Urologie最新文献

Background and objective of the study: Hospitals, especially surgical departments, are among the largest producers of waste in Germany. Data on waste management in the operating room (OR) are largely lacking. The aim of this study was to assess and discuss the possibilities of reducing waste and recovering recyclable materials in general surgery against the background of current practice.

Methodology: Surgical departments throughout Germany were surveyed on waste management. First, the theoretical waste separation possibilities for laparoscopic appendectomy were determined. Subsequently, a simple system for the separation of recyclables was established and practically tested in 35 operations. These were compared with 35 appendectomies without separation.

Results: Only 25.7% of hospitals perform waste separation. Theoretically, 20.7% of waste can be recycled, in practice up to 18.9%. Paper, cardboard and plastics, especially polyethylene terephthalate (PET) and high-density polyethylene (HDPE) were separated. This leads to a significant reduction in residual waste without extending the operation time.

Discussion: Separation of recyclables can contribute to more sustainable waste management in the OR. High-value recyclables can be recycled and the residual waste mass can be significantly reduced. This is possible without special effort and does not delay the processes in the OR. The opportunities for this have hardly been used in Germany to date.

The University of Ulm was founded in 1967. Except for the Department of Urology all other specialities of the existing municipal hospital joined the University Medical Center. At that time, the department of urology was-with > 250 beds-the world's largest urology department. There is conflicting historical data, but based on new information the first chairperson took office in July 1984. Initially the Department of Urology was a section of the Surgical Center, but it quickly attained the status of an independent University Urology Clinic. The clinic was a well-known transurethral resection of the prostate (TUR-P) center (Hösel, Marquardt), which evolved to include, among other things, an extracorporeal shock wave lithotripsy (ESWL) center and most notably an oncologic surgery, pioneering the development of the ileal neobladder (INB). The term "neobladder" was coined in Ulm. Large annual live surgeries and operative teaching seminars, and more than 100 visiting professors in Ulm popularized the INB technique and enhanced the clinic's reputation. Significant structural improvements included expanded operating capacity, which was facilitated by 4 operating rooms exclusively for the use of Department of Urology and a dedicated urology intensive care unit jointly managed by anesthesiologists and urologists. The staff of the department increased significantly with external reinforcement by senior physicians from other institutes, and ultimately 4 chairmen of renowned departments (Berlin, Charité, Munich, Klinikum rechts der Isar, Gainsville, Florida, USA, and Bangkok, Thailand) emerged from Ulm as well as numerous heads of national urology departments (e.g., in Karlsruhe, Kassel, and Wiesbaden).

Background: Since robot-assisted laparoscopic prostatectomy (RALP) has become widely accepted in German-speaking countries, there needs to be an agreement on the most efficient surgical techniques. This should be based on the video-anatomy of the prostate and a summary of the actual literature.

Materials and methods: Based on video material of different surgical techniques, a systematic literature search in PubMed has been performed focusing on preservation of continence and minimal rates of positive margins. This is based on the anatomy of the male pelvis applying a standard nomenclature. The original 3825 publications could be reduced to 604 articles according to the inclusion criteria (randomized controlled trials, meta-analyses, systematic reviews, and clinical studies). When expanding the search to encompass individual operation techniques, we identified 27 relevant articles.

Results: Crucial surgical details include preserving the levator fascia, the puboprostatic collar, a long urethral stump with protection of the urethral lissosphincter and posteriorly reconstruction of the rectourethralis with the prostatovesical muscle. Fascial preservation for the levator ani muscle results in 1‑year continence between 78.0 and 98.3%, preservation of the puboprostatic collar and detrusor apron between 95.6 and 100%, maximal functional urethral length between 90.5 and 97.5%. Posterior reconstruction leads to a 3-month continence between 92.3 and 96.9%. Preserving the Retzius' space and thus the total anterior sphincter apparatus results in 1‑year continence of 95.8%; however, it is associated with a higher rate of positive surgical margins (14-42 vs. 10-29%).

Conclusion: Based on the increase of knowledge and the feasibility to translate this into novel surgical techniques, the continence rates could be significantly improved. This includes approaches to spare anatomical structures of the sphincter apparatus, such as preservation of the levator fascia, the puboprostatic collar, the urethral lissosphincter, but also reconstructive techniques, such as posterior reconstruction of the vesicoprostatic and rectourethralis muscle. Demanding techniques, such as the Retzius-sparing approach result in higher continence rates, but are also associated with a higher rate of surgical margins.

The climate crisis has been identified as the largest threat to human health; paradoxically, the healthcare sector is responsible for 5% of the global greenhouse gas emissions that are driving this crisis. These emissions are largely due to carbon-intensive facilities, energy use, complex global supply chains, transportation and pharmaceuticals. In its role of safeguarding the health of both current and future populations, the healthcare sector must take actions to minimise its environmental impact. Strategies for emission reduction include sustainable infrastructure, clinical practice innovations, and procurement and supply chain reform. This article aims to examine current evidence on the health impacts of climate change and explore strategies through which the healthcare sector can reduce its environmental impact while continuing to deliver high-quality care.

Background: Adjuvant pembrolizumab decreases the risk of recurrence and prolongs survival after surgery for high-risk clear cell renal cell carcinoma. Cost-effectiveness analyses evaluate therapy associated risks, toxicity, quality of life, costs of therapies and follow-up regimens and represent an essential adjunct for the evaluation of new therapies. At present, there is no cost effectiveness analysis for adjuvant pembrolizumab within the German healthcare system.

Methods: A Markov model was used to evaluate cost-effectiveness. The impact of variables on the cost-effectiveness of therapy were investigated with one-way deterministic and probabilistic sensitivity analysis and thresholds were determined.

Results: The adjuvant treatment with pembrolizumab was cost-effective over a 5-year period, with an ICER (incremental cost-effectiveness ratio) of 68,278 €/QALY (quality-adjusted life year) assuming a WTP (willingness to pay) threshold of 100,000 €/QALY.

Conclusion: Adjuvant treatment in high-risk patients with pembrolizumab has been shown to be cost-effective when applied within the German health system. It should therefore be offered to all patients with an increased risk for recurrence after curative surgery.