Testicular torsion and subsequent testicular function in young men from the general population.

STUDY QUESTION: Is prior testicular torsion associated with testicular function (semen quality and reproductive hormones) in young men from the general population? SUMMARY ANSWER: In young men from the general population, no differences in semen parameters were observed in those who had experienced testicular torsion compared to controls and observations of higher FSH and lower inhibin B were subtle. WHAT IS KNOWN ALREADY: Testicular function may be impaired after testicular torsion, but knowledge is sparse and based on studies with small sample sizes and no control group or a less than ideal control group. STUDY DESIGN, SIZE, DURATION: A cross-sectional population-based study was carried out including 7876 young Danish men with unknown fertility potential, examined from 1996 to 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: All men (median age 19.0 years) had a physical examination, provided a blood and semen sample, and filled in a questionnaire including information about prior testicular torsion, birth, lifestyle and current and previous diseases. Markers of testicular function, including testis volume, semen parameters and reproductive hormones, were compared between men operated for testicular torsion and controls, using multiple linear regression analyses. MAIN RESULTS AND THE ROLE OF CHANCE: The average participation rate was 24% for the entire study period. In total, 57 men (0.72%) were previously operated for testicular torsion (median age at surgery 13.4 years) of which five had only one remaining testicle. Men with prior testicular torsion were more often born preterm (25% versus 9.5% among controls), and they had significantly higher FSH and lower inhibin B levels, and a lower inhibin B/FSH ratio than controls in crude and adjusted models. The association was mainly driven by the subgroup of men who had undergone unilateral orchiectomy. No differences in semen parameters were observed. LIMITATIONS, REASONS FOR CAUTION: A limitation is the retrospective self-reported information on testicular torsion. Also, results should be interpreted with caution owing to the high uncertainty of the observed differences. WIDER IMPLICATIONS OF THE FINDINGS: Overall, the results of our study are reassuring for men who have experienced testicular torsion, especially when treated with orchiopexy, for whom reproductive hormone alterations were subtle and without obvious clinical relevance. Our study found no differences in semen parameters, but follow-up studies are needed to assess any long-term consequences for fertility. STUDY FUNDING/COMPETING INTEREST(S): Financial support was received from the Danish Ministry of Health; the Danish Environmental Protection Agency; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); A.P. Møller and wife Chastine Mckinney Møllers Foundation; Svend Andersens Foundation; the Research Fund of the Capital Region of Denmark; and ReproUnion (EU/Interreg). The authors have nothing to declare. TRIAL REGISTRATION NUMBER: N/A.

Average sperm count remains unchanged despite reduction in maternal smoking: results from a large cross-sectional study with annual investigations over 21 years.

STUDY QUESTION: How are temporal trends in lifestyle factors, including exposure to maternal smoking in utero, associated to semen quality in young men from the general population? SUMMARY ANSWER: Exposure to maternal smoking was associated with lower sperm counts but no overall increase in sperm counts was observed during the study period despite a decrease in this exposure. WHAT IS KNOWN ALREADY: Meta-analyses suggest a continuous decline in semen quality but few studies have investigated temporal trends in unselected populations recruited and analysed with the same protocol over a long period and none have studied simultaneous trends in lifestyle factors. STUDY DESIGN, SIZE, DURATION: Cross-sectional population-based study including ~300 participants per year (total number = 6386) between 1996 and 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study is based on men from the Greater Copenhagen area, Denmark, with a median age of 19 years, and unselected with regard to fertility status and semen quality. The men delivered a semen sample, had a blood sample drawn and a physical examination performed and answered a comprehensive questionnaire, including information on lifestyle and the mother's pregnancy. Temporal trends in semen quality and lifestyle were illustrated graphically, and trends in semen parameters and the impact of prenatal and current lifestyle factors were explored in multiple regression analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Throughout the study period, 35% of the men had low semen quality. Overall, there were no persistent temporal trends in semen quality, testicular volume or levels of follicle-stimulating hormone over the 21 years studied. The men's alcohol intake was lowest between 2011 and 2016, whereas BMI, use of medication and smoking showed no clear temporal trends. Parental age increased, and exposure in utero to maternal smoking declined from 40% among men investigated in 1996-2000 to 18% among men investigated in 2011-2016. Exposure to maternal smoking was associated with lower sperm counts but no overall increase in sperm counts was observed despite the decrease in this exposure. LIMITATIONS, REASONS FOR CAUTION: Information of current and prenatal lifestyle was obtained by self-report, and the men delivered only one semen sample each. WIDER IMPLICATIONS OF THE FINDINGS: The significant decline in in utero exposure to maternal smoking, which was not reflected in an overall improvement of semen quality at the population level, suggest that other unknown adverse factors may maintain the low semen quality among Danish men. STUDY FUNDING/COMPETING INTEREST(S): The study has received financial support from the ReproUnion; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314,QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); the Danish Ministry of Health; the Danish Environmental Protection Agency; A.P. Møller and wife Chastine McKinney Møllers foundation; and Svend Andersens Foundation. None of the funders had any role in the study design, collection, analysis or interpretation of data, writing of the paper or publication decisions. TRIAL REGISTRATION NUMBER: N/A.

