J. Steffens

[Ureteric reconstruction with reconfigured ileal segments according to Yang-Monti. A 4-year prospective report].

BACKGROUND We report on 4 years experience with ileal ureteric replacement using the Yang-Monti procedure. PATIENTS AND METHODS From April 2001 to January 2009 reconfigured ileal segments were used for total (in 16) or partial (in 2) substitution of the ureter in 18 patients (mean age 47.4 years) with functional ureteric loss secondary to radiogenic or iatrogenic conditions. An antireflux implantation into the native bladder was done in 16 patients. All patients were followed prospectively according to a standardized protocol. RESULTS The mean follow-up was 4.2 years (0.5-8 years). There were no perioperative deaths. Ultrasound controls showed an improvement of the upper tract dilatation in 11, a constant finding in 5 and a worsening in 2 cases. All of the treated renal units had evidence of improved renal function in ten and stabilization in eight patients. Neither a metabolic complication nor mucous obstruction was observed. Minor short-term complications, mainly febrile urinary tract infection and paralytic ileus, occurred in 50% and long-term complications, infections and hernia in 22%. CONCLUSIONS The ileal ureteral substitute with reconfigured segments offers distinct advantages. A short bowel segment is used with the consequent absence of metabolic complications and excessive mucous production. It allows construction of an ileal ureter with a suitable cross-sectional diameter without any need for tailoring and makes it possible to use an antireflux technique. The intermediate results are encouraging.

Harnleiterrekonstruktion mit rekonfigurierten Ileumsegmenten nach Yang-Monti

BACKGROUND We report on 4 years experience with ileal ureteric replacement using the Yang-Monti procedure. PATIENTS AND METHODS From April 2001 to January 2009 reconfigured ileal segments were used for total (in 16) or partial (in 2) substitution of the ureter in 18 patients (mean age 47.4 years) with functional ureteric loss secondary to radiogenic or iatrogenic conditions. An antireflux implantation into the native bladder was done in 16 patients. All patients were followed prospectively according to a standardized protocol. RESULTS The mean follow-up was 4.2 years (0.5-8 years). There were no perioperative deaths. Ultrasound controls showed an improvement of the upper tract dilatation in 11, a constant finding in 5 and a worsening in 2 cases. All of the treated renal units had evidence of improved renal function in ten and stabilization in eight patients. Neither a metabolic complication nor mucous obstruction was observed. Minor short-term complications, mainly febrile urinary tract infection and paralytic ileus, occurred in 50% and long-term complications, infections and hernia in 22%. CONCLUSIONS The ileal ureteral substitute with reconfigured segments offers distinct advantages. A short bowel segment is used with the consequent absence of metabolic complications and excessive mucous production. It allows construction of an ileal ureter with a suitable cross-sectional diameter without any need for tailoring and makes it possible to use an antireflux technique. The intermediate results are encouraging.

[Process design in high-reliability organizations].

ZusammenfassungDie moderne Medizin ist eine hochkomplexe Dienstleistungsbranche, in der die einzelnen Leistungserbringer stark vernetzt sind. Die Komplexität und Vernetzung birgt jedoch Risiken für die Sicherheit des einzelnen Patienten. Anderen hochkomplexen Branchen wie der Luftfahrt ist es gelungen, trotz stark gestiegener Passagierzahlen das Sicherheitsniveau konstant zu halten bzw. sogar zu steigern. Standardverfahren, „crew ressource management“ (CRM) sowie operative Risikoeinschätzung sind historisch gewachsene und bewährte Bestandteile eines umfassenden und systemisch angelegten Sicherheitsprogramms. Wenn die Medizin diesen Quantensprung auf dem Weg zu mehr Patientensicherheit nachvollziehen will, muss sie sich intensiv mit den Ergebnissen anderer Hochzuverlässigkeitsbranchen auseinander setzen und nach kritischer Begutachtung Schritt für Schritt einführen.AbstractModern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.Modern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.

