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Εισαγωγή: Ο ισχαιμικός πριαπισμός είναι η πιο συχνή μορφή πριαπισμού και χαρακτηρίζεται από την ανάπτυξη ισχαιμίας στα σηραγγώδη σώματα με δυνητικά καταστροφικές συνέπειες για τη στυτική λειτουργία του ασθενούς. Η πλήρης παθοφυσιολογία του ισχαιμικού πριαπισμού και οι συνέπειες της καθυστερημένης αντιμετώπισής του δεν είναι ακόμη πλήρως κατανοητά..Σκοπός: Σκοπός της παρούσας διατριβής είναι η κατανόηση των υποκείμενων μεταβολών, που λαμβάνουν χώρα στα σηραγγώδη σώματα, ώστε να συμβάλλει στην ανάπτυξη ενός βελτιωμένου αλγόριθμου όσον αφορά τη διαχείριση της νόσου. Ειδικότερα οι στόχοι της μελέτης είναι να αξιολογήσει τη διαγνωστική δυνατότητα του έγχρωμου υπερηχογραφικού doppler, να ερευνήσει τις ιστολογικές μεταβολές των λείων μυϊκών ινών των σηραγγωδών σωμάτων και να αξιολογήσει την αποτελεσματικότητα της χειρουργικής επέμβασης Τ–shunt με ταυτόχρονη διαστολή των σηραγγωδών σωμάτων διαβαλανικά για την θεραπεία των ασθενών με ισχαιμικό πριαπισμό.Υλικό και Μέθοδοι: Σε χρονικό διάστημα 36 μηνών, μελετήθηκαν 45 ασθενείς με ισχαιμικό πριαπισμό. Οι ασθενείς χωρίστηκαν σε υποομάδες ανάλογα με τη διάρκεια του πριαπισμού. Σε όλους τους ασθενείς διενεργήθηκε έγχρωμος Doppler υπερηχογραφικός έλεγχος και, μετά από μια ανεπιτυχή αρχική θεραπεία, υποβλήθηκαν σε T-shunt και ενδοσηραγγώδης διαστολή. Ελήφθησαν επίσης βιοψίες των λείων μυϊκών ινών από τα σηραγγώδη σώματα. Ιστοχημικές και ανοσοϊστοχημικές τεχνικές χρησιμοποιήθηκαν για την ανάλυση και την ποσοτικοποίηση της εξωκυττάριου πλέγματος και των λείων μυϊκών ινών. Όλοι οι ασθενείς συμπλήρωσαν ένα ερωτηματολόγιο IIEF-5 πριν και 6 μήνες μετά την επέμβαση.Αποτελέσματα: Οι μελέτες μας με CDU έδειξαν ποικίλες σηραγγώδεις αρτηριακές ροές σε διάφορα επεισόδια πριαπισμού σχεδόν ανάλογης διάρκειας. Συγκρίνοντας τα αποτελέσματα των βιοψιών με αυτά του CDU πέους διαπιστώσαμε ότι συσχετίζονται σχεδόν απόλυτα όσον αφορά την διάγνωση και έκβαση του πριαπισμού, όταν δεν ανιχνεύεται καθόλου ροή αίματος στο εγγύς τμήμα των σηραγγωδών αρτηριών. Η μελέτη αυτή επίσης έδειξε ότι τα ιστοπαθολογικά αποτελέσματα των βιοψιών των σηραγγωδών σωμάτων συσχετίζονται απόλυτα με την έκβαση της κατάστασης της στυτικής λειτουργίας των ασθενών. Τα αποτελέσματα έδειξαν ότι νέκρωση των λείων μυϊκών ινών εμφανίστηκε σε όλους τους ασθενείς με διάρκεια πριαπισμού > 48 ωρών, η οποία επίσης συσχετίζεται με την ανάπτυξη σοβαρής στυτικής δυσλειτουργίας. Σε ασθενείς με διάρκεια έως 24 ώρες υπήρχαν ακόμα99κάποια χαρακτηριστικά της νέκρωσης των λείων μυϊκών ινών, αλλά μόνο το 20% αυτών των ασθενών εμφάνισε σοβαρή στυτική δυσλειτουργία σε μακροχρόνια παρακολούθηση. Αποδείχτηκε τέλος, ότι η επιτυχία της T-shunt ενδοσηραγγώδους επέμβασης διάνοιξης των σηραγγωδών σωμάτων εξαρτάται από την διάρκεια του πριαπισμού. Όταν η διάρκεια είναι 48 ώρες, η χειρουργική επέμβαση συνήθως αποτυγχάνει να επιλύσει το πριαπισμό και ο στυτικός ιστός καταλήγει σε ίνωση λόγω νέκρωσης των λείων μυϊκών ινών.Συμπέρασμα: Η τεχνική T-shunt είναι μια χρήσιμη μέθοδος θεραπείας στα αρχικά στάδια του πριαπισμού, αλλά μετά από 48 ώρες είναι λιγότερο αξιόπιστη, δεδομένου ότι δεν αντιμετωπίζει το πριαπισμό, ούτε αλλάζει το αναπόφευκτο αποτέλεσμα της σωματικής ίνωσης. Αυτό είναι πιθανό να οφείλεται στην αναλογία των βιώσιμων / νεκρωτικών λείων μυϊκών ινών εντός του σηραγγώδους σώματος και είναι πιθανό ότι η κρίσιμη ανισορροπία συμβαίνει εντός της περιόδου από 24 έως 48 ώρες ισχαιμίας. Η βιοψία των σηραγγωδών σωμάτων, ως εκ τούτου συνιστάται κατά τη διάρκεια κάθε χειρουργικής επέμβασης λύσης του πριαπισμού, καθώς το αποτέλεσμα αυτής θα προβλέψει το ποσοστό επιτυχίας της χειρουργικής επέμβασης και τις πιθανότητες για τη διατήρηση της στυτικής λειτουργίας. Θα δώσει επίσης πληροφορίες και θα βοηθήσει στη λήψη της απόφασης για τοποθέτηση πεικής πρόθεσης. Σε αυτούς τους ασθενείς με ισχαιμικό πριαπισμό, που δεν ανταποκρίνονται στην αναρρόφηση και ενδοπεϊκή χορήγηση α-αδρενεργικών αγωνιστών ή έχουν πριαπισμό >48 ώρες επειδή είναι πιθανό να έχουν ήδη συμβεί μη αναστρέψιμες αλλαγές στα σηραγγώδη σώματα, που θα οδηγήσουν αναπόφευκτα σε ίνωση και στυτική δυσλειτουργία, συνιστάται η τοποθέτηση πεικής πρόθεσης.

