Urologie最新文献

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.

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.

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: Purulent infection of the pubic symphysis (infectious bacterial symphysitis, IBS) is a rare but serious disease of the symphysis and parasymphyseal structures. It can develop following surgery, interventions in the lower urinary tract, or pelvic radiation therapy.

Objective: We report on one of the largest urological cohorts with post-therapeutic IBS, with the aim of increasing awareness for this severe condition and optimizing diagnosis and treatment.

Methods: We conducted a descriptive retrospective data analysis at a university hospital over the years 2018-2022. Of the total collective, 25 patients were treated for underlying urological diseases and are part of this subgroup analysis.

Results: Of the 25 patients with IBS, 24 were suffering from or had been treated for urological malignancies (19/24 [79%] prostate cancer; 5/24 [21%] urothelial cancer). Two patients had been treated for nonmalignant urological diseases. The average interval between surgery or intervention in the lower urinary tract due to the underlying urological disease and the diagnosis of IBS was 73.9 months (SD ± 55.7 months). Relevant fistula formations were detected in 14/25 (56%) cases, most frequently between bladder and symphysis (8/14, 57%). Of the 25 patients, 11 (58%) could be treated conservatively, while 14 (56%) had required complex, interdisciplinary, reconstructive, and, above all, multiple surgical procedures.

Conclusion: Purulent infection of the pubic symphysis is a severe clinical condition that can occur during-and even years after-urological and uro-oncological treatments. This study illustrates the importance of ruling out IBS even years after urological disease or surgery or interventions in the lower urinary tract. Interdisciplinary treatment involving colleagues from orthopedic and trauma surgery should always be sought, as should treatment in a center with the appropriate experience, case numbers, and infrastructure. As diagnosis and treatment are demanding, creation of an interdisciplinary guideline could be useful. We present an algorithm which includes diagnostic steps and rational therapeutic options.

Environmental sustainability has become increasingly important in recent years, not only in social discourse but also in the healthcare sector. The healthcare sector in Germany contributes significantly to total CO₂ emissions, accounting for over 5%, and consumes roughly the same amount of resources. Areas that are particularly relevant to urology, such as pharmaceuticals, medical devices, and instrument logistics, are among the most intensive consumers of resources, alongside construction measures, the operation of clinics and practices, and food supply. In light of this, the German Society of Urology (DGU) has recognized the urgency of the situation and developed a sustainability strategy that includes all sectors of the field and aims to provide concrete perspectives for the responsible use of existing resources.