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Background: Urachal remnants are a rare congenital defect resulting from failure of obliteration of a fibrous tube that connects the umbilicus to the bladder dome during embryological development. Oftentimes a urachal remnant will go undiagnosed, but occasionally a patient may present with a variety of symptoms, ultimately leading to the identification of the remnant. Given its rarity, there is very limited literature available on the management of symptomatic urachal remnants, especially in adults. Surgical resection has been the first-line management of urachal remnants for years, especially given the risk of the development of urachal adenocarcinoma secondary to recurrent infection, persistent irritation, and urinary stasis associated with some urachal remnants., Aim: We present our experience in the management of symptomatic urachal remnants in adults at our institute and perform a brief literature review of the same., Methods: A retrospective review of all cases who underwent surgical management of symptomatic urachal remnants between December 2015 and January 2022 was performed. Seven cases of urachal remnant excision in total were identified over the time period. Patient characteristics and perioperative parameters were analysed. Post-operative complications were measured in accordance with the Clavien-Dindo grading system., Result: In total, 7 cases of urachal remnants were treated at our institute over the study period. Four patients were treated with a TURBT and 3 patients were treated with a laparoscopic partial cystectomy. There were no intraoperative complications and one post-operative complication requiring readmission for intravenous antibiotics. There was one mortality but this was not as a direct result of the operative procedure. Mean length of stay was 1.71 days. Two of patients had histologically confirmed urachal adenocarcinoma and the remaining five patients had benign histology. Each patient was seen in the outpatients department 6 weeks post-operatively for clinical review and review of histology. No further follow-up was required for the patients with benign histology given resolution of symptoms and follow-up for the malignant histology was arranged appropriately following MDM., Conclusion: There is a paucity of data available on the management of urachal remnants in the adult population; however, an endoscopic or laparoscopic approach is a safe and effective method of excising symptomatic urachal remnants., (© 2023. The Author(s).)

Background: Male genital form and function may be rendered abnormal by a number of disease processes, with profound associated psychological and functional consequences. The aim of the study is to review our reconstructive experience with cases of genital loss or distortion due to nonmalignant diseases processes and atypical neoplasia., Materials and Methods: A retrospective review of a prospectively maintained database was performed to identify reconstructive cases performed from 2018 to 2020 under the care of a single surgeon. Male patients 18 years or older with a disease diagnosis other than squamous cell carcinoma affecting genital form were included. Disease processes, patient factors, surgical techniques, and both functional and cosmetic outcomes were reviewed., Results: Fourteen cases were identified. The patients had a mean age of 52.2 years (range, 21-72 years). Acquired buried penis was present in 8 patients. Etiology of genital abnormality included balanitis xerotica obliterans (n = 6), excess skin loss at circumcision (n = 2), self-injection of petroleum jelly to penile shaft (n = 1), Fournier gangrene (n = 1), hidradenitis suppurativa (n = 1), extramammary Paget disease (n = 1), idiopathic lymphoedema (n = 1), and penoscrotal webbing (n = 1). Reconstructive techniques performed included penile debridement/shaft skin release, scrotectomy, suprapubic apronectomy, and division of penoscrotal webbing, in combination with split-thickness skin grafting where required. A penile implant was inserted in one patient. Reconstructive planning, techniques, and outcomes are described., Conclusions: A variety of reconstructive techniques in andrology can be used to improve the aesthetic and functional outcomes of multiple disease processes affecting the male external genitalia., Competing Interests: No conflict of interest has been declared by the author., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.)

Introduction: Growing interest surrounds the concept of en bloc transurethral resection of bladder tumors (ERBT). Theoretical advantages include improved adherence to oncological principles and potential yield of superior pathological specimens. Multiple ERBT methods exist. This review summarizes the current evidence regarding application of differing techniques and technologies to ERBT., Methods: A systematic review of MEDLINE/EMBASE/Scopus databases was performed, using terms "en bloc," "ERBT," "bladder," and "urinary bladder neoplasm." Template-based data extraction included technique of ERBT, feasibility, tumor size, activation of obturator nerve reflex, operative complications, detrusor muscle sampling rate, and recurrence data., Results: Multiple approaches to ERBT have evolved, using a variety of energy sources. The feasibility of electrocautery, laser, combined waterjet/electrocautery, and polypectomy snare techniques have been confirmed in achieving ERBT. ERBT appears safe, with a low complication rate. The use of laser energy sources reduces the risk of activating the obturator nerve reflex during lateral wall resections. Otherwise, no energy source is unequivocally superior in achieving ERBT. The rate of detrusor muscle sampling is high with use of ERBT and appears superior to that achieved with conventional TURBT (cTURBT) in multiple comparative studies. A limited number of largely non-randomized trials assess bladder tumor recurrence; current evidence suggests this is similar between ERBT and cTURBT groups., Conclusions: ERBT using a variety of technologies is feasible and safe, with a high detrusor muscle sampling rate. Further research is required to determine whether rates of residual disease or recurrence can be reduced with ERBT vs. cTURBT.