INTRODUCTION AND OBJECTIVES:There is still a lack of consensus in the literature about the timing of penile (PP) prosthesis surgery following refractory ischaemic priapism (IP). The aim of this stu...

Lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH-LUTS) are a highly prevalent problem, and with considerable burden to quality of life. Evidence has emerged that a strong correlation exists in men suffering both BPH-LUTS and erectile dysfunction (ED). Phosphodiesterase type 5 inhibitors (PDE5i) have been shown to be highly effective in treating ED and more recently there is evidence that men with LUTS also benefit. In this review article we discuss the common pathogenic pathways of ED and LUTS, the scientific basis of PDE5i use, the efficacy of PDE5i in LUTS either as monotherapy or in combination with other established medications used in LUTS.

The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography.Patients' clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated.The mean age was 39.5 years (range 21-72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively.Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

The Nash arbitration scheme tries to model the equilibrium of a game. This is an arbitration scheme where the players decide to accept a fair and reasonable outcome of the game. We then approach the outcome based on rationality axioms, linearity, symmetry and independence. Working on this approach, we present some additional solutions to the problem by applying different methods such as the Lagrange method and also the Cauchy method. In both cases the outcomes confi rm those of the Nash method.

Objective To investigate the learning curve for performing extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP) in patients with intermediate- and high-risk prostate cancer. Patients and methods In all, 500 patients underwent ePLND for intermediate- or high-risk prostate cancer by one surgeon during a 48-month period. A transperitoneal laparoscopic approach was used in all patients to allow adequate access to the internal iliac vessels. The variables chosen as being the most important discriminators of the quality of ePLND were operating time, complication rate and lymph node (LN) yield. The learning curves for ePLND were calculated using the cumulative sum and cumulative average methods and the number of procedures performed until attainment of acceptable failure rates (competence levels) was calculated. LN parameters were compared with the results from the preceding 311 cases where limited PLND was undertaken. Results The median (range) preoperative PSA level was 8.0(1–62.5) ng/mL and biopsy Gleason score was 7(6–10). In all, 64% of patients had intermediate-risk and 36% had high-risk prostate cancer. There were no intraoperative blood transfusions and no conversions to open surgery. The median (range) blood loss was 200(10–1400) mL and the postoperative transfusion rate was 1.6%. The operating time fell at a steady rate of 2.7% after the 15th case and plateaued after 130 patients. At competence levels of 5% and 10%, the learning curve for all complications ended after 346 and 136 patients, respectively. At a 5% competence level the learning curve for PLND-specific complications was 40 cases and there was no learning curve at a 10% competence level. The overall complication rate was 7.2% of which almost half (47%) were deemed to be PLND-specific. The cumulative average of the LN counts plateaued after 150 procedures. Furthermore, the median LN count after ePLND was more than double that of the authors' historical standard PLND controls (14 vs 6, P

