Using machine learning models to predict synchronous genitourinary cancers among gastrointestinal stromal tumor patients.

Objectives: Gastrointestinal stromal tumors (GISTs) can occur synchronously with other neoplasms, including the genitourinary (GU) system. Machine learning (ML) may be a valuable tool in predicting synchronous GU tumors in GIST patients, and thus improving prognosis. This study aims to evaluate the use of ML algorithms to predict synchronous GU tumors among GIST patients in a specialist research center in Saudi Arabia. Materials and Methods: We analyzed data from all patients with histopathologically confirmed GIST at our facility from 2003 to 2020. Patient files were reviewed for the presence of renal cell carcinoma, adrenal tumors, or other GU cancers. Three supervised ML algorithms were used: logistic regression, XGBoost Regressor, and random forests (RFs). A set of variables, including independent attributes, was entered into the models. Results: A total of 170 patients were included in the study, with 58.8% (n = 100) being male. The median age was 57 (range: 9-91) years. The majority of GISTs were gastric (60%, n = 102) with a spindle cell histology. The most common stage at diagnosis was T2 (27.6%, n = 47) and N0 (20%, n = 34). Six patients (3.5%) had synchronous GU tumors. The RF model achieved the highest accuracy with 97.1%. Conclusion: Our study suggests that the RF model is an effective tool for predicting synchronous GU tumors in GIST patients. Larger multicenter studies, utilizing more powerful algorithms such as deep learning and other artificial intelligence subsets, are necessary to further refine and improve these predictions.

A study of the histopathology of collagen fleece (TachoSil) patching of tunica albuginea in the rat penis and a literature review of penile graft materials in experimental animals.

Background: A penile tunica defect may arise during surgery in patients with Peyronie's disease. Collagen fleece (TachoSil) has recently gained popularity in penile surgery to cover the tunica albuginea (TA) defect associated with clinical success. However, it is not known what the histological outcomes of these grafts are in the penis. We aimed to study the histopathology of the TachoSil graft in an experimental animal model for the regeneration of TA, inflammation, fibrosis, and the underlying cavernous tissue. Methods: Six adult male Sprague Dawley rats were used. The penis was degloved through a circumferential subcoronal incision. A longitudinal 1 mm × 10 mm defect was created at the base of the lateral aspect of the penis. A TachoSil patch (Takeda, Japan) was applied to the defect. The penile skin covering was then restored. At 2 months, the rat penis was excised and examined with hematoxylin, eosin, and trichrome stains. We conducted a literature review of penile grafts in animals for comparison. Results: Rats weighed 369.2 gm (standard deviation: 31.5). At 2 months, all rats showed normal-looking penis with complete healing, no scaring, tethering, or gross inflammatory features. Histopathology of the patch site showed fibrosis, chronic inflammation, and foreign body giant cell reaction. There was no generation of a new TA, or new vascularity. No inflammatory or pathological reaction affected the underlying corpus cavernous tissue. One rat died on the 6th postoperative day. Postmortem showed massive multiorgan hemorrhage consistent with disseminated intravascular coagulopathy (DIC). Unlike some other reported grafts, there is no TA regeneration. Conclusions: TachoSil patching of penile TA defect forms a distinctive barrier against inflammation, protecting the underlying corpus cavernosum. However, no regeneration of the tunica defect is observed at 2 months. DIC is a potential complication of systemic absorption of TachoSil.

The association of genitourinary cancer among Saudi patients with gastrointestinal stromal tumors and a systematic literature review.

The gastrointestinal tract's most commonly occurring primary mesenchymal tumor is the gastrointestinal stromal tumor (GIST). However, few cases worldwide were reported associated with renal cell carcinoma (RCC). Therefore, we aimed to identify the association of genitourinary tumors in patients with GIST in our tertiary care hospital in Saudi Arabia and compare it to the literature. We identified all patients in the pathology department database with the diagnosis of GIST. We excluded duplicate and recurrent cases. We examined patients' files for the presence of RCC, adrenal tumors, or other genitourinary cancer. A systematic review of the association was conducted. From 2003 to 2020, 170 patients had a histopathologic diagnosis of primary GIST, 100 men and 70 women, median age of 57 (range 9-91) years at the time of diagnosis. The site of primary GIST was gastric 103, small bowel 43, mesenteric 5, omentum/peritoneum 7, abdomen 4, isolated adrenal 1, and other 7. Six patients had associated primary genitourinary cancer. Three patients had RCC (two clear cell RCC and one radiologic diagnosis only), and three had adrenal tumors (one adrenal carcinoma, one an isolated adrenal GIST, and one pheochