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To compare efficacy and safety of parecoxib and paracetamol for treatment of acute renal colic due to ureteric stones.A randomized, double blinded, controlled trial included adult patients presented to emergency department with acute renal colic due to ureteric calculi between June 2019 and August 2020. Patients with hypersensitivity to either drug, peptic ulcer, coronary ischemia, peripheral vascular or cerebrovascular disease, hepatic impairment (Child-Pugh score10) or chronic kidney disease stage 4 or 5 were excluded. Eligible patients were randomized to group 1 who received 1g intravenous Paracetamol infusion or group 2 who received 40mg intravenous Parecoxib infusion. Pain analogue score was evaluated before treatment and 30 minutes afterwards. The primary endpoint was the need for rescue analgesia for persistent pain. Safety was evaluated by the incidence of adverse events.The study included 203 patients (102 in group 1 and 101 in group 2). Pretreatment patients' data were comparable for both groups. The mean pain analogue score decrease from 7.6 to 3.8 in paracetamol group (P.001) and from 7.8 to 3.4 in parecoxib group (P.001). Rescue analgesia were needed in 36 patients (35.3%) in paracetamol group and 27 patients (26.7%) in parecoxib group (P = .187). Minor adverse events developed in 2 patients (2%) in paracetamol group and 3 patients (3%) in parecoxib group (P=0.683).Paracetamol and Parecoxib were effective for treatment for patient with acute renal colic. Both treatments showed comparable results in reduction of pain and need for rescue analgesia with minimal adverse events.

Background: Partial segmental thrombosis of the corpus cavernosum, known as partial priapism, is an uncommon urological condition which predominantly affects young men in which the proximal part of one corpus cavernosum is thrombosed. Many risk factors have been described in the literature, however, the exact etiology of penile thrombosis and its pathogenesis remains unclear. Several treatment options are available ranging from conservative medical treatment, surgical intervention, or simple follow-up observation without treatment. Aim: In this study, we describe a patient with sickle cell anemia who presented with pain and a perineal swelling that was eventually diagnosed as partial priapism utilizing MRI scan and was treated conservatively with a successful outcome. We then performed a literature search of similar cases highlighting incidence, risk factors and management of this rare presentation. Case Presentation: A 23-year-old male who is known with sickle cell anemia presented to casualty with a 1-day history of perineal pain of a sudden onset associated with perineal swelling and vomiting. Genitourinary exam findings confirmed the absence of classic priapism. Careful examination of his perineal area revealed the presence of a fixed, hard, and tender mass at the proximal part of the penis. It was not attached to the overlying skin and no enlarged pelvic lymph nodes were felt. Once stabilized, MRI of the pelvis was performed showing right intra-tunical corpus cavernosum features suggestive of hematoma in keeping with partial segmental thrombosis of the corpus cavernosum. Conservative treatment was initiated, and the patient was managed expectantly in which he improved gradually with eventual disappearance of the perineal mass. Conclusion: Partial segmental thrombosis of the corpus cavernosum is a rare urological condition. Pathogenesis and etiologies are poorly understood but risk factors have been advocated of which sickle cell anemia is one of them. MRI has a crucial role in the diagnosis under this condition. Conservative treatment appears to be a reliable initial therapeutic option.

Objective To compare emergency with elective ureteroscopy (URS) for the treatment of a single ureteric stone. Patients and methods The files of adult patients with a single ureteric stone were retrospectively reviewed. Patients with fever or turbid urine on passage of the guidewire beside the stone underwent ureteric stenting or nephrostomy drainage. Patients who underwent URS were included and divided into two groups: the emergency (EM) Group, those who presented with persistent renal colic and underwent emergency URS within 24 h; and the elective (EL) Group, who underwent elective URS after ≥14 days of diagnosis. Patients with ureteric stents were excluded. The technique for URS was the same in both groups. Safety was defined as absence of complications. Efficacy was defined as the stone-free rate after a single URS session. Results From March 2015 to September 2018, 179 patients (107 in the EM Group and 72 in the EL Group) were included. There were significantly more hydronephrosis and smaller stones in the EM Group (P = 0.002 and P = 0.001, respectively). Laser disintegration was needed in more patients in the EL Group (83% vs 68%, P = 0.023). Post-URS ureteric stents were inserted in more patients in the EM Group (91% vs 72%, P = 0.001). Complications were comparable for both groups (4.2% for EL and 5.6% for EM, P = 0.665). Stone-free rates were also comparable (93% in the EL Group and 96% in the EM Group, P = 0.336). Conclusions Emergency URS can be as safe and effective as elective URS for the treatment of a single ureteric stone if it is performed in patients without fever or turbid urine. Abbreviations: EL Group: elective group; EM Group: emergency group; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; MET: medical expulsive therapy; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy

