Long-term outcomes of urethral catheterisation injuries: a prospective multi-institutional study.

PURPOSE: There are no prospective data describing the incidence and spectrum of long-term complications associated with traumatic urethral catheterisation (UC). We prospectively monitored the long-term clinical outcomes and complications of patients with traumatic UC injuries. METHODS: A prospective study at two tertiary university hospitals was performed to record all referrals for iatrogenic urethral injuries caused by UC. Long-term follow-up was prospectively maintained by regular outpatient department visits and by monitoring all urological interventions and their outcomes from urinary catheter-related injuries. RESULTS: The incidence of traumatic UC was 13.4 per 1000 catheters inserted in male patients and 37 iatrogenic urethral injuries were recorded. The mean age was 74 ± 12 years and the mean length of follow-up was 37 ± 3.7 months. Urethral injuries were caused by inflating the catheter anchoring balloon in the urethra (n = 26) or by creating a false passage with the catheter tip (n = 11). In total, 29 patients (78%) developed urethral stricture disease during their follow-up; of which 11 have required at least one urethral dilation and two have required one urethrotomy. Three patients required long-term indwelling suprapubic catheter placement and seven patients opted for a long-term indwelling urethral catheter. There were eight patient mortalities; one of which was due to severe urosepsis resulting from catheter balloon inflation in the urethra. CONCLUSION: Catheter-related injuries are associated with significant long-term complications in this vulnerable patient cohort. In future, such injuries may be preventable if the safety profile of the urinary catheter is modified.

Blunt testicular trauma - is surgical exploration necessary?

OBJECTIVES: EAU and AUA guidelines recommend urgent surgical exploration in cases of suspected testicular rupture. However, the management of rupture to other encapsulated organs (e.g. kidney) is primarily non-operative. The aim of this study was to evaluate the conservative management of blunt scrotal trauma. METHODS: Standard practice in our Level II trauma centre is to manage all blunt scrotal injuries conservatively with analgesia, antibiotics and scrotal support. Ultrasonography is performed where testicular injury or haematocoele is suspected clinically. All patients are offered a 3 month follow-up appointment. A retrospective chart review was performed on all patients who underwent ultrasonography for blunt scrotal trauma between 1998 and 2014. Each patient was contacted by telephone to assess for testicular atrophy. RESULTS: Thirty-seven consecutive patients were identified for inclusion in the study. Twenty-three patients (62%) were diagnosed with significant testicular injury (rupture of tunica albuginea or large haematocele). All were managed conservatively regardless of ultrasound findings. Four patients had evidence of testicular atrophy at their three month follow up appointment. None reported chronic pain or required delayed orchidectomy. Four patients later underwent repair of an asymptomatic post-traumatic hydrocoele. CONCLUSIONS: Our experience shows that blunt scrotal trauma can be safely managed conservatively and may reduce the risk of atrophy compared to case series where the testis was surgically explored.

Attitudes of GP trainees towards the training received in urology on the GP training scheme.

INTRODUCTION: The majority of patients with scrotal problems or urinary symptoms will first present to their general practitioner (GP). The importance of the initial examination performed by the GP is often underestimated; however, it frequently determines the course of investigation and ultimately treatment. Unfortunately, medical schools have devoted increasingly less time to teaching urology over the past decade. The impact of this decline in teaching on a GP trainee's assessment of urological complaints remains unclear. The aim of this study was to investigate the self-reported competency of GP trainees in assessing urological presentations. METHODS: A questionnaire was circulated to 101 GP trainees from five separate training programmes. Respondents rated their confidence in evaluating four different urological presentations. They were also invited to give their opinion regarding the teaching of urology on their current scheme and whether they would be in favour of the addition of urology as an optional rotation. RESULTS: Only 18 trainees (19 %) felt urology was adequately covered on their curriculum. A small yet significant number of respondents felt uncomfortable in their assessment of testicular (28 %, 28/101) or prostate (35 %, 35/101) pathology and male (17 %, 17/101) or female (10 %, 10/101) urinary symptoms. Twenty-six trainees (26 %) would choose a rotation in urology if available. Another ten trainees felt that attending urology outpatient clinics would benefit training. CONCLUSION: This study highlights a number of concerns among GP trainees in relation to their training in urology. These issues should be addressed to ensure that the training scheme sufficiently prepares GPs to manage common urological conditions.

