Urological diseases during pregnancy

Pyelonephritis and urinary calculi are the most frequent urological complications during pregnancy. They are followed by injuries of the urinary system during birth or in connection with multiple traumas in traffic accidents. Kidney transplantation or permanent urinary diversion (Ileum- or Colon-Conduit) are not an absolute obstacle for pregnancies when closely followed. Problematic for mother and child is the coincidence of pregnancy and malignant tumours. In that case good cooperation among the different specialities is necessary. This study provides a concept for the diagnostic and therapeutic procedures. Knowledge of adequate methods of examination and modern techniques and a timely treatment meeting the demands of the situation prevent complications and sequelae of the pregnancy.     

Artificial urinary sphincter implantation after pubectomy for bone tumor

We report 2 cases of unilateral and bilateral excision of pubic bone tumors (chondrosarcoma and giant cell tumor). Postoperative stress incontinence was corrected by implantation of an artificial sphincter (AMS800) following which both patients were continent. The etiology of the incontinence was lack of bladder and urethral support, which was not correctable by bladder neck suspension procedures.     

耻骨下部分切除修复复杂性外伤性后尿道闭锁（附六例报告）

为了提高复杂性外伤性后尿道闭锁的手术效果，自１９９２年１月至１９９５年６月，采用切除耻骨下部分途径修复６例复杂性创伤性后尿道闭锁。术野显露良好，便于尿道成形。６例术后排尿通畅，无尿失禁。详细介绍了手术方法，并对其适应证及耻骨切除范围，合并后尿道直肠瘘、长段尿道缺损的处理，防止尿失禁等进行讨论。     

Urological injuries during cesarean section: intraoperative diagnosis and management

PURPOSE: We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting. MATERIALS AND METHODS: From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data. RESULTS: In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent. CONCLUSIONS: Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.     

Urological emergencies

Urological emergencies that require specialist treatment include testicular torsion, gross hematuria, urogenital injuries and acute flank pain. After initial symptoms-adapted therapy, patients should be transferred immediately to an urological department for imaging (e.g. ultrasound, IVP, CT) and further specific examinations (e.g.blood tests, urine analysis, microbiology). Acute lower abdominal and scrotal pain in young men may be symptomatic of testicular torsion, which requires immediate urological surgery. Gross hematuria is usually not a life-threatening emergency. Nevertheless, urogenital tumor has to be ruled out by an urologist. Patients with urogenital injuries are triaged into surgical and non-surgical treatments. Differential diagnosis of acute flank pain falls into several medical fields. After initial symptom-related therapy, further diagnostic procedures have to be performed. Septic presentation may be symptomatic of infectious hydronephrosis which requires immediate urological intervention.     

Telesurgery. Remote monitoring and assistance during laparoscopy

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.     

机器人泌尿外科手术

1 Introduction
In past few decades, better understandings of anatomy and advance in techniques and technology have revolutionized urological surgery. Laparoscopic surgery has now become one of the basic instruments of urologists. Laparoscopic radical nephrectomy is currently the standard of care in most urological centers. Laparoscopic radical prostatectomy and cystectomy are also becoming the preferred approach in some institutes. However, the learning curve of the above surgeries is steep, which limits both urologists and patients from enjoying the full benefit of minimally invasive surgery.     

Urological medical malpractice

PURPOSE: Like all other medical and surgical practitioners, urologists are occasionally confronted with the unpleasant realization that they are being sued for medical malpractice. These suits are generated through any number of acts or failures to act during innumerable circumstances. We reviewed all urological claims presented to 1 representative insurance company and delineated the types of acts, settings, expenses and disposition of these claims. This review was performed to understand better the claims confronting urologists and provide future guidance to urologists in the medical malpractice setting. METHODS AND MATERIALS: Working with The St. Paul Companies 259 medical malpractice claims against urologists consecutively closed from 1995 to 1999 were reviewed. Claims were defined as urological malpractice when the insured-defendant in a malpractice claim was a urologist. Each claim was reviewed in terms of disposition, patient age, geographic location, office-hospital setting, purported negligent act, procedure if applicable, litigation status and expenses incurred. Data ascertained were then compared to national practice statistics provided by the American Urological Association (AUA) and American Medical Association. In addition, a literature search with the key words urology and malpractice was performed. Related pertinent documents were reviewed and incorporated into this analysis. RESULTS: We reviewed 259 urological medical malpractice claims closed between 1995 and 1999. During this period The St. Paul Companies insured various numbers of private practice urologists. In the years ending 1995 to 1999, 489, 492, 438, 377 and 426 individual urologists, respectively, were insured with respective premiums paid in the amounts of $6.27, $6.23, $5.80, $5.15 and $3.87 million. Claims were analyzed by AUA section. The greatest incidence of claims occurred in the Southeastern section, followed by the North Central, South Central, Mid-Atlantic, New England, Western and New York sections. According to AUA statistics the greatest number of practicing urologists are in the Southeastern section, followed by the Western, North Central, South Central, Mid-Atlantic, New York, New England and Northeastern sections. When analyzing average expenses, the New England section had the most costly claims, followed by the Mid-Atlantic, North Central, Southeastern, South Central, Western and New York sections with respective mean expenses of $266,887, $145,031, $47,667, $41,843, $38,365, $30,037 and $1,065 per claim, respectively. The greatest percent of claims arose from the categories of inpatient, adult and surgical procedures. Endourological procedures resulted in the greatest incidence of surgical claims. However, claims related to prostatectomy involved the most expensive claims with a mean cost of $185,345. Of the surgical procedures incidents defined as postoperative complications were the most common acts of negligence generating a malpractice claim. The majority of malpractice claims were filed in court but subsequently voluntarily dismissed by the plaintiff. CONCLUSIONS: Medical malpractice persists as an issue confronting urologists. Urologists must strive to maintain open, honest, in-depth communications with their patients when occurrences with potential malpractice overtones arise.     

Urological complications following chemonucleolysis

Urinary complications following chemonucleolysis have not been reported in the urological literature. We report a case of urinary retention, perineal hypoesthesia and penile dysesthesia following L5 to S1 chemonucleolysis with chymopapain and review the literature in this area.