Objectives: To develop and validate a scoring system to assess the need for emergency intervention (EI) in patients with uncomplicated acute renal colic (ARC) due to ureteric stones. Patients and methods: From May 2017 to April 2019, 382 adult patients presented to emergency department with ARC due to ureteral stones diagnosed by non-contrast computed tomography. Patients with solitary kidney, complications secondary to obstruction (intractable vomiting, fever or sepsis), bilateral ureteric stones, Stage ≥3 chronic kidney disease or those who underwent treatment of urolithiasis within the past 6 months were excluded. EI was performed in cases with persistent or recurrent pain despite analgesics. Multivariate analysis was performed for the first 200 patients to detect risk factors for EI. The score was developed from significant factors. Sensitivity and specificity of the ARC score were calculated using receiver operator characteristic (ROC) curve analysis. The data of last 182 patients were used for validation of the score. Results: In the first 200 patients, EI was needed in 119 patients (59.5%) and included ureteric stents in 92, ureteroscopy in 25 and percutaneous nephrostomy in two. Significant factors for EI were stone location (relative risk [RR] 3.34, P = 0.026), creatinine level (RR 1.04, P

Sacral neuromodulation is a minimally invasive option to manage voiding dysfunction that is refractory to conservative measures and oral pharmacotherapy. The technique involves implantation of a sacral tined lead that is connected to a pulse generator to modulate the pelvic area. The procedure is carried out over two stages. Surgical explantation of the entire device with debridement of the infected tissue is recommended in instances of infection. Nevertheless, solid reports about management of device infections or skin erosions are lacking. Thus, I present a case of a tined lead wire skin exposure in a perfectly functioning device that was salvaged with surgical reposition without complications.

Introduction: Chronic pelvic pain (CPP) is a diagnostic and therapeutic challenge affecting women of all ages globally. The syndrome is not well understood, but the association of interstitial cystitis (IC) with endometriosis in causing CPP should not be overlooked in managing this cohort. Herein, we present a mini review of this association to evaluate the literature in determining the prevalence of endometriosis and IC concomitantly in patients with CPP, diagnostic limitations, and clinical implications. Methods: A Medline search of the key words “evil twins’ syndrome,” “interstitial cystitis,” “bladder pain syndrome,” and “endometriosis” was conducted for full-text articles published in English over the past 20 years. The search yielded 40 articles, of which 21 were selected. Cross-referencing bibliographies of each publication yielded an additional 25 references. Results: Both endometriosis and IC share a similar array of symptoms that are often exacerbated during the perimenstrual period. Multiple authors have reported the frequent coexistence of these two conditions. Over 80% of patients with CPP were found to have both conditions. The prevalence of endometriosis and IC coexistence was greater than that of each condition separately. Conclusions: It is crucial to look beyond the traditionally diagnosed endometriosis as the cause of CPP. This is true especially in patients whose previous treatment was ineffective. Simultaneous assessment for both conditions is essential to avoid the frequently delayed diagnosis and prevent unsuccessful medical and surgical therapies.

Introduction: Sacral neuromodulation is a well-established treatment option to manage refractory lower urinary tract and pelvic floor disorders. The technique involves implantation of a lead and an internal pulse generator that delivers electrical impulses to modulate the sacral area. Many patients worldwide have been implanted with MRI-non-compatible devices. Currently, MRI head only can be performed safely in these patients. Therefore, we present a case report of a patient who underwent MRI of the head as well as neck in the presence of a sacral neuromodulator without serious complications. Case Report: A 33-year-old lady known to have systemic lupus erythematosus, refractory overactive bladder, and recurrent urinary tract infection started complaining of right sided neck pain for 3 months in which she required MRI of the head and neck to further assess the nature of the pain. The patient was already implanted with sacral neuromodulator with excellent outcome to manage her refractory overactive bladder. Following careful discussion with the patient and radiologist, MRI study was conducted at 1.5 tesla and total procedure duration was 8 minutes for T1, T2 sagittal and axial cuts. The patient revealed feeling minimal tingling of the right lower limb and mild lower back pain during MRI, all of which disappeared once the study was terminated. Device was functioning well afterwards. Conclusion: MRI may be feasible for certain sacral neuromodulation patients under certain conditions without any serious adverse events.

This study aimed to translate and validate the 8-item overactive bladder questionnaire (OAB-V8). Utilizing a multistep process, the English version of the OAB-V8 was translated into Arabic by three urologists and one independent translator. It was validated by asking 46 patients with overactive bladder and 58 healthy individuals to complete the questionnaire. Healthy individuals were involved in establishing the discrimination validity. The scores of both groups were compared using the Mann-Whitney test. The reliability of the Arabic version was evaluated utilizing Cronbach’s alpha test for internal consistency. Spearman’s correlation coefficient (r) was utilized to evaluate the domain structures and the inter-domain associations. Internal consistency was high (Cronbach’s alpha = 0.923). There were good correlations among frequency, urgency, sudden urge to urinate, waking up at night to urinate and uncontrollable urge to urinate. There were weak or no correlations among urge, incontinence and nocturia. For discrimination validity, there were significant changes in all domain scores when comparing patients with ureteric stents and healthy individuals (P

Objectives To describe a case of right testicular vein thrombosis in a child and to review the literature describing similar cases and their management. Methods An extensive literature review of the English language literature was conducted using the following databases: PubMed, ScienceDirect and Google Scholar. Results Six cases were reported previously and summarized in this article. Conclusion A 14-year-old boy who suffered from spontaneous right testicular vein thrombosis was treated with right orchiectomy and oral anticoagulation. We also reviewed and summarized the previously described cases of pediatric testicular vein thrombosis.