A comparative bibliometric analysis of the top 150 cited papers in hypospadiology (1945-2013).

INTRODUCTION: Hypospadias, the most common congenital malformation of the penis, is characterized by an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis, and an abnormal distribution of the foreskin around the glans, with a ventrally-deficient hooded foreskin, and has been described in modern peer-reviewed literature since Noble's description in 1853. A dramatic increase in the literature on hypospadiology has focused on two main topics: The aetiology of the condition including molecular mechanisms and environmental influences, as well as surgical techniques to repair the defect, however there have been a number of facets of research stemming from this poorly understood condition in a developing subspecialty (Figure). The majority of these publications focus on the evolution of surgical technique and management. Urethral reconstruction should offer the ability to stand to urinate and combine a satisfactory cosmetic result. The tubularized incised plate repair, popularized by Snodgrass et al., and the Mathieu repair, have been the mainstay for distal hypospadias, however, there have still been a large number of well-described techniques, with no consensus as to the ideal method of repair, some of which is attributed to non-uniform standards of reporting outcomes. There is also no standard objective means to qualitatively assess the importance of each of these contributions. OBJECTIVE: The objective of this study was to determine the top 150 peer-reviewed articles in the field of hypospadiology by way of citation analysis as a means to determine the importance/relevance of each contribution throughout 8 decades of research. STUDY DESIGN: A cited reference search was carried out for indexed citations within Web of Science™ Core Collection. The top 150 indexed cited articles containing the topic "hypospadias" in specific subject categories were compiled using a component of Science Citation Index command. References were then evaluated, and analysed across a number of indices, and over time. RESULTS: The mean number of citations was 76 for each article. The top 150 articles were published across 21 countries, with the majority originating from the USA. The lead research institution was the University of Texas (Southwestern) Medical Center. In total, the top 3 centers represented 33 publications within the top 150 citations. The most commonly utilized journal was the Journal of Urology. The most cited author was W.T. Snodgrass. 39% papers in the top 150 cited articles were published prior to 1990. Three out of the five papers cited in the 1940s dealt with operative technique to repair hypospadias. The period 2000-2010 in contrast, demonstrated a significant inverse correlation between molecular biology citations, and those for operative techniques, with the incidence of the latter dropping to 6% of all cited papers. DISCUSSION: This is the first study of its kind to analyse the most influential articles in hypospadiology, and their characteristics assessed for authorship, content and impact factor. Furthermore it allows data analysis by topic and between time points. This not only de-clutters the wealth of accumulated data on this subject, but also provides an important adjunct to education and training. As with this study, other citation analytical studies in urology found a significant preponderance in cited studies originating from the USA. The prevalence of the US in cited papers doesn't reflect any inherent bias, just a greater number of publications. CONCLUSION: Although there are inherent potential elements of bias in citation analysis, this study demonstrates that citation analysis in a complicated topic can provide a high-throughput, uncomplicated method of quickly deciphering important contributions of authors and institutions to the field of hypospadias research.

Paediatric urology training: what does the future hold?

BACKGROUND: Paediatric urology training is not a mandatory part of higher surgical training in urology in Ireland. It is predicted there will be a shortfall of surgeons trained in paediatric surgery in the coming years leading to a reliance on specialist paediatric surgical centres. AIM: The aim of this study was to assess the attitudes of urological trainees regarding the current state of paediatric urology training and to address the potential future changes to training structures. METHODS: A voluntary anonymous internet-based survey was emailed to all urological trainees. Parameters assessed included sex, level of training, attitudes towards paediatric urology training and levels of competence regarding core paediatric urological procedures. RESULTS: 69.2 % (n = 18) responded to the survey. 94.4 % (n = 17) would favour mandatory paediatric training-of these, 52.9 % (n = 9) would favour this in a dedicated paediatric hospital with a paediatric urologist. 66.7 % (n = 12) would like to provide a paediatric urology service as a consultant. 55.6 % (n = 10) felt they were competent to perform circumcision or scrotal exploration independently and manage all associated complications. No trainee felt themselves to be competent to perform orchidopexy independently and manage all complications. CONCLUSION: Our study demonstrates a promising desire to provide paediatric services in the future. A greater emphasis on structured paediatric urology training is required to maintain the standard currently offered by adult urologists.

