative activity of uridine-phosphorylase [EC 2.4.2.3] and the salvage activity of uridine kinase [EC 2.7.1.48] were detected in human spermatozoa. HPLC analysis depicted the uptake of exogeneous 14C-labelled adenine, but not of uridine and of hypoxanthine, into nucleotide pools of boar spermatozoa. On addition of uridine, the computer-assisted semen analysis (CASA) of human cells revealed a reduction of the percentage of motile spermatozoa in contrast to an elevation of some velocity parameters. It is concluded that exogeneous uridine could function as suppressor for early capacitation and as a substrate for phosphorolysis, if ribose is needed, rather than to satisfy a demand for intracellular pyrimidine nucleotides.

[Cost of fertility and erectile dysfunction therapy: who has to pay what in the GVK?]. / Kosten einer Fertilitäts- und ED-Therapie Wer zahlt was in der GKV?

From 1 January 2004 new legislation changed the liability of the public health insurance regarding diagnostic and therapy both of erectile dysfunction and infertility. Before 2004 medical therapy of erectile dysfunction (autoinjection therapy, PDE5 inhibitors) was included in the coverage of the general health insurance; however, it is now excluded by law. Before 2004 sterilization was covered by public health insurance only if medically indicated. The costs of vasovasostomy or artificial fertilization after sterilization were only covered by health insurance if the sterilization was carried out for medical reasons. In the field of infertility the liability of statutory health insurance has only been restricted concerning artificial fertilization. Since 2004 there have been restrictions concerning the age of the insured person, and 50% of the costs have to be payed by the patient herself. Moreover, for the different methods of artificial fertilization, the number of trials and the indications have been defined by the Federal Committee. The statutory health insurance is not liable if the number of trials exceeds the limit.

Diagnosis and therapeutic management of 18 patients with prostatic abscess.

OBJECTIVES: Our retrospective study aimed to analyze the findings and therapeutic strategies in 18 men who were admitted to our department as outpatient emergency cases with prostatic abscess. METHODS: During the period 1985 to 1997, prostatic abscess was diagnosed in 18 patients (mean age 48 years, range 20 to 68) on the basis of evidence of fluctuation at digital rectal examination and transrectal ultrasound (TRUS) findings. Diagnostic workup included analysis of midstream urine and abscess fluid for leukocytes and pathogens. Therapeutic options were conservative treatment and/or draining procedures. RESULTS: Predisposing diseases were found in 13 men. Fluctuation at digitorectal palpation was present in 15 patients. In 3 patients, diagnosis was based on TRUS. All men demonstrated leukocytes in their midstream urine. Causative pathogens in midstream urine were found in 11 patients. In 3 men, additional microbiologic evaluation of abscess fluid revealed uncommon pathogens. All patients received antibiotic treatment. Nine men with monofocal abscess less than 1 cm in diameter were treated with antibiotic therapy and a suprapubic catheter. Surgical drainage (transperineal or transrectal puncture, partly guided by TRUS, or transurethral unroofing) was performed in 12 patients and included 3 patients in whom conservative treatment failed. CONCLUSIONS: Our data confirm the importance of predisposing factors in the pathogenesis of prostatic abscess. Medical history and analysis of midstream urine indicated a diagnosis that was confirmed by digital palpation. In some cases, TRUS may improve diagnosis and treatment. Although both operative and conservative therapy strategies appear feasible, prostatic abscess chiefly requires individually selected drainage procedures.

Long-term results of Essed-Schroeder plication by the use of non-absorbable Goretex sutures for correcting congenital penile curvature.

This study evaluated the long-term outcome of the Essed-Schroeder procedure for correcting congenital penile curvature using non-absorbable Goretex sutures. The Essed-Schroeder procedure was performed in 35 patients with congenital ventral penile curvature (minimum 30 degrees ). Follow-up included a standardized interview with measurement of angulation. Twenty-three of 35 patients were available for complete long-term follow-up (average 34.3 months). The mean preoperative ventral curvature was 54 degrees. In 17/23 patients, the penis remained straightened. Recurrent curvature (average 23 degrees ) was observed in six of 23 patients. Fifteen of 23 patients complained of penile shortening (average 1.8 cm). Two of 23 patients reported disturbing side effects that were caused by plication nodes. In most cases, the results of penile straightening by the Essed-Schroeder procedure are excellent with a high grade of subjective satisfaction. Regarding the main problem, that is recurrent curvature, there is no decisive advantage of applying Goretex sutures. Discomfort caused by plication nodes can be reduced to a minimum by using a combination of soft Goretex sutures with the 'inverting stitch-technique'.