Objective To present a case of urinary bladder repair after vesico-uterine fistulectomy and hysterectomy using ‘omentum wrap’, as vesical fistulae, irrespective of their distal component, are a challenge for urologists and uro-gynaecologists alike. The complex nature of these fistulae and their repair has affected outcomes of the documented treatment modalities. In general, higher fistula origin and insertion, and prolonged presentation are indices of poorer outcomes of treatment. Methods We present the case of a 54-year-old multiparous woman who presented to our clinic with total urinary incontinence (UI). She has had a history of use of vaginal pessaries and misdiagnosis with stress UI that had led to the performance of trans-obturator tape (TOT) insertion, unnecessarily. Post-TOT the patient’s UI worsened from occasional to total. Investigations initially showed vesico-vaginal fistula, but examination under anaesthesia by cystoscopy and hysteroscopy showed a large vesico-uterine fistula. Lower midline fistula repair was complicated by a chronically inflamed friable bladder on cystostomy and total abdominal hysterectomy after uterine transection due to adherent uterine and anterior vaginal walls to the bladder. Bladder repair was augmented with omental flap interposition posteriorly to cover the fistula site, and omental flap wrapping superiorly, laterally and anteriorly to enhance its recovery. The patient had an uneventful postoperative recovery and follow-up cystography showed a small capacity bladder but no leakage. Results To our knowledge this is the first attempt of its kind to utilise an omental flap to support bladder repair in a wrapped fashion. The omentum is known for its extraordinary support mechanisms, mechanical and anti-inflammatory, and has been incorporated into many forms of repairs as a flap and graft. In what looked like a poor outcome bladder repair due to extremely inflamed tissue, the bladder healed completely in a short time. Conclusion Vesical fistulae are difficult entities to diagnose and treat. Incorporation of innovative surgical principles of repair from other experiences can improve outcomes of traditional procedures.

Introduction Erectile dysfunction affects over 50% of men 70 years and above, and penile prosthesis (PP) is its third-line treatment. Complications of PPs include infection, however, no formal guidelines exist for its management. Methods We performed a literature search and reviewed 53 recent published literatures of experiences with management of PP infections, prevention, and treatment. Results Acute infection can present early with pain and discharge and detection of early signs is of utmost importance. MRI studies are more sensitive than CT studies to diagnose and plan surgical intervention. Introduction of antibiotic impregnated devices attributed to the reduction of infection rates with superiority proven for certain types; the no-touch technique had further reduced this rate. The Mulcahy salvage remains the most widely used surgical approach for treatment despite modifications and novel techniques described; conservative management of PP infections is recently reported with promising results. Conclusions Despite absence of strict guidelines for the management of infected PPs, we reviewed and discussed numerous panel opinions and suggestions throughout literature. More research into the pathology, prevention, conservative management and advances in surgical treatment of this condition are called for to produce guidelines that unite the efforts to tackle these infections.

INTRODUCTION Sacral neuromodulation (SNM) is a safe and effective therapy for patients with lower urinary tract dysfunction (LUTD). It is used in patients who have exhausted conservative and first line therapeutic options. The selection of eligible candidates could predict a successful therapeutic outcome. Although many factors have been identified, psychological/psychiatric disturbances are neither well understood nor are routinely evaluated prior to implantation. CASE REPORTS We report three cases where identified psychological/psychiatric disturbances post-implantation could have influenced explantation in an otherwise successful implantation of SNM device assessed both subjectively and objectively. The device had to be explanted in two of the three. One more patient has requested but has not-yet undergone explantation and is receiving treatment for severe depression. One of the explanted cases has successfully undergone re-implantation after successful treatment of her diagnosed psychological condition, while the other's request for re-implantation has not yet been fulfilled. CONCLUSIONS Psychological/psychiatric disturbance have possibly affected the treatment outcome and explantation of SNM in our patients despite a high success in resolution of the urinary symptoms. Addressing such disturbances when determining patient eligibility for SNM therapy could reduce the explantation rate after a successful therapeutic response, and is an interesting point of interest for future research into predictors of successful SNM implantation and therapy.

Objective To investigate the controversy that still exists regarding the time of onset of symptom relief after intraoperative detrusor injection of botulinum toxin A (BOTOX) in patients with neurogenic and non-neurogenic overactive bladder syndrome (OAB), as intra-detrusor injection of botulinum toxin has emerged as a second-line option for patients with neurogenic and non-neurogenic OAB who are refractory to first-line treatment modalities. Methods This is a retrospective study of 71 patients, who underwent intra-detrusor injection of botulinum toxin A from December 2012 to December 2017. All procedures were performed in a single institute by the same surgeon. Data analysed included patient demographics, disease specifics, and outcomes of the procedure. Results The mean (range) age of the 71 patients was 44 (14–75) years, 48 of which were females (68%). In all, 58% of the patients had neurogenic bladder and 42% had non-neurogenic bladder. Metabolic syndrome was identified in 36 patients (50%) and 24 (34%) had neurological deficits. The neurogenic bladder group received 200 U of BOTOX, whereas the rest received 100 U. The median response time to BOTOX injection was 7 days and this was used as a threshold: Group 1 was early response ( ⩽ 7 days) and Group 2 late response ( > 7 days). This was utilised to analyse the effect of certain variables on response time. Age, gender, smoking status and underlying pathology had no significant effect on response time with P values of 0.14, 0.95, 0.71 and 0.7, respectively. Only diabetes and type of incontinence (wet vs dry) played a significant role with regards to response time with P values of 0.004 and 0.009, respectively. Conclusion The median time of onset after intradetrusor BOTOX injection was found to be 7 days. Only diabetes and type of incontinence significantly affected the response time to BOTOX injection. A larger sample size and a prospective analysis of data are warranted to verify and validate these findings.

Overactive bladder (OAB) is a common syndrome that has a negative impact on daily activities and quality of life. The first-line treatment to manage this condition includes behavioral modifications, physical treatment, and oral pharmacotherapy with antimuscarinics. Botulinum toxin has emerged as an alternative and second-line treatment option for patients with OAB who are refractory to first-line treatment modalities when injected into the detrusor muscle. Although its application in the management of OAB remains off label, studies have shown its efficacy both subjectively and objectively. It is considered as a minimally invasive and reversible alternative. Adequate dosage of the toxin, number of injection sites, and reinjection rates are yet to be determined. This review attempts to provide an update on the current position of botulinum toxin in managing refractory OAB addressing contemporary data on the mechanism of action, technique, safety, complications, and clinical results.

The US Food and Drug Administration approved sacral neuromodulation (SNM) in 1997 as a treatment option for patients with urge incontinence and in 1999 for urgency/frequency and nonobstructive urinary retention. SNM uses direct, continuous stimulation of the third sacral nerves through implantation of a pulse generator and electrode. Off-label use of neuromodulation has been used successfully in patients with interstitial cystitis/painful bladder syndrome. This review attempts to provide an update on SNM as an off-label management option for adults with interstitial cystitis based on the available clinical evidence concerning its efficacy.

Erectile dysfunction (ED) results from various functional and organic causes. Its management has always been a challenge to urologists and other physicians. After failing to respond to medical and intracorporal injections, patients might resort to surgical penile prosthesis implants to improve their sexual performance. Apart from functional outcome, cosmetic results also concern such patients. Cosmetic is also affected in patients with undescended testis or those who underwent an orchiectomy. We discuss the case of a diabetic 59-year-old gentleman with a left undescended testis who was receiving medical treatment for longstanding ED with unsatisfactory results of recent. The patient was counseled appropriately and his medical conditions were optimized prior to any possible surgical intervention. A planned laparoscopic orchiectomy was followed 5 months later by implantation of a 3-piece penile prosthesis device, with successfully placing the pump in a fashioned dartos pouch in the empty left hemiscrotum, attaining both satisfactory functional and cosmetic results for the patient. The prosthesis and the implantation of the pump in the empty left hemiscrotum helped the patient attain satisfactory sexual function and a cosmetic and textural resemblance of a full left hemiscrotum the likes of having a normal left testis. This approach boosted his self-confidence about his sexual performance and image, as reported by the patient after years of erectile dysfunction and having an undescended left testicle. Attention should be paid when planning and executing any surgery that will impact a patient's sexual function. Allowing for surgical innovation and studying the current setting could result in great results beyond the presenting complaint. The ability to restore a male patient's sexual function with implantable prosthesis along with good cosmetic results of the penis and the hemiscrotums can enhance the patient's final experience and level of satisfaction.

Objective To report on a case of traumatic testicular displacement (TTD) and torsion, which is a rare consequence of pelvic trauma. Methods A 34-year-old motorcycle rider who presented immediately following a head-on collision with a car. His past surgical history included bilateral inguinal varicocoele repair. The patient recalled that his genitals collided with a part of the motorcycle before coming off the vehicle. He complained of left-sided groin pain and was found to have an empty left hemi-scrotum, a tender palpable lump in the left suprapubic region, and bruising in the area. A contrast-enhanced computed tomography (CT) scan revealed an empty scrotum and an ovoid structure measuring 5 × 3 × 4 cm in the subcutaneous tissue with an adjacent spermatic cord and surrounding fat stranding. He was immediately transferred to the operating theatre for surgical exploration of the lower abdomen. Results After anaesthesia, the testis was repositioned into the scrotum and then we proceeded with exploration of the scrotum that revealed a torted left testicle. De-torsion, warm fomentation and orchidopexy of a viable left testicle was performed. He made an uneventful recovery. He was then transferred to a tertiary trauma centre for further management of his injuries. TTD is defined as migration of one or both testicle outside the scrotum. The most common mechanism of trauma is a rapid deceleration straddle injury against a motorcycle fuel tank. Predisposing factors include inguinal hernia repair, wide external inguinal ring, and atrophic testes. Radiological examinations of choice include colour-flow Doppler ultrasonography and CT scans of the abdomen and pelvis. Management consists of either closed reduction of the testicle or surgical exploration. Conclusion Early diagnosis and management of TTD is imperative to preserve the displaced testicle.