Impact of lifestyle intervention for obese women during pregnancy on maternal metabolic and inflammatory markers.

BACKGROUND: Offspring of obese mothers have increased risk of developing obesity and related short- and long-term disease. The cause is multifactorial and may partly be explained by the unfavorable intrauterine environment. Intervention during pregnancy leading to a healthier lifestyle among obese may alter this. OBJECTIVE: To assess the effect of lifestyle intervention on markers of maternal metabolism and inflammation in 'the TOP (Treatment of Obese Pregnant Women) study', a randomized controlled trial. METHODS: In the TOP-study 425 participants with body mass index ⩾30 kg/m2 were randomized to intervention with dietary advices and physical activity assessed by pedometer (PA+D), physical activity assessed by pedometer (PA) or control (C). Of 389 participants completing the study 376 had available blood samples. Serum was analyzed for insulin, c-peptide, lipid profile, leptin, high-sensitivity CRP (hsCRP) and Soluble urokinase Plasminogen Activator Receptor (suPAR), in week 18-20 and 28-30, and simultaneously a 2-h oral glucose-tolerance-test was performed. Diet was assessed in gestational week 11-14 and 36-37 using a validated 360-item Food Frequency Questionnaire. RESULTS: Median levels of hsCRP in gestational week 28-30 were lower in each of the intervention groups (8.3 mg/l in PA+D group, P=0.03; and 8.8 mg/l in PA group, P=0.02) versus the control group (11.5 mg/l). Obtaining 11 000 steps per day as aimed for resulted in a 21% lower hsCRP compared to non-compliant women. Women reporting high carbohydrate intake had around 30% higher hsCRP concentrations in late gestation than women reporting the lowest intake. There were no differences in lipid profile or any of the metabolic markers in gestational week 28-30 when comparing the intervention and control groups. CONCLUSIONS: Lifestyle intervention in obese women can reduce hsCRP representing a marker of inflammation during pregnancy. The effect may partly be mediated by more physical activity and partly by changes in intake of carbohydrates and the glycaemic load.

Permissive and protective roles for neutrophils in leishmaniasis.

Leishmania parasites are the causative agents of leishmaniasis, a neglected tropical disease that causes substantial morbidity and considerable mortality in many developing areas of the world. Recent estimates suggest that roughly 10 million people suffer from cutaneous leishmaniasis (CL), and approximately 76,000 are afflicted with visceral leishmaniasis (VL), which is universally fatal without treatment. Efforts to develop therapeutics and vaccines have been greatly hampered by an incomplete understanding of the parasite's biology and a lack of clear protective correlates that must be met in order to achieve immunity. Although parasites grow and divide preferentially in macrophages, a number of other cell types interact with and internalize Leishmania parasites, including monocytes, dendritic cells and neutrophils. Neutrophils appear to be especially important shortly after parasites are introduced into the skin, and may serve a dual protective and permissive role during the establishment of infection. Curiously, neutrophil recruitment to the site of infection appears to continue into the chronic phase of disease, which may persist for many years. The immunological impact of these cells during chronic leishmaniasis is unclear at this time. In this review we discuss the ways in which neutrophils have been observed to prevent and promote the establishment of infection, examine the role of anti-neutrophil antibodies in mouse models of leishmaniasis and consider recent findings that neutrophils may play a previously unrecognized role in influencing chronic parasite persistence.

