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This study examines the outcomes of patients undergoing the Neuromonics tinnitus treatment protocol at a single, tertiary referral center over a 2-year period. A retrospective review of patient records was performed with the objective of collecting demographic and audiological information and identifying changes in score on an established tinnitus questionnaire (Tinnitus Reaction Questionnaire [TRQ]) after treatment. Forty-seven patients initiated treatment with the Neuromonics device during the study period. Fourteen patients completed treatment, and another 18 were actively undergoing treatment at the end of the study period. The mean pure-tone average for the study group (N = 47) was 23.4 dB for the involved ear. Of those who completed the treatment, the mean posttreatment TRQ score was significantly lower than the pretreatment score ( p ~ .001). Fifteen patients (31.9%) returned the device or did not complete treatment. Across all 47 patients, 48.9% achieved a successful reduction of 40% or greater in TRQ score. There was no correlation among pure-tone average, initial TRQ score or duration of use, and percentage change in TRQ score for those with at least one follow-up test. Based on these preliminary findings, treatment with the Neuromonics device is successful in reducing TRQ scores in appropriately selected patients with tinnitus. [ABSTRACT FROM AUTHOR]

Gender identity disorder (GID), or transsexualism as it is more commonly known, is a highly complex clinical entity. Although the exact aetiology of GID is unknown, several environmental, genetic and anatomical theories have been described. The diagnosis of GID can be a difficult process but is established currently using standards of care as defined by the Harry Benjamin International Gender Dysphoria Association. Patients go through extensive psychiatric assessment, including the Real Life Experience, which entails living in the desired gender role 24 h a day for a minimum period of 12 months. The majority of GID patients will eventually go on to have gender realignment surgery, which includes feminising genitoplasty. The clinical features, diagnostic approach and management of male-to-female GID in the UK are reviewed, including the behavioural, psychological and surgical aspects. [ABSTRACT FROM AUTHOR]

Bladder pain syndrome (BPS) is a poorly understood condition. In pregnancy, lower urinary tract symptoms and pain are common, but the possibility of BPS is rarely considered and almost never explored. The consequences of BPS on pregnancy and vice versa are poorly understood, and management options appear to be limited. This article reviews the current evidence to allow us to better counsel, investigate, diagnose and manage patients with suspected or known BPS who fall pregnant or who are considering pregnancy. MEDLINE, EMBASE and PubMed were searched for a combination of mesh terms of keywords: 'cystitis', 'interstitial', 'bladder', 'pain' and 'pregnancy'. Relevant articles were identified, reviewed and further relevant articles identified from the references. CONCLUSION: BPS symptoms are very common in pregnancy, with limited data suggesting significant negative effects on the woman and pregnancy. There are safe options for investigation, diagnosis and management in pregnancy. There is a need to raise awareness of the impact of BPS symptoms in pregnancy and the available options for diagnoses and management, improving patient experience and outcomes. PATIENT SUMMARY: Patients with BPS or symptoms akin to BPS need not be abandoned in pregnancy. There is data to support them in making decisions around investigation and management in pregnancy., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: co-author J Goddard Peer reviewer for: European Urology Annals of the Royal College of Surgeons of England Asian Andrology Journal Postgraduate Medical Journal World Journal of Urology de Historia Urologiae Europaeae Journal of Clinical Urology. Abstract Marker for EAU Annual Meeting BAUS Annual Meeting RSM Urology Section., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction and Hypothesis: The objective was to assess the efficacy of intravesical hyaluronic acid (HA) and chondroitin sulfate (CS), alone or in combination, for recurrent urinary tract infections (RUTIs) in adult female patients using a systematic review and meta-analysis., Methods: English-language articles were obtained from the MEDLINE, Embase, and Cochrane databases through November 2016, by manual searching and cross-referencing. Randomized and nonrandomized trials of adult female patients with a documented history of RUTIs who received HA, CS or HA plus CS were included. The random effects model was applied to all pooled analyses. Risk of bias was assessed for individual studies and across studies., Results: Two randomized (n = 85) and six nonrandomized (n = 715) studies met the inclusion criteria. These studies assessed HA ± CS; studies of CS alone were not identified in the search. HA ± CS decreased the UTI rate per patient-year (pooled mean difference [MD] -2.56; 95% confidence interval [CI] -3.86, -1.26; p < 0.001) and increased the time to first UTI recurrence (pooled MD 130.05 days; 95% CI 5.84, 254.26; p = 0.04). There was heterogeneity in most outcomes considered, and publication bias in many studies. The standard of trial reporting was low. The patient population size, and the number of studies included, were small., Conclusions: HA ± CS appears to reduce the rate of UTI and increase the time to recurrence in women with RUTI. As randomized controlled studies are available only for HA plus CS, the quality of evidence is higher for the combination than for HA alone.

