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Mitchell Egerton Barns,1 Matthew Vinh-Hoan Dinh Chau,1 Patrick Ely Teloken,1 Rupert Hodder2 1Sir Charles Gardiner Hospital, Department of Urology, Perth, WA, Australia; 2Sir Charles Gardiner Hospital, Department of General Surgery, Perth, WA, AustraliaCorrespondence: Mitchell Egerton Barns, Sir Charles Gardiner Hospital, Department of Urology, Perth, WA, 6009, Australia, Tel +61 409 439 006, Email Mitchell.barns@health.wa.gov.auAbstract: Here we present two cases of post-operative obstructive renal failure following major abdomino-pelvic sarcoma surgery. In both cases, prophylactic ureteric stents were inserted to aid the identification and protection of the ureters during resection of these complex retroperitoneal masses. In case one, obstructive renal failure occurred following ureteric stent removal on day 0 post-operatively. In case two, obstructive renal failure developed on day 1 post-operatively despite having a ureteric stent in situ. Here we propose that a combination of reflex anuria/ureteric edema and papillary sloughing led to the obstructive renal failure in both cases. Re-insertion of bilateral ureteric stents in case one, and replacement of a right ureteric stent in case two saw prompt excretion of urine and sloughy debris with rapid improvement of renal function. This article presents these cases in detail and further reviews the use of prophylactic ureteric stents in major abdomino-pelvic surgery along with the current guidelines for their usage.Keywords: ureteric injury, prophylactic ureteric stenting, endourology, obstructive renal failure, slough papillae

Background: Intracavernosal injection therapy (ICI) is a well-established therapeutic strategy for men with erectile dysfunction. Complications are often related to patient error when performong ICI., Aim: The objective of this study was to examine patient errors in an established patient training program for performing ICI and identify factors that could predict major errors., Methods: Patients enrolled in our ICI program are trained on technical aspects, and dose titration is begun. Patients are given explicit instructions during training, both verbally and in written form. Records were reviewed for men using ICI for ≥6 months. Multivariable analysis was used to define predictors of major errors., Outcomes: Errors were listed as minor (zero-response injection, penile bruising, expired medication) and major (errors potentially leading to priapism: dose self-titration, double injecting)., Results: Overall, 1368 patients met the inclusion criteria and were included in the analysis. The mean patient age was 66 ± 22 (range 29-91) years. Regarding education, 41% of patients had graduate-level education, 48% had college education, and 11% high school education. Mean follow-up was 3.2 ± 7.6 (range 0.5-12) years. The agents used were trimix (62%), bimix (35%), papaverine (2%), and prostaglandin E1 monotherapy (1%). At least 1 error occurred during self-administration in 42% of patients during their time in the program. Errors included zero response to medication due to technical error (8% of patients), penile bruising (34%), use of an expired bottle (18%), self-titration (5%), and double injecting (4% of patients); 12% of men committed ≥1 error during their time in the program. On multivariable analysis, independent predictors of the occurrence of a major error included: young age, graduate-level education, and <12 months of injection use., Clinical Implications: To the best of our knowledge, this is the first reported study to investigate ICI errors and risk factors. The identification of factors predictive of major errors allows for more tailored and intensive training in this subset of patients., Strengths and Limitations: Strengths of this study include a large patient population (1386 men) with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions, enhances the accuracy and reliability of the results. Despite the strengths of the study, recall bias may be a limitation concern., Conclusion: The majority of patients were error free, and the majority of the errors were minor in nature. Major errors occurred in <10% of patients. Younger age, graduate-level education, and less experience with ICI were independent predictors of major errors., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Access represents one of the main challenges in performing posterior urethroplasty (1, 2). Several approaches and tactics have been previously described (3). This video demonstrates the Anterior Sagittal Transrectal Approach (ASTRA), which allows better visualization of the deep perineum (4)., Materials and Methods: Our patient was a 65-year-old man with post radical prostatectomy vesicourethral anastomotic stenosis. He failed repeated endoscopic interventions, eventually developing urinary retention and requiring a cystostomy. We offered a vesicourethral anastomotic repair through ASTRA. The patient was placed in the jackknife position and methylene blue instilled through the cystostomy. To optimize access to the bladder neck, an incision of the anterior border of the rectum is performed. Anastomosis is carried out with six 4-0 PDS sutures. These are tied using a parachute technique, after insertion of a 16F Foley., Results: The patient was discharged after 72 hours, and the Foley catheter was removed after 4 weeks. There were no access-related complications. Retrograde urethrogram 3 months after surgery confirmed patency of the anastomosis. Upon review 5 months after surgery the patient had urinary incontinence requiring 5 pads/day and was considered for an artificial urinary sphincter., Discussion: In our series of 92 patients who have undergone reconstructive procedure through ASTRA there have been no cases of fecal incontinence. Two patients with prior history of radiotherapy developed rectourethral fistulas. Urinary incontinence was observed in those patients with stenosis after radical prostatectomy., Conclusion: This video presents a step-by-step description of ASTRA, an approach that provides excellent visualization to the posterior urethra, representing an alternative access for repair of complex posterior urethral stenosis., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Introduction: Tissue transfer has been used in urethral reconstruction for decades, and several grafts have been described (1, 2). The ideal graft would have optimal tissue characteristics and lead to minimal morbidity at the donor site. Urethroplasty using bladder mucosa was first described by Memmelaar in 1947 (3). The main limitation in using bladder mucosal grafts has been the invasiveness of open harvesting (4). We describe an endoscopic technique using Holmium:YAG laser to harvest bladder mucosal graft for substitution urethroplasty., Methodology: A 33-year-old male with no history of urethral instrumentation, trauma, or infection presented with obstructive lower urinary tract symptoms. On retrograde urethrogram a 6cm bulbar urethral stricture was identified. Several options were discussed, and the patient opted for a one-sided onlay dorsal urethroplasty (5) using a bladder mucosal graft. Equipment used to harvest the graft included an 18.5Fr continuous flow laser endoscope with a Kuntz working element (RZ) and a 60W Holmium Laser (Quanta) with 550μm laser fiber. The procedure was started by making a perineal incision, urethral mobilization and incision of the stricture segment. The laser endoscope was then introduced via the perineum. Settings of 0.5J, 30 Hz, and long pulse were used and a 7 x 2.5cm graft was harvested from the posterior bladder wall. Hemostasis of the harvest site was performed. The bladder mucosal graft was thinned in similar fashion to a buccal mucosal graft and sutured as per previously described techniques., Conclusion: Endoscopic Holmium Laser harvesting of bladder mucosal graft is feasible and may allow this graft to become an alternative to buccal mucosa. Further studies are required to define its role in urethral reconstruction., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

