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This is an Accepted Manuscript of an article published by Taylor & Francis in Journal of investigate surgery on 09 July 2019. Final version including figures, is available online: https://doi.org/10.1080/08941939.2019.1637038. Purpose: To compare two clinically relevant anesthetic agents, i.e., isoflurane versus propofol with respect to protection of the kidney in a porcine renal ischemia reperfusion model. Materials and Methods: 14 hybrid pigs were randomized to anesthesia with either isoflurane or propofol prior to laparoscopic surgery. Following anesthesia, the left kidney hilum was clamped for 60 min and the right kidney removed. After 48 h of reperfusion, urine was sampled for analysis of neutrophil gelatinase-associated lipocalin (NGAL), albumin, and creatinine. The left kidney was harvested for histologic scoring of injury. Results: Histologic examination of renal injury revealed a statistically significant difference in favor of isoflurane on denuded basement membrane score (isoflurane group 1.58 ± 0.38 vs. propofol 2.42 ± 0.80, p = .026). Median (25–75 percentile) urinary albumin 3.4 g/L (2.25–7.48) vs. 8.9 g/L (3.73–13.8), (p = .041) and urinary albumin/creatinine ratio 1.17 (0.76–1.82) vs. 1.76 (1.63–5.99), (p = .026) were both significantly lower in the isoflurane group. Median (25–75 percentile) urinary NGAL was 167 (51–215) pg/ml in the isoflurane group compared with 362 (149–508) pg/ml in the propofol group (p = .093). Conclusion: Isoflurane increases tolerance to renal ischemia reperfusion injury compared to propofol in this model.

Background. Telementoring is a technique that has shown potential as a surgical training aid. Previous studies have suggested that telementoring is a safe training modality. This review aimed to review both the technological capabilities of reported telementoring systems as well as its potential benefits as a mentoring modality. Methods. A systematic review of the literature, up to July 2017, was carried out in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study quality was assessed using the Oxford Levels of Evidence proforma. Data were extracted regarding technical capabilities, bandwidth, latency, and costs. Additionally, the primary aim and key results were extracted from each study and analyzed. Results. A total of 66 studies were identified for inclusion. In all, 48% of studies were conducted in general surgery; 22 (33%), 24 (36%), and 20 (30%) of studies reported telementoring that occurred within the same hospital, outside the hospital, and outside the country, respectively. Sixty-four (98%) of studies employed video and audio and 38 (58%) used telestration. Twelve separate studies directly compared telementoring against on-site mentoring. Seven (58%) showed no difference in outcomes between telementoring and on-site mentoring. No study found telementoring to result in poorer postoperative outcomes. Conclusions. The results of this review suggest that telementoring has a similar safety and efficacy profile as on-site mentoring. Future analysis to determine the potential benefits and pitfalls to surgical education through telementoring are required to determine the exact role it shall play in the future. Technological advances to improve remote connectivity would also aid the uptake of telementoring on a larger scale.

Dissection of the pudendal nerve (PN) and its branches in 71 cadavers revealed anatomic variations not previously described. Knowledge of this variation is necessary to prevent nerve injury resulting in sexual of sensory dysfunction. Because descriptions vary, this study re-evaluated the anatomy of the PN as implicated in perineal procedures in South Africans. The course of the PN from the gluteal region into the perineum was dissected in an adult sample of both sexes and of African and European ancestry. Distances between PN and branches to applicable landmarks were measured. Basic descriptive statistics and comparisons were carried out between groups. In 5/13 African females, the inferior rectal nerve (IRN) entered the gluteal region separately and in 12/13 cases it passed medial to the ischial spine with the PN. The dorsal nerve of the clitoris or penis (DNC/DNP) was closer to the bony frame in those of European ancestry. The IRN branches were more superficial in females, but deeper in males of European ancestry. In African females, a PN block and Richter stitch should be placed more medial. Outside-in transobturator tape procedures might endanger the DNC/DNP in obese individuals. In females of European ancestry the IRN branches are compromised during ischioanal abscess drainage. In males of European ancestry, the dorsal penile nerve block might be less effective. Predictions should be verified clinically.