Introduction: Pulmonary hypertension is life limiting. Delays in diagnosis are common, and even after treatment has been initiated, pulmonary hypertension has marked effects on many aspects of social and physical function. We believed that a new approach to examining disease impact could be achieved through a combination of narrative research and creative writing., Methods: Detailed unstructured narrative interviews with people with pulmonary hypertension were analysed thematically. Individual moments were also summarised and studied using creative writing, in which the interviewer created microstories from narrative and interview data. Stories were shared with their subjects, and with other patients, clinicians, researchers and the wider public. The study was carried out in hospital and in patients' homes., Results: Narrative analysis generated a rich data set which highlighted profound effects of pulmonary hypertension on identity, and demonstrated how the disease results in very marked personal change with ongoing and unpredictable requirement for adaptation. The novel methodology of microstory development proved to be an effective tool to summarise, communicate and explore the consequences of pulmonary hypertension and the clinical challenges of caring for patients with this illness., Conclusions: A holistic approach to treatment of chronic respiratory diseases such as pulmonary hypertension requires and benefits from explicit exploration of the full impacts of the illness. Narrative analysis and the novel approach of targeted microstory development can form a valuable component of the repertoire of approaches to effectively comprehend chronic disease and can also facilitate patient-focused discussion and interventions., Competing Interests: Competing interests: None declared.

Objective: Translabyrinthine resection of intracranial tumors results in single-sided deafness, which can be treated by surgical and nonsurgical means. Here we describe the first series examining complication and device usage rates among patients receiving a surgically implanted bone-anchored hearing device (BAHD) at the time of translabyrinthine tumor removal., Study Design: Case series with chart review., Setting: Private tertiary neurotologic referral center., Patients: Patients (N = 154) undergoing concurrent BAHD placement and translabyrinthine tumor resection., Intervention: Concurrent BAHD placement and translabyrinthine tumor removal., Main Outcome Measures: Postoperative complication rates and BAHD usage., Results: Of the 154 patients, 121 (78.6%) had no device-related complications. The most common device-related complications were skin overgrowth (8.4%), acute infection (5.2%), and chronic infection (3.2%). The overall and specific complication rates did not differ from published BAHD complication rates. One patient (0.6%) developed a cerebrospinal leak through the surgical site for the device. At the time of last follow-up (mean, 39.8 months), 151 patients (95.0%) were still using their devices., Conclusion: Patients undergoing concurrent translabyrinthine tumor removal and BAHD placement exhibit similar device-related complication profiles as patients undergoing standard device placement. Based on these outcomes and the high long-term usage rates, BAHD insertion at the time of translabyrinthine intracranial surgery can be considered a safe and useful procedure., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objectives: To examine audiometric outcomes, symptom control rates, and complication rates following semicircular canal plugging for superior semicircular canal dehiscence syndrome., Study Design: Retrospective chart review., Setting: Private, neurotologic tertiary referral center., Subjects and Methods: Patients undergoing semicircular canal plugging for superior semicircular canal dehiscence syndrome from January 1, 2007, to December 31, 2012. Pre- and postoperative audiometry, vestibular testing, operative findings, and clinical symptoms were assessed through chart review., Results: A total of 24 ears underwent a canal plugging procedure during the study period for superior canal dehiscence syndrome. Pre- and postoperative air conduction pure-tone averages were 21.1 and 22.5 dB (P = .42, not significant [NS]). The average pre- and postoperative word recognition scores were 95.8% and 95.1% (P = .48, NS). Vestibular evoked myogenic potential data showed reduced thresholds in 7 patients with canal dehiscence. Complications were limited to a single, temporary facial weakness. Complete symptom improvement was noted in 35.7% of all patients, while at least partial symptom improvement was found in over 80% of patients., Conclusion: Semicircular canal plugging procedures are associated with excellent hearing outcomes and may reduce preoperative symptoms in patients with superior semicircular canal dehiscence., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objective: Review audiological outcomes after revision stapedectomy using hydroxyapatite cement., Study Design: Retrospective case review., Setting: Tertiary neurotological referral center., Patients: Thirty-seven cases of previously treated otosclerosis where incus erosion was observed during revision stapedectomy., Intervention(s): Hydroxyapatite cement was used to rebuild the eroded incus and stabilize the prosthesis during revision stapedectomy., Main Outcome Measure(s): Pre- and postoperative bone conduction (BC) and air conduction (AC) pure-tone averages (PTA) (0.5, 1, 2, 3 kHz) including high tone BC (1, 2, 4 kHz), air-bone gap (ABG), and speech discrimination scores were measured. Short-term (3 wk) and longer-term (average 12 mo) hearing outcomes were measured. Data are reported according to the most recent guidelines of the AAO-HNS Committee on Hearing and Equilibrium., Results: Among 37 ears undergoing revision stapedectomy with hydroxyapatite cement, the AC PTA was 59.8 dB preoperatively and 34.6 dB postoperatively (p < 0.0001) at latest follow-up. The mean postoperative ABG was 8.8 dB (SD = 8.6, range -1.3-36.3 dB) while a mean improvement of 2.1 dB (SD = 6.5, range -8.33-15.0 dB) of the high tone BC PTA was observed. One revision case was noted during the follow-up period., Conclusion: Hydroxyapatite cement is useful to reconstruct and stabilize the prosthesis in revision stapedectomy when erosion of the long process is encountered. Short- and longer-term hearing results are favorable when compared to previously reported results of revision stapedectomy.