What's known on the subject? and What does the study add? The management of patients with non-obstructive azoospermia (NOA) and some cases of obstructive azoospermia involves testicular sperm extraction (TESE or micro-dissection TESE) combined with intracytoplasmic sperm injection (ICSI). Several studies have investigated the effect of the male age, the cause of azoospermia, testicular histopathology, the type of sperm used, and the use of pentoxyphilline, on the ICSI cycle outcome in men with azoospermia. The present study showed that none of these factors influenced the ICSI outcome in men with azoospermia, thus once sperm is found in an azoospermic male, no other male factor seems to influence the ICSI outcome. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology. Objectives To access the effect of: male age, the cause of azoospermia (obstructive azoospermia vs non-obstructive azoospermia [NOA]), testicular histopathology, the type of sperm used (fresh vs frozen-thawed), and the use of pentoxyphilline on the intracytoplasmic sperm injection (ICSI) cycle outcome in men with azoospermia. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology. Patients and Methods A retrospective analysis of 137 testicular sperm extraction-ICSI cycles performed between 2001–2010, involving 103 men with azoospermia, with 26 couples having repeat cycles. Results Analysis of the results did not show any statistically significant differences in the fertilization, embryo cleavage, clinical pregnancy, live birth and miscarriage rates in relation to the male age, cuase of azoospermia, testicular histopathology, type of sperm used and the use of pentoxyphilline. Conclusion Once sperm is found in a man with azoospermia, no other male factor seems to influence the ICSI outcome.

Stuttering priapism is rare and under-investigated clinical entity. Although it shares similarities with ischaemic priapism, by definition, stuttering priapism has distinct characteristics that advocate for a different management in the clinical setting. Therefore, the management of stuttering priapism aims primarily to prevent recurrence rather than the resolution of spontaneous attacks. A multimodal approach and the individualization of each case are essential because of the diversity of the condition and the plethora of proposed therapeutic strategies. Understanding the underlying pathophysiology and familiarity with contemporary, past and emerging future agents and therapeutic options are required in order to provide an optimal solution for each patient. In addition, patient counselling and the option to combine therapeutic strategies and challenge second-line therapies are essential weapons in the armament of the urologist. Although further clinical trials and studies are mandatory in order to obtain solid data and provide recommendations, all therapeutic options are analysed, with specific interest in the potential advantages and disadvantages. A structured evaluation procedure is also described.

The artificial urinary sphincter (AUS) is the gold-standard treatment for male stress urinary incontinence. This chapter covers the history of AUS development and the technical modifications that have resulted in the most commonly used device worldwide, the AMS 800. The indications and contraindications to surgery are highlighted, followed by a discussion of the importance of accurate patient investigation and assessment prior to surgery. The surgical technique to insert an AUS is followed by a review of the outcomes of sphincter implantation. Finally the management of postoperative complications and device malfunction are discussed

Background The management of carcinoma in situ (CIS) of the penis is controversial, with relatively high local recurrence rates after minimally invasive therapies. Objective Report the surgical technique and outcome of partial glans resurfacing (PGR) and total glans resurfacing (TGR) as primary treatment modalities for CIS of the glans penis. Design, setting, and participants Between 2001 to 2010, 25 patients with biopsy-proven CIS underwent TGR ( n =10) or PGR ( n =15), defined as Surgical procedure Excision of the glans epithelium and subepithelium of either the entire glans or the locally affected area, with a macroscopic clear margin. The penis was then reconstructed using a split skin graft. Measurements Positive surgical margin (PSM) rates and rates of recurrence and progression were collated. Complications, cosmesis, and patient satisfaction were evaluated. Results and limitations Mean follow-up was 29 mo (range: 2–120 mo). There were no postoperative complications, and 24 of 25 patients (96%) had complete graft take with excellent cosmesis. Overall, 12 of 25 patients (48%) had PSMs. Only 7 of 25 (28%) required further surgery, 2 of 25 (8%) for extensive CIS at the margin and 5 of 25 (20%) for unexpected invasive disease. Additional surgery consisted of further resurfacing in 4 of 25 cases (16%) or glansectomy in 3 of 25 cases (12%). Those undergoing further surgery had no further compromise to their oncologic outcome. The overall local recurrence rate was 4%. There were no cases of progression. Conclusions Glans resurfacing is a safe and effective primary treatment for CIS. The procedure maintains a functional penis without compromising oncologic control, while ensuring that definitive histopathlogy is obtained. Glans resurfacing has a low risk of recurrence and progression. Patients need to be warned that approximately 28% will require further surgery for PSM or understaging of their primary disease, although the need for further surgery does not compromise oncologic control.