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. OBJECTIVES: The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. EVIDENCE ACQUISITION: A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. EVIDENCE SYNTHESIS: Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. CONCLUSIONS: ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

Objective To report and identify the predictors of early and long-term complications in a large series of extraperitoneal robot-assisted radical prostatectomy using the standardized Martin criteria. MaterialS and Methods A total of 1503 patients underwent extraperitoneal robot-assisted radical prostatectomy for the treatment of clinically localized prostate cancer from July 2003 to August 2010 at a tertiary referral center. The median follow-up was 28.9 months. Fisher’s exact test was used to examine the association of multiple variables in a bivariate analysis with the incidence and types of complications. Independent predictors were also examined in a multivariate analysis using logistic regression models. Results A total of 151 complications were recorded in 127 of 1503 patients (8.45%). Approximately one third (30.5%) were classified as major complications requiring intervention (Clavien grade III and IV). The most commonly encountered complications were lymphocele (1.46%), bladder neck contracture (1.33%), and anastomotic leak (1.20%). The operative time was a significant predictor of all complications and of major complications on multivariate analysis. Surgeon experience was also predictive of complications on multivariate analysis. Conclusion Extraperitoneal robot-assisted radical prostatectomy remains an underused alternative approach for the treatment of localized prostate cancer. Its safety profile is equivalent to that of other approaches in experienced hands.

Robotic technologies have had a significant impact on surgery. We report what is to our knowledge the first use of microrobots to perform laparoscopic urological surgery in a canine model.Nonsurvival laparoscopic radical prostatectomy and radical nephrectomy were performed using microrobotic camera assistance. Following the administration of general anesthesia miniature camera robots were inserted in the insufflated abdomen via a 15 mm laparoscopic port. These microrobots were mobile, controlled remotely to desired locations and provided views of the abdominal cavity, assisting the laparoscopic procedures. Additional ports and laparoscopic instruments were placed in the abdomen using the views provided by these microrobots.One dog underwent laparoscopic prostatectomy and another underwent laparoscopic nephrectomy. The 2 procedures were completed successfully. Microrobots provided additional views from several angles, aiding in the performance of the procedures.Miniature camera robots (microrobots) provide a mobile viewing platform. With added functionality these new robots have the potential to further evolve the robotic armamentarium for surgeons.

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n = 70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P

Although extraperitoneal robot-assisted radical prostatectomy (RARP) is gaining popularity, the majority of these procedures are performed transperitoneally. The purpose of this study was to compare the transperitoneal and extraperitoneal approaches for RARP.We randomized 62 consecutive patients undergoing RARP into two equal groups according to the route of access. The groups were evaluated for age, body mass index (BMI), preoperative serum prostate specific antigen (PSA) concentration, total operating time, estimated blood loss, specimen weight, pathologic Gleason score and stage, intraoperative and postoperative complications, and surgical-margin status.No significant differences were noted the extraperitoneal and transperitoneal groups with respect total operative time (181 v 191 minutes), blood loss (199 v 163 mL), pathologic Gleason score (6.6 v 6.7), specimen weight (53 v 48 g), or positive-margin status (0 v 1 patient). There were no significant differences in age (56 v 59 years) or PSA (7.8 v 6.1 ng/dL). However, the BMI was significantly higher in the extraperitoneal group (29.8 v 26.5 kg/m(2); P0.01). The only complication in the study was a urine leak, which occurred in the transperitoneal group and was managed conservatively.There were no significant differences in operative parameters in the two groups. Choice of access should be based on patient characteristics as well as surgeon preference. Patients who have had abdominal operations are best suited for the extraperitoneal route. Surgeons should be familiar with both approaches in order to provide patients with the best care.