Long-Term Gynecological Outcomes in Women with Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency.

Background. Our knowledge on long-term outcome in CAH remains incomplete. Methods. In a prospective study (33 CAH patients, 33 age-matched controls), reproductive outcomes, self-rating of genital appearance and function, and sexuality were correlated to degree of initial virilisation, genotype, and surgery. Results. Patients had larger median clitoral lengths (10.0 mm [range 2-30] versus 3.5 [2-8], P < .001), shorter vaginal length (121 mm [100-155] versus 128 [112-153], P = .12), lower uterine volumes (29.1 ml [7.5-56.7] versus 47.4 [15.9-177.5], P = .009), and higher ovarian volumes (4.4 ml [1.3-10.8] versus 2.8 [0.6-10.8], P = .09) than controls. Satisfaction with genital appearance was lower and negatively correlated to degree of initial virilisation (r(s) = ≤-0.39, P ≤ .05). More patients had never had intercourse (P = .001), and age at 1st intercourse was higher (18 yrs versus 16 yrs, P = .02). Conclusion. Despite overall acceptable cosmetic results, reproductive outcomes were suboptimal, supporting that multidisciplinary teams should be involved in adult follow up of CAH patients.

Pheochromocytomas, PASS, and immunohistochemistry.

Differentiation between malignant and benign pheochromocytomas of the adrenal gland traditionally relies on the presence of clinically detectable metastases. The PASS system for differentiating between benign and malignant pheochromocytomas is based on defined morphological criteria, of which some are related to tumour cell proliferation and survival. Immunohistochemical markers for important events in the cell cycle were explored in order to characterise differences in apoptosis, G1 checkpoints, and S phase in more detail. A panel consisting of p53, tenascin, bcl-2, pRb, cyclin D1, mcm2, and p27 was employed. Only for pRb a statistically significant difference between PASS 3 and less and PASS 4+ tumours was detected, indicating qualitative differences in the mitotic cycle, probably immediately before early S phase. These results are discussed in relation to similar studies in recent literature.

Expression of EZH2 and Ki-67 in colorectal cancer and associations with treatment response and prognosis.

BACKGROUND: Enhancer of zeste homologue 2 (EZH2) is a member of the Polycomb group of genes that is involved in epigenetic silencing and cell cycle regulation. METHODS: We studied EZH2 expression in 409 patients with colorectal cancer stages II and III. The patients were included in a randomised study, and treated with surgery alone or surgery followed by adjuvant chemotherapy. RESULTS: EZH2 expression was significantly related to increased tumour cell proliferation, as assessed by Ki-67 expression. In colon cancer, strong EZH2 expression (P=0.041) and high proliferation (>or=40%; P=0.001) were both associated with better relapse-free survival (RFS). In contrast, no such associations were found among rectal cancers. High Ki-67 staining was associated with improved RFS in colon cancer patients who received adjuvant chemotherapy (P=0.001), but not among those who were treated by surgery alone (P=0.087). In colon cancers stage III, a significant association between RFS and randomisation group was found in patients with high proliferation (P=0.046), but not in patients with low proliferation (P=0.26). Multivariate analyses of colon cancers showed that stage III (hazard ratio (HR) 4.00) and high histological grade (HR 1.80) were independent predictors of reduced RFS, whereas high proliferation indicated improved RFS (HR 0.55). CONCLUSION: Strong EZH2 expression and high proliferation are associated features and both indicate improved RFS in colon cancer, but not so in rectal cancer.

Resection rectopexy for external rectal prolapse reduces constipation and anal incontinence.

BACKGROUND AND AIMS: The main aim was to examine constipation and anal incontinence in patients before and after resection for external rectal prolapse. MATERIAL AND METHODS: Twenty patients had ligament preserving suture rectopexy and sigmoid resection (resection rectopexy) for external rectal prolapse by laparoscopic (n = 15) or open (n = 5) technique during 2001-2005. They were prospectively evaluated for constipation and anal incontinence using validated incontinence and KESS-constipation scores. RESULTS AND CONCLUSIONS: Constipation score was significantly reduced from mean 7.7 (5.4-9.9) to 4.5 (2.5-6.4) after median 4 months (1-19) and to 4.3 (2.2-6.3) after median 17 months (4-51). Six and four patients were constipated preoperatively and 17 months postoperatively, respectively. The four symptoms feeling incomplete evacuation of stool, minutes in lavatory per attempt, use of enemas/digitation and painful evacuation effort were significantly reduced, whilst stool consistency increased. Fourteen patients (70%) had anal incontinence. Corresponding and significant reduction in their scores were from mean 12.5 (9.4-15.5) to 5.1 (2.1-8.1) and to 3.6 (1.3-5.9). Incontinence was improved in 13 and unaltered in one patient(s). Two patients with worse outcome had increased stool consistency and constipation scores. Resection rectopexy for rectal prolapse reduced anal incontinence and constipation.