Trigonal versus extratrigonal botulinum toxin-A: a systematic review and meta-analysis of efficacy and adverse events.

INTRODUCTION AND HYPOTHESIS: Botulinum toxin-A (BoNT-A) is a potent neurotoxin that is an effective treatment for patients with pharmacologically refractory detrusor overactivity (DO). Data assessing the effectiveness of trigonal BoNT-A are limited. This study evaluates adverse events (AEs) and short-term efficacy associated with trigonal and extratrigonal BoNT-A. METHODS: Electronic databases (PubMed, EMBASE, and the Cochrane database) were searched for studies comparing trigonal and extratrigonal BoNT-A for DO. Meta-analyses were performed using the random effects model. Outcome measures included incidence of AEs and short-term efficacy. RESULTS: Six studies describing 258 patients met the inclusion criteria. The meta-analysis did not show significant differences between trigonal and extratrigonal BoNT-A for acute urinary retention (AUR; 4.2 vs 3.7 %; odds ratio [OR]: 1.068, 95 % confidence interval [CI]: 0.239-4.773; P = 0.931) or high post-void residual (PVR; 25.8 vs 22.2 %; OR: 0.979; 95 % CI: 0.459-2.088; P = 0.956). The incidence of urinary tract infection (UTI; 7.5 vs 21.0 %; OR: 0.670; 95 % CI: 0.312-1.439; P = 0.305), haematuria (15.8 vs 25.9 %; OR: 0.547; 95 % CI: 0.264-1.134; P = 0.105) and post-operative muscle weakness (9.2 vs 11.3 %; OR: 0.587; 95 % CI: 0.205-1.680, P = 0.320) was similar in both groups. Finally, differences in short-term cure rates between two study arms were not statistically significant (52.9 vs 56.9 %; OR: 1.438; 95 % CI: 0.448-4.610; P = 0.542). CONCLUSIONS: Although data are limited, no significant differences between trigonal and extratrigonal BoNT-A in terms of AEs and short-term efficacy were observed. Additional randomised controlled trials are required to define optimal injection techniques and sites for administering intra-vesical BoNT-A.

The use of smartphone applications by urology trainees.

OBJECTIVE: Mobile phone technology is continuously advancing- the smartphone allows users instant access to information via the internet. Downloadable applications (apps) are becoming widespread across medical specialities. The aim of this study was to assess the use of smartphone apps among urology trainees in Ireland. METHODS: An anonymous electronic survey was distributed via Survey Monkey(®) to all urology trainees in Ireland assessing their ownership and use of smartphones and downloadable apps. A search of urology apps was performed using the Apple App Store and the Android Market. RESULTS: 36 (81.8%) of trainees responded with 100% ownership of smartphones. 28 (77%) report downloading apps with 11 (30.6%) reporting paying for them. The mean number of apps downloaded was 4 (Range 1-12). 16 (44.4%) trainees think apps for smartphones are very useful in clinical practice, 14 (42.4%) think they are useful. A total of 126 urology apps were available. 76 (60.3%) were designed for physicians, 46 (36.5%) for patients, 2 (1.6%) for students and 2 (1.6%) for urological nurses. CONCLUSION: There are an ever increasing number of urology apps available. Urology trainees are using smartphones as an educational and reference tool and find them a useful aide in clinical practice.

A prospective audit of emergency urology activity in a university teaching hospital.