In contemporary urological practice periurethral abscesses are rare. We report the case of a 61-year-old presenting with a painless penile mass and urinary retention. He underwent imaging with ultrasonography, targeted antibiotics and successful source control through open incision and drainage. He has been symptom, recurrence and complication free at 24 months post intervention. Risk factors for abscesses include obstruction, trauma, urethral diverticula and urethral carcinoma. Inadequate detection and treatment may lead to urethral fistulae, strictures and rarely, necrotizing fasciitis. To our knowledge, this is the first report of a periurethral abscess presenting as a painless penile mass causing urinary retention., (© 2022 Published by Elsevier Inc.)

Background: Transrectal (TR) and transperineal (TP) approaches for prostate biopsy have different morbidity profiles. Our institution transitioned to a preference for multiparametric MRI-based triage and TP biopsy since 2014. The aim of this study was to compare clinical, microbiological and health economic outcomes between TR and TP prostate biopsy., Methods: A consecutive cohort study considered prostate biopsies over an 11 year period. Hospital presentations across the region within 30 days of biopsy were analysed for details and subsequent outcomes according to biopsy approach. Cost for each encounter (routine and unplanned) were analysed and generalised linear models applied, as well as cost implications for inclusion of mpMRI-based triage and TP biopsy preference., Results: In total, 2048 prostate biopsies were performed. Similar re-presentation rates per occurred for each biopsy approach (90 patients, TR 4.8%, TP 3.8%, p = 0.29), with 23 patients presenting more than once (119 total presentations). Presentations after TR biopsy were more likely to be of infectious aetiology (TR 2.92%, TP 0.26% de novo, p < 0.001) and result in hospital admission (TR 43/49, 93.4%; TP 14/24, 58.3%; p = 0.007) for similar rates of urinary retention (TR 2.76% vs TP 3.63%, p = 1). The mean overall cost (biopsy and re-presentations) was higher for the TP group (p < 0.001), adjusted for year and age, but reduced over time and was similar for patients who re-presented (p = 0.98). Incorporation of mpMRI (with subsequently avoided biopsies), TP biopsy and re-presentations resulted in AU$783.27 saving per biopsy., Conclusions: TR biopsy resulted in more infectious complications and hospital admissions than TP biopsy for similar rates of re-presentation and urinary retention. TP biopsy costs reduced over time and use in conjunction with mpMRI provides an overall cost saving. Routine TP biopsy is safe and feasible, with further cost savings expected with other approaches (local anaesthetic) under investigation.

Purpose: Testosterone replacement therapy (TRT) is commonly used for various causes of androgen deficiency and subsidized by the Pharmaceutical Benefits Scheme (PBS) in Australia when appropriate. In response to a sharp increase in the prescribing of subsidized TRT, the Australian government instituted new, stricter prescription criteria in April 2015. We aim to demonstrate longitudinal changes in the prescription patterns of subsidized TRT over time., Materials and Methods: The publicly available PBS database was accessed for TRT prescription data between 1992-2018. Population estimate data was collected from the Australian Bureau of Statistics for population-adjustment. Data analysis was performed according to class and specific formulation of TRT. Total and population-adjusted trends were considered, as was indexation to 2015 when restrictions were implemented., Results: Longitudinal trends in subsidized TRT prescription demonstrated a progressive overall increase since 2000, according to total prescriptions and population-adjusted estimates, with greater use of topical formulations (gel, patch, cream/spray) and injections. Since 2015, a 37% decline in total population-adjusted prescriptions was observed (1,399-883 per 100,000 persons). Since 2015, relatively increased use of injections (50%) and 1% gel (30%) comprise the majority of contemporary TRT. Annual financial burden due to TRT was $AU16,768 per 100,000 persons prior to 2000 (mean cost 1992-2000), increasing to $AU112,539 in 2018 (due to use of injections). The rate of change in costs slowed after the restrictions were introduced in 2015., Conclusions: The restrictions in subsidized TRT eligibility enforced by the PBS have reduced overall TRT prescriptions and slowed the cumulative financial burden., Competing Interests: The authors have nothing to disclose., (Copyright © 2021 Korean Society for Sexual Medicine and Andrology.)