Parathyroid carcinoma in multiple endocrine neoplasia type 1 (MEN1) syndrome: two case reports of an unrecognised entity.

CONTEXT: Primary hyperparathyroidism occurs in almost all patients with the syndrome of multiple endocrine neoplasia type 1 (MEN1), but the association of MEN1 with parathyroid carcinoma has only been described previously in a single patient. In this report, we describe two further cases of parathyroid carcinoma presenting in MEN1 syndrome. CASE REPORTS: The first patient was a 69-yr-old woman, who presented with severe primary hyperparathyroidism and tracheal compression by a large mediastinal mass, which was shown histologically to be a parathyroid carcinoma with a second similar lesion in the neck. She was treated with total parathyroidectomy followed by resection of the mediastinal mass with resolution of the hypercalemia. Remarkably, she also reported primary amenorrhea and was found to have an invasive pituitary lactotroph adenoma, which was treated with cabergoline and external beam radiotherapy. Magnetic resonance imaging (MRI) of the pancreas revealed a small lesion characteristic of an islet-cell tumor, which was clinically and biochemically non-functioning. The second patient was a 32-yr-old man who presented with symptomatic hypercalemia and markedly raised serum PTH concentration. Neck exploration revealed two parathyroid glands only. One of the parathyroid glands contained a tumor with fibrous banding, atypical mitoses, extra-capsular extension and moderate Ki 67 staining; features which are highly suggestive of carcinoma. He also had intractable dyspepsia associated with raised serum gastrin concentration. A lesion was localized to the neck of the pancreas by endocopic ultrasound, and a selective arterial calcium stimulation catheter suggested the presence of both a gastrinoma and an insulinoma, although he had no hypoglycemic symptoms. Pituitary MRI was normal. The patient's mother had primary hyperparathyroidism. CONCLUSIONS: This case report describes two further patients in whom parathyroid carcinomas occurred in the context of MEN1, which gives a new insight to the possible presenting phenotype of this condition. Both patients had negative genetic screening for classic MEN1 gene mutation, which may suggest that one or more novel occult mutations may be responsible for this aggressive phenotype.

Towards a non-invasive method for early detection of testicular neoplasia in semen samples by identification of fetal germ cell-specific markers.

BACKGROUND: Testicular germ cell tumours (TGCTs) originate from a common precursor, carcinoma in situ (CIS). Diagnosis at the CIS stage is desirable as it minimizes the necessary treatment. A detailed clinical evaluation of an approach to detect CIS cells in the ejaculate using primordial germ cell/gonocyte markers is presented. METHODS: Immunocytological staining for AP-2gamma [and in some cases, OCT-3/4, NANOG or placental alkaline phosphatase (PLAP)] was performed in semen samples from 294 infertile patients and 209 patients with TGCTs or other diseases. RESULTS: Presence of AP-2gamma-stained cells was detected in 50% of participants with CIS and in 33.9% of TGCT patients before treatment (non-seminomas: 56.6%, seminomas: 17.4%). OCT-3/4 results were similar to those of AP-2gamma, whereas NANOG and PLAP stainings were unsuitable. Sensitivity was 54.5% for participants harbouring pre-invasive CIS but reduced in participants with overt TGCTs, perhaps because of obstruction. Assay specificity was 93.6%, positive predictive value (PPV) 83.3% and negative predictive value (NPV) 60.3%. CONCLUSIONS: Immunocytological semen analysis based on expression of fetal germ cell markers in exfoliated cells has auxiliary diagnostic value, as it detects some patients with CIS/incipient tumour, but a negative result does not exclude TGCT. Further effort is needed to improve this assay, for example, by employing a more sensitive biochemical method of detection.

