Netzgestützte Operationstechniken in der Urogynäkologie

The vaginal and abdominal operation strategies with autologous tissue established for decades show acceptable results with moderate side effects but an up to 30 % relapse due to the existing connective tissue insufficiency. In recent years established methods employing alloplastic and biological meshes have in particular significantly increased the anatomical success rate. However, in addition to only moderate subjective improvements, new and sometimes serious side effects, such as mesh arrosion up to 20 %, pain syndromes, dyspareunia, infections, obstructions and urinary urgency syndrome can occur. Current guidelines confirm the use of meshes in relapse situations and in individual exceptional primary cases; however, there is no scientifically-based evidence for a general application in primary prolapse situations. Improved training of surgeons, refined diagnostics and individual comprehensive informed consent on the planned operation and possible alternatives as well as testing materials in randomized studies before becoming commercially available, all make valuable contributions to an improvement in postoperative results and a reduction of complications and side effects.     

Herz und Diabetes

Antidiabetic therapies have to prove cardiovascular safety and efficacy in addition to blood glucose lowering potential. In recent studies metformin administration and dipeptidyl peptidase-4 (DPP-4) inhibition both reduced hypoglycemic and cardiovascular events in comparison to sulfonylurea. High-density lipoprotein (HDL) cholesterol has recently received much attention as a modulator of cardiovascular risk; however, drug-induced increase of HDL cholesterol was unable to reduce cardiovascular events in patients on optimal statin therapy. Therefore, HDL cholesterol levels remain an important risk predictor without being a therapeutic target. In the field of interventional cardiology the FREEDOM trial demonstrated bypass operations to be superior to drug-eluting stent implantation in patients with diabetes and advanced coronary heart disease.     

Partialrupturen der Supraspinatus- und Subskapularissehne

Lesions of the subscapularis tendon are often associated with lesions of the supraspinatus and long head of the biceps tendons. Clinical and radiographic examination can be unreliable which can lead to incidental findings of these lesions during arthroscopy. Operative treatment of anterosuperior partial tears of the rotator cuff is now mostly performed arthroscopically. An evaluation whether tears are significant or non-significant is an essential step regarding further operative treatment. Non-significant tears are usually debrided. Significant combined partial tears of the supraspinatus and subscapularis tendons require a technically demanding reconstruction of both tendons combined with treatment of the biceps tendon. The following article describes diagnostic procedures as well as aids for efficient planning and outlines the operative steps of an all-arthroscopic technique.     

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.     

Neue Aspekte der ovariellen Stimulation

New aspects of ovarian stimulation for assisted reproduction techniques focus on minimizing patient burden and therapeutic risks while maintaining the classic concept of gonadotropin stimulation in combination with gonadotropin releasing hormone (GnRH) analogues. The introduction of a long-acting follicle stimulating hormone (FSH) preparation (corifollitropin alfa) allows dispensing with daily injections during the first week of stimulation while achieving comparable ovarian responses and clinical outcome. Another milestone is the possibility of completely avoiding ovarian hyperstimulation syndrome (OHSS) by the use of GnRH agonists for ovulation induction in a GnRH antagonist protocol for patients with suspected high response. Various treatment modalities are still under discussion to optimize the outcome of infertility therapy in patients with previous or suspected poor response (POR). In summary, the introduction and new combination of preparations allows a more individualized ovarian stimulation in order to optimize treatment outcome and minimize risks and patient burden during assisted reproduction techniques.     

Operation hämatogener Metastasen

Urological malignancies represent approximately 40?% of all solid tumors. Synchronous or metachronous organ metastases develop in 30?% of patients. Depending on the tumor entity and tumor characteristics, resection of metastases can improve patient survival. Surgical resection of residual tumors is an integral part of the multimodal therapy concept of patients with nonseminomatous metastatic germ-cell cancer. Surgical inoperability is the only reason not to resect. Resection of hematogenous metastases from renal cell carcinoma has been postulated as a standard therapy for decades. Appropriate patient selection is the key for a survival benefit. Prognosticators such as patient’s general condition as well as number, location, and size of metastases help to counsel and select patients accordingly. Metastases of transitional cell or penile carcinoma should only be resected when a response to systemic treatment is evident in the individual case. There is no evidence in favor of resecting organ-metastases of prostate cancer in the current guidelines and the literature. In this article, arguments against resection of metastases following the current literature and guidelines are described.