Objective: To describe and illustrate a novel technique of uretero-ileal anastomosis for use in urinary diversion - the Pull-through Anastomosis of Ureter To Enteric Conduit (PAUTEC). A second objective was to evaluate the surgical outcomes of the PAUTEC anastomosis., Materials and Methods: Our novel anastomotic technique was described step-by-step and visually depicted with illustrations and the accompanying narrated video. Additionally, to evaluate safety and efficacy, a retrospective review of a prospectively maintained database was performed. Patients who underwent radical cystectomy alone or during pelvic exenteration, with ileal conduit diversion incorporating PAUTEC, 2016-2020 with ≥6 months follow-up were included. Surgical outcomes and renal function were analysed., Results: PAUTEC anastomosis was performed on 43 ureters in 23 patients. Mean age was 66 years [50-80] and 21 of 23 patients were male. One patient had a conservatively-managed small urine leak. No ureteric strictures have been identified to date. Mean serum creatinine was 1.15 mg/dL [0.69-2.08] (102umol/L, range 61-184 umol/L) preoperatively, and 1.09 mg/dL [0.61-2.59] (96.3 umol/L, range 54-229 umol/L) at follow-up, demonstrating no significant change (P= .26, paired t-test). Mean follow-up was 15 months [6-44]., Conclusion: A PAUTEC technique of uretero-ileal anastomosis is feasible and technically straightforward, with satisfactory outcomes observed to date., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To assess patient-reported outcomes of oncoplastic penile reconstruction using standardized questionnaires. Whilst organ-preserving penile cancer surgery has evolved, aiming to preserve genital function, reduce psychological morbidity of radical penectomy, and maximise patient quality of life, few studies have evaluated patients' final perceptions., Methods: Following ethical approval, patients post partial/radical glansectomy with reconstruction 2016-2019, under a single surgeon, were identified. Patients were posted a modified Index of Male Genital Image, the IIEF-5, a customised questionnaire exploring outcomes of urinary and sensory function and the EORTC QLQ-C30 to complete and return. Questionnaires were nonidentifiable, however study ID linked responses to the procedure performed., Results: A total of 130 questionnaires were received from 35 patients post penile reconstruction, giving a response rate of 71.4% (35/49). Mean time from surgery was 22 months (4-51), and mean age 61 years (31-79). The majority (82.4%, n = 28) were satisfied or felt neutral about the appearance of their genitalia. High satisfaction with postprocedure urinary function was reported; 85.3% (29/34) could void from a standing position and 79.4% (27/34) reported little or no spraying of urine. Nineteen patients (55.89%) were sexually active, with mean IIEF-5 scores of 14.9 (5-25) (partial glansectomy) and 15.8 (5-25) (radical glansectomy). Mean QoL over past week on 7-point EORTC QLQ-C30 scale was 5.88 (3-7)., Conclusion: We report good aesthetic and functional outcomes in a unique study exploring penile cancer surgery patient-reported outcome measures. These results strongly support phallus-preserving phallic-preserving strategies as the standard of care in eligible patients undergoing penile cancer surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aim COVID-19 has posed an unprecedented challenge to healthcare systems. We aimed to observe the impact on urological care delivery in an Irish university hospital. Methods Data on urological activity was prospectively collected for 3 months from March 2020. A retrospective review of the same period in 2019 was performed for control data. Results Over the 2020 study period, 356 urological admissions were recorded; a 23.1% decrease from the 2019 corresponding period(n=463). A 21.7% decrease in flexible cystoscopies was seen (162 versus 207). 125 theatre cases (36 off-site) were performed in the 2020 period, versus 151 in 2019. Emergency case load remained stable, with 69 cases in the 2020 period. The percentage of trainee-performed cases was preserved. COVID-era outpatient activity increased, to involve 559 clinic consultations compared to 439 the preceding year; a reflection of annual growth in service demand and facilitated by virtual clinic application (n=403). There were 490 instances of patients cancelling/failing to attend outpatient appointments, compared to 335 in 2019. Conclusion The Irish COVID-19 outbreak has created obstacles for urological care. Nonetheless, urgent/emergent urological cases persist. Our unit has managed this to-date with flexible adaptation of service delivery. The global challenge posed by COVID-19 will demand ongoing resourcefulness to minimise impact on patients with time-sensitive urological conditions., Competing Interests: The authors have no conflicts of interest to declare.