Objective To compare the results of emergency vs elective ureteroscopy (URS) for the treatment of a single ureteric stone. Methods We prospectively constructed a database for patients who underwent URS in the Al-Amiri Hospital from March 2015 through December 2017. Inclusion criteria were adult patients with a single ureteric stone diagnosed by computed tomography of the kidneys, ureters and bladder. Patients who had fever or ureteric stents were excluded. The emergency URS group (EM Group) included patients who presented to the emergency department with persistent renal colic and underwent emergency URS. The elective URS group (EL Group) included patients who underwent elective URS after admission through the outpatient appointment system. The technique for URS was the same in both groups. Safety was defined as absence of complications, whilst effectiveness was defined as stone-free rate after a single URS session. The chi-squared and t -test were used to compare the data of both groups. Results The study included 124 patients with a mean (SD) age of 41.4 (12.6) years. The EM Group included 67 patients and the EL Group included 57 patients. Laser disintegration was needed in 48 patients (84%) in the EL Group and 43 (64%) in the EM Group ( P = 0.012). Post-URS stents were placed in 43 patients (75.4%) in the EL Group and 60 (89.6) in the EM Group ( P = 0.037). Complications were comparable (3.5% for the EL and 4.5% for EM groups, P = 0.785). Ureteric perforation in one patient in the EM Group was treated with a JJ stent. Sepsis in one patient in each group was treated with culture-sensitive antibiotics. Upper tract obstruction after removal of the ureteric catheter in one patient in the EL Group required a JJ stent. Haematuria in one patient in EM Group was treated with blood transfusion. Stone-free rates were comparable, 93% in the EL Group and 97% in the EM Group ( P = 0.297). Conclusion Emergency URS in selected cases can be as safe and effective as elective URS for treatment of a single ureteric stone.

Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea of the penis. It is characterized by different degrees of penile curvature and sexual dysfunction. Several medical treatments have been employed to manage the disorder, with variable success rates. Surgical therapy is reserved for patients with severe penile deformity that fails to improve with medical treatment and impedes coital function. The advantages and disadvantages of various surgical approaches have long been debated. Herein, we describe the evolving surgical techniques for PD using knowledge obtained from the contemporary literature. In addition, we discuss the emerging data regarding the role of phosphodiesterase 5 inhibitors in the management of PD.

Purpose: To evaluate the effect of the position of the proximal and distal ends of Double-J ureteral stents on postprocedural flank pain, lower urinary-tract symptoms, and quality of life. Patients and Methods: The study included 120 patients who required unilateral Double-J ureteral stents for various indications. They were randomized into two equal groups. Group 1 had longer stents, with the proximal end in the upper calix and the distal end crossing the midline of the bladder. Group 2 had proper stent length with the proximal end in the pelvis and the lower end just beyond the vesicoureteral junction. Patients answered a questionnaire regarding flank pain, dysuria, and urgency as well as quality of life after 1 week of stenting. Results: Forty patients (67%) of group 1 and 43 (72%) of group 2 had mild flank pain, especially during urination. There was no significant difference in the degree of flank pain in the two groups. Moderate to severe dysuria was reported by 53 patients (88%) in group 1 and 11 p...

Objectives To present our series of laparoscopic radical nephrectomy in patients with level I tumor thrombus. The existence of renal vein tumor thrombus presents a technical challenge in securing hilar control during the resection of a renal mass. To our knowledge, this experience represents one of the largest series of laparoscopic nephrectomy for renal cell carcinoma associated with a macroscopic renal vein thrombus. Methods From April 2002 to June 2004, 12 patients (8 men and 4 women) were diagnosed with renal masses. In addition to computed tomography, cavography and magnetic resonance imaging were used to determine the levels of tumor thrombi preoperatively in those who had suspicious involvement of the renal vein on computed tomography. Results Laparoscopic nephrectomy was performed in a standard fashion. Hand-assisted laparoscopic nephrectomy was used in 6 cases involving large tumors with bulky hilar adenopathy. All renal veins were stapled using an endoscopic vascular stapler. Intraoperative laparoscopic ultrasonography was used to delineate the extent of the vein thrombus in 4 cases to enable proper stapler positioning. No intraoperative complications occurred, and 2 cases were electively converted to open nephrectomy. The postoperative narcotic requirements and hospitalization times were low. Pathologic examination of the tumor specimens demonstrated negative resection margins in all patients. Conclusions In carefully selected patients, laparoscopic resection of renal masses with level I renal vein thrombi is feasible. Because of technical considerations that may be identified intraoperatively, early conversion to open nephrectomy should be anticipated. Long-term results regarding oncologic control continue to be assessed.