Objective: The aim of our study was to demonstrate our experience regarding the surgical treatment of complications after foreign body ingestion. Subject and Methods: From 1997 to 2005, we treated 16 adult patients (mean age 44.8 years, range 21–77), who presented with complications after foreign body ingestion. Results: The complications treated were perforation-peritonitis: n = 7 (44%), intra-abdominal abscess formation: n = 5 (31%), upper gastrointestinal bleeding: n = 3 (19%) and inflammatory mass formation: n = 1 (6%) patient. The diagnosis was made intra-operatively in 13 (81.3%) of the cases. The commonest anatomical position of the perforation was the large bowel, in 7 (43%) of the cases. Bony food parts were the commonest foreign bodies accidentally swallowed, in 9 (56%) patients. The median hospital stay was 7 days (2–18), while no death occurred in the postoperative period among the patients of the study. The postoperative morbidity rate was 22.2%. Conclusions: The most common complication after foreign body ingestion was the perforation of the gastrointestinal tract. The risk of perforation was higher when sharp foreign bodies were ingested. The pre-operative diagnosis was difficult, and it was usually achieved intra-operatively.

The aim of this experimental study was to investigate whether insulin-like growth factor I (IGF-I) can protect the colonic healing from the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU).Eighty male Wistar rats were randomized into four groups of 20 rats each. Immediately after anastomoses were performed, rats in the control group were injected with 1 mL/100 gr of intraperitoneal saline solution, which was repeated daily until killed. Rats in the 5-FU and IGF-I +5-FU groups received 5-FU in a dose of 20 mg/kg body weight intraperitoneally, from the day of operation until killed. Rats in the IGF-I and IGF-I +5-FU groups received IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on 2nd, 4th, and 6th postoperative day. Rats were sacrificed on the 7th postoperative day.The dehiscence rate in the 5-FU group was 30% and it was significantly higher compared with the control and the IGF-I group (P = 0.020 for both comparisons). However, in the IGF-I +5-FU group, the dehiscence rate decreased to 10%. The administration of IGF-I resulted in a significant rise of bursting pressure in the IGF-I +5-FU group compared with the 5-FU group (P0.001). There was no statistical difference in bursting pressure between the IGF-I +5-FU and control groups (P = 1.000). The hydroxyproline levels were higher in the IGF-I and the IGF-I +5-FU groups as a result of the stimulating act of IGF-I.IGF-I, when given intraperitoneally, seems to mediate some of the adverse effects of 5-FU on the colonic healing in rats.

The aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids.Our study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy.During the postoperative period, 6 patients (10.7%) experienced pain for 7-14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3-8 weeks. Median follow-up was 72.1 months (range, 55-86 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage.Stapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Early insertion of a penile prosthesis in prolonged ischaemic priapism is easier to perform than late prosthesis placement, and preserves the penile length. The aim of this study was to assess whether a delayed exchange to an inflatable implant allows upsizing of the cylinders in patients who have undergone early insertion for refractory ischaemic priapism.Over a 30 month period, 10 patients with ischaemic priapism underwent an early insertion of a malleable penile prosthesis. The mean age was 41.3 years and the mean duration of priapism was 188 h. Following a median period of 130.5 days, all of these patients underwent exchange of the malleable to an inflatable prosthesis.At the time of penile implant exchange, a median upsize in the length of the cylinders of 1 cm in either one or both corporal bodies (range 0-3 cm) was recorded. Five patients had deliberate downsizing at the initial operation owing to a previous shunt. The mean score on the five-item International Index of Erectile Function (IIEF-5) before insertion of the malleable prosthesis was 24 (range 20-25). Three months after the initial insertion of a malleable penile implant the satisfaction rate according to the IIEF-5 score was 80%. Three months after the exchange, the patient satisfaction rate increased to 90%.Insertion of a malleable penile prosthesis is an acceptable option for patients with refractory ischaemic priapism. Although some patients deliberately have a shorter implant inserted initially owing to a previous distal shunt procedure, following a period of resolution the cylinders can be upsized at a later operation.

Objective The aims of this prospective study were to determine carcinoembryonic antigen (CEA) levels and incidence of cytology in peritoneal washings of patients with colorectal cancer, correlate the results with various histopathological factors and determine their significance as prognostic factors of the disease. Methods From 1992 to 1999, 98 patients with adenocarcinoma of the colon or intraperitoneal rectum underwent curative surgery and enrolled in this study. Results Overall, 25 (26.3%) of 95 patients were found to have positive cytology. The proportion of patients with positive cytology was higher in the recurrence group (36.4%) than in the groups of 5-year survival and hepatic metastases (24.6% and 26.3%, respectively), but this difference was not significant. The 5-year survival group had the lowest peritoneal CEA levels compared with the other groups, but this difference was not significant. Peritoneal cytology and CEA level alone were not sensitive, specific or accurate enough indicators in predicting survival, hepatic metastases or local recurrence. The analysis of patients with positive cytology and high peritoneal CEA level revealed that their combination can predict local recurrence with accuracy of 85%. Conclusions The presence of free malignant cells, as detected by cytology and CEA level, in the peritoneal cavity of patients with resectable colorectal cancer had no detectable impact on survival, hepatic metastases or local recurrence rate. However, local recurrence can be predicted with accuracy of 85% in patients who have positive cytology and high peritoneal CEA level at the same time.