Background: Outpatient (<24 hour stay) total joint arthroplasty (TJA) has emerged as an alternative to traditional inpatient TJA. Patient-reported outcomes in the past have revealed favorable comparisons with inpatient controls. However, a higher outpatient TJA readmission rate has been reported. The goal of our study is to report outcomes, readmissions, and unplanned access to care data on the first 1,000 TJAs performed at a de novo ambulatory surgery center (ASC)., Methods: From March 2014 to May 2016, a consecutive series of 1,000 primary, total hip, and total knee arthroplasties (TKAs) were performed at a same-day surgical center. All patients were ≤66 years old, met the ASC inclusion criteria, and received preoperative training. All patients were discharged <24 hours after surgery to postoperative care suites. Oxford scores, visual analog scale for pain, patient satisfaction, ambulation, complication, and adverse events data were collected., Results: A consecutive series of 543 TKAs and 457 total hip arthroplasties (THAs) were performed. Mean age was 57.2 years (range 28 to 66 years). The TKA patients consisted of 55.2% women, whereas THA patients consisted of 45.3% women. Overall infection rate was 0.8%. Hospital readmission rate was 1.5%, and early/unplanned access to care was 11.7%. Oxford Knee and Oxford Hip scores showed 15.7 and 21.1 point improvements, respectively, whereas pain scores improved 71% for TKA and 81% for THA at 6 months postoperatively ( P < 0.01)., Conclusions: Our immediate and short-term complications, readmissions, and outcomes for all patients compared favorably with published inpatient data. This study provides baseline data for quality metrics and functional outcomes for ASC-based total joint procedures.

Urinary tract infections are one of the most common infectious diseases diagnosed in the community and in the hospital setting. Their treatment is complicated by drug-resistant pathogens and the colonization by microbes of indwelling urinary catheters. This study assessed the occurrence and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) uropathogens isolated for 5 consecutive years at University Hospital Waterford between 2010 and 2014. We created 4 clinically relevant subdivisions, based on urine source: hospital inpatients, patients from the Emergency Department, patients referred from their General Practitioner, and Nursing Home patients. We performed a retrospective review from the hospital's electronic microbiological system and calculated resistance rates for each of the standard antimicrobial agents. During the 5-year study period, we studied 151 urine isolates obtained from 128 patients who had an MRSA cultured in their urine sample. There was 100% resistance of all MRSA isolates to Flucloxacillin and Coamoxiclav. Ninety-eight percent of isolates were resistant to Ciprofloxacin. The resistance rate for Trimethoprim was 7.4% and there was only 2.7% resistance for Nitrofurantoin. For a clinical subset of patients, we also demonstrated 100% sensitivity for samples tested against Teicoplanin and Vancomycin. Urinary MRSA is an infrequently studied phenomenon, but with the rising trend of hospital superbugs nationally, its management is of critical importance. Suitable agents to address this within our population include Nitrofurantoin in the well patient requiring urinary MRSA eradication or Vancomycin/Teicoplanin in the unwell patient requiring intravenous therapy. In all groups, fluoroquinolones should be avoided due to significant resistance rates.

Introduction: Kidneys from extended criteria donors are associated with higher rates of delayed graft function (DGF). Hypothermic machine perfusion (MP) for storage is associated with more favourable outcomes., Methods: A retrospective analysis was performed in 93 patients where the kidney was stored using hypothermic MP (LifePort(®)) and compared to an age-matched control group where the kidney was stored in cold static storage (CSS) using University of Wisconsin solution., Results: Median age was similar in both groups (59.2 years in MP vs 59.9 years in CSS, p = 0.5598). Mean cold storage time was 15.6 h in MP vs 17.9 h in CSS. Post transplant mean serum creatinine was as follows; MP group-144.7 μmol/L at 1 month; 138.3 μmol/L at 3 months and 129.5 μmol/L at 12 months. In the CSS group-163 μmol/L at 1 month; 154.9 μmol/L at 3 months and 140.2 μmol/L at 12 months. There was a statistically significant difference at 1 month (p = 0.0096) and 3 months (p = 0.0236). DGF was defined as the need for haemodialysis within 7 days post transplant. In the MP group, DGF occurred in 17.2 % patients with mean of 6 days (range 1-18). In the CSS group, 25.8 % patients with mean of 8.1 days (range 3-25). One-year graft survival rate was better in the MP group (97.85 vs 96.77 %)., Conclusion: Our experience to date recommends the use of hypothermic MP for storage of kidneys from extended criteria deceased heart-beating donors.