Objective: To examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018., Patients and Methods: Annual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000-2018. Population-adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH., Results: Overall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezūm™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply., Conclusion: Despite reduced national BPH-related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Background: 68Ga prostate specific membrane antigen PET/CT (68Ga-PSMA PET/CT) may be superior to multiparametric MRI (mpMRI) for localisation of prostate cancer tumour foci, however the concordance and differences between 68Ga-PSMA PET/CT and mpMRI when applied to all biopsied patients and potential benefit in patients with negative mpMRI is unclear., Methods: Retrospective analysis of patients undergoing mpMRI, prostate biopsy and 68Ga-PSMA PET/CT over a 3-year period. Diagnostic performance of 68Ga-PSMA PET/CT and mpMRI were assessed using biopsy histopathology for the entire cohort and radical prostatectomy specimen in a subset of patients. Lesion concordance and additional detection of each modality were determined, including in a dedicated cohort of patients with mpMRI PIRADS 2 scans., Results: A total of 144 patients were included in the study. Index lesion/foci detection was similar between 68Ga-PSMA PET/CT and mpMRI (sensitivity 83.1% vs 90.1%; p = 0.267), however lesions missed by mpMRI were larger (1.66 cm 3 vs 0.72 cm 3 ; p = 0.034). Lesion detection rates were similar across the biopsy histopathology and radical prostatectomy specimen subset, with a high concordance for index (80.1%) and a moderate concordance for total (67%) lesions between the 2 imaging modalities. The additional detection yield favoured 68Ga-PSMA PET/CT over mpMRI for index (13.5% vs 4.3%) and total (18.2% vs 5.4%) lesions; both modalities missed 2.1% and 12.3% of index and total lesions, respectively. 68Ga-PSMA PET/CT identified 9 of 11 patients with PIRADS 2 mpMRI but subsequently diagnosed with Gleason ≥ 3 + 4 disease., Conclusions: Despite high concordance rates, 68Ga-PSMA PET/CT incrementally improved tumour localisation compared with mpMRI. These results suggest that 68Ga-PSMA PET/CT may have an incremental value to that of mpMRI in the diagnostic process for prostate.

Purpose: Multiparametric magnetic resonance imaging (mpMRI) improves clinically significant prostate cancer (csPCa) detection by facilitating targeted biopsy (cognitive, fusion technology, or in-gantry MRI guidance) and reducing negative biopsies. This study sought to describe the feasibility of introducing an mpMRI-based triage pathway, including diagnostic performance, applicability to training, and cost analysis., Methods: An observational retrospective cohort study of consecutive patients attending a large public tertiary referral training hospital who underwent mpMRI for suspicion of prostate cancer was considered. Standard clinical, MRI-related, histopathological, and financial parameters were collected for analysis of biopsy avoidance, diagnostic accuracy of biopsy approach, and operator (consultant and resident/registrar) and logistical (including financial) feasibility., Results: 653 men underwent mpMRI, of which 344 underwent prostate biopsy resulting in a 47% biopsy avoidance rate. Overall, 240 (69.8%) patients were diagnosed with PCa, of which 208 (60.5%) were clinically significant, with higher rates of csPCa observed for higher PIRADS scores. In patients who underwent both systematic and targeted biopsy (stTPB), targeted cores detected csPCa in 12.7% and 16.6% in more men than systematic cores in PIRADS 5 and 4, respectively, whereas systematic cores detected csPCa in 5% and 3.2% of patients, where targeted cores did not. A high standard of performance was maintained across the study period and the approach was shown to be cost effective., Conclusions: Introdution of an mpMRI-based triage system into a large public tertiary teaching hospital is feasible, cost effective and leads to high rates of prostate cancer diagnosis while reducing unnecessary biopsies and detection of insignificant PCa.

Background: This study aimed to describe perioperative, oncological and learning curve outcomes for robotic-assisted radical cystectomy (RARC) across the first 100 cases performed by an Australian high-volume, fellowship-trained robotic surgeon., Methods: A retrospective cohort study was performed on a consecutive group of 100 patients who underwent RARC between 2010 and 2016 in Brisbane, Australia. Perioperative, oncological and survival data were collected. Demographic, survival and learning curve analyses were performed in MedCalc., Results: A total of 100 patients underwent RARC over the study period. Median operative time was 389 min, with a reduction in median times from 420 to 330 min when comparing the first 50 versus the second 50 patients (P < 0.001). Median estimated blood loss was 500 mL, while urinary diversion was performed extracorporeally in 20 patients, intracorporeally in 69 patients and using a hybrid technique in 11 patients. Median length of hospital stay was 11 days. Post-operative complications occurred in 56% of patients (Clavien-Dindo classification I-II 32%, III-V 24%). Positive operative margins were 2% and median lymph node yield was 21 nodes. Overall recurrence-free survival was 50.3 months., Conclusion: Initial short-term experience with RARC shows favourable outcomes with regard to operative, perioperative and pathological indicators compared to open radical cystectomy and other RARC series., (© 2019 Royal Australasian College of Surgeons.)