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient’s degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.

The aim of our study was to determine the anastomotic leakage rate after the performance of low anterior resection without protective stoma. During the time period from 1989 to 2001, 82 consecutive patients underwent low anterior resection for rectal carcinoma without protective stoma. Thirteen anastomoses were hand sewn (15.8%) and the remaining 69 (84.2%) were constructed with the use of a circular stapling gun. The mean distance of the anastomoses from the anal margin was 6.2 cm (range, 3-9 cm). None of the 82 low anterior resections was covered by a defunctioning stoma. Clinical anastomotic leakage occurred in 4 patients (4.9%) and 4 other patients presented radiologically detected leakage (4.9%). No death occurred in the 8 patients that presented anastomotic dehiscence. Non-specific complications were detected in 11 (13.4%) of 82 patients. In conclusion, the low leakage rate of the anastomoses in our patients allows us to recommend low anterior resection without defunctioning stoma.

To determine the threshold waveform characteristics at Doppler ultrasound (DUS) to differentiate between ischaemic and non-ischaemic priapism.Fifty-two patients were categorised into "ischaemic" and "non-ischaemic" types based on clinical and blood-gas findings: 10 patients with non-ischaemic priapism; 20 with ischaemic priapism before surgical shunt placement and 22 with ischaemic priapism after surgical shunt placement. DUS traces were analysed: peak systolic velocity (PSV) and mean velocity (MV) were calculated. Histological samples were obtained at the time of surgery. Three clinical outcome groups were defined: (1) normal, (2) regular use of pharmacostimulation, and (3) refractory dysfunction/penile implant.All non-ischaemic priapism cases had a PSV50 cm/s and all but one had an MV of6.5 cm/s. In pre-surgery ischaemic cases, all men had a PSV50 cm/s and MV6.5 cm/s. Two flow patterns were observed in this group: PSV25 cm/s in all men scanned before needle aspiration; and in 6/14 after needle aspiration, a high velocity/high resistance (low net inflow) pattern, with peak systolic flows22 cm/s but diastolic reversal. In post-surgery ischaemic priapism, flow parameters overlapped with the non-ischaemic group. PSV/MV did not predict clinical outcome or histology.In the present cohort, PSV50 cm/s and MV6.5 cm/s were predictive of ischaemic priapism (pre-shunt; p0.01). Patients with ischaemic priapism may show PSV22 cm/s, but have diastolic reversal and therefore low net perfusion. Post-shunt, DUS findings were extremely variable and did not predict histology or clinical outcome.

RESULTS: A total of 168 patients underwent RP during the study period. The mean patient age was 36.2 years (range 11months to 78 years). UPJO was primary (no prior attempt at correction) in 79% while 21% had previously failed endopyelotomy or pyeloplasty. A crossing vessel was encountered in 44.4% of all patients. All patients were stented during RP with mean stent duration of 42.5 days. Two complications were encountered: 1 patient developed self-limiting right shoulder pain due to positioning while 1 patient was readmitted postoperatively for pyelonephritis. 7 patients were lost to follow-up as a result of Hurricane Katrina. In the remaining 161 patients, follow-up was available for 63 patients with a mean follow-up of 23.4 months. 60 patients (95.2%) had successful RP confirmed by post-operative imaging and resolution of pre-operative symptoms. 3 patients (4.8%) failed RP resulting in 1 repeat pyeloplasty, 1 laparoscopic nephrectomy, and 1 percutaneous nephrolithotomy for persistent symptomatic UPJO. CONCLUSIONS: Robotic pyeloplasty is a safe, feasible, and effective minimally invasive technique for treating UPJO. In our longterm institutional experience, RP is a durable procedure that offers a high success rate.

OBJECTIVE To report on the high rectal fistula rate associated with salvage high-intensity focused ultrasound (HIFU) after the failure of combined brachytherapy and external beam radiotherapy (EBRT) for prostate cancer; salvage ablative therapy for prostate cancer is indicated when there is local recurrence after RT, brachytherapy or their combination. PATIENTS AND METHODS We retrospectively reviewed all men with prostate cancer treated with HIFU between 1 March 2005 and 31 May 2007, and identified five men treated after the failure of both brachytherapy and EBRT for localized prostate cancer. RESULTS Three of the five men had iodine-seed implantation brachytherapy combined with EBRT as primary treatment, one had high-dose rate brachytherapy combined with EBRT and one had salvage iodine-seed brachytherapy for failed EBRT. Three of the five patients developed a recto-urethral fistula after HIFU. CONCLUSIONS The high rate of recto-urethral fistula formation in this group might reflect an impaired blood supply or HIFU-associated near-field heating of the rectal wall. Tissue viability and healing might affect this group regardless of the salvage method. Careful patient selection and avoidance of rectal diagnostic biopsies might minimize the risk. Emerging ablative therapies regarded as less invasive than traditional therapies must be used with caution.