Lymphoceles after radical retropubic prostatectomy. A treatment algorithm

ZusammenfassungLymphozelen stellen eine gelegentliche Komplikation nach Lymphadenektomie dar und können neben ihrer Symptomatik zu schwerwiegenden sekundären Komplikationen führen. Die publizierten Ergebnisse zur Therapie und unsere eigenen, auf einer prospektiven Untersuchung basierenden Erfahrungen bilden die Grundlage für den vorgestellten Algorithmus zur Behandlung einer Lymphozele nach retropubischer Prostatektomie.Die Therapie einer Lymphozele ist von verschiedenen Faktoren wie Ausdehnung und Lage, Infektionsrisiko und produzierter Flüssigkeitsmenge sowie dem Risiko sekundärer Komplikationen abhängig. So wird das Punktat symptomatischer Lymphozelen zunächst auf eine mögliche Infektion hin untersucht. Bei Sterilität ist der Versuch einer perkutanen Drainage bzw. einer Sklerosierung gerechtfertigt. Bei Versagen dieser Maßnahmen besteht die Indikation zur laparoskopischen Marsupialisation. Die erst nach dem Fehlschlagen dieser Methode indizierte offen operative Versorgung sollte sich bei infizierten Lymphozelen unverzüglich anschließen.Die laparoskopische Fensterung von Lymphozelen als Folge einer radikalen retropubischen Prostatektomie stellt ein effektives, sicheres und minimal-invasives Verfahren dar. Zur Therapie steriler symptomatischer Lymphozelen sollte dieses Verfahren vorrangig angewendet werden.AbstractLymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage.Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.Lymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage. Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.

Lymphozele nach radikaler retropubischer Prostatektomie

ZusammenfassungLymphozelen stellen eine gelegentliche Komplikation nach Lymphadenektomie dar und können neben ihrer Symptomatik zu schwerwiegenden sekundären Komplikationen führen. Die publizierten Ergebnisse zur Therapie und unsere eigenen, auf einer prospektiven Untersuchung basierenden Erfahrungen bilden die Grundlage für den vorgestellten Algorithmus zur Behandlung einer Lymphozele nach retropubischer Prostatektomie.Die Therapie einer Lymphozele ist von verschiedenen Faktoren wie Ausdehnung und Lage, Infektionsrisiko und produzierter Flüssigkeitsmenge sowie dem Risiko sekundärer Komplikationen abhängig. So wird das Punktat symptomatischer Lymphozelen zunächst auf eine mögliche Infektion hin untersucht. Bei Sterilität ist der Versuch einer perkutanen Drainage bzw. einer Sklerosierung gerechtfertigt. Bei Versagen dieser Maßnahmen besteht die Indikation zur laparoskopischen Marsupialisation. Die erst nach dem Fehlschlagen dieser Methode indizierte offen operative Versorgung sollte sich bei infizierten Lymphozelen unverzüglich anschließen.Die laparoskopische Fensterung von Lymphozelen als Folge einer radikalen retropubischen Prostatektomie stellt ein effektives, sicheres und minimal-invasives Verfahren dar. Zur Therapie steriler symptomatischer Lymphozelen sollte dieses Verfahren vorrangig angewendet werden.AbstractLymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage.Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.Lymphoceles represent a common complication following pelvic lymphadenectomy and radical retropubic prostatectomy. Relevant articles published in the last 25 years and our own results based on a prospective study were taken as the basis for a treatment algorithm for lymphoceles after radical prostatectomy.The type of intervention depends on the clinical situation of the patient. Symptomatic lymphoceles can be managed initially by percutaneous aspiration with or without instillation of sclerosing agents. However, lymphocele recurrence rates are high. Symptomatic, sterile lymphoceles appear to be ideally suited for drainage by laparoscopic techniques. This method is effective, usually immediately definitive, results in minimal patient morbidity, and allows for a more rapid recovery. Infected lymphoceles require percutaneous or open surgical drainage. Laparoscopic marsupialization of symptomatic lymphoceles after pelvic lymphadenectomy for prostate cancer appears to be safe and effective. Because of the minimal postoperative morbidity, rapid convalescence, and low recurrence rate, laparoscopic lymphadenectomy should be considered as a first-line treatment for symptomatic, uninfected sterile lymphoceles.

Katheterisierbarer Kontinenzmechanismus für verschiedene Harnableitungsreservoire

In a retrospective multicenter study of four clinics perioperative complications as well as incontinence and stoma stenosis of serosa-lined tapered ileum as catheterizable continence mechanisms for different urinary diversions were analyzed. Between 2008 and 2012 a total of 40 patients received a continent catheterizablestoma, 15 (37.5%) in combination with continent vesicostomy and closure of the bladder neck due to postoperative incontinence and recurrent stenosis including radical prostatectomy, transurethral resection (TUR) of the prostate, bladder neck incision (n=11), neurogenic bladder with reduced capacity and incontinence (n=2), interstitial cystitis (n=1) and recurrent urethral tumor following ileal neobladder (n=1). Of the patients 25 (62.5%) received this continence mechanism in combination with a modified Mainz pouch I, in 19 patients as primary and in 6 patients as secondary efferent segment for trouble shooting. The complications were subdivided according the Clavien classification. In 29 patients information concerning continence and stenosis were obtained, the median follow-up was 25 months (range 1-111 months). In patients with continent vesicostomy (n=11) the incontinence rate was 9.1% (1/11) and the stenosis rate 18.2% (2/11). In 18 patients with an ileocecal pouch, incontinence and stenosis rates were 0% and 11.1% (2/18), respectively. The presented technique is a safe continence mechanism for various catheterizable continent urinary diversions for both primary and secondary indications.