[Rational diagnosis of erectile dysfunction]. / Rationelle Diagnostik der erektilen Dysfunktion.

In diagnostics of erectile dysfunction there are different simple or large-scale procedures available. Referring to a three-step-scheme that makes difference in the diagnostics in I. non-invasive, II. semi-invasive and III. invasive procedures the current diagnostic measures will be explained. To the non-invasive measures do account the extensive patients history taking including the sexual history and the psychological diagnostics, the physical examination and laboratory screenings. The semi-invasive procedures include the intracavernous injection test with vasoactice substances, the doppler sonography and duplex or color duplex sonography, the corpus-cavernosum-electromyogram (CC-EMG) and other neurophysiological examinations. The third invasive step contains the dynamic infusion pharmacological cavernosography and cavernosometry (DICC) and the selective pharmacological phallo-arteriography. The procedures of this step are essentially limited to patients with erectile dysfunction who are planned for surgical interventions.

[Diagnosis and therapy of erectile dysfunction: a function of legal health insurance?]. / Diagnostik und Therapie der erektilen Dysfunktion: eine Leistung der gesetzlichen Krankenversicherung?

From the medical point of view erectile dysfunction (ED) is accepted as a disease. However, there is a difference between the medical definition and the definition used by the official health insurance companies. This means that these health insurance companies have sometimes refused payment to the urologists for work done in the diagnosis and treatment of ED, especially in elderly men. Studies on the sexual behavior of elderly men show that 53-80% of men older than 75 years are still interested in sex and that 26% of this group have intercourse several times a month. Therefore, no one can say that sexual interest and activity decrease in elderly men to the point of complete inactivity. For this reason, the basic principle of maintaining the health of the individual is just as applicable in this case as it is in elderly people who are hard-of-hearing or who have weak eyesight. Thus, the diagnosis and therapy of ED must, strictly speaking, be considered a medical service that is recognized and paid for by the official health insurance companies. The substances used have not been licensed for this indication by the German BGA (German equivalent of the FDA), but this does not influence the possibility of prescribing them. Generally speaking papaverine, papaverine/phentolamine and prostaglandin E1 can be prescribed. In our opinion, prostaglandin E1 is to be preferred.

[Testicular biopsy in azoospermia before fertilization interventions--uni- or bilateral? Initial results of a prospective study]. / Hodenbiopsie bei Azoospermie vor fertilisierenden Eingriffen--ein-oder beidseitig? Erste Ergebnisse einer prospektiven Studie.

Azoospermia can have testicular or posttesticular causes. For confirmation of the diagnosis, a testicular biopsy is recommended. Whether bilateral biopsy is necessary is the subject of some controversy. In a prospective study, 44 consecutive male patients (mean age 32.4 [20-52] years) with azoospermia were examined in our andrological department. Spermatogenesis was analyzed by means of a semi-thin technique and with reference to a modified Johnsen-Score. There was no difference in median size between the right (13.5 [8.5-15] ml) and the left testis (11 [7-15] ml). In the analysis of the score values, we found no differences between the two testes (median scores: right side 3 [2-7.2], left side 3.75 [2.1-7.45]). In one quarter of the patients who had a difference of more than 2 ml in testicular size the higher score was found in the smaller testis. In linear regression analysis, no correlation was found between differences in testicular volume and score differences. There was a qualitative difference in spermatogenesis in two patients. In no patient was a carcinoma in situ detected. The above results led us to the conclusion that a unilateral biopsy is adequate from both qualitative and quantitative aspects.

[Cryptorchism--assessment from an andrologic viewpoint]. / Kryptorchismus--eine Betrachtung aus andrologischer Sicht.

This report deals with the pathology, diagnosis and therapy of cryptorchidism from the andrological point of view. Hypothalamic-pituitary gonadal failure and a reduced transformation of gonocytes are the key factors in fertility disorders. The aim of all well-timed therapy must be to improve the fertility potential of the sexually mature male. At present, the determination through biopsy of the fertility index during orchiopexy offers the only possibility of prospective diagnosis in this respect. In the future, it will be necessary to have a standardized procedure in order to guarantee the long-term effect of correctly timed orchiopexy on fertility.

Transurethral laser therapy and urinary tract infections.