Totally intracorporeal robotic-assisted radical cystectomy (RARC) has perceived difficulties compared to open radical cystectomy (ORC). As the technique is increasingly adopted around the world, the benefits of RARC with intra- or extracorporeal urinary diversion or ORC for the patients are still unclear. In this article, we consider the current evidence for this issue. We assessed two questions through using expert opinion and the medical literature: (A) Is RARC better than ORC for removing the cancer surgery and outcome? (B) Is RARC better than ORC for the urinary diversion? (A) RARC is better than ORC for shorter length of stay, blood loss and complication rates. (B) Intracorporeal orthotopic neobladder may have a significant physiological and surgical benefit to the patient recovery. RARC with total intracorporeal reconstruction has potential benefits to the patient. We recommend that all surgeons document patient-related outcome measures, urodynamics and enhanced recovery protocols for cystectomy patients to help us understand the real improvements within bladder cancer surgery and reconstruction.

Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy.A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded.Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured.The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Peyronie's disease (PD) is characterised by penile plaque formation, pain, penile deformity and erectile dysfunction. It is a fibrotic disorder of the tunica albuginea with a poorly understood aetiology and epidemiology. PD may be classified into inflammatory (acute) and chronic stages. Medical treatment is usually instigated during the inflammatory phase of the disease. A review of the literature reveals a wide range of oral, intralesional and alternative therapies that are discussed in relation to established pathophysiological mechanisms of the disease. The advantages and disadvantages of each treatment are summarised. This review also discusses the ongoing therapeutic dilemmas of PD and suggests a treatment strategy based on an analysis of the urological literature.

Priapism is characterised by the presence of prolonged, often painful penile erection in the absence of a sexual stimulus. This rare condition has a range of aetiologies, but is most common following self-administration of injection therapy for impotence. Priapism may be classified into high- and low-flow states. Low-flow priapism is an emergency ischaemic condition requiring prompt recognition and treatment to avoid devastating long-term complications of erectile dysfunction. Wide-ranging medical therapies are covered in this review. Diagnostic and treatment algorithms are suggested in light of the current available literature.

A retrospective analysis of our seven-year experience with the Memokath urethral stent for the treatment of detrusor sphincter dyssynergia (DSD) in spinal cord injured (SCI) patients.Twenty five patients with SCI underwent rhabdosphincter Memokath stent insertion. The mean age was 45.5 years (range 32-65 years). The level of injury was cervical in 14 and thoracic in 11 patients. All patients were shown to have neurogenic detrusor overactivity with DSD associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (VCMG). The Memokath stent was inserted using a standardized protocol. Follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months after insertion, and a follow-up VCMG at six months. The pre-operative and six-month post-operative VCMG results were analysed by the paired t-test and p value0.05 was taken as significant.There was a significant reduction in maximum detrusor pressure, duration of contraction and residual urine volume (p0.05) on the VCMG six months after insertion of the stent. At present six patients have a Memokath stent in situ at a mean of 34.7 months (range 6-86 months). Nineteen stents were removed for several reasons at a mean of 20.3 months (range 0.25-41 months). These include, exacerbation of autonomic dysreflexic symptoms (n=3); stent migration (n=7); encrustation and stone formation (n=5); incomplete bladder emptying without obstruction (n=3); entrance into fertility program (n=1).The Memokath stent is safe, easy and quick to insert with minimal trauma to the urethra. It is effective in the management of DSD and decreasing the detrusor pressure and residual urine volume in SCI patients. Moreover the ease of its removal in a non-traumatic fashion makes this stent an attractive option when patients are still contemplating the method of bladder management, in those wishing to be involved in fertility program and in recently SCI patients who may recover some manual dexterity to perform clean intermittent self-catheterisation. It must be remembered that this is a temporary stent, as our study clearly shows that the majority are removed within two years of insertion.

Objective To summarize the urological procedures recorded in Hospital Episodes Statistics (HES, 1998–99) and to examine the accuracy of coding and HES. Materials and methods Data on the 10 commonest urological procedures from the Department of Health website ( www.doh.gov.uk/hes ) were extracted, summarized and presented. Results Urethral catheterization, endoscopic procedures on the bladder, prostate, urethra and ureter (excluding ureteric stone extraction), minor open procedures on the foreskin and the vas, bladder instillation, extracorporeal shockwave lithotripsy and prostatic biopsy are the 10 commonest procedures, according to finished consultant episodes. There is published evidence that the data from coding and HES are not completely accurate. Conclusion This study highlights shortfalls in the HES data (1998–99) which may directly affect the funding of urological services.