The unmet burden of surgical disease in developing countries is large and growing. We successfully initiated two surgical field hospitals in austere environments. Similar problems were encountered in the areas of facility development, operations, and social considerations. A literature review was performed to contextualize our experience and compare it with that of others.

Introduction: Active surveillance (AS) is a management strategy for addressing the widely acknowledged problem of over diagnosis and over treatment of clinically indolent prostate cancer., Methods: A total of 80 patients were enrolled on the AS program in our institution between January 2008 and June 2012. All data were collected prospectively in a secure database., Results: The mean age of patients enrolled was 62.7 years (range 50-72). Median PSA at enrolment was 5.6 ng/mL (range 1.2-13.4). The mean follow-up was 32 months (range 2-54). In total, 85 % of patients had a repeat biopsy after 1-year with 30 % having another biopsy after 3 years. Overall, 45 % of patients remain on AS. In the remainder; 42.5 % of patients have been removed from AS for definitive treatment, while 8.75 % of patients are now on watchful waiting, 2.5 % of patients self discharged from the program and one patient died of cardiovascular disease. The prostate cancer specific survival rate is 100 %. Reasons for removal from AS and referral for treatment were; 67.6 % of patients had upgrade of disease on repeat biopsy, 17.6 % of patients had PSA progression, 11.8 % patients had progression of disease on MRI, and one patient developed a palpable nodule. Regarding definitive treatment; 52.9 % of patients have been for referred for external beam radiotherapy, 14.7 % have been referred for brachytherapy, 29.4 % have been referred for surgery and one patient has refused definitive treatment., Conclusion: Our findings to date support active surveillance as a valid strategy for early, localised prostate cancer.

Background: We assess our long-term experience with regards the safety and efficacy of Mycophenolate Mofetil (MMF) in our low risk renal transplant population and compared it retrospectively to Azathioprine (AZA) immunosuppressive regimen. Patients and methods. Between January 1999 and December 2005, 240 renal transplants received MMF as part of their immunosuppressive protocol (MMF group). AZA group of 135 renal transplants was included for comparative analysis (AZA group). Patients received Cyclosporine was excluded from this study., Results: The incidence of biopsy proven 3-month acute rejections was 30 (12.5%) in MMF group and 22 (16%) in AZA group respectively (P = 0.307). Patient survival rates at 1 and 5 years for the MMF group were 97 and 94%, respectively, compared to 100% and 91% at 1 and 5 years respectively for the AZA group (P = 0.61). Graft survival rates at 1 and 5 years for the MMF group were 95 and 83%, respectively, compared to 97 and 84% at 1 and 5 years, respectively for the AZA group (P = 0.62)., Conclusion: There was no difference in acute rejection episodes between MMF and AZA based immunotherapy. Additionally, we observed no significant difference concerning graft survival in the MMF group when compared to AZA group.

We assessed our long-term experience with regards to the safety and efficacy of MMF in our pediatric renal transplant population and compared it retrospectively to our previous non-MMF immunosuppressive regimen. Forty-seven pediatric renal transplants received MMF as part of their immunosuppressive protocol in the period from January 1997 till October 2006 (MMF group). A previously reported non-MMF group of 59 pediatric renal transplants was included for comparative analysis (non-MMF group). The MMF group comprised 29 boys and 18 girls, whereas the non-MMF group comprised 34 boys and 25 girls. Mean age was 11.7 and 12 yr in the MMF and non-MMF groups, respectively. The incidence of acute rejection episodes was 11 (23.4%) and 14 (24%) in the MMF and non-MMF group, respectively. Two (3.3%) grafts were lost in the non-MMF group compared with one (2.1%) in the MMF group. Twenty-one (44.68%) patients in the MMF group developed post-transplant infections compared with 12 (20.33%) in the non-MMF group (p < 0.0001). In conclusion, the use of MMF in pediatric renal transplantation was not associated with a lower rejection rate or immunological graft loss. It did, however, result in a significantly higher rate of viral infections., (© 2009 John Wiley & Sons A/S.)