To date transurethral laser ablation of the prostate (TULAP) in benign prostatic hyperplasia (BPH) is the commonest form of transurethral laser surgery. The invention of the so-called "sidefire" laser fibre was the prerequisite condition for effective transurethral laser ablation of the prostate. Since the first transurethral laser ablation in human BPH was performed by Costello in September 1990, a multitude of urologists have adopted this technique. In the meantime, a great many studies have been carried out and a lot of data have been published. The initial, to some extent euphoric, enthusiasm of some urologists as well as some patients, especially in the USA and Europe, has turned into a more critical reflection. There is no doubt at all that TULAP is a feasible alternative treatment method with reasonable results. Especially in the high-risk patient, there is neither severe blood loss nor an uptake of irrigation fluid. It is also beneficial to allow unlimited treatment in patients on anticoagulant medication. Nevertheless, the value of TULAP in comparison to transurethral electroresection of the prostate (TURP), generally accepted as the "gold-standard" in the surgical therapy of BPH, remains unclear. A final assessment will only be possible when further data on mortality, short and long term morbidity and outcome with this method have been presented. Strong evidence exists that the operation can be performed without blood loss and uptake of irrigation fluid. A further advantage seems to be preservation of sexual function, especially anterograde ejaculation in the majority of patients, in comparison to the "gold-standard" TURP. In most studies, the value of TULAP is further compared with regard to the elimination of obstruction by means of pressure-flow-studies. The aspect most frequently neglected by all investigators to date is the frequency and severity of urinary tract infections (UTI) in patients in whom TULAP is performed. Basically, UTI in the form of cystitis, ascending infections such as male adnexitis or pyelonephritis, prostatitis of the remaining parts of the prostate and catheter-induced urethritis are associated with transurethral surgery in general. Certain data indicate an age-related frequency of UTI. From a rate of approximately 1% of UTI in infants, the frequency rises to 30% in the 8th decade of life. According to these data, one can expect that in a study of TULAP in high risk patients, most of whom are elderly, a large number present for surgery with a preexisting UTI. Other data demonstrate that after 4.5 days 50% and more of patients with an indwelling catheter develop an ascending UTI, although a closed urinary drainage system has been used. In most cases enterobacteriaceae, in 80% Escherichia coli, are detected. Especially in TULAP, a period of prolonged catheterisation has to be expected in the majority of patients. The risk of UTI in the perioperative phase is therefore expected to be higher. There are several higher risks and possibilities of complications in transurethral surgery in patients with UTI. Taking this into account, all our patients routinely undergo low dose antibiotic prophylactic treatment. The frequency of infections of the remaining parts of the prostate after prostatic surgery is strongly correlated to the flow characteristics in the prostatic urethra and to the amount of destruction of the prostatic tissue. Here are further reasons for a higher risk of infection after TULAP. Due to the fact that the prostatic tissue is not removed by a clear cut, but coagulated by laser beam, a rough surface due to tissue necrosis results. This is an ideal culture medium for bacteria aggravated by the disturbed laminar flow in the prostatic urethra, which favours an intraprostatic reflux of infected urine. There is evidence that UTI are the most important factor of morbidity during the first weeks after TULAP because of their bothersome symptoms.(ABSTRACT TRUNCATED)

[Costs and benefits of quality management]. / Kosten und Nutzen eines Qualitätsmanagements.

The establishment of quality management (QM) has been mandatory for health care providers of the national health insurance since 2004; however, certification is so far only compulsory for rehabilitation clinics. The costs have so far only been quantified in a few medical studies, while they are widely known in business administration with a basic distinction made between planning, steering, auditing, and declaration costs. Another business economics approach differentiates between prevention, appraisal, and non-conformance costs. The benefits of QM relates to customers, employees, external service providers, and health insurance providers. Also important in our consideration of the patient as a customer is that they should not be considered a customer in the usual business sense because the patient is in an emergency situation and can not freely decide. Improvements in treatment quality and in reducing the rate of adverse events make up the largest portion of the benefits of QM. Furthermore, QM can have a positive influence on motivation and employee recruitment. In addition, the cost savings that result despite costs for QM must not be forgotten.

Comparison of expressed prostatic secretions with urine after prostatic massage--a means to diagnose chronic prostatitis/inflammatory chronic pelvic pain syndrome.