Bladder cancer patients suffer significant treatment failure, including high rates of recurrence and poor outcomes for advanced disease. If mechanisms to improve tumour cell treatment sensitivity could be identified and/or if tumour response could be predicted, it should be possible to improve local-control and survival. Previously, we have shown that radiation-induced DNA damage, measured by alkaline Comet assay (ACA), correlates bladder cancer cell radiosensitivity in vitro. In this study we first show that modified-ACA measures of cisplatin and mitomycin-C-induced damage also correlate bladder cancer cell chemosensitivity in vitro, with essentially the same rank order for chemosensitivity as for radiosensitivity. Furthermore, ACA studies of radiation-induced damage in different cell-DNA substrates (nuclei, nucleoids and intact parent cells) suggest that it is a feature retained in the prepared nucleoids that is responsible for the relative damage sensitivity of bladder cancer cells, suggestive of differences in the organisation of DNA within resistant vs. sensitive cells. Second, we show that ACA analysis of biopsies from bladder tumours reveal that reduced DNA damage sensitivity associates with poorer treatment outcomes, notably that tumours with a reduced damage response show a significant association with local recurrence of non-invasive disease and that reduced damage response was a better predictor of recurrence than the presence of high-risk histology in this cohort. In conclusion, this study demonstrates that mechanisms governing treatment-induced DNA damage are both central to and predictive of bladder cancer cell treatment sensitivity and exemplifies a link between DNA damage resistance and both treatment response and tumour aggression., (© 2013 The Authors. Published by Wiley Periodicals, Inc. on behalf of UICC.)

Hallermann-Streiff syndrome, also known as oculomandibulofacial syndrome, is a rare congenital disorder affecting growth and cranial, dental, ocular, pilocutaneous, and mental development. In addition to routine audiologic testing in patients with this syndrome, high-resolution computed tomography of the temporal bones should be performed in those with documented or suspected sensorineural hearing loss. Cochlear implantation may be considered, as in other children with syndromic hearing loss and certain inner ear abnormalities, if the appropriate audiologic, psychosocial, and medical criteria are met. The current case report radiographically and clinically characterizes inner ear dysplasia in an 8-year-old patient with Hallermann-Streiff syndrome. High-resolution computed tomography of the temporal bones revealed a hypoplastic bony island between the vestibule and horizontal semicircular canals, as well as incomplete bony coverage of the posterior semicircular canal crura bilaterally. To our knowledge, this is the first report of a pediatric patient demonstrating bilateral posterior semicircular canal dehiscence.