Purpose: We examined the process and causes of diagnostic delay, defined as the interval from symptom onset to diagnosis, for testis (germ cell) cancer and the change with time. Diagnostic delay influences disease burden and may be subdivided into symptomatic interval, defined as symptom onset to first presentation, and diagnostic interval, defined as first presentation to diagnosis., Materials and Methods: We performed a single center review of 100 consecutive cases. Diagnostic delay in weeks, and symptomatic and diagnostic intervals in days were calculated, and related factors were recorded. Previous reports by the senior author (JT) in the same health care system allowed the examination of change during 2 decades., Results: Mean±SD diagnostic delay was 12.5±17.4 weeks (median 6, range 1 to 104), a substantial decrease in the mean of 10 months reported by one of us (JT) in 1987. Mean symptomatic interval was 65.4±100.9 days (median 29, range 0 to 720). Mean diagnostic interval was 21.9±63.5 days (median 7, range 1 to 540). Symptomatic interval exceeded or was equal to diagnostic interval in 80 men., Conclusions: This terminology allows detailed examination of the diagnostic process for testis cancer. Aberrant diagnostic delay for testis cancer is decreasing and is now dominated by patient dependent factors. Select cases suggest that physician error remains a factor in a minority., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background/aims: Unilateral ureteral obstruction (UUO) results in renal injury. Studies report increased injury indices in male rats following UUO. Our study examined whether this gender-based renal response to UUO was reflected in sustained differences following relief of obstruction., Methods: Adult male/female rats (200-400 g) were subjected to either sham surgery (S/RN) or UUO (UUO/RN). At 24 h, obstruction was relieved and all animals underwent contralateral nephrectomy. Five days after initial surgery, animals were placed in metabolic cages and given water ad libitum for 24 h followed by a 24-hour period of complete water restriction. On day 7, animals were euthanized and samples harvested. Tubular injury, urinary volume/osmolality, creatinine clearance, plasma arginine vasopressin, renal medullary V2 receptor and aquaporin 2 (AQP2) expression were measured., Results: Male UUO/RN rats showed increased renal apoptotic injury and reduced creatinine clearance rates (glomerular filtration rate) vs. females. No gender-dependent differences were observed in urinary osmolality or concentrating ability. AQP2 expression increased post-obstruction., Conclusion: Increased injury in males following UUO remains manifest during early recovery after release of obstruction. Despite this, the grade of postobstructive diuresis is not significantly altered between sexes. This may reflect reduced glomerular filtration rate and elevated AQP2 in male rats., (Copyright (c) 2010 S. Karger AG, Basel.)

Objective: To examine whether hypoxia (one of the many components of ischaemic preconditioning) can induce a protective response in culture renal tubular cells, and thus determine if non-lethal periods of hypoxia could confer protection against apoptotic injury to human proximal tubular cells during cold storage and subsequent cytotoxic insult, and establish the cellular mechanisms by which this protection is induced., Materials and Methods: Human proximal tubular cells (HK-2) were pre-incubated for 24 h in normoxic or hypoxic conditions and then incubated at 4 degrees C for 6 h to mimic cold storage, before being returned to normal conditions and exposed to varying concentrations of cyclosporine A (CSA). Cell viability and apoptosis were measured using propidium iodide staining and flow cytometry. The expression of heat-shock protein (HSP)-70 was determined by Western blotting., Results: Hypoxia had no effect on cell viability or apoptosis. Pre-exposure of cells to hypoxia significantly protected against CSA-induced damage even after a period of cold storage. Western blotting analysis showed that hypoxia up-regulated the anti-apoptotic protein HSP-70. HK-2 cells over-expressing HSP-70 mimicked hypoxia preconditioning, in that they were protected during cold storage and CSA-induced apoptosis., Conclusion: Exposure of renal tubular cells to a sequential model of cold storage, reperfusion and incubation with CSA resulted in apoptotic cell death. Preconditioning these cells with hypoxia induced a protective response and up-regulation of the anti-apoptotic protein HSP-70. There was a similar response in non-preconditioned cells over-expressing HSP-70. Further understanding of the cellular changes occurring during this period of preconditioning will allow the development of more targeted, clinically relevant methods of preconditioning in renal transplantation.