Objective: To characterize national clinical practice trends in the treatment of prostate cancer (PCa) in Australia., Patients and Methods: Population-level data were extracted from existing Medicare Benefits Schedule data for radical prostatectomy (RP) and brachytherapy (2002-2016), as well as external beam radiotherapy (EBRT; 2012-2016). Treatment rates were calculated relative to whole and PCa populations among privately treated patients. Overall age-related and geographical trends were analysed., Results: The use of RP and low-dose-rate (LDR) brachytherapy increased between 2002 and 2009, but subsequently decreased to 124 and 6.9 per 100 000 men, respectively, in 2016. More dramatic decreases were observed for men aged <65 years. From 2012, rates of RP (15% drop) and LDR brachytherapy (58% drop) decreased, while the use of EBRT remained steady, falling by 5% to 42 per 100 000 men in 2016. Overall treatment increased in the age group 75-84 years, with the rate of RP increasing by 108%., Conclusion: National claims data indicate there has been a reduction in PCa treatment since 2009, which is mostly attributable to a reduction in the treatment of younger patients and reduced use of brachytherapy. RP is most commonly used and its use is rising in men aged >65 years., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

The use of emerging nanotechnologies, such as plasmonic nanoparticles in diagnostic applications, potentially offers opportunities to revolutionize disease management and patient healthcare. Despite worldwide research efforts in this area, there is still a dearth of nanodiagnostics which have been successfully translated for real-world patient usage due to the predominant sole focus on assay analytical performance and lack of detailed investigations into clinical performance in human samples. In a bid to address this pressing need, we herein describe a comprehensive clinical verification of a prospective label-free surface-enhanced Raman scattering (SERS) nanodiagnostic assay for prostate cancer (PCa) risk stratification. This contribution depicts a roadmap of (1) designing a SERS assay for robust and accurate detection of clinically validated PCa RNA targets; (2) employing a relevant and proven PCa clinical biomarker model to test our nanodiagnostic assay; and (3) investigating the clinical performance on independent training ( n = 80) and validation ( n = 40) cohorts of PCa human patient samples. By relating the detection outcomes to gold-standard patient biopsy findings, we established a PCa risk scoring system which exhibited a clinical sensitivity and specificity of 0.87 and 0.90, respectively [area-under-curve of 0.84 (95% confidence interval: 0.81-0.87) for differentiating high- and low-risk PCa] in the validation cohort. We envision that our SERS nanodiagnostic design and clinical verification approach may aid in the individualized prediction of PCa presence and risk stratification and may overall serve as an archetypical strategy to encourage comprehensive clinical evaluation of nanodiagnostic innovations.

Purpose: We assessed the impact of prostatic zone tumor origin on pathological prognostic features and subsequent biochemical outcomes after radical prostatectomy., Materials and Methods: A total of 7,051 patients who underwent radical prostatectomy between September 1998 and December 2016 in Western Australia were divided into a high grade group, defined as Gleason sum 4 + 3, 8 and 9 or greater and ISUP (International Society of Urological Pathology) groups 3, 4 and 5, and a low grade group, defined as Gleason sum 6 or less and 3 + 4, and ISUP groups 1 and 2. The t-test and the Pearson chi-square test were used to evaluate differences between transition zone and peripheral/central zone cancer. The Kaplan-Meier method with the log rank test was used to determine differences in biochemical recurrence-free survival at 5 years in patients with high grade disease. Univariate and multivariable Cox proportional hazard regression analyses were performed. Model calibration was determined by the internal validation method., Results: High grade transition zone cancer was associated with significantly increased prostate specific antigen, tumor volume and incidence of positive surgical margins but a lower incidence of intraductal carcinoma, extraprostatic spread, seminal vesicle invasion, lymph node involvement and biochemical failure after radical prostatectomy. Patients with low grade prostate cancer had excellent biochemical recurrence-free survival regardless of tumor origin. The high grade multivariable model had a c-index of 0.78 and improved predictive accuracy, particularly for high grade transition zone disease., Conclusions: Transition zone tumor origin independently and positively impacts biochemical outcomes of high grade prostate cancer. A high grade postoperative prognostic model including transition zone tumor origin as an independent predictor was developed and predictive accuracy was significantly improved in patients with high grade, transition zone disease., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: In the last decade, there has been a significant increase in interest for public reporting of outcome data and performance comparison across institutions and surgeons. This study aims at comparing postoperative mortality after colorectal cancer surgery across units and individual consultants in Australia and New Zealand using funnel plots., Methods: The Bi-National Colorectal Cancer Audit database was used. Unadjusted and adjusted funnel plots of inpatient mortality were constructed. Risk adjustment was based upon multivariable logistic regression models using purposeful covariate selection., Results: A total of 10 008 patients undergoing surgery for colorectal cancer from 56 surgical units and 90 consultants were identified. Overall inpatient mortality was 1.51%, corresponding to 1.1% for elective and 3.9% for urgent cases. Logistic regression identified age, American Society of Anesthesiologists score, urgent surgery and open surgery to be independently associated with inpatient mortality. Unadjusted and adjusted funnel plot analysis identified three (5.3%) units exceeding the inner limit and none exceeding the outer limit. Six (6.6%) consultants had inpatient mortality between the upper inner and outer limits and one (1.1%) between the inferior inner and outer limits. Upon adjustment, seven (7.7%) consultants had inpatient mortality between the inner and outer limit. Potential limitations of this study include: residual confounding being responsible for the association of open surgery and mortality; incomplete case-mix adjustment resulting in outlier identification; and bias towards inclusion of larger institutions., Conclusion: Mortality figures in Australia and New Zealand are comparable to recently reported international data. The vast majority of units and consultants are performing within the expected boundaries., (© 2016 Royal Australasian College of Surgeons.)