Murine models are ideal for studying cochlear gene transfer, as many hearing loss-related mutations have been discovered and mapped within the mouse genome. However, because of the small size and delicate nature, the membranous labyrinth of the mouse is a challenging target for the delivery of viral vectors. To minimize injection trauma, we developed a procedure for the controlled release of adeno-associated viruses (AAVs) into the scala media of adult mice. This procedure poses minimal risk of injury to structures of the cochlea and middle ear, and allows for near-complete preservation of low and middle frequency hearing. In this study, transduction efficiency and cellular specificity of AAV vectors (serotypes 1, 2, 5, 6 and 8) were investigated in normal and drug-deafened ears. Using the cytomegalovirus promoter to drive gene expression, a variety of cell types were transduced successfully, including sensory hair cells and supporting cells, as well as cells in the auditory nerve and spiral ligament. Among all five serotypes, inner hair cells were the most effectively transduced cochlear cell type. All five serotypes of AAV vectors transduced cells of the auditory nerve, though serotype 8 was the most efficient vector for transduction. Our findings indicate that efficient AAV inoculation (via the scala media) can be performed in adult mouse ears, with hearing preservation a realistic goal. The procedure we describe may also have applications for intra-endolymphatic drug delivery in many mouse models of human deafness.

The epidemiology, diagnostic features, differential diagnosis, and treatment of vestibular neuritis are reviewed. The authors present considerations for physical examination, imaging, and management in both the acute and chronic phases of this disease. The authors also present a dizziness questionnaire in the Appendix of this publication., (Copyright © 2011 Elsevier Inc. All rights reserved.)

In the present study, glial cell responses to spiral ganglion neuron (SGN) degeneration were evaluated using a murine model of auditory neuropathy. Ouabain, a well-known Na,K-ATPase inhibitor, has been shown to induce SGN degeneration while sparing hair cell function. In addition to selectively removing type I SGNs, ouabain leads to hyperplasia and hypertrophy of glia-like cells in the injured auditory nerves. As the transcription factor Sox2 is predominantly expressed in proliferating and undifferentiated neural precursors during neurogenesis,we sought to examine Sox2 expression patterns following SGN injury by ouabain. Real-time RT-PCR and Western blot analyses of cochlea indicated a significant increase in Sox2 expression by 3 days posttreatment with ouabain. Cells incorporating bromodeoxyuridine(BrdU) and expressing Sox2 were counted in the auditory nerves of control and ouabain-treated ears. The glial phenotype of Sox2+cells was identified by two neural glial markers: S100 and Sox10. The number of Sox2+ glial cells significantly increased at 3 days post-treatment and reached its maximum level at 7 days post-treatment. Similarly,the number of BrdU+ cells increased at 3 and 7 days post-treatment in the injured nerves. Quantitative analysis with dual-immunostaining procedures indicated that about 70% of BrdU+ cells in the injured nerves were Sox2+ glial cells. These results demonstrate that up-regulation of Sox2 expression is associated with increased cell proliferation in the auditory nerve after injury.

Objective: To determine whether Gleason score up-grading is still occurring in men diagnosed with adenocarcinoma of the prostate via extended biopsy regimens, and factors that might predict this., Patients and Methods: Between September 1999 and February 2007, 211 men (age: 42-70 years; mean: 60 years) underwent trans-rectal ultrasound-guided prostate biopsies confirming clinically localized adenocarcinoma followed by radical prostatectomy (RP), within our department. Univariate and multivariate logistic regression (LR) analyses using age, serum PSA, prostate volume, clinical stage and total length of cores taken were performed to determine whether Gleason score up-grading could be predicted., Results: A total of 7/20 (35%), 24/64 (38%) and 36/127 (28%) men with 6, 7-9 and at least 10 core biopsies experienced Gleason score up-grading (p = nonsignificant between the 3 groups). Both univariate and multivariate LR analyses failed to determine any of our variables as a predictor of Gleason score up-grading from biopsy to RP., Conclusion: Despite increasing the number of cores taken at biopsy, in order to improve prostate cancer diagnosis, a substantial percentage of men still experience Gleason score up-grading from biopsy to RP. In addition, we were unable to determine any predicting factors for this up-grading., (Copyright (c) 2010 S. Karger AG, Basel.)