INTRODUCTION: Urology cover is commonly available out-of-hours in most teaching hospitals. However, increased pressure to reduce hospital expenditure has forced many institutions to consider removing middle grade cover outside of normal working hours. The aim of this study was to audit the emergency urology activity in our institution over a 12-month period. METHODS: A prospective logbook was maintained for all urology referrals from the emergency department between August 2012 and March 2013. The diagnosis and patient outcome was recorded for each referral. The emergency theatre logbook was retrospectively evaluated for all emergency urology procedures carried out over the same time period. A basic cost analysis was performed to calculate the cost of providing the on-call service. RESULTS: A total of 752 patients were referred to the urology service over a 12-month period. The most common reasons for referral were renal colic and scrotal pain. Approximately 41 % of referrals were discharged directly from the emergency department. There were 167 emergency operations performed in total. The majority of emergency operations and referrals from the emergency department took place outside of normal working hours. A basic cost analysis revealed an associated cost saving of €58,120. CONCLUSION: Emergency urology activity constitutes a large proportion of the workload at our institution. Restricting emergency urology cover would limit essential training opportunities for urology trainees, increases length of stay and delay treatment of urological emergencies. Urology "out of hours" cover is a cost-efficient method of service provision.

Paediatric orchidopexy: a need for dedicated paediatric surgical training among urologists?

BACKGROUND: Undescended testis (UDT) is one of the most common congenital abnormalities with a prevalence of about 1% at the age of 1 year. UDT is associated with an increased risk of testicular tumours and infertility. AIMS: The aim of this study was to assess who is carrying out paediatric orchidopexy in Ireland. METHODS: A survey was distributed via Survey Monkey to all Consultant Paediatric Surgeons and Urologists in Ireland. RESULTS: Twenty-seven (64.3%) urologists and five (71.4%) paediatric surgeons responded to our online survey. Of the urologists, 100% reported formal training in paediatric orchidopexy. Eight (29.6%) underwent a dedicated paediatric fellowship. 13 (48.1%) currently perform paediatric orchidopexy. Nine (33%) think it should be carried out by a urologist, whereas eight (29.6%) think it should be carried out by paediatric surgeon. The mean age at which urologists think an orchidopexy for UDT should be performed by was 18 months (range 1-4 years). Approximately 400 orchidopexies are performed per year by the surveyed urologists. Of the paediatric surgeons, three (60%) feel it should be carried out by a paediatric surgeon whereas two (40%) feel it does not matter. All paediatric surgeons feel it should be performed by 1 year of age. Approximately 700 orchidopexies are performed per year by the surveyed paediatric surgeons. CONCLUSION: UDT is a concerning condition which requires intervention at an early stage. Dedicated training in core paediatric procedures is required to continue to meet this need for the future to prevent delayed orchidopexy and resultant increased risk of testicular tumours.

Buccal mucosa urethroplasty: a 10-year retrospective review of maxillofacial and urological outcomes.

BACKGROUND: Reconstruction of a urethral stricture poses a difficult surgical problem. Anastomotic repair remains the gold standard. Strictures longer than 2 cm may require substitution urethroplasty. This is a retrospective review of all patients who underwent urethral reconstruction with an autologous free buccal mucosa graft at a Regional hospital between 1998 and 2009. METHODS: Variables recorded included; demographics: patient gender/age; follow-up period. Urology: pre-operative diagnosis/aetiology; presenting complaint; previous urological surgery, pre-operative retrograde urethrogram, stricture length, graft size, operative time/blood loss, morbidity, complications. Maxillofacial: pre-/post-operative inter-incisal opening, patency of Stenson's parotid duct, ipsilateral parotid swelling, sensory nerve deficit. RESULTS: A total of eight male patients were included. Mean age was 33 years. Two patients had one-stage dorsal onlay urethroplasty, and the remaining six had a two-stage BMG urethroplasty. All patients underwent a urethrogram 20 days post-operatively, which demonstrated no leak, and a good caliber grafted urethra in all cases. A flexible cystoscopy scope was accommodated in all patients 8 weeks post-operatively. Mean follow-up was 42 months. At long-term follow-up, there was no evidence of stricture formation, and all patients were voiding well. There were no long-term intra-oral complications. CONCLUSION: This study suggests that anterior urethral strictures up to 6 cm in length may be predictably and safely managed with buccal mucosal urethroplasty. The buccal mucosa is easy to harvest, and can be used successfully in one- and two-stage grafting procedures. The rate of complications, from both a urological and maxillofacial perspective, in the group of patients studied was low.