Background: Outcomes of patients with stage I colorectal cancer submitted to surgery with curative intent have not been thoroughly explored in contemporary series., Methods: All patients with colon or rectal adenocarcinoma who underwent resection from the St John of God Hospital (1996-2013) and BioGrid (1991-2013) databases were identified. Patients submitted to local excision, polypectomies or neoadjuvant treatment were excluded. Outcomes included recurrence (combined local and systemic), recurrence-free and overall survival, and survival after recurrence., Results: A total of 1193 patients with stage I disease were included. Median age was 67 (interquartile range 59-75) and median follow-up was 3.2 years (interquartile range 1.4-5.8). Five-year recurrence rate was 7.1% (95% confidence interval (CI) 5.4-9.4%; 5.0% for colon and 11.1% for rectal cancer). Rectal location was an independent predictor of recurrence (hazard ratio (HR) 1.97, 95% CI 1.09-3.55; P = 0.024). Lymphovascular invasion was an independent predictor of recurrence only in patients with rectal cancer (HR 3.0, 95% CI 1.2-7.6; P = 0.018). Five-year recurrence-free survival was 83.2% (95% CI 80.3-85.4%). Age (HR 1.05, 95% CI 1.03-1.07; P < 0.001), elective surgery (HR 0.41, 95% CI 0.21-0.80; P = 0.011) and the American Society of Anesthesiologists (ASA) score (HR 3.08, 95% CI 1.51-6.31; P < 0.001) were independently associated with recurrence-free survival. Median survival after recurrence was 41 months. Resection of recurrence was attempted in 39% of patients., Conclusion: Patients with stage I colorectal cancers still have a clinically significant risk of recurrence. Rectal location is independently associated with higher recurrence. Age, elective surgery and ASA are independently associated with recurrence-free survival. A significant proportion of patients with recurrence underwent further resection., (© 2015 Royal Australasian College of Surgeons.)

Background: Urgent surgery for acute intestinal presentations is generally associated with worse outcomes than elective procedures. This study assessed the outcomes of patients undergoing urgent colorectal surgery., Methods: Patients were identified from a prospective database. Surgery was classified as urgent when performed as soon as possible after resuscitation and usually within 24 h. Outcome measures included 30 days mortality, return to theatre, anastomotic leak and overall survival., Results: Two hundred forty-nine patients were included in the analysis. Median age was 65 years (interquartile range 48-74). The most common presentations were obstruction (52.2%) and perforation (23.6%). Cancer was the disease process responsible for presentation in 47.8% of patients. Thirty-day mortality was 6.8%. Age (odds ratio 1.08 95% confidence interval (CI) 1.02-1.15; P = 0.01), American Society of Anesthesiologists 4 (odds ratio 7.14 95% CI 1.67-30.4; P = 0.008) and cancer (odds ratio 6.61 95% CI 1.53-28.45; P = 0.011) were independent predictors of 30 days mortality. Relaparotomy was required in six (2.4%) cases. A primary anastomosis was performed in 156 (62.6%) patients. Anastomotic leak occurred in four (2.5%) patients. In patients with cancer, overall 5-year survival was 28% (95% CI 19-37), corresponding to 54% (95% CI 35-70) for stages I and II, 50% (95% CI 24-71) for stage III and 6% (95% CI 1-17) for stage IV disease. Urgent surgery was independently associated with worse overall survival (hazard ratio 2.65; 95% CI 1.76-3.99; P < 0.001)., Conclusion: In patients undergoing an urgent resection within a colorectal unit, performing a primary anastomosis is feasible and safe in the majority, relaparotomies are required in a minority and urgent surgery is an important predictor of worse prognosis in those with colorectal cancer., (© 2014 Royal Australasian College of Surgeons.)

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103., (Copyright © 2013 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Erectile function recovery after radical prostatectomy is affected by surgical technique and patient factors. Age and preoperative erectile function are the 2 patient factors that have been consistently shown to impact postoperative erectile function. The presence of vascular risk factors preoperatively seems to negatively impact erectile function recovery after radical prostatectomy independently from age, preoperative erectile function and surgical technique., Objective: To examine whether vascular risk factors (VRFs) affect erectile function (EF) recovery after radical prostatectomy (RP)., Patients and Methods: From our prospective database we identified patients with clinically localised prostate cancer who had undergone RP and had preoperative information on EF and VRFs (hypertension, hypercholesterolaemia, diabetes mellitus, coronary artery disease [CAD], and cigarette smoking), surgeon-graded nerve-sparing status, and EF data collected between 24 and 30 months after RP., Results: In all, 984 patients were included in the analyses. The frequency of the VRFs was as follows: hypertension (38%), hypercholesterolaemia (36%), diabetes mellitus (7%), CAD (5%), and cigarette smoking (37%). On univariate analysis, EF between 24 and 30 months was associated with age (r = 0.37, P < 0.001), EF before RP (r = 0.41, P < 0.001), NSS (r = 0.35, P < 0.001), and VRFs (0-2 vs >3 VRFs; r = 0.15, P = 0.003). On multivariable analysis all variables remained statistically significant, and accounted for 28% of the total variance in EF between 24 and 30 months after RP., Conclusions: The presence of VRFs seems to adversely affect EF recovery after RP independently of other factors. This observation might be useful for improving patient counselling before treatment and to support the development of new treatment strategies for erectile dysfunction after RP., (© 2012 BJU International.)

