UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management.

UNLABELLED: Study Type - Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision-making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra-operative demonstration of and, potentially, storage of sperm. OBJECTIVES: To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010. • To make recommendations for contemporary practice. SUBJECTS AND METHODS: Three consecutive questionnaire-based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010. • Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso-vasostomy used. • In 2005 additional information was obtained about the availability of fertility treatments and sub-specialization of the urologist and in 2010 about the eligibility criteria for in-vitro fertilization (IVF) treatment and synchronous sperm retrieval. RESULTS: Overall there was a 47% response rate with >80% of respondents still performing vaso-vasostomy. • More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options. • Only 41% gave their personalized outcomes from vaso-vasostomy, whilst >80% were using some form of magnification intra-operatively. • Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso-vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation. CONCLUSIONS: • Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso-vasostomy. • Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome. • Vaso-vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub-specialist with access to appropriate micro-surgical training and assisted reproductive technologies.

Hoechst 33342 side population identification is a conserved and unified mechanism in urological cancers.

Mutation within the adult human stem cell (SC) compartment has been proposed as a factor in the initiation and promotion of carcinogenesis. Isolation of these cancer stem cells (CSCs) has proven difficult, limiting their subsequent phenotypic, functional, and genetic characterization. We have used the Hoechst 33342 dye efflux technique to isolate an epithelial side population (SP) from genitourinary (GU) cancers, which is enriched for cells with SC traits. With informed consent, samples were taken from patients with primary tumors and undergoing surgery for prostatic (CaP), invasive bladder transitional cell (TCC), and renal cell carcinomas (RCC). Single cell epithelial suspensions were extracted from these and incubated with Hoechst 33342. Hoechst SP/non-SP profiles were then generated by flow cytometry using standardized protocols. SP/non-SP cell cycle status was established by Hoechst 33342 and Pyronin Y staining. Immunocytochemistry staining was performed for markers suggested as stem markers as well as lineage-specific markers. Functionality was determined using colony-forming assays and long-term monolayer culture. A characteristic verapamil-sensitive SP was isolated from all 3 urological malignancies and represented 0.57% +/- 0.11% (CaP), 0.52% +/- 0.49% (TCC), and 5.9% +/- 0.9% (RCC) of the total epithelial population. Cell cycle analysis showed that the SP had enhanced numbers of cells in G(0) as compared to the total cell population (CaP 12.4% +/- 3.2 vs. 3.8% +/- 1.0, RCC 23.2% +/- 3.4 vs. 1.8% +/- 0.9, and TCC 28.5% +/- 4.9 vs. 4% +/- 1.3). Immunocytochemistry demonstrated an increased expression of proliferative and putative stem markers within the SP fraction. Cultures confirmed significant enhancement of colony-forming ability and proliferative capacity of the SP fraction. A characteristic SP enriched for stem-like cells has been isolated from the 3 most common urological malignancies. This provides strong evidence that Hoechst 33342 efflux is a conserved and unified mechanism in GU cancer.

Male adnexal tumour of wolffian origin: the first report of metastatic disease.

The first case of a male adnexal tumour of probable wolffian duct origin to develop metastatic disease is reported. The characteristic histological appearance and immunohistochemical profiles of the primary and metastatic male tumours are discussed. The scanty experience relating to metastatic disease makes decisions about the most appropriate treatment challenging.

Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon.

BACKGROUND: Early surgical results of anterior sphincter repair for faecal incontinence can be good, but in the longer term are often disappointing. This study aimed to determine the short and long term outcomes from anterior sphincter repair and identify factors predictive of long term success. METHODS: Patients who underwent anterior sphincter repair between 1989 and 2001 in one institution were identified. Postal questionnaires were sent to patients, which included validated scoring systems for symptom severity and quality of life assessments for faecal incontinence. Patient demographics and risk factors were recorded as were the results of anorectal physiology studies and endoanal ultrasound. RESULTS: Eighty-five patients underwent repair by one consultant. The length of follow up ranged from 1 to 12 years. Most patients (96%) had early symptom improvement postoperatively. Of the 47 patients assessed long term (> or = 5 years), 28 (60%) maintained this success. Significant improvements in quality of life were observed (P < 0.001). Neither patient, surgical nor anorectal physiology study parameters were predictive of outcome. CONCLUSION: There were no predictive factors of outcome success and no changes in anal manometry identified, however anterior sphincter repair remains worthwhile. Changes in compliance of the anorectum may be responsible for symptom improvement.

Adenocarcinoma of the caecum metastatic to the bladder: an unusual cause of haematuria.

BACKGROUND: Primary malignancies of colorectal origin can metastasise to the bladder. Reports are however extremely rare, particularly from the caecum. CASE REPORT: The report describes the case of a 45-year old male with Duke's B caecal carcinoma treated with a laparoscopically-assisted right hemicolectomy and adjuvant 5-Fluorouracil chemotherapy. Subsequently, a metastatic lesion to the bladder was demonstrated and successfully excised by partial cystectomy. CONCLUSION: In order that optimal therapeutic options can be determined, it is important for clinicians to distinguish between primary disease of the bladder and other causes of haematuria. Various immunohistochemical techniques attempt to differentiate primary adenocarcinoma of the bladder from secondary colorectal adenocarcinoma. Suspicion of metastatic disease must be raised when histologically unusual bladder tumours are identified.

Successful endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy.

Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. Fenestrated endografts overcome the problem of a short proximal neck, but at present their deployment is time consuming and therefore not easily applicable to a ruptured AAA. In this case report, the authors describe a hybrid device (a composite thoracic and infrarenal stent graft) that was able to overcome the problem of a short wide proximal neck in a patient with a ruptured AAA.