Evaluation of endoscopic laser excision of polypropylene mesh/sutures following anti-incontinence procedures.

PURPOSE: We reviewed our experience with and outcome of the largest series to our knowledge of patients who underwent endoscopic laser excision of eroded polypropylene mesh or sutures as a complication of previous anti-incontinence procedures. MATERIALS AND METHODS: A total of 12 female patients underwent endoscopic laser excision of suture/mesh erosions at 1 center during a 10-year period. Primary outcome variables were the requirement of additional endoscopic or open surgery to remove mesh/sutures. Secondary outcome variables were persistence of urinary symptoms, postoperative complications, continence status and requirement of additional anti-incontinence procedures. RESULTS: The mean interval from previous surgery to erosion was 59 months (range 7 to 144) and the duration of presenting symptoms ranged from 3 to 84 months (mean 19). Ten patients underwent endoscopic excision of the mesh/suture with the holmium:YAG laser and 2 underwent excision with the thulium laser. Mean operative duration was 19 minutes (range 10 to 25) and followup was 65.5 months (range 6 to 134). Postoperatively 6 patients remain asymptomatic and 2 required a rectus fascial sling for recurrent stress urinary incontinence. Four patients underwent a second endoscopic excision due to minor persistence of erosion. Only 1 patient ultimately required open cystotomy to remove the eroded biomaterial. No intraoperative complications were recorded and all patients are currently asymptomatic. CONCLUSIONS: Endoscopic laser excision is an acceptable first line approach for the management of eroded biomaterials due to its high long-term success rate and minimally invasive nature.

Perioperative management of chronic anticoagulation therapy in urological patients: a cross-sectional survey of practice.

BACKGROUND: There has been a significant increase in the volume of urological patients on daily anticoagulation therapy requiring invasive elective urological procedures. AIMS: We sought to assess whether urologists are familiar with appropriate perioperative management strategies in this patient cohort. METHODS: Urologists completed a questionnaire on their current management strategy for warfarin during the perioperative period in patients undergoing elective urological surgery. Eleven urological procedures graded as minor, endoscopic and major were assessed in the study. In addition, respondents were also asked whether they administered bridging therapy with heparin when warfarin was discontinued perioperatively. RESULTS: The response rate was 52.5% (210/400). Procedure grade did not influence the duration warfarin was discontinued preoperatively with respondents discontinuing the agent 4.71 ± 1.52 days (range 2-10 days) prior to minor procedures, 4.74 ± 1.43 days (range 2-10 days) prior to endoscopic procedures and 4.88 ± 1.34 days (range 2-10 days) prior to major procedures (p > 0.05). Postoperatively, procedure grade significantly affected the day to recommencement with respondents recommencing warfarin 2.41 ± 2.31 days (range 1-14 days) after minor procedures, 3.07 ± 3.52 days (range 1-28 days) after endoscopic procedures and 4.38 ± 3.53 days (range 1-14 days) after major procedures (p < 0.0001). In total, 60 ± 0.52% of the respondents who discontinued warfarin routinely administered bridging therapy with heparin perioperatively. CONCLUSIONS: Our study demonstrates variations in perioperative management practices for patients on chronic anticoagulation therapy undergoing urological procedures. Urologists should familiarise themselves with standardised guidelines if this patient subgroup are to receive optimal perioperative management.

Porcine extracellular matrix scaffolds in reconstructive urology: An ex vivo comparative study of their biomechanical properties.