OBJECTIVES: To compare the analysis of urine after prostatic massage (VB3) with expressed prostatic secretions (EPS) to assess the significance of leukocyte analysis in VB3 and to give a first hint of the diagnosis of inflammatory chronic pelvic pain syndrome (CPPS) when EPS cannot be obtained. METHODS: Three hundred twenty-eight men (mean age 38 years, range 18 to 70) with expressible prostatic secretions were investigated. EPS were stained using the Papanicolaou stain and analyzed for leukocytes per high power field (HPF) (x1000). Additionally, identical aliquots of first voided urine (VB1), midstream urine (VB2), and VB3 were centrifuged, stained (Papanicolaou), and analyzed for leukocytes (x400). Patients with increased numbers of leukocytes in VB1 and VB2 (2 or more per x400) were excluded. For statistical analysis, Spearman's correlation coefficient for nonparametric tests was used. RESULTS: Of 180 men with less than 10 leukocytes per HPF in EPS, 178 (98.9%) had less than 10 leukocytes per view field in VB3. In 148 men with 10 or more leukocytes per HPF in EPS, 136 (91.9%) also had elevated leukocyte counts in VB3. The presence of elevated leukocytes in VB3 predicted the presence of increased leukocytes in EPS with a high certainty: 91.9% sensitivity, 98.9% specificity, and 95.7% accuracy, with a positive and negative predictive value of 98.6% and 93.7%, respectively. CONCLUSIONS: We conclude that the determination of leukocytes in VB3 is a feasible and reliable method compared with the analysis of EPS. However, although this association does not directly prove the significance of VB3 in those patients from whom no EPS can be obtained, we suggest this method be taken into account as an indirect indicator in the diagnosis of inflammation.

Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach.

In severe oligozoospermia or azoospermia, low ejaculate volume, low ejaculate pH and little or no fructose in seminal plasma suggest an obstruction of the seminal pathways at the level of the prostate gland, when vasal aplasia and ejaculatory disorders are excluded. We report on our standardized surgical approach in 16 consecutive patients with this condition after clinical evaluation, semen analysis, endocrine assessment, testicular biopsy and transrectal ultrasonography. Pre-operatively, sperm analysis demonstrated typical low-volume ejaculates with azoospermia in 12 and severe oligozoospermia in four cases. Ultrasonography demonstrated seven central (Müllerian) and five lateral cystic lesions. Four cases with central obstruction revealed no ultrasonographic pathology. After intra-operative vasopuncture and vasography for definite localization of the level of obstruction, transurethral incision and/or resection of ejaculatory ducts (TURED) was performed. Patency was proven in 15 out of 16 cases by 'intra-operative chromotubation'. In nine out of 12 patients, spermatozoa could be harvested intra-operatively from the vas. During the follow-up of 12 months, post-operative ejaculates showed persistent patency in six out of seven Müllerian cysts with concomitant improvement of sperm quality. Only three of the other nine cases remained patent with the worst results in lateral cystic lesions. Only two of the patients with Müllerian cysts have fathered a child so far. The data provide evidence for the effectiveness of surgical treatment of ejaculatory duct obstruction, especially in the case of central cystic lesions. The combination of surgery, cryostoring of spermatozoa retrieved intra-operatively and the possible storage of ejaculated spermatozoa post-operatively creates the possibility of subsequently using reproductive techniques if pregnancy is not achieved.

Vasovasostomy.

Vasovasostomy after sterilisation vasectomy is the most frequently performed microsurgical intervention in refertilizing surgery. Causes for obstruction other than vasectomy such as juvenile hernia repair and other kinds of surgery affecting the seminal cord appear to be rare. The pre-operative diagnostic approach follows the rules of conventional diagnostics in male infertility. The significance of the intra-operative evaluation of aspirates from the duct and its role in surgical decision-making is controversely debated in the literature. Similar controversies are evident concerning the microsurgical technique that is applied. In particular, the advantages of the two-layered technique (gold standard) of the anastomosis versus the single-layered technique are discussed. Other techniques such as laser applications and fibrin glue are not routinely used in humans. Even difficult microsurgical problems in cases with extended obstructions and cases of re-vasovasostomy can nowadays be managed and have significant success rates. Important prognostic factors appear to be the interval of obstruction, sperm granulomas, and length of the testicular end of the duct. High success rates accompanied by a lower profile in cost make the microsurgical approach (refertilization) superior versus the primary use of ART techniques such as ICSI.

New aspects in Peyronie's disease--a mini-review.