We report a case of serious lung injury from beanbag bullet. A 46-year-old gentleman, shot with beanbag bullets was brought to the emergency department. Upon arrival he was in obvious respiratory distress and complained of severe pain in the right chest. A 3.0×3.5 cm entry wound on the right parasternal area was identified. Chest x-ray revealed a right haemopneumothorax, parenchymal changes at the right lung base and a radiopaque foreign body. A right-sided intercostal chest tube was inserted, draining air and 750 ml of blood. After stabilisation patient underwent a right thoracotomy. A beanbag bullet was found in the oblique fissure of the right lung, with extensive haematoma of the middle lobe. The bullet and skin fragments overlying the lung and along the bullet track were extracted. The pleural cavity was washed with normal saline and haemostasis was confirmed. The patient had an uneventful postoperative recovery.

Introduction: As a vascular test, dynamic infusion cavernosometry (DIC) has lost popularity, and in the urologic community, penile duplex Doppler ultrasound (DUS) has become the sole test to investigate a vascular etiology of erectile dysfunction. Vasoactive agent redosing has been shown to increase the accuracy of DUS., Aim: To define the erectile hemodynamics in men with previously diagnosed venous leak on DUS., Methods: Prospective data were collected on patients who (i) had been given a diagnosis of venous leak based on an outside DUS; (ii) elected to undergo a repeat DUS; and (iii) when the repeat DUS suggested venous leak, underwent DIC., Main Outcome Measures: DUS: peak systolic velocity and end-diastolic velocity. DIC: flow to maintain., Results: 292 patients were included. Mean ± standard deviation age was 44 ± 26 years. On repeat DUS, 19% (56/292) had completely normal hemodynamics and 7% (20/292) had arterial insufficiency only without venous leak. DIC revealed normal hemodynamics in 13% (38/292), while in 58% (152/292) of patients, the venous leak diagnosis was confirmed. Overall, 47% (137/292) of patients who had been given a diagnosis of venous leak had completely normal hemodynamics, and in only 43% (126/292), the venous leak diagnosis was confirmed upon repeat vascular testing. On multivariable analysis, younger age (<45 years), failure to obtain an adequate erection during the original DUS, and having <2 vascular risk factors were predictive of a false diagnosis of venous leak., Conclusions: Penile DUS has a propensity to inaccurately assign a diagnosis of venous leak. Great care should be taken when performing DUS especially in younger men without a significant vascular risk factor history, and the failure to obtain a good erection should make the clinician cautious in assigning a diagnosis of venous leak. Furthermore, there still exists a role for cavernosometry, which appears to have a greater accuracy at diagnosing venous leak., (© 2011 International Society for Sexual Medicine.)

Objectives: • To compare the influence of a 4-week course of empirical antimicrobial therapy or observation on the prostate-specific antigen (PSA) levels of asymptomatic patients with a raised baseline PSA. • To identify whether a decrease in PSA can predict the risk of prostate cancer (PCa) detection on prostate biopsy., Patients and Methods: • Patients were referred to our ambulatory centre because of a raised PSA level (>2.5 ng/mL) with a normal digital rectal examination. A 12-core prostate biopsy was indicated in these patients and they were offered antibiotic treatment with levofloxacin 500 mg daily for 30 days. • Patients who did not agree to use antibiotics but who still showed interest in participating underwent simple observation, serving as controls. • Total and free PSA levels at baseline and after 45 days were measured. Variation in PSA level was calculated. • All patients underwent a 12-core prostate biopsy 6 weeks after the initial visit., Results: • In all, 245 men were enrolled, but 43 were lost due to follow-up. A total of 145 patients who used antibiotics and 57 controls were included in the analysis. • The median baseline PSA levels were 7.6 and 7.7 ng/mL in the antibiotic and control groups, respectively, with median follow-up levels of 6.8 and 7.0 ng/mL. The follow-up PSA level was significantly lower than the initial PSA level (P = 0.009). • Mean absolute and percentage variation in PSA level were similar in both groups (P = 0.828 and 0.128, respectively). • The overall PCa detection rate was 15.8%, and did not differ among the groups (P = 0.203). Regarding the percentage variation in PSA level, patients diagnosed with PCa tended to have their PSA level increased (22.4 vs -5.3%; P = 0.001). Indeed, a decrease of 20% in PSA was not predictive of a negative prostate biopsy (P = 0.41). • The area under the receiver operating characteristic curve for percentage PSA variation as a predictor of PCa was 0.660., Conclusions: • PSA levels tend to fall when repeated after 45 days, regardless of antibiotic use. • Despite being associated with the chance of PCa, no percentage PSA variation threshold value exhibits satisfactory discriminatory properties., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Purpose: Despite the clear demonstration that different histological subtypes of renal cell carcinoma show distinct pathogenesis and genetic alterations, the impact of histology on prognosis remains controversial. We evaluated our experience with tumor histology in patients with localized renal cell carcinoma., Materials and Methods: We identified 1,863 patients with localized clear cell, papillary or chromophobe renal cell carcinoma who were treated surgically between 1989 and 2006 at our tertiary care center. Cox proportional hazards regression models were used to evaluate the relationship between tumor histology and outcome, defined as metastasis or death from disease, adjusting for age, sex, operation type, American Society of Anesthesiologists score, TNM stage and tumor size., Results: Of 1,863 patients 1,333 (72%) had clear cell histology, and 310 (17%) and 220 (12%) had papillary and chromophobe renal cell carcinoma, respectively. Median followup in patients without an event was 3.4 years. On univariate analysis patients with clear cell histology had a worse clinical outcome. Five-year probability of freedom from metastasis or death from disease was 86% (95% CI 84, 88), 95% (95% CI 91, 97) and 92% (95% CI 85, 96) in patients with clear cell, papillary and chromophobe histology, respectively (p <0.001). On multivariate analysis chromophobe (HR 0.40; 95% CI 0.20, 0.80) and papillary (HR 0.62; 95% CI 0.34, 1.14) histology was also significantly associated with better outcome (p = 0.014)., Conclusions: Clear cell histology seems to be independently associated with worse outcomes in patients who undergo surgery for renal cell carcinoma even after controlling for widely accepted factors influencing prognosis.