The field of minimally invasive surgery (MIS) including traditional laparoscopy, single port surgery, and Robotics, has now taken centre stage in modern clinical practice. With continued evolution in technologies, there is now the need to train the surgeon in a continuous manner. No surgeon is “too” experienced to benefit themselves and the patient.

In recent years, surgical technique for radical retropubic prostatectomy (RRP) has evolved with increasing attention to preservation of anatomic structures and its impact on outcome and quality of life. Technical aspects of nerve-sparing RRP are described. A careful and thorough technique has impact on erectile function and urinary continence and should be performed in all patients. For successful nerve preservation we advocate a lateral approach to the prostate, improvising visualization and simplifying the dissection of the neurovascular bundles from the dorsolateral prostatic capsule. Control of bleeding in the ligation and incision of the Santorini’s plexus ensures the success of the remaining steps. Meticulous apical dissection with preservation of a maximal urethral length and bladder neck are other important factors for the optimal surgery outcomes.

Technological barriers of telemedicine and surgical telementoring have decreased during recent years, and high-quality videoconference equipment is accessible on a commercial basis. Surgical telementoring has been described as a natural fit in surgery, with solutions demonstrated for laparoscopic and robotic surgery, and mobile telemetering solutions have been demonstrated. Telemedicine is widely used in multidisciplinary teams, assessing pelvic cancer. Evidence exists for cost-effectiveness and safety of telementoring systems, but there is insufficient data for educational outcomes. This chapter focuses on the increasing demand for pelvic cancer surgeons, and how telemedicine can be used to meet societies demand for new surgeons, by improving surgical education and decreasing the obstacles created by distance.

Background: The potential rehabilitative and protective effect of phosphodiesterase type 5 inhibitors (PDE5-Is) on penile function after nerve-sparing radical prostatectomy (NSRP) remains unclear. Objective: The primary objective was to compare the efficacy of tadalafil 5 mg once daily and tadalafil 20 mg on demand versus placebo taken over 9 mo in improving unassisted erectile function (EF) following NSRP, as measured by the proportion of patients achieving an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score >= 22 after 6-wk drug-free washout (DFW). Secondary measures included IIEF-EF, Sexual Encounter Profile question 3 (SEP-3), and penile length. Design, setting, and participants: Randomised, double-blind, double-dummy, placebocontrolled trial in men = 22, SEP-3, and penile length. Results and limitations: Four hundred twenty-three patients were randomised to tadalafil once daily (n = 139), on demand (n = 143), and placebo (n = 141). The mean age was 57.9 yr of age (standard deviation: 5.58 yr); 20.9%, 16.9%, and 19.1% of patients in the tadalafil once daily, on demand, and placebo groups, respectively, achieved IIEF EF scores >= 22 after DFW; odds ratios for tadalafil once daily and on demand versus placebo were 1.1 (95% confidence interval [CI], 0.6-2.1; p = 0.675) and 0.9 (95% CI, 0.5-1.7; p = 0.704). At the end of double-blind treatment (EDT), least squares (LS) mean IIEF-EF score improvement significantly exceeded the minimally clinically important difference (MCID: DIIEF-EF >= 4) in both tadalafil groups; for SEP-3 (MCID >= 23%), this was the case for tadalafil once daily only. Treatment effects versus placebo were significant for tadalafil once daily only (IIEF-EF: p = 0.016; SEP-3: p = 0.019). In all groups, IIEF-EF and SEP-3 decreased during DFW but continued to improve during open-label treatment. At month 9 (EDT), penile length loss was significantly reduced versus placebo in the tadalafil once daily group only (LS mean difference 4.1 mm; 95% CI, 0.4-7.8; p = 0.032). Conclusions: Tadalafil once daily was most effective on drug-assisted EF in men with erectile dysfunction following NSRP, and data suggest a potential role for tadalafil once daily provided early after surgery in contributing to the recovery of EF after prostatectomy and possibly protecting from penile structural changes. Unassisted EF was not improved after cessation of active therapy for 9 mo. (C) 2013 Published by Elsevier B.V. on behalf of European Association of Urology.

