Acute management of priapism in men.

UNLABELLED: What's known on the subject? and What does the study add? Priapism is a rare event. However, various medications and medical conditions may increase the risk. Priapism can be ischaemic, non-ischaemic or stuttering. It is paramount to distinguish the type of priapism, as misdiagnosis may lead to significant morbidity. Ischaemic priapism represents a compartment syndrome of the penis and is therefore a medical emergency. A delay in management may significantly affect future erectile function. Stuttering priapism represents recurrent subacute episodes of ischaemic priapism, which may lead to erectile dysfunction. Thus episodes must be minimised. Non-ischaemic priapism is not a medical emergency. However, misdiagnosis and injection with sympathomimetic agents can result in system absorption and toxicity. This review article provides a summary of the evaluation and management of priapism. Furthermore, a step by step flow chart is provided to guide the clinician through the assessment and management of this complex issue. OBJECTIVES: To review the literature regarding ischaemic, non-ischaemic and stuttering priapism. To provide management recommendations. PATIENTS AND METHODS: A Medline search was carried out to identify all relevant papers with management guidelines for priapism. RESULTS: Ischaemic priapism represents a compartment syndrome of the penis and urgent intervention is required to decrease the risk of erectile dysfunction. Non-ischaemic priapism is not a medical emergency; however, it can result in erectile dysfunction. The treatment objective for stuttering priapism is to reduce future episodes with systemic treatments, whilst treating each ischaemic episode as an emergency. CONCLUSIONS: Priapism is a complex condition that requires expert care to prevent complications and irreversible erectile dysfunction.

Prostate weight is the preferred measure of prostate size in radical prostatectomy cohorts.

OBJECTIVE: To evaluate the accuracy of calculated prostate volume variables in a radical prostatectomy (RP) cohort, as many recent studies use these measures of prostate size instead of prostate weight. To determine whether this accuracy could be improved by modifying the mathematical model used in the volume estimation. PATIENTS AND METHODS: Patients who underwent RP for prostate cancer at our associated institutions had calculated specimen volumes and weights from RP specimens determined at one pathology institution and transrectal ultrasonography (TRUS) volumes were recorded preoperatively (n= 236). Correlation analysis was performed and errors were determined for calculated volume variables when compared with prostate weight. Bland-Altman plots were drawn and concordance coefficients calculated. Analysis was repeated with smaller prostates mathematically modelled as bullet-shaped rather than ellipsoid (n= 165). RESULTS: Although correlation was good for both TRUS and specimen volumes, they equally underestimated prostate weight with a large range of errors and poor concordance coefficients. Only 22% of TRUS volumes and 11% of calculated specimen volumes were within 10% of weight measurements. Application of a bullet-shaped mathematical model for prostates <55 g did not correct the large individual variation seen within these values. CONCLUSION: Calculated prostate volume variables are prone to a large range of individual error regardless of the mathematical model used and should be avoided in statistical studies involving RP cohorts, and the more accurate prostate weight variable should instead be used as a size variable or correction factor.

Complete stone clearance using a modified supine position: initial experience and comparison with prone percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: The recently described Galdakao-modified supine Valdivia position for percutaneous nephrolithotomy (PCNL) has become increasingly popular. We have made further modifications to this and describe our recent experience compared with our previous prone cases. PATIENTS AND METHODS: From April 2011, all patients undergoing PCNL have been placed in the modified supine position. A suction beanbag is used to secure the patient and improve renal access. Data on patient age, comorbidities, stone size, operative time, radiation exposure, complications, stone clearance, and length of stay was collected, analyzed, and compared with data from our previous year's prone surgery. RESULTS: Thirty-six patients in each group underwent 41 PCNLs. The groups were well matched for age, sex, and comorbidity. The supine patients tended to have a higher body mass index. Stones in the supine group were larger (32.6 vs 25.7 mm, P=0.0402), and the operative time was shorter (86.2 vs 116.6 min, P=0.003). Radiation time was similar in the two groups, but the dose was higher in the supine group. Stone clearance rates, length of stay (2.5 days), and complications were similar. Nineteen (46%) patients underwent simultaneous lower urinary tract procedures including 4 (10%) with complete staghorn calculi for which ureterorenoscopy was used to fragment ureteral and upper renal pole stones. CONCLUSIONS: The modified supine position for PCNL has a number of advantages for the patient and staff compared with the prone position. Despite a more obese study group with larger stones, we have maintained stone clearance rates and significantly reduced operative time with no increase in complications. The technique has been easy to learn and teach. A major advantage has been simultaneous access to the lower urinary tract for ureteroscopy and stent placement, and this has helped with complete stone clearance.

Prostate tumour volume is an independent predictor of early biochemical recurrence in a high risk radical prostatectomy subgroup.

AIMS: To assess if accurately determined tumour volume variables could serve as independent predictors of early biochemical recurrence in high risk prostate cancer patients who underwent radical prostatectomy. METHODS: Tumour volume variables were calculated by digital planimetry in 269 prostatectomy specimens of patients with high risk prostate cancer. The associations to biochemical progression of tumour volume and clinicopathological variables, including age, pre-operative prostate specific antigen (PSA) levels, final Gleason score, pathological T stage, and surgical margins, were examined using univariate and multivariate Cox proportional hazards analyses. RESULTS: Median tumour volume was 3.7 ml [interquartile range (IQR) 2.1-6.1 mL] and median follow-up time was 12 months (IQR 6-24 months). Biochemical recurrence occurred in 64 men (24%) during this period, with a median time to recurrence of 7.5 months (IQR 3.0-15.5 months). On univariate analysis all of the tumour volume variables were strongly correlated with the clinicopathological variables, as well as biochemical recurrence (p < 0.001). On multivariate analysis, we found that tumour volume variables served as independent predictors of PSA progression whilst other routinely reported pathological variables did not. CONCLUSION: Accurately assessing tumour volume in the high risk setting may aid in identifying patients at greatest risk of developing early biochemical recurrence and most in need of adjuvant therapy.