Aims: The newer 1998 WHO/ISUP grading system for bladder transitional cell carcinoma combined grade 3 (G3) and high grade tumour subset of grade 2 (G2) of the older 1973 WHO grading system into one homogenous high grade group. We evaluated for possible differences in survival and progression between these 2 grades in pT1 bladder tumours., Methods: From Jan 1(st) 1991-Dec 31(st) 2003, 105 (61 G2 and 44 G3) pT1 bladder tumours fulfilled the 1998 WHO/ISUP high grade criteria. Survival and progression of these tumours were assessed., Results: Of the 44 patients with G3 tumours, 20 are alive versus 22 of the 61 patients with high grade tumour subset of G2 (P=0.04). Of the 44 patients with G3 tumours, 13 progressed versus 12 of the 61 patients with high grade tumour subset of G2 (P=0.02). In multivariate analysis, G3 was a significant predictor of tumour progression (P=0.05) and marginally non-significant predictor of poor patient survival (P=0.056)., Conclusions: A notable difference in survival and progression between high grade tumour subset of G2 and G3 is observed.

Cold storage and reperfusion injury to transplanted kidneys contributes to increased incidence of delayed graft function and may have a negative impact on graft survival. This study examined the mechanisms by which previous heat shock protects against cell death in an in vitro model of kidney storage. Cold storage is mimicked by incubating human renal proximal tubular epithelial (HK-2) cells in University of Wisconsin solution at 4 degrees C with and without subsequent rewarming. Heat shock was induced by incubation of cells at 42 degrees C for 1 h. Altered protein expression was measured by Western blot, and cell viability and apoptosis were measured by propidium iodide DNA staining using flow cytometry. The specific role of heat-shock protein 70 (HSP-70) was determined both by siRNA knockdown and by stable overexpression approaches. Cold storage and rewarming-induced cell death was associated with decreased expression of HSP-70, HSP-90, HSP-27, and Bcl-2. Previous heat shock significantly reduced HK-2 cell death after cold storage and rewarming and was associated with the maintenance of HSP-70, HSP-27, and Bcl-2 protein levels. Blocking heat stress-induced HSP-70 with siRNA did not significantly block the protective effect of heat stress against cold storage and rewarming cell death; however, overexpression of HSP-70 protected HK-2 cells from this stress. It is concluded that previous heat shock protects HK-2 cells from cold storage and rewarming injury. siRNA inhibition of HSP-70 induction did not block the protective effect of heat shock, indicating that HSP-70 is not essential to the heat stress-induced protective effect reported in this study.

Prompt and delayed gamma-ray cascades in doubly magic 132Sn and its neighbor 131Sn have been studied at Gammasphere using a 248Cm fission source. Isotopic assignments of unknown gamma rays were based on coincidences with known transitions in A = 112-116 Pd fission partners. The yrast level spectra of both tin nuclei are interpreted using empirical nucleon-nucleon interactions from the 132Sn and 208Pb regions. Results include identification of the (nuf(7/2)h(-1)(11/2))9(+) aligned state in 132Sn and of extensive (nuf(7/2)h(-2)(11/2)), (nuf(7/2)d(-1)(3/2)h(-1)(11/2)) and (nuh(-1)(11/2)x3(-)) multiplets in 131Sn. The previously reported beta(-) decay of an unusual 131In high-spin isomer to levels in 131Sn is also elucidated.

Spectra of the E2 quasicontinuum gamma rays feeding different spin regions of the 154Dy yrast line have been extracted. These are compared with corresponding theoretical spectra obtained by numerical simulations based on temperature-dependent Hartree-Fock theory, with thermal shape fluctuations. In this manner, different regions of the spin-energy plane can be examined. The results support the predictions of a smeared-out phase transition at high spin above the yrast line.

We reviewed the results of reoperation in ninety-five patients who had acute subluxation (ten patients) or dislocation (eighty-five patients) of the hip after conventional cemented total hip-replacement arthroplasty. Postoperatively, fifty-eight patients (61 per cent) had no subsequent dislocation or subluxation. Seven of thirty-seven patients who had had recurrent dislocation had occasional subluxation during follow-up. Of the remaining thirty patients in whom instability persisted after the reoperation, twenty-eight had at least one dislocation, and nine had bothersome subluxation. Ten of these thirty-seven patients had another operation for the persistent instability. The causes of instability were classified as malrotation of the component, disruption of the trochanteric-abduction mechanism, impingement, or multiple and unknown, and appropriate treatment was provided. The component was revised in forty-five patients, revision and advancement of the trochanteric component was done in twenty-five patients, and impinging bone or cement was removed from six patients; a combination of these procedures was done in nineteen patients. Over-all, fifty-eight procedures (61 per cent) were successful (no additional subluxations or dislocations). We concluded that the results of operative treatment for an unstable total hip replacement can be optimized when a precise determination of the cause of the instability is made and appropriate measures are applied.