Emerging data indicate that outcomes of surgical procedures are improved if surgery is performed in high-volume hospitals or by high-volume surgeons. This principle seems to hold true for penile prosthesis surgery, but careful consideration is necessary before adopting a 'center of excellence' model for this, or any, procedure.

Sacral neuromodulation (SNM) is an effective and increasingly used therapeutic option for refractory urge incontinence, chronic urinary retention and symptoms of urgency-frequency. The potential for neuromodulation has also been shown in patients with interstitial cystitis and neurogenic urge incontinence secondary to refractory detrusor hyperreflexia. With the increasing number of patients, obvious concerns and challenges raised. Young female patients who desire to conceive showed concerns pertaining to neuromodulation in pregnancy including possible teratogenic effect, symptom management during pregnancy & the effect of mode of delivery on the Sacral electrode. Another concern is the need for MRI follow up in neurogenic patients. Post operative troubleshooting raises another challenge in patient management. In our chapter, we will discuss these challenges in details.

Interest in the definition and management of premature ejaculation (PE) has been increasing significantly among all healthcare professionals and its clinical perceptions continue to evolve in recent years. Accumulating evidence suggests that it is considered to be the most common male sexual disorder (Metz & Pryor, 2000). Obtaining a universally accepted definition for PE has been problematic. Nevertheless, all definitions to date have repeatedly included two basic components which are the inability to control or delay ejaculation, and the resultant distress to one or both partners. Based on these components, the currently accepted definitions have been reported by a number of authorities which are authoritybased rather than evidence-based (Table 1). In addition, PE can be divided into primary, that begins when the patient becomes sexually active, and secondary, which by definition is acquired later in life (Godpodinoff, 1989). Further subdivisions include global PE presenting in all circumstances, versus situational PE which occurs only with certain partners and situations (Donatucci, 2006). Intravaginal ejaculatory latency time (IELT) refers to the time between vaginal penetration and ejaculation, usually measured with a stopwatch or simply estimated in retrospect (Payne & Sadovsky, 2007). There has been no widely accepted standard for ‘normal’ IELT. In 2005, Patrick et al. found on a large community-based population of men and their partners that the median IELT, recorded using a partner-held stopwatch, was 7.3 min for men without PE, whereas men with PE had a median IELT of 1.8 min (Patrick et al., 2005). A multinational population survey of IELT by Waldinger et al. showed that 90% of 110 men with self-reported lifelong PE had an IELT of less than 60 seconds (Waldinger et al., 2005). IELT of less than 2 minutes is generally accepted as defining PE (Waldinger et al, 1998). A small percentage of men will ejaculate even before penetration. Others have advocated not to define the disorder with a specific time duration and instead suggested that a diagnosis is made when the man ejaculates too early for female partner satisfaction in greater than one-half of encounters (Masters & Johnson, 1970).

Overactive bladder (OAB) is a common disorder that negatively affects the quality of life of our patients and carries a large socioeconomic burden. According to the International Continence Society, it is characterized as urinary urgency, with or without urge incontinence, usually, with frequency and nocturia in the absence of causative infection. The pathophysiology of this disease entity varies between neurogenic, myogenic, or idiopathic factors. This paper provides a review of the contemporary theories behind the pathophysiology of OAB.

The current case describes an interesting event in a male patient in which detumescence of an ischemic priapism was obtained following an inadvertent intra-cavernosal injection of fentanyl mistaken for phenylephrine. Detumescence was achieved after injecting a total of 4.0 mls. Patient tolerated the procedure well and his vital signs were stable throughout the entire process. The possible causes of such an outcome as well as the miscommunication that has lead to such an injection are discussed.

To evaluate the clinical outcomes of intracavernosal injection (ICI) use in an undifferentiated group of men with erectile dysfunction at various stages after radical prostatectomy. Retrospective charts, mailed questionnaires, and a telephone survey of patients after radical prostatectomy prescribed ICI by a single urologist from January 2006 to January 2008. The patient demographics and prostate cancer profiles, current ICI use patterns, adverse outcome, and clinical efficacy were collected. A total of 117 patients completed the questionnaire. The mean age was 65 ± 6.2 years, and the patients had undergone radical prostatectomy 4.1 ± 2.7 years earlier. Most patients had hypertension (38%) and dyslipidemia (26%); 51% of the patients actively used ICI, with a median of 3 attempts monthly. Sixty-eight percent of all patients were sexually active (98% of ICI users vs 36% of ICI nonusers, P