Nationwide quality assurance of rectal cancer treatment.

OBJECTIVE: The purpose of this prospective study was to examine the influence of the efforts for nationwide quality assurance of rectal cancer treatment. The study focuses on local recurrence and overall survival. METHODS: This study includes all 3388 Norwegian patients with a rectal cancer within 15 cm from the anal verge treated with curative intent in the period November 1993-December 1999. A comprehensive educational programme was established, and training courses were arranged in different Health Regions demonstrating the TME technique. A specific Rectal Cancer Registry enabled the monitoring of outcome of rectal cancer treatment for single hospitals. Radiotherapy was given to 10% of the patients. RESULTS: The risk of local recurrence has been significantly reduced, so that in 1999 the level was 50% below that observed in 1994 (Hazard ratio (HR)1999=0.5; 95% CI 0.4-0.8, P=0.002). Similarly, during 1998, the mean national overall survival was significantly improved, compared to the rate in 1994 (HR1998=0.8; 95% CI 0.6-1.0, P=0.014). CONCLUSION: The prognosis for rectal cancer can be improved by increased organizational focus on rectal cancer treatment and by establishing a rectal cancer registry monitoring treatment standards throughout the country.

Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer.

AIMS: The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis. METHODS: Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months. RESULTS: Mean QoL scores for body image and male sexual problems were better following AR than APR (P<0.01), also in patients with a low (< or = 3 cm) anastomosis. Patients who had undergone AR had higher mean scores for constipation (P<0.001) and more often used anti-diarrhoeal medication (P=0.005), than patients who had undergone APR. Patients with a low anastomosis (< or = 3 cm) had more incontinence for gas and solid stools (P<0.05), and had more incontinence (P=0.006) compared with patients with higher anastomosis, but there was no difference in QoL. Subgroup analysis showed that irradiated patients (n=34) had worse rectal function in terms of frequency, urgency, and incontinence (P<0.01). CONCLUSIONS: Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR.

A subfertile patient diagnosed with testicular carcinoma in situ by immunocytological staining for AP-2gamma in semen samples: case report.

The incidence of testicular cancer is rising. Despite a high cure rate, efforts should be made to obtain diagnosis at the pre-invasive intratubular carcinoma in situ (CIS) stage, as the disease is potentially lethal and treatment has severe side-effects, especially regarding reproductive function. CIS diagnosis is presently only possible by a surgical biopsy of the testis. Immunocytological staining for transcription factor activator protein (AP-2gamma), previously identified as a marker for neoplastic germ cells, was performed in centrifuged samples of ejaculates obtained from 104 andrological patients, including patients with testicular cancer and subfertility. Cells positive for AP-2gamma were found only in semen samples from patients diagnosed a priori with testicular neoplasms and, surprisingly, in a 23 year old control subject with oligozoospermia and no symptoms of a germ cell tumour. Testicular biopsies performed during the follow-up of this patient revealed widespread CIS in one testicle, thus proving a potential diagnostic value of the new marker. For the first time, a patient without clinical symptoms of testicular neoplasia was diagnosed at the pre-invasive CIS stage using a new, simple method based on immunocytological staining of a semen sample for AP-2gamma, a novel marker for CIS. The value of this method for diagnostic use in the clinic requires further careful validation in a large series of patients and controls, but the preliminary results are promising.

Design, organization and management of a controlled population screening study for detection of colorectal neoplasia: attendance rates in the NORCCAP study (Norwegian Colorectal Cancer Prevention).

BACKGROUND: In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination. METHODS: A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT). RESULTS: The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT. CONCLUSIONS: The present FSIFS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.

[Perforated ulcer]. / Ulcus perforatum.