Objectives: Frequently, the term "quality of life" has been used to justify personal and professional decisions in all fields of medicine. Nowadays, quality of life studies are based on development and validation of sensitive measures of patient outcomes, incorporating functional status and perceived health status. Thus, quality of life has become an outcome as important as survival and effectiveness., Methods: A systematic review using Pubmed and Medline was performed, searching for papers concerning health related quality of life and urology. The most relevant articles where questionnaires and interviews were described and validated were listed., Results: Based on psychometric properties, a search between 1970 and 2007 identified a total of 25 recommendable articles with generic inventories and specific modules that have been developed, validated and used in clinical practice or research. Historical aspects, quality of life concepts, validation of questionnaires and structured interviews, and most used instruments in generic health-related quality of life, general urology and urological oncology have been discussed., Conclusions: A brief review of historic background of health related quality of life and urology was performed.

Introduction: Phosphodiesterase type 5 inhibitor (PDE5) use is a treatment strategy for prostate cancer patients with post-radiation therapy (RT) erectile dysfunction (ED)., Aim: To define the predictors of sildenafil response in men treated with RT for prostate cancer., Main Outcome Measures: International Index of Erectile Function (IIEF)., Methods: Patients were enrolled prospectively if they met the following criteria: (i) either a three-dimensional conformal external beam (EBRT) or brachytherapy (BT) with or without androgen deprivation (AD) for prostate cancer; (ii) self-reported ability to have sexual intercourse prior to RT; (iii) experienced onset of ED following RT; (iv) candidates for sildenafil citrate use; (v) followed-up periodically; and (vi) completed the IIEF at least 12 months after RT. Failure to respond to sildenafil was defined as IIEF-erectile function (EF) domain score of <22., Results: One hundred fifty-two patients met all the criteria: 110 in the EBRT group and 42 in the BT group. Mean age was 62 years. The mean follow-up was 38 months. Mean radiation dose for EBRT was 78 Gy and for BT was 101 Gy. Thirty-five patients received AD, 25% of EBRT, and 62% of BT patients. Sixty-one percent of the patients receiving AD had exposure only pre-RT, whereas 39% had pre- and post-RT AD exposure. The mean duration of AD was 4.6 months. Post-RT IIEF-EF domain score at >24 months was 17. Successful response to sildenafil occurred in 68% of men at 12 months after RT, 50% at 24 months, and 36% at 36 months. On multivariable analysis, predictors of failure to respond to sildenafil were: older age, longer time after RT, AD > 4 months duration, and RT dose > 85 Gy. Modality of radiation delivery was not predictive of sildenafil failure., Conclusions: A steady decrease in sildenafil response was seen with increasing duration after RT. Several factors were predictive of sildenafil failure.

It is now known that endothelial health is essential for normal erectile function, and changes in endothelial integrity or function may lead to erectile dysfunction (ED). Because phosphodiesterase type 5 (PDE-5) inhibitors have been shown to improve endothelial function, many investigators have questioned whether PDE-5 inhibition will lead to improvement in erectile function. Data from the studies reviewed in this article show that therapy with PDE-5 inhibitors results in improvement in flow-mediated dilation, nocturnal penile tumescence and rigidity, and carotid artery intima-media thickness as well as higher scores on the Sexual Health Inventory for Men, International Index of Erectile Function, Erection Function Domain, and other instruments. Further research is needed to determine whether long-term PDE-5 inhibition can reverse ED and whether use of these agents will decrease cardiovascular morbidity in high-risk populations.

Introduction: Hypogonadism is a clinical and biochemical syndrome that may cause significant detriment in the quality of life and adversely affect the function of multiple organ systems. With the increase in life expectancy and prostate cancer (PCa) survival, a significant increase in the number of men with hypogonadism who have undergone presumably curative treatment for PCa is anticipated., Aim: To critically review the literature regarding testosterone replacement therapy (TRT) after PCa treatment with curative intent., Main Outcome Measures: Review of peer-reviewed literature. There was special focus on the potential implications and safety of TRT in men with hypogonadism who have undergone curative treatment for PCa., Methods: English-language relevant publications were identified via electronic medical databases (MEDLINE, EMBASE, and DARE)., Results: Despite the wide spread of contraindication of testosterone replacement in men with known or suspected PCa, there is no convincing evidence that the normalization of testosterone serum levels in men with low but no castrate levels is deleterious. In the few available case series describing testosterone replacement after treatment for PCa, no case of clinical or biochemical progression was observed., Conclusions: Although further studies are necessary before definitive conclusions can be drawn, the available evidence suggests that TRT can be cautiously considered in selected hypogonadal men treated with curative intent for PCa and without evidence of active disease.