Introduction: The objective of this study was to identify and compare the costs of laparoscopic radical prostatectomy (LRP) and radical retropubic prostatectomy (RRP) at our centre. Methods: We conducted a retrospective chart review of our first 70 consecutive LRP cases and 70 consecutive RRP cases at St. Joseph’s Healthcare in Hamilton, Ontario, Canada. We performed cost analysis, including operating room costs, disposable instruments, blood transfusions, analgesic requirements and length of hospital stay. Overall expenses were then analyzed and compared. Results: Preoperative patient demographics and disease stages were comparable between the LRP and RRP groups. On a per procedure basis, large discrepancies were found in mean disposable instrument costs (LRP = $659.18 vs. RRP = $236.59), operating room costs (LRP = $4278.00 vs. RRP = $3139.00), mean cost of blood transfusions (LRP = $21.00 vs. RRP = $394.34), mean analgesia requirements (LRP = $12.94 vs. RRP = $41.06) and mean hospital stay bed costs (LRP = $3690.00 vs. RRP = $5027.14). Overall, costs for all patients in the LRP and RRP groups, respectively, were $606 307.29 and $618 721.57 with a cost saving of $12 414.28 in favour of the LRP arm. Conclusion: At our institution, we found that LRP costs are slightly less than those for RRP. Higher operative time and disposable instrument expenses are offset by the shorter hospital stays, fewer blood transfusions and less analgesic requirements for the LRP group. Further financial advantages for LRP will likely be achieved with additional reduction of operating room time and by minimizing disposables. Introduction : Le but de cette etude etait de comparer les couts d’une prostatectomie radicale par laparoscopie (PRL) et d’une prostatectomie radicale par voie retropubienne (PRR) a notre centre. Methodologie : Nous avons procede a un examen retrospectif des dossiers des 70 premiers cas consecutifs de PRL et de 70 cas consecutifs de PRR au centre St. Joseph’s Healthcare a Hamilton, en Ontario (Canada). Nous avons procede a une analyse des couts, y compris les couts relies a l’utilisation des salles d’operations, au materiel jetable, aux transfusions sanguines, aux analgesiques requis et a la duree du sejour a l’hopital. Les depenses globales ont ensuite ete analysees et comparees. Resultats : Les deux groupes etaient comparables quant aux donnees demographiques et au stade de la maladie avant l’operation. Des differences importantes ont ete decelees selon l’intervention dans les couts moyens du materiel jetable (PRL = 659,18 $; PRR = 236,59 $), les couts lies a la salle d’operation (PRL = 4278,00 $; PRR = 3139,00 $), le cout moyen des transfusions sanguines (PRL = 21,00 $; PRR = 394,34 $), les exigences moyennes en matiere d’analgesie (PRL = 12,94 $; PRR = 41,06 $) et les couts moyens pour un lit pendant une hospitalisation (PRL = 3690,00 $; PRR = 5027,14 $). Globalement, les couts pour l’ensemble des patients ayant subi une PRL ou une PRR etaient de 606 307,29 $ et de 618 721,57 $, respectivement; l’economie realisee grâce a la PRL etait donc de 12 414,28 $. Conclusion : A notre centre, nous avons observe que les couts lies a la PRL etaient legerement inferieurs a ceux d’une PRR. Des couts plus eleves en lien avec le temps d’operation et le materiel jetable sont compenses par des sejours plus courts en hopital et un nombre inferieur de transfusions sanguines et de doses d’analgesiques requises dans le groupe ayant subi une PRL. D’autres avantages financiers lies a la PRL decouleront probablement d’une plus grande reduction du temps d’operation et de la quantite de materiel jetable utilise.

Introduction Penile fracture is a well‐recognized clinical entity. It is relatively uncommon and is considered a urological emergency. Its management has been a subject of controversy. Aim In this article, we will review contemporary knowledge of the epidemiology, pathophysiology, evaluation, and evolving management strategies of penile fracture. Methods A case report was discussed followed by an English‐language Medline review. Main Outcome Measure Review of the available literature to establish best‐practice management. Results The injury is defined as the traumatic rupture of the corpus cavernosum secondary to a blunt trauma of the erect penis. The condition is underreported. The commonest causes were coital injuries and penile manipulation. The diagnosis was usually fairly straightforward because of the stereotypical clinical presentation. Associated injuries included urethral rupture. Imaging was helpful in selected cases. Conservative measures were associated with increased complications. Most authors advocated early surgical repair. False explorations have been reported. Conclusions Penile fracture is a clinical diagnosis. The ideal management has evolved and remains largely surgical. Preoperative imaging should not delay surgical repair. Al‐Shaiji TF, Amann J, and Brock GB. Fractured penis: Diagnosis and management. J Sex Med 2009;6:3231–3240.