BACKGROUND: We wanted to review patients operated for perforated peptic ulcer at Ullevål University Hospital, Oslo, Norway in the period 1992-1997. MATERIAL AND METHODS: Data from 84 operated patients (43 men) were obtained retrospectively from patient and hospital files. Median age was 69 years (range 20-92 years). RESULTS: 41 patients had perforated duodenal ulcer and 43 had perforated gastric ulcer (pylorus included). Median time from start of symptoms until admission to hospital was 5 hours (range 2-24 hours; n = 40) and from admission to start of surgery 5 hours (range 1 1/2-48 hours; n = 69). 64 out of 74 patients had pneumoperitoneum on preoperative abdominal X-ray examination. 77 patients were operated with rafi and/or tegmentation of the perforation; six patients with Billroth II or Billroth I; one patient was treated with percutaneous drainage. Median duration of surgery was 68 minutes (range 40-240 minutes). Thirteen patients died in hospital. Post-operative complications were recorded in 30 patients. INTERPRETATION: Early surgical intervention is important to reduce lethality from ulcus perforatum. A patient with clinical peritonitis and suspected perforated peptic ulcer should be operated without time-consuming examinations.

[Functional outcome after reservoir surgery in ulcerative colitis]. / Funksjonelt resultat etter reservoarkirurgi ved ulcerøs kolitt.

BACKGROUND: The aim of this study was to examine whether the functional result of restorative proctocolectomy for ulcerative colitis deteriorated by postponing follow-up from three to eight years after pouch surgery. MATERIAL AND METHODS: All patients (n = 58) operated for ulcerative colitis from 1984-97, who still had intact reservoir, responded to a questionnaire on defecating pattern, stool leakage, perianal irritation, urinary function, workload, sexual life, social life, and the patient's opinion on outcome. The results for the first 29 patients were compared to last 29 patients operated. Median follow-up was eight for the first 29 patients and three years for the last 29. RESULTS: There were no significant difference in functional outcome and patient opinion after pouch surgery between the first 29 and last 29 patients (n = 58). Respective figures for median 24-hour stool frequency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defecation 86% and 97%, perianal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) had improved for 11 (19%) and deteriorated for seven patients (12%). Potency was reduced in five (15%) and ejaculation in four patients (12%), one of whom (3%) had retrograde ejaculation. Three (5%) had received a disability pension and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and three (6%) felt worse because of frequent bowel emptying (n = 3), perianal eczema (n = 1) and pouch fistula (n = 1). INTERPRETATION: The results do not demonstrate any significant deterioration of functional outcome after pouch surgery for ulcerative colitis by postoperative increase of follow-up from three to eight years.

Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis.

OBJECTIVE: To find out whether a threefold increase in follow up (median 108 compared with 36 months) influenced major morbidity and functional outcome between the first 32 and the last 32 patients consecutively operated on with J-pouch ileoanal anastomosis for ulcerative colitis from 1984 to 1997. DESIGN: Retrospective and prospective study. SETTING: University hospital, Norway. PATIENTS: 64 patients with ulcerative colitis who had proctocolectomy and ileal pouch-anal anastomoses. INTERVENTIONS: The pouches were mainly hand anastomosed (n = 61) to the dentate line after mucosectomy or anastomosed by double stapling technique without mucosectomy (n = 3). The 58 patients who still had their pouches responded to a questionnaire on functional outcome and satisfaction. MAIN OUTCOME MEASURES: Morbidity, functional outcome, and patients' satisfaction. RESULTS: Major morbidity in these 64 patients comprised pelvic sepsis in 3 (5%), operation for intestinal obstruction in 5 (8%), pouchitis in 12 (19%), fistulas in 7 (11%) and pouch excision in 6 (9%). Thirteen patients (20%) had 35 reoperations and 11 patients (17%) had 22 re-laparotomies. There were more complications among the first 32 patients with the longest follow up than among the last 32 patients, but this difference was significant only concerning the rate of reoperations (31% compared with 9%) because of the higher number of pouch excisions (5 compared with 1) in this group. There were no significant differences in the functional outcome and degree of patient satisfaction between the first 29 and the last 29 patients. Respective values for 24 hour median stool freqency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defaecation 86% and 97%, perineal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) was improved in 11 (19%) and reduced in 7 (12%). Potency was reduced in 5 (15%) and ejaculation in 4 (12%), one of whom (3%) had retrograde ejaculation. Three (5%) received disability pensions and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and 3 (6%) felt worse because of frequent bowel emptying, perineal eczema, or pouch fistula. CONCLUSION: Continence-preserving proctocolectomy carries considerable morbidity, but the long term functional outcome is satisfactory and does not seem to deteriorate substantially.

Bladder and sexual dysfunction after mesorectal excision for rectal cancer.

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced. METHODS: Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group. CONCLUSION: Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.