Functional reconstruction of the human urinary bladder has been attempted by replacing defective bladder tissue with tissue-engineered xenogenic extracellular matrix (ECM) scaffolds. However, experimental studies that demonstrate the effects of implanted ECMs on important biomechanical properties such as total bladder capacity (TBC) and compliance (C) are lacking. In the current study, the effects of ECM scaffold surface area (SA) on TBC and C was assessed, ex vivo, in an ovine model (n=5). TBC and C were measured at pressures (P) of 5, 10, 15 and 20 mm Hg prior to performing a 3×3 cm (9 cm(2)) partial cystectomy defect. Equal-sized 3×3 cm (9 cm(2)) and larger 6×6 cm (36 cm(2)) urinary bladder matrix (UBM) scaffolds of porcine origin replaced the 3×3 cm cystectomy defect, and TBC and C were re-recorded for comparative analysis. The results showed that TBC decreased by 39.6%±0.005% (122.9 ml±15 ml, p<0.05) and C by 38.9%±0.51%, (ΔP=0-5mmHg, p<0.05) in ovine bladders reconstructed with 3×3 cm UBM scaffolds compared to their native values. It was also found that TBC increased by 25.6±0.64% (64.2 ml ± 8.8 ml, p>0.05) and C by 24.5±0.43% (ΔP=0-5mmHg, p>0.05) in the 6×6 cm UBM scaffold group compared to the 3×3 cm UBM scaffold group; however, these values were not statistically significant. The present work demonstrates that a fourfold increase in ECM scaffold SA relative to its intended defect does not lead to a significant improvement in TBC and C values.

Xenogenic extracellular matrices as potential biomaterials for interposition grafting in urological surgery.

PURPOSE: The field of tissue engineering focuses on developing strategies for reconstructing injured, diseased, and congenitally absent tissues and organs. During the last decade urologists have benefited from remodeling and regenerative properties of bioscaffolds derived from xenogenic extracellular matrices. We comprehensively reviewed the current literature on structural and functional characteristics of xenogenic extracellular matrix grafting since it was first described in urological surgery. We also reviewed the clinical limitations, and assessed the potential for safe and effective urological application of extracellular matrix grafting in place of autogenous tissue. MATERIALS AND METHODS: We performed literature searches for English language publications using the PubMed® and MEDLINE® databases. Keywords included "xenogenic," "extracellular matrix" and "genitourinary tract applications." A total of 112 articles were scrutinized, of which 50 were suitable for review based on clinical relevance and importance of content. RESULTS: Since the mid 1990s xenogenic extracellular matrices have been used to successfully treat a number of pathological conditions that affect the upper and lower genitourinary tract. They are typically prepared from porcine organs such as small intestine and bladder. These organs are harvested and subjected to decellularization and sterilization techniques before surgical implantation. Bioinductive growth factors that are retained during the preparation process induce constructive tissue remodeling as the extracellular matrix is simultaneously degraded and excreted. However, recent documented concerns over durability, decreased mechanical strength and residual porcine DNA after preparation techniques have temporarily hampered the potential of extracellular matrices as a reliable replacement for genitourinary tract structures. CONCLUSIONS: Extracellular matrices are a useful alternative for successfully treating a number of urological conditions that affect the genitourinary tract. However, clinical concerns regarding mechanical limitations and biosafety need to be addressed before their long-term role in reconstructive urological surgery can be clearly established.

Current concepts in female stress urinary incontinence.

Urinary incontinence is a social burden for up to one-third of the adult female population. Careful assessment, a methodical approach and appropriate treatment can lead to long-term success in the management of these patients. This article gives an outline of current concepts in the evaluation and treatment of stress urinary incontinence.

Diagnostic accuracy of hand-held Doppler in the management of acute scrotal pain.

We evaluate the reliability of hand-held Doppler (HHD) in the management of acute scrotal pain of 24 h or less duration. Between October 2003 and December 2004, patients presenting with acute scrotal pain were enrolled in this prospective study. After clinical examination, all patients had a HHD assessment. Presence or absence of Doppler arterial signals and its intensity were recorded. A blinded assessor corroborated HHD findings with the clinical, ultrasound, operative findings and final diagnosis. Primary outcome measured were sensitivity and specificity of HHD in the diagnosis of testicular torsion. Twenty-five patients presented during the study period with acute scrotal pain. The final diagnosis was testicular torsion in nine, epididymitis in 13, twisted cyst of Morgagni in two and Henoch-Schoenlein purpura in one patient. The HHD predicted all patients of testicular torsion correctly, preoperatively. HHD is a reliable diagnostic tool in the management of patients with acute scrotal pain.

The Snodgrass repair: is stenting always necessary?