There have been several advances in elucidation of the pathogenesis of Peyronie's disease. Transforming growth factor beta 1 seems to play a major role in this disease, while the importance of penile trauma is a matter of debate. High-resolution ultrasound sonography is the method of choice in detecting penile plaques, while magnetic resonance imaging is useful in the evaluation of actively inflamed plaques. There are still differences of opinion on the best drug therapy in noncalcified plaques. The results on tamoxifen or interferon therapy vary between useless and useful. Potassium-para-aminobenzoate seems to have a significant effect in decreasing plaque size and deviation angle. The operative strategy for big plaques or complex deviation has changed to the 'small incision' graft, leading to far lower post-operative impotence rates. Iontophoresis seems to be worthy of further trials, while the results of extracorporal shock wave therapy have to be discussed critically.

Clinical findings in congenital absence of the vasa deferentia.

In a clinical study, 105 patients with congenital bilateral absence of the vas deferens (CBAVD) and 18 with congenital unilateral absence of the vas deferens (CUAVD) were investigated. CUAVD was observed on the left side in 66%. Renal agenesis was more frequent in CUAVD (73.7%) than in CBAVD (11.8%). The leading signs of CBAVD are low pH level (average 6.5) and low volume of the ejaculate (average 0.95 ml). Testicular biopsies of 52 patients revealed normal spermatogenesis or hypospermatogenesis (33% in CBAVD; 45% in CUAVD). Genetic probing and counselling concerning cystic fibrosis are necessary if extracorporal micro-fertilization is considered. The absence of the vas deferens was often overlooked by the first investigator, the average time until correct diagnosis being 4.3 years. As artificial reproduction technology becomes more common, detection of vasal agenesis will certainly be made earlier and more frequently in the future. In order to assure compatibility of subsequent prospective studies about CBAVD and CUAVD, the following investigations are considered to be necessary: (i) semen analysis (pH, volume); (ii) renal ultrasonography or excretory urogram (screening for renal agenesis); (iii) genetic cystic fibrosis screening.

Sexual dysfunction in Peyronie's disease: an analysis of 222 patients without previous local plaque therapy.

PURPOSE: We obtained an objective evaluation of erectile function in patients with Peyronie's disease. MATERIALS AND METHODS: Sexual dysfunction was analyzed in 222 patients with Peyronie's disease without previous local plaque therapy using a standardized protocol. RESULTS: Of the 222 patients 70 (31.5%) complained of not being able to perform intercourse. In 4 men (1.8%) standardized diagnostic procedure demonstrated only a severe angulation making coitus impossible, and in 3 men (1.4%) intercourse became unsatisfactory due to pain. Seven men (3.1%) reported distal penile flaccidity, including 4 in whom dynamic pharmacocavernosometry and pharmacocavernosography revealed veno-occlusive dysfunction. Of 56 men who complained of a complete loss of erection 51 did not respond to intracavernous pharmacological injection with prostaglandin E1, and 27 (48.2%) had abnormal arterial blood flow as shown by duplex sonography of the cavernous arteries, 47 (83.9%) had evidence of veno-occlusive dysfunction based on cavernosometric criteria and 33 (58.9%) also had cavernosographic evidence of the condition. Plaque associated venous drainage was evident in 15 of the 56 impotent patients (26.8%), equivalent to 45.5% of all cases with abnormal cavernosographic findings. CONCLUSIONS: Sexual dysfunction was evaluable in 31.5% of patients, and the main cause of impotence and loss of erection was veno-occlusive dysfunction.

Value of magnetic resonance imaging in patients with penile induration (Peyronie's disease).

Magnetic resonance imaging (MRI) is a noninvasive procedure that enables exact imaging of penile anatomy. A total of 34 patients with clinical Peyronie's disease underwent palpation, ultrasound and MRI after intracavernous injection of 10 micrograms. prostaglandin E1. MRI images were obtained before and after intravenous application of gadolinium-diethylenetriaminepentaacetic acid. In 34 patients 45 plaques were palpable. Ultrasound revealed evidence of lesions in 66.6% of the cases. On MRI 36 of 45 palpable plaques (80%) were detected. Not palpable or sonographically revealed indurations could be shown in 4 cases. After intravenous application of gadolinium-diethylenetriaminepentaacetic acid 4 plaques demonstrated contrast enhancement, thus indicating local inflammatory activity. The combination of clinical examination and sonography remains the method of choice for diagnosis and observation of patients with Peyronie's disease. MRI enables exact imaging of penile structures but it does not provide a significant advantage over standard investigative procedures.