Objective To evaluate and assess the long-term complications of using the thermo-expandable, nickel-titanium alloy stent (Memokath™ 051, Engineers & Doctors A/S, Hornbaek, Denmark) for managing benign ureteric strictures. Patients and methods Over a 3-year period, 13 Memokath stents were inserted in 11 patients (mean age 58 years, range 35–85) with 12 lower ureteric strictures. The cause of the stricture was benign in all cases, i.e. radiation fibrosis in three, retroperitoneal fibrosis, ischaemic uretero-ileal anastomosis and scarring after ureteroscopy in two each, and diathermy damage, extraluminal endometriosis and stone passage in one each. Four stents were 9 F with proximal expansion to 17 F and the other nine used were 10.5 F with proximal expansion to 20 F. The patients were followed for a mean (range) of 18 (1.5–33) months. Results No complications or side-effects occurred with nine stents; four stents were removed at a mean (range) of 16.3 (4–33) months. Three of these had become encrusted, two of which had been placed in patients who had either a history of stone disease or recurrent urinary tract infection. The other stent had migrated. Conclusion The Memokath stent appears to have a useful role in managing benign ureteric strictures, but it must be closely monitored in patients who are predisposed to encrustation.

A significant proportion of men undergoing transrectal ultrasound (TRUS) and prostate biopsy report pain during the procedure. A number of different methods of pain relief have been suggested in the literature. We prospectively evaluated the effect of diclofenac suppositories on pain experienced by men undergoing TRUS and prostate biopsy.A prospective, randomized, double-blind, placebo controlled study was performed in 72 patients requiring prostate biopsy. Patients were randomly assigned to receive 100 mg diclofenac or placebo 1 hour prior to the procedure. They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during the procedure. The patients were then seen 2 weeks later and any morbidity, including infection and bleeding, was assessed.Patients given diclofenac had significantly lower pain scores than those given placebo (2.8 vs 4.9, p0.001). The 2 groups were similar in regard to age, prostate volume, biopsy number, prostate specific antigen, histological diagnosis and complication rate.Rectal administration of diclofenac 1 hour prior to TRUS and prostate biopsy is a simple procedure that significantly relieves the pain experienced with no increase in morbidity. With the trend toward more core samples, screening for prostate cancer and the younger age of patients undergoing biopsy we urge urologists to provide analgesia for this painful procedure.

Anatomical Aspects of the Extra- and Retroperitoneal Space.- Essential Instruments in Laparoscopic and Robotic Surgery.- Upper Tract Retroperitoneal Access Techniques.- Laparoscopic Adrenalectomy.- Retroperitoneoscopic Simple and Radical Nephrectomy.- Laparoscopic and Robotic Partial Nephrectomy.- Retroperitoneal Robotic Partial Nephrectomy.- Laparoscopic and Robotic Mid and Distal Ureteral Reconstructive Surgery.- Robot Assisted Laparoscopic Nephroureterectomy.- Laparoscopic Pelvic Lymphadenectomy in Prostate Cancer.- Laparoscopic Simple Prostatectomy.- Extraperitoneal Laparoscopic Radical Prostatectomy.- Robotic- Assisted Extraperitoneal Laparoscopic Prostatectomy.- Laparoendoscopic Single-Site Retroperitoneal Surgery.- On the Horizon