To evaluate the need for stenting in Snodgrass hypospadias repairs. Sixty-five boys underwent hypospadias repairs between April 1996 and July 2001. A variety of techniques were employed. Snodgrass repair was performed in 39 patients, MAGPI in 18, Glanular approximation procedures in 4, Mathieu procedures in 3 and one Duckett Onlay-flap. Seventeen patients, all Snodgrass repairs, had placement of a urethral stent for one week postoperatively. Follow-up at six weeks and one year or when toilet-trained was carried out on all patients. A Fisher's exact test was performed analysing the difference in outcome of the distal Snodgrass repairs depending on the presence or absence of a urethral stent. The patient age at the time of surgery ranged from 8-115 months, with a median of 21 months. Postoperative complications included 1 stent migration, 1 urethral diverticulum and 4 fistulas. Also in one patient part of the ventral skin flap on one side sloughed away, this was debrided and allowed to close by secondary intention. The fistula rate in the entire group is 6%, with an incidence of 10.5% in patients undergoing Snodgrass repair. In the cases having Snodgrass repair for meatal position other than mid- or proximal shaft there was no statistical difference in the incidence of fistula whether or not a stent was used. The long-term follow-up of the entire group indicates that 5 patients developed meatal narrowing, 3 in stented Snodgrass repairs, one patient who had a MAGPI and one GAP patient. Otherwise the long-term outcome of the surgery has been excellent for the entire group. We believe that stenting can be abandoned in distal repairs without compromising patient outcomes.

Hypospadias associated undescended testis in a Spigelian hernia.

BACKGROUND: First described in 1764, Spigelian hernias are rare. The patient profile is of an overweight, 50-year-old with associated respiratory disease. However we report the case of a four-month-old, with an associated hypospadias and cryptorchidism, where the testis was lying in a spigelian hernia. AIMS: To highlight this unusual presentation of cryptorchidism. CONCLUSION: Embryological development is a complex event that relies on the sequencing of hormonal surges for anatomical development. In this case report we postulate that the findings are secondary to hormonal disruption.

Ureteral endometriosis and ovarian mucinous cystadenoma presenting with acute pyonephrosis.

BACKGROUND: Endometriosis is a common disease, but ureteral involvement is rare. Nonspecific clinical presentations of ureteral endometriosis may result in diagnostic difficulty. AIM: To discuss the diagnosis and management of such a case. METHODS: To report a case of ureteral involvement with endometriosis and review the literature. RESULTS: The case presented with right lower quadrant pain giving rise to initial diagnostic possibility of acute appendicitis. Subsequent evaluation revealed the diagnosis of right pyonephrosis due to midureteral endometriosis with right ovarian mucinous cystadenoma. CONCLUSION: The diagnosis of ureteral endometriosis requires a high index of clinical suspicion. The importance of ultrasound in the evaluation of acute abdomen in women can not be overemphasised.

Pubovaginal sling for urodynamic stress incontinence: effect on patient quality of life.

To report the medium term effects of the pubovaginal sling (PVS) on patient quality of life (QOL). Patients and Methods Over a two year period, 72 females aged between 17 and 63 years (mean 46.1 years) underwent PVS for urodynamic stress incontinence (USI). All data were accrued prospectively. Preoperative assessment consisted of a full history (including King's Health and SF-36 questionnaires), physical examination, urinalysis and urodynamics. Postoperatively all patients were assessed at 6 weeks and 6 months. At these intervals each patient was questioned regarding persistence or recurrence of USI, presence of urge/urge incontinence (UI) and QOL. Preoperatively, 60 patients (83.3%) demonstrated type II USI and 12 (16.7%) had type III USI. Detrusor overactivity (DO) was also present in 3 patients. At 6 weeks 100% of patients remained completely dry, 8 (11%) patients complained of urgency but none complained of UI. At 6 months 95% of the subjects remained dry, 3 complained of recurrent USI, 7 complained of urgency and 1 of UI. The incidence of de novo urgency was 5.5%. There were significant improvements in 4 of the 8 domains of the SF-36, and in 8 of the 9 domains of the King's Health questionnaire, at both 6 weeks and 6 months follow-up. PVS is effective in the treatment of all types of USI, with early success rates of up to 95%. The procedure is associated with minimal morbidity and has a positive impact on patient QOL.