To evaluate the effect of the position of the proximal and distal ends of Double-J ureteral stents on postprocedural flank pain, lower urinary-tract symptoms, and quality of life.The study included 120 patients who required unilateral Double-J ureteral stents for various indications. They were randomized into two equal groups. Group 1 had longer stents, with the proximal end in the upper calix and the distal end crossing the midline of the bladder. Group 2 had proper stent length with the proximal end in the pelvis and the lower end just beyond the vesicoureteral junction. Patients answered a questionnaire regarding flank pain, dysuria, and urgency as well as quality of life after 1 week of stenting.Forty patients (67%) of group 1 and 43 (72%) of group 2 had mild flank pain, especially during urination. There was no significant difference in the degree of flank pain in the two groups. Moderate to severe dysuria was reported by 53 patients (88%) in group 1 and 11 patients (18%) in group 2 (P0.001). Moderate to severe urgency was reported by 48 patients (80%) in group 1 and in 14 (23%) in group 2 (P0.001). A worse quality of life was reported by patients in group 1, among whom moderate to severe bother was noted by 51 (85%) compared with group 2, in which moderate to severe bother was reported by only 13 patients (22%) (P0.001).Ureteral stents are associated with flank pain and lower urinary-tract symptoms. The flank pain was not affected by the length of stent. Urgency and dysuria as well as a worse quality of life were significantly more common in the patients who had longer stents.

Introduction: Sacral neuromodulation (SNM) has become an established therapy for voiding dysfunction. Additional benefits, such as improved bowel functions and bladder pain, have been reported. Improvement in female sexual function after SNM treatment has been suggested; however, reports examining the effects of SNM on female sexual functions are scarce. We evaluate the effects of SNM on female sexual function and its impact on quality of life and analyze any correlation.Methods: Data were collected from January 2010 to May 2012 for all female patients who underwent SNM InterStim (Medtronic, Minneapolis, MN) therapy at a single centre in Canada. They were treated for voiding dysfunction, including refractory overactive bladder, frequency-urgency syndrome and non-obstructive urinary retention. Patients were screened by percutaneous nerve evaluation (PNE) to assess their response to therapy using a 4-day voiding diary. Patients who experienced 50% or more improvement in their voiding parameters were permanently implanted. All patients completed the Female Sexual Function Index (FSFI), Short-Form Health Survey (SF-36), and incontinence questionnaires (Urinary Distress Inventory [UDI]-6) preoperatively and 4 months postoperatively.Results: A total of 33 female patients had SNM therapy; 10 were excluded from the study because they were not sexually active. The indications were: refractory overactive bladder in 19, frequency urgency syndrome in 2, and non-obstructive urinary retention in another 2 patients. SNM therapy significantly improved the total FSFI score (p = 0.011); the components of desire and orgasm showed significant improvement (p = 0.014 and p = 0.035, respectively). Age, body mass index, diagnosis, and urinary symptoms did not show significant correlation with FSFI score improvement. Quality of life showed significant improvement after SNM treatment in 5 categories. There was no correlation between improvement in quality of life and FSFI.Conclusion: SNM may improve female sexual function and quality of life, yet there is no correlation between the improvement in FSFI and quality of life.

Penile prosthesis surgery plays a vital role in the treatment of erectile dysfunction (ED). As far as outcome is concerned, it is one of the most rewarding procedures for both patients and surgeons. We describe our surgical technique for implantation of the three-piece inflatable penile prosthesis and point out the major surgical pitfalls accompanying this procedure and their specific management. The psychological outcome of penile prosthesis surgery is also discussed. Different surgical approaches are available when performing the procedure. A number of procedure-related problems can be encountered and a thorough knowledge of these is of paramount importance. Penile prosthesis surgery has a favorable psychological outcome. Surgery for implantation of an inflatable penile prosthesis is a rewarding procedure, with a high yield of patient satisfaction. Urologists should have thorough understanding of the surgical pitfalls peculiar to this procedure and their management. Keywords: Penile prosthesis, psychological outcome, surgical pitfallsJournal of Surgical Technique and Case Report | Jul-Dec 2011 | Vol-3 | Issue-2

Erectile dysfunction (ED) associated with ­cancer therapy is commonly encountered whenever ­surgical interventions, radiotherapy, or systemic chemotherapy compromise the pelvic blood vessels or nerves. Currently, available treatment modalities frequently achieve long-term cancer remissions, and as a consequence, with advancing age patients are likely to face sexual dysfunctions and suffer their devastating effects on quality of life (QoL) long after the cancer treatment has been completed. The diagnosis of cancer is tough to overcome, but when its therapy results in alteration of basic bodily functions, it can be hard to deal with for patients and their partners.

Objective: To investigate the effect of urodynamic urethral catheter on uroflowmetry (UFM) parameters, as urodynamic studies (UDS) are an integral part in assessing voiding symptoms in both genders and its settings and components are points of debate for possible effects on results that sometimes vary from preliminary diagnoses, particularly the urethral or vesical catheters used in filling and voiding cystometry and their effect on UFM parameters. Methods: We prospectively enrolled 150 patients undergoing UDS for established voiding symptoms from January 2016 to March 2018. Exclusion criteria were pre-UDS voided volume of