Introduction: Transurethral resection of the prostate (TURP) is commonly performed as the surgical management of lower urinary tract symptoms due to clinically benign disease. However, prostate cancer is not uncommonly diagnosed after such a procedure. We, therefore, determined in a retrospective study the incidence and factors that might predict the detection of prostate cancer after TURP., Patients and Methods: Between June 2005 and June 2007, a total of 476 men underwent TURP at our department. Of these, 411 men (86%) were thought to have benign disease and were included in the study. Univariate and multivariate logistic regression analyses using age, serum prostate-specific antigen (PSA), urinary retention status, prostate resection weight, FBC and U&E were performed to determine whether prostate cancer could be predicted., Results: A total of 47 men (11.4%) were diagnosed with prostate cancer [24/47 with pT1a (51%) and 23/47 with pT1b (49%)]. Furthermore, the Gleason scores ranged from 5 to 9. Univariate logistic regression analyses revealed that only age (mean: 76 years, range: 54-90 vs. mean: 71 years, range: 49-91 for prostate cancer and non-cancer cases, respectively) and serum PSA (mean: 14.9 ng/ml, range: 0.4-78.0 vs. mean: 7.4 ng/ml, range: 0.2-90.0 for prostate cancer cases and non-cancer cases, respectively) were able to distinguish between cancer and non-cancer cases. In addition, using multivariate logistic regression, age and serum PSA were also the only variables that separated the two groups with a ROC-AUC of 70%., Conclusions: Our retrospective study has demonstrated that a substantial percentage of men are unexpectedly found to have prostate cancer after TURP. In addition, age and serum PSA were independent predictors of those who are likely to have prostate cancer., (Copyright (c) 2009 S. Karger AG, Basel.)

Background: The utility of image guidance (image-guided surgery [IGS]) and intraoperative computed tomography (CT) scanning as a tool for less experienced endoscopic surgeons to aid in localization of paranasal sinus and skull base anatomic structures was evaluated., Methods: Partial endoscopic dissection was performed on cadaver specimens by three fellowship trained rhinologists. Anatomic sites within and around the sinuses were tagged with radio-opaque markers. Otolaryngology residents identified tagged anatomic sites using four successive levels of technology: endoscopy alone (simulating outpatient clinic), endoscopy plus preoperative CT (simulating endoscopic sinus surgery [ESS] without IGS), endoscopy plus IGS registered to preoperative CT (simulating current ESS with IGS), and endoscopy plus IGS registered to real-time intraoperative CT. Responses were graded as follows: consensus rhinologist answer (4 points), close answer without clinically significant difference (3 points), within anatomic region but definite clinical difference (2 points), outside of anatomic region (1 point), no answer (0 points)., Results: Eleven residents participated. Of 20 specific anatomic sites, IGS-intraoperative CT provided the most accurate anatomic identification at 16 sites. For 8 sites, IGS-intraoperative CT had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.29-0.67). For 6 sites, IGS-preoperative CT scan had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.30-0.67). All participants found that IGS-intraoperative CT scan made them most comfortable in identifying anatomy., Conclusion: Combined IGS and intraoperative CT scan technology may be an instructional adjunct for less experienced paranasal sinus surgeons for dissection and evaluation of unfamiliar or distorted anatomy.

Objective: Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices., Study Design: Experimental prospective study., Subjects and Methods: Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses., Results: Total sinus distribution was greater post-ESS (P < 0.001). Additional distribution was gained with medial maxillectomy (P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray (P < 0.001). Frontal sinus penetration was greatest after surgery (P = 0.001)., Conclusion: ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray solutions in un-operated sinuses provide little more than nasal cavity distribution. Use of squeeze bottle/neti pot post-ESS offers a greatly enhanced ability to deliver solutions to the paranasal sinuses.

Application of ouabain to the round window membrane of the gerbil selectively induces the death of most spiral ganglion neurons and thus provides an excellent model for investigating the survival and differentiation of embryonic stem cells (ESCs) introduced into the inner ear. In this study, mouse ESCs were pretreated with a neural-induction protocol and transplanted into Rosenthal's canal (RC), perilymph, or endolymph of Mongolian gerbils either 1-3 days (early post-injury transplant group) or 7 days or longer (late post-injury transplant group) after ouabain injury. Overall, ESC survival in RC and perilymphatic spaces was significantly greater in the early post-injury microenvironment as compared to the later post-injury condition. Viable clusters of ESCs within RC and perilymphatic spaces appeared to be associated with neovascularization in the early post-injury group. A small number of ESCs transplanted within RC stained for mature neuronal or glial cell markers. ESCs introduced into perilymph survived in several locations, but most differentiated into glia-like cells. ESCs transplanted into endolymph survived poorly if at all. These experiments demonstrate that there is an optimal time window for engraftment and survival of ESCs that occurs in the early post-injury period.