Purpose: Radiation therapy is a widely accepted strategy for prostate cancer. Erectile dysfunction is a common complication of radiation therapy. Adjuvant androgen deprivation was shown to prolong survival in select patients. There is controversy regarding the impact of androgen deprivation on erectile function. We defined the impact of androgen deprivation on the sildenafil response in patients with erectile dysfunction following radiation therapy., Materials and Methods: Patients were enrolled prospectively if they underwent radiation therapy in the form of 3-dimensional conformal external beam or brachytherapy with or without androgen deprivation, reported functional erections before radiation therapy, experienced the onset of erectile dysfunction following the completion of radiation therapy, had comprehensive erectile dysfunction evaluation, including a thorough history and physical examination, attempted sildenafil periodically and completed the International Index of Erectile Function on at least 2 occasions throughout the first 3 years following the completion of radiation therapy., Results: A total of 152 patients were enrolled. Mean age +/- SD was 62 +/- 14 years. No significant difference existed in age or radiation dose between patients with and without androgen deprivation exposure. Mean androgen deprivation duration was 3.8 +/- 1.8 months. For patients with conformal external beam and brachytherapy the sildenafil response, mean erectile function domain score and percent who experienced erectile function domain normalization at each time point were lower in those with vs without androgen deprivation., Conclusions: Androgen deprivation seems to exert a deleterious effect on erectile function in men undergoing radiation therapy for prostate cancer. This was observed in men treated with conformal external beam and brachytherapy at short-term, medium term and long-term followup.

Objectives: Erectile dysfunction (ED) is a major health problem that seriously affects the quality of life of patients and their partners. Although all three selective phosphodiesterase type 5 inhibitors (PDE5-Is) are effective in the majority of ED cases, PDE5-I therapy is less efficacious in some hard-to-treat populations (diabetics, men after radical prostatectomy), prompting the development of new approaches, including gene therapy strategies for ED., Methods: Gene therapy approaches are discussed in terms of the possible role of gene therapy for the treatment of ED, potential targets for gene transfer, vectors to carry targeted genes, and gene strategies for ED in certain disease states, such as diabetes, ageing, arterial and venogenic insufficiency, and cavernous nerve injury., Results: The penis is a convenient tissue target for gene therapy because of its external location and accessibility, the ubiquity of endothelial-lined spaces, and low level of blood flow, especially in the flaccid state. Gene therapy approaches have focused on a number of signaling pathways that are crucial for penile erection, such as nitric oxide/cyclic guanosine monophosphate, RhoA/Rho-kinase, growth factors, ion channels, peptides, and control of oxidative stress., Conclusions: The need for effective ED therapies in difficult-to-treat patients has encouraged investigators to seek novel modalities for the treatment of ED. Recent preclinical and clinical trials have demonstrated that gene therapy strategies may be feasible for these purposes.

Objectives: To assess overactive bladder (OAB) prevalence, associated factors and implications in a young population., Methods: An independent population-based study was carried out. A self-applicative questionnaire covering urinary symptoms, coping strategies, quality of life and treatment seeking behavior was developed., Results: A total of 848 subjects between 15 and 55 years completed the questionnaire. The overall prevalence of OAB was 18.9%. Women were significantly more affected than men (p = 0.001). All age groups were equally affected (p = 0.152). Subjects with OAB reported significant impairment on household chores (p = 0.009), physical activities (p = 0.016), sleep (p < 0.001), work (p < 0.001), social life (p < 0.001) and sexual life (p < 0.001). In addition, OAB individuals present higher prevalence of depression (p = 0.036), anxiety (p < 0.001), shame (p < 0.001) and tiredness (p < 0.001) OAB was independently associated to sexual life impairment (OR = 3.36, 95% CI=1.20-9.39). Only 27.5% of OAB subjects sought for medical counseling., Conclusions: OAB is a highly prevalent condition, even in such a young population. It affects both genders, yet it is more frequently observed in women. OAB is an important health condition, with serious impact on quality of life and sexual function. A large percentual of individuals remain unrecognized, under treated and consequently suffer for long periods of time.

Objectives: To conduct a study using validated sexual function and sleepiness inventories to define whether sleep apnea syndrome (SAS) is associated with erectile dysfunction and whether any correlation exists between the severity of SAS and the severity of erectile dysfunction. Previous work has suggested that sleep disorders are associated with erectile dysfunction., Methods: Men presenting to a sleep clinic with symptoms consistent with SAS were given the Epworth Sleepiness Scale and an erectile dysfunction risk factor inventory, the International Index of Erectile Function. A database was constructed and statistical analysis conducted to define the correlation between the two entities., Results: A total of 50 men met the criteria for inclusion. Of the 50 men, 60% had abnormal Epworth Sleepiness Scale scores and 80% of these patients had erectile dysfunction as determined by inventory scores compared with 20% of the men with normal Epworth Sleepiness Scale scores. There were statistically significant differences between men with normal and abnormal sleepiness scores for the total and erectile function domain of the International Index of Erectile Function. The correlation between the severity of the sleepiness and the severity of erectile dysfunction was good (r = -0.80, P = 0.012)., Conclusions: Men presenting with symptoms consistent with SAS have a significant risk of erectile dysfunction, and the correlation between the severity of sleep apnea and the severity of erectile dysfunction is strong.

Recurrent idiopathic priapism is a rare condition that, if not properly treated, may lead to impaired quality of life and erectile dysfunction. Treatment can be achieved by prevention of priapism episodes with systemic therapy or by early intervention with intracavernosal self-injection of sympathomimetic agents. We describe a case of a young patient with recurrent idiopathic priapism who has used etilefrine self-injection for the past 10 years with good efficacy and libido and erectile function preservation. This report suggests that this approach may be safely indicated in selected cases, particularly when sexual function preservation is a major concern.