Scrotal lymphedema (scrotal elephantiasis) is uncommon outside of filariasis endemic regions. We present a case of a 65-year-old with idiopathic lymphedema of the scrotum and functional impairment of the penis. The patient underwent surgical excision of the edematous subcutaneous tissues and plastic reconstruction of his penis and scrotum. Three years later, the patient showed no signs of local recurrence, had complete restoration of urinary and sexual function and was extremely satisfied with the result. Surgical management was an effective strategy in the management of scrotal lymphedema in this case.

Non-ischaemic priapism is a rare type of priapism and is associated with penile or perineal trauma. The absence of ischaemia should theoretically prevent smooth muscle necrosis and corporal fibrosis which occurs in ischaemic priapism. The aim of this study was to first report a patient series with non-ischaemic priapism that developed distal corpus cavernosum fibrosis and erectile dysfunction. Over a 5 year period, a cohort of 6 patients diagnosed with non-ischaemic priapism presented to a single centre. The diagnosis was based on a clinical history, penile examination with confirmation using a combination of cavernosal blood gas analysis, colour duplex ultrasonography of the penis and angiography. Patients were followed up in clinic at regular intervals with clinical examination and repeat imaging. Following a median follow up of 4 weeks (range 2-12) the patients reported either the development of erectile dysfunction with distal penile flaccidity. Five patients required the use of PDE-5 inhibitors to achieve full tumescence. The remaining patient eventually underwent insertion of a penile prosthesis due to the failure of pharmacotherapies. Based on these findings we suggest that superselective embolisation of non-ischaemic priapism cases occasionally should be performed after a shorter period of conservative treatment.

Stapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long–term results after SH for third–degree haemorrhoids. A total of 126 consecutive patients (67 men and 59 women) with third–degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38–84 months). During the postoperative period, 7 patients (5.8%) experienced pain for 5–12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2–8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%). SH is a safe, low–pain and, in the long–term, effective technique for the treatment of third–degree haemorrhoids.

The current management of ischemic priapism that is refractory to conventional medical therapy is a form of shunt procedure that diverts blood away from the corpus cavernosum. We assessed the outcome of the T-shunt and intracavernous tunneling for the management of ischemic priapism.During a 36-month period 45 patients presented with prolonged ischemic priapism. Patients were divided into subgroups according to the duration of priapism. All patients had an unsuccessful primary treatment, and underwent a T-shunt and intracavernous tunneling with cavernous muscle biopsies. All patients completed an IIEF-5 (International Index of Erectile Function-5) questionnaire preoperatively and 6 months postoperatively.Resolution of the priapism using a T-shunt and snake maneuver occurred in all patients with a priapism duration of less than 24 hours and in only 30% of those with priapism lasting more than 48 hours. After a 6-month median followup the IIEF-5 score was significantly reduced from a mean of 24 (range 23 to 25) preoperatively to 7.7 (range 5 to 24), which was related to the duration of the priapism (p0.0005). All patients with priapism for more than 48 hours had necrotic cavernous smooth muscle on biopsy and had severe erectile dysfunction requiring the insertion of a penile prosthesis. Those patients with moderate and mild erectile dysfunction were treated with phosphodiesterase type 5 inhibitors.The success of the T-shunt with snake tunneling is dependent on the duration of priapism. When it is less than 24 hours the results are favorable, although erectile dysfunction is still present in 50% of patients. In those with a priapism duration greater than 48 hours the technique usually fails to resolve the priapism and all patients end up with erectile dysfunction due to smooth muscle necrosis.