Objective: To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period., Patients and Methods: Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction., Results: In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations., Conclusion: This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.

Introduction: Determining the history and development of feminizing genitoplasty is fascinating and instructive but fraught with difficulty. Earliest examples relate to practices carried out in ancient cultures. Gender reassignment surgery (GRS) developed from reconstructive procedures for congenital abnormalities. Some surgery was disguised, techniques were not recorded, and operations were carried out in secret., Aim: The aim of this article is to review the historical development of male-to-female GRS., Methods: Information was gleaned from Medline and general Internet searches. Further evidence was found by reviewing the references of early articles. A fascinating insight was also found in the autobiographies of GRS patients., Results: The first recorded case was by Abrahams in 1931. Techniques evolved from the early vaginal absence work of Beck and Graves. Pioneers of GRS were Sir Harold Gillies in England and Georges Burou of Casablanca. In the 1950s, they both used invagination of the penile skin sheath to form a vagina. Howard Jones, of Johns Hopkins, published the second classic technique using penile and scrotal skin flaps. These two methods form the basis of male-to-female GRS today. The history of GRS reveals a struggle to improve functionality as well as cosmesis. In particular, the neovagina but also a functioning neoclitoris, which has developed from a cosmetic swelling into an innovated organ, derived from the glans penis and harvested penile neurovascular bundle., Conclusions: Improved function and cosmesis continue to be the aim of the gender dysphoria surgeon. However, this review suggests the future management of transwomen should address not only refinements of surgical techniques but also prospective collection of posttreatment quality-of-life issues.

Penile cancer requires careful clinical follow-up. Therefore, when a patient presented with a florid papillary lesion at his penectomy site, it was immediately biopsied. The histologic examination, however, revealed a benign angiokeratoma with no evidence of recurrent cancer. Angiokeratoma on the scrotum after treatment for carcinoma of the penis has only been documented once. To our knowledge, this is the first description of it causing a diagnostic dilemma with recurrence. A radiotherapy association has only been documented in vulval lesions. Symptomatic treatment is laser vaporization. This emphasizes the importance of histologic assessment before any oncologic surgery intervention.

Purpose: The aim of this study was to examine the expression and prognostic relevance of thrombospondin-1 (TSP-1) in tumor biopsies taken from a consecutive series of liver resections done at the University Hospitals of Leicester and the Royal Liverpool Hospital., Experimental Design: Patients having undergone a liver resection for colorectal liver metastases at our institutions between 1993 and 1999 inclusive were eligible. Inclusion criteria were curative intent, sufficient tumor biopsy, and patient follow-up data. One hundred eighty-two patients were considered in this study. Standard immunohistochemical techniques were used to study the expression of TSP-1 in 5-microm tumor sections from paraffin-embedded tissue blocks. TSP-1 was correlated with survival using the Kaplan-Meier method and log-rank test for univariate analysis and the Cox proportional hazard model for multivariate analysis., Results: One hundred eighty-two patients (male, n = 122 and female, n = 60) ages between 25 and 81 years (mean, 61 years) were included. TSP-1 was expressed around blood vessels (n = 45, 25%) or in the stroma (n = 59, 33%). No expression was detected in the remaining tumors. TSP-1 significantly correlated with poor survival on univariate (P = 0.01 for perivascular expression and P = 0.03 for stromal expression) and multivariate analysis (P = 0.01 for perivascular expression)., Conclusion: TSP-1 is a negatively prognostic factor for survival in resected colorectal liver metastases.

Surgeons of the Royal Navy during the Napoleonic and revolutionary wars, between 1793 and 1815, were solely responsible for all health care of the officers, men, and boys of their ships. This paper examines the genitourinary medicine and surgery encountered by the naval surgeons at the time of Nelson. Primary sources are examined to explore the presentation, case mix, and management of genitourinary disease during this period. A general overview is given of the life and work of the Royal Naval surgeons at the end of the 18th century. The documents that were examined contained 39 surgeon's journals, these were written by 26 surgeons on 13 different ships. The journals contained 446 presentations to the sick list of men with genitourinary symptoms. The presenting symptoms are grouped together under the following headings; venereal disease, penile pathology, scrotal pain and swelling, urinary symptoms and retention, stone disease and trauma. Examination of these journals permits a glimpse of medical life in the Royal Navy during the time of Nelson. The case load and management of genitourinary disease shows the diversity of presentation to these surgeons.