Lichen sclerosus mit Meatusstenose

A novel technique is reported to relieve stenosis of the external urinary meatus in men and boys with lichen sclerosus. A total of 21 patients underwent the new operation of Malone in a 4-year period. The mean patient age was 41.7 years (range: 7-75 years) and mean follow-up was 3.4 years (6 months to 4.1 years). The procedure combines a small ventral with an extensive dorsal meatotomy and ends with an inverted V-shaped relieving incision to correct puckering caused by dorsal meatotomy. Patients were mailed a questionnaire asking if they were pleased with the functional and cosmetic results There were no complications or recurrences. A total of 18 patients replied to the questionnaires. All patients were pleased with the functional and 15 were satisfied with the cosmetic results. The technique relieves stenosis of the external urinary meatus in the short term.It is rapid and easy to perform, avoids a hypospadiac meatus and provides good results.

Prozessgestaltung in Hochzuverlässigkeitsorganisationen

ZusammenfassungDie moderne Medizin ist eine hochkomplexe Dienstleistungsbranche, in der die einzelnen Leistungserbringer stark vernetzt sind. Die Komplexität und Vernetzung birgt jedoch Risiken für die Sicherheit des einzelnen Patienten. Anderen hochkomplexen Branchen wie der Luftfahrt ist es gelungen, trotz stark gestiegener Passagierzahlen das Sicherheitsniveau konstant zu halten bzw. sogar zu steigern. Standardverfahren, „crew ressource management“ (CRM) sowie operative Risikoeinschätzung sind historisch gewachsene und bewährte Bestandteile eines umfassenden und systemisch angelegten Sicherheitsprogramms. Wenn die Medizin diesen Quantensprung auf dem Weg zu mehr Patientensicherheit nachvollziehen will, muss sie sich intensiv mit den Ergebnissen anderer Hochzuverlässigkeitsbranchen auseinander setzen und nach kritischer Begutachtung Schritt für Schritt einführen.AbstractModern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.Modern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.

[Catheterizable continence mechanisms for various urinary diversion reservoirs: serosa lined and tapered ileum].

In a retrospective multicenter study of four clinics perioperative complications as well as incontinence and stoma stenosis of serosa-lined tapered ileum as catheterizable continence mechanisms for different urinary diversions were analyzed. Between 2008 and 2012 a total of 40 patients received a continent catheterizablestoma, 15 (37.5%) in combination with continent vesicostomy and closure of the bladder neck due to postoperative incontinence and recurrent stenosis including radical prostatectomy, transurethral resection (TUR) of the prostate, bladder neck incision (n=11), neurogenic bladder with reduced capacity and incontinence (n=2), interstitial cystitis (n=1) and recurrent urethral tumor following ileal neobladder (n=1). Of the patients 25 (62.5%) received this continence mechanism in combination with a modified Mainz pouch I, in 19 patients as primary and in 6 patients as secondary efferent segment for trouble shooting. The complications were subdivided according the Clavien classification. In 29 patients information concerning continence and stenosis were obtained, the median follow-up was 25 months (range 1-111 months). In patients with continent vesicostomy (n=11) the incontinence rate was 9.1% (1/11) and the stenosis rate 18.2% (2/11). In 18 patients with an ileocecal pouch, incontinence and stenosis rates were 0% and 11.1% (2/18), respectively. The presented technique is a safe continence mechanism for various catheterizable continent urinary diversions for both primary and secondary indications.

Zukunftssicherung der Urologie

Can urology overcome the socioeconomic changes in the coming decade? Important is the establishment of networks and connections in order to cover the highest number of branches of urology possible. The responsibility of urologists necessitates changes and personnel placements in research, clinical and private practice. The author explains this exemplified by five selected aspects.ZusammenfassungKann die Urologie die sozioöknomischen Veränderungen des kommenden Jahrzehnts bewältigen? Wichtig ist die Schaffung von Netzwerken und Verbünden, um möglichst viele Teilgebiete der Urologie abzudecken. Die Verantwortung der Urologen erfordert strukturelle Änderungen und personelle Besetzungen in Forschung, Klinik und Praxis. Der Autor erörtert dies anhand von fünf ausgewählten Aspekten.AbstractCan urology overcome the socioeconomic changes in the coming decade? Important is the establishment of networks and connections in order to cover the highest number of branches of urology possible. The responsibility of urologists necessitates changes and personnel placements in research, clinical and private practice. The author explains this exemplified by five selected aspects.