The range of urological procedures performed with robotic assistance has widened with increasing experience with the da Vinci robotic system. We describe the use of the da Vinci SI Surgical System for excision of a seminal vesicle cyst in a patient who had associated ipsilateral renal agenesis (Zinner’s syndrome). The robotic platform afforded a minimally invasive procedure with precise dissection and no collateral damage to neighbouring vital anatomy.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The management of patients with non-obstructive azoospermia (NOA) and some cases of obstructive azoospermia involves testicular sperm extraction (TESE or micro-dissection TESE) combined with intracytoplasmic sperm injection (ICSI). Several studies have investigated the effect of the male age, the cause of azoospermia, testicular histopathology, the type of sperm used, and the use of pentoxyphilline, on the ICSI cycle outcome in men with azoospermia. The present study showed that none of these factors influenced the ICSI outcome in men with azoospermia, thus once sperm is found in an azoospermic male, no other male factor seems to influence the ICSI outcome. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology.To access the effect of: male age, the cause of azoospermia (obstructive azoospermia vs non-obstructive azoospermia [NOA]), testicular histopathology, the type of sperm used (fresh vs frozen-thawed), and the use of pentoxyphilline on the intracytoplasmic sperm injection (ICSI) cycle outcome in men with azoospermia. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology.A retrospective analysis of 137 testicular sperm extraction-ICSI cycles performed between 2001-2010, involving 103 men with azoospermia, with 26 couples having repeat cycles.Analysis of the results did not show any statistically significant differences in the fertilization, embryo cleavage, clinical pregnancy, live birth and miscarriage rates in relation to the male age, cuase of azoospermia, testicular histopathology, type of sperm used and the use of pentoxyphilline.Once sperm is found in a man with azoospermia, no other male factor seems to influence the ICSI outcome.

The purpose of this study is to present the incidence of anastomotic leakage after colon resection and intraperitoneal anastomosis for colorectal cancer. In the last ten years, 205 patients underwent colonic resection with intraperitoneal anastomosis for colon cancer. The surgical management of colorectal cancer consisted of 66 right hemicolectomies, 3 transverse colectomies, 17 left hemicolectomies, 98 sigmoid colectomies and 21 high anterior resections of the rectum. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal CT-scans. Anastomotic leakage occurred in 5 out of 205 patients (2.4%). One of these patients underwent emergency surgery and the other 4 elective surgery; 3 by manual, 2 by mechanical suture. Three patients with anastomotic leakage were reoperated on days 4, 5 and 7, and 2 patients were treated conservatively. Two of the patients (20%) with anastomotic leakage died due to sepsis. Even though the rate of anastomotic leakage in patients with intraperitoneal anastomosis after colon resection for colorectal cancer is low, it remains a significant complication and a major cause of postoperative morbidity and mortality.

This study was aimed at examining whether the addition of fibrin glue to a sutured colonic anastomosis improves its healing or not. We studied the effect of adding fibrin glue on a sutured colonic anastomosis. Thirty-six Wistar rats were randomized into two groups of 18 rats each. A sutured anastomosis was performed in all rats. Fibrin glue was applied around the anastomosis of the rats of group B. Rats were sacrificed on the eighth postoperative day. The rate of anastomotic leakage was found not to be significantly different between the two groups. The mean bursting pressure of the colonic anastomoses was significantly higher in group B (fibrin-treated) than in group A. Fibrin glue application around a sutured anastomosis provides a safer anastomosis which is stronger than the sutured one.

Objective To characterize conservative management of urorectal fistulae (URF). Methods URF are a recognized but rare complication of treatments for prostate and rectal cancers. URF can lead to incontinence, fecaluria, pain, urinary infection, and sepsis, and thus are usually treated surgically. We present a series of 3 patients whose complex URF were managed conservatively. Between 2004 and 2010, 43 patients were diagnosed with URF resulting from treatment for prostate or rectal cancer. All patients were evaluated and offered surgical treatment; 40 patients elected surgical therapy, and 3 patients chose conservative, nonoperative management of the URF. The primary outcome was the patient choosing or needing formal surgical URF closure. Because this was not a comparative study, no formal statistical analysis was undertaken. Results The 3 patients have been regularly monitored and have required symptomatic and episodic care. None, however, has opted for formal surgical fistula repair, and to date, all continue in conservative management of their URF. Conclusion Spontaneous URF closure is uncommon and is unknown to occur in complex URF. Surgery is the mainstay of treatment. Patients should consider treatment options, potential outcomes, and their quality of life when choosing or not choosing treatment. The applicability and durability of conservative management of URF remains unclear.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The management of patients with non-obstructive azoospermia (NOA) involves testicular sperm extraction (TESE or microdissection TESE) combined with intracytoplasmic sperm injection (ICSI). Sperm retrieval is successful in up to 50% of men with NOA; however, there is no single clinical finding or investigation that can accurately predict a positive outcome. Several studies have concluded that testicular biopsy is the best predictor of a successful TESE. The present study shows that the strongest predictor of the success of TESE is when tubules with mature spermatozoa (Johnsen score ≥8) are found in the histopathology specimen, irrespective of the overall state of spermatogenesis. The findings suggest that a lower limit threshold value of 2% of tubules with spermatogenesis in the histopathology specimen will result in a positive sperm retrieval. However, it is not practical to perform a diagnostic biopsy before TESE because this would mean that patients undergo two surgeries, which adds to the cost and increases the complications. The diagnostic biopsy is best coupled with an initial TESE before starting the ICSI cycle. Based on the findings of the histopathology specimen, patients may be then offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI. Also, if the initial TESE was negative, the biopsy result will help in the decision to offer a repeat TESE. This regimen is more cost-effective because the ICSI cycle will be started only if adequate sperm is retrieved.To assess whether testicular histopathology can predict the outcome of testicular sperm extraction (TESE) in men with non-obstructive azoospermia (NOA) and therefore the role of preoperative diagnostic testis biopsy.The study comprised a retrospective analysis of 388 patients with azoospermia who were referred from 2005 to 2010. Information collected included a clinical history and an examination including age and testicular size, serum follicle-stimulating hormone, two semen analyses and testicular histology collected at the time of surgical sperm retrieval (TESE or microdissection TESE).In total, 388 patients with a mean (range) age of 37 (18-66) years were included in the present study. Based on the history, clinical and laboratory findings, 112 patients had obstructive azoospermia and 276 patients had NOA. All patients in the obstructed group had a positive sperm retrieval. The sperm retrieval rate for the NOA group was 50%. An analysis of the results showed that the best predictor of a positive sperm retrieval was when tubules with mature spermatozoa were seen at biopsy, irrespective of the overall state of spermatogenesis (P0.001).The presence of tubules with spermatazoa on biospy is the best predictor of a positive surgical sperm retrieval in patients with NOA. The diagnostic biopsy is best coupled with an initial TESE before starting the intracytoplasmic sperm injection (ICSI) cycle. Based on the findings of the histopathology specimen, patients may be offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI, or a redo TESE if the initial TESE was negative.