OBJECTIVES Pure laparoscopic urologic surgery is becoming the standard of care for many urologic procedures. Training surgeons without any experience in the field is still a challenge. It is well recognized that two-dimensional optics causes difficulty for the novice. Thus, we assessed a new-generation, three-dimensional (3D) visualization system. METHODS Fifteen laparoscopically novice surgeons were asked to perform five validated laparoscopic training exercises using the two-dimensional and 3D systems in random order: (a) linear cutting and suturing; (b) curved cutting and suturing; (c) tubular suturing; (d) dorsal vein complex suturing simulation; and (e) urethrovesical anastomosis. The objective (time taken to complete the task versus the time needed by an expert) and subjective (accuracy on completion versus an expert's) scoring were performed independently by advanced laparoscopists. Statistical analysis was performed using the t test. RESULTS All tasks were completed by the participants. The statistical analysis revealed a trend toward improved task performance using 3D visualization. CONCLUSIONS Our preliminary testing has suggested that the new-generation, 3D system used will be helpful for developing skills in laparoscopy for the novice surgeon.

Background: The Page kidney phenomenon, whilst a known condition, is in itself a rare entity. This report illustrates a case following partial nephrectomy which presented as post-operative renal failure. Case Presentation: The authors present a case of renal cell carcinoma in a solitary kidney that after partial nephrectomy resulted in a subcapsular haematoma formation and acute renal failure. Conclusion: The condition of Page kidneys are typically described in young patients after trauma. However, with the increasing usage of surgical interventions, post-operative bleeding can result in a compression-induced necrosis.

Sildenafil revolutionised the treatment of erectile dysfunction (ED) on its introduction in 1998. Not only is it effective, but is, perhaps even more importantly, an extremely acceptable manner in which to treat ED (i.e., oral pharmacotherapy), compared to the other treatments that were available at that time (e.g., intracavernosal injection). Whilst sildenafil remains the market leader for ED treatment, it does have some shortcomings: its clinical efficacy is diminished in 'difficult to treat' patient groups, such as diabetics, side effects, such as blue-tinged vision and headache, and the need to time the ingestion of sildenafil to 1 h prior to expected time of sexual intercourse. Recently, newer phosphodiesterase inhibitors ('sons of viagra') have become available, and potentially to improve upon, what has become regarded as the gold standard for ED treatment. This review article discusses the differences between vardenafil, tadalafil and sildenafil, in order to allow the clinician to make an informed decision as to which phosphodiesterase inhibitor to prescribe when dealing with the ever expanding number of patients seeking help for ED.

We summarize the literature addressing factors that influence treatment decisions made by men with prostate cancer.A MEDLINE search of the English language literature published between 1969 and 2000, using the combined MESH key words "prostatic neoplasms," "patient participation," "Internet" and "decision making," generated 181 abstracts. Only 23 of these publications addressed factors influencing treatment decisions made by men with prostate cancer. Nine additional relevant studies were identified from references in the original 23 articles. Subsequently a search for the term "prostate cancer" using several popular Internet search engines yielded more than 1 million hits. A further search was performed using the key words "prostate cancer" and "prostate" within on-line archives of the United Kingdom television channels BBC, ITV, and channels 4 and 5, and newspapers The Sun, The Daily Mail, The Observer, The Guardian and The Times.When there is poor quality evidence or little professional consensus to support a particular treatment over another, no clinical guidelines regarding treatment are possible. Patients are faced with a series of options, and the data reveal that the process of choosing between these options is based on input from a large number of sources. These sources differ in the way that benefits of treatment are emphasized over harms and vice versa. We identified little evidence regarding which type of input exerts the greatest influence on patients. It may be that the sources associated with the most bias have the greatest influence.There is a paucity of information on how patients with prostate cancer use different types of input in the treatment decision making process. The physician, as principal caregiver, still appears to have the most direct influence on patient choice. Just how long this status will continue is uncertain.

Renal transplantation in all age groups is well documented but has rarely been performed in recipients older than 75 years. There are older people who have negligible comorbidity and lead active lifestyles. This fact has provoked much debate about geriatric renal transplant with ongoing ethical discussions concerning elderly people being denied renal transplant, and the possible use of the aged population as a source of renal allografts.1 We report on the oldest recorded recipient (82 years old) and donor (79 years old) combination to date with a combined age of 161 years. CASE REPORT