Objective: Evaluate treatments for epistaxis., Study Design and Setting: Retrospective review of Nationwide Inpatient Sample (1998-2000)., Results: A total of 9778 admissions with admitting diagnosis "epistaxis" were identified. Among admissions involving 1 treatment, 454 (9.6%) received arterial ligation, 94 (2.0%) embolization, and 4188 (88.4%) nasal packing. There were no differences in length of stay, transfusions, complications, or deaths between groups (all P > 0.05). Mean total hospital charges were USD 6,282 for the packing group, USD 12,805 for the ligation group, and USD 17,517 for the embolization group; differences between ligation and packing groups, and embolization and packing groups demonstrated significance ( P < 0.05)., Conclusions: Nasal packing is used commonly for epistaxis that requires inpatient management. Although embolization and arterial ligation are associated with higher hospital charges, complications, transfusion rates, and lengths of stay are similar. Further studies are needed to quantify other outcome measures, such as recurrence rates and patient quality of life., Significance: Nasal packing is associated with lower hospital charges and similar complication rates as arterial ligation or embolization.

Purpose: The purpose of this study was to determine whether angiogenesis, as measured by microvessel density (MVD), at presentation is related to subsequent progression of superficial bladder cancer (SBC)., Experimental Design: Archived primary bladder tumors from 180 patients were stained with a monoclonal antibody against cluster determinant 34 to label vessels. Image analysis was used to count MVD in 30 randomly selected areas in each case., Results: Of the 170 patients evaluated, 37 progressed to muscle invasive disease. A strong association was found between the intensity of angiogenesis and clinical stage, pT1 tumors having a higher MVD than pTa disease. The median MVD was significantly higher at presentation in those patients that subsequently developed progressive SBC than in those that did not progress (P < 0.0001). pT1 (P = 0.001), grade 3 disease (P = 0.002), and MVD (P = 0.008) were found to predict subsequent disease progression on univariable analysis. Both MVD (P = 0.007) and pT1 disease (P = 0.044) remained significant predictive factors for subsequent disease progression on multivariable analysis., Conclusion: MVD in SBC at presentation is significantly higher in those cases that subsequently progress to muscle invasive disease.

Objectives: Superficial bladder cancer (SBC) presents a difficult clinical dilemma at diagnosis as only a small subgroup of patients will subsequently develop invasive disease. Study of cancer biology has found that angiogenesis is central to growth and spread. This study examines the relationship between the angiogenic inhibitory factor Thrombospondin-1 (TSP-1) at initial presentation and subsequent progression of SBC., Methods: Using immunohistochemistry, 220 cases of SBC were examined for pattern and extent of expression of TSP-1 at initial presentation., Results: TSP-1 was detected in perivascular tissue, at the epithelial-stromal junction, in the stroma and in tumour cells and reduced perivascular TSP-1 staining at presentation was an independent predictive factor for the subsequent development of muscle invasive or metastatic disease., Conclusion: This adds further weight to the theory that TSP-1 plays a major part in the biology of bladder cancer possibly through the control of angiogenesis.

Microvessel density (MVD) is a widely used surrogate measure of angiogenesis in pathological specimens and tumour models. Measurement of MVD can be achieved by several methods. Automation of counting methods aims to increase the speed, reliability and reproducibility of these techniques. The image analysis system described here enables MVD measurement to be carried out with minimal expense in any reasonably equipped pathology department or laboratory. It is demonstrated that the system translates easily between tumour types which are suitably stained with minimal calibration. The aim of this paper is to offer this technique to a wider field of researchers in angiogenesis.

Correlation of electrophysiological and morphological, including ultrastructural, characteristics of neurones is important for understanding the functional organization of neuronal systems. Further correlation with neurotransmitter content is essential for determining the neurochemical(s) used by a given neurone for propagating its signal. The two main neuronal markers presently available (lucifer yellow and horseradish peroxidase) are not satisfactory for correlating all three aspects. We have devised a new simple procedure whereby retinal interneurones can be labelled with biocytin by positive ionophoresis of an unbuffered solution. Biocytin readily crosses gap junctions thus revealing extensive networks of coupled cells. In the case of H1 horizontal cells, which are known to be GABAergic, the neurotransmitter can also be demonstrated by superimposed immunocytochemistry.