The purpose of this experimental study was to assess the effects of the immediate postoperative intraperitoneal administration of oxaliplatin and 5-FU on the healing of colonic anastomoses in rats. Sixty rats were randomized into 4 groups of 15 rats each and were subjected to colonic anastomoses. To the 1st group, saline solution was administered immediately postoperatively, intraperitoneally. To the 2nd group, 5-FU was administered, to the 3rd group oxaliplatin and to the 4th group 5-FU and oxaliplatin were administered immediately postoperatively, intraperitoneally. After killing the rats on the 8th postoperative day, the anastomoses were examined macroscopically and the anastomotic bursting pressures were measured. The anastomoses were also examined histologically and the hydroxyproline contents were determined. Rupture of the anastomosis was observed in no rats of the 1st group, in 3 rats of the 2nd group, in 4 rats of the 3rd group and in 7 rats of the 4th group (P = 0.016). The bursting pressure (P

INTRODUCTION AND OBJECTIVES: Non-ischaemic priapism is due to unregulated cavernous arterial inflow. Although rare, it is commonly associated with perineal or penile trauma. Since the venous outflow mechanism is unaffected the corpus cavernosum is perfused with oxygenated blood and therefore these patients can be managed conservatively. We report on our series of patients with non-ischaemic priapism who have developed fibrosis of the distal corpus cavernosum following a period of conservative treatment. METHODS: Over a 5 year period, 7 patients with non-ischaemic priapism presented to our unit. The mean age was 37.4 years (range 20 56). The etiology in 6 cases was secondary to a perineal injury and in 1 case conversion of an ischaemic priapism to a non ischaemic priapism following surgical intervention. The diagnosis of non-ischaemic priapism in all patients was based on the clinical history and examination, cavernosal blood gas analysis, colour duplex ultrasonography of the penis and pudendal angiography. 4 cases (57%) also underwent a penile MRI. RESULTS: Although the diagnostic tests confirmed non-ischaemic priapism, follow up Doppler studies and MRI penis showed the development of distal corpus cavernosum fibrosis. Pudendal artery super selective embolization was eventually performed in all of the patients, of which 2 (28.5%) patients underwent a second attempt at embolisation. On follow up these patients reported the development of erectile dysfunction due to poor distal penile tumescence in all cases and the penile MRI demonstrated distal corpus cavernosum fibrosis. Four patients (57%) eventually underwent insertion of a penile implant due to failed pharmacotherapies. A further 3 (43%) patients are using PDE-5 inhibitors. The conditions were reproduced in an in vitro model using precontracted strips of rabbit corpus cavernosum superfused at high pO2 levels. This showed that the smooth muscle tone reduced by 43% of the initial tone (n 4) after superfusion for 12 hours indicating irreversible smooth muscle dysfunction. CONCLUSIONS: The risk of ischaemic damage in non-ischaemic priapism is expected to be minimal due to the oxygenation of the corpus cavernosum being maintained. However, corpus cavernosum perfusion with higher than normal pO2 levels may result in oxidative stress due to the formation of reactive oxygen species (ROS). Irreversible damage to the smooth muscle is followed by the development of fibrosis, Based on these findings we suggest that superselective embolisation of these cases should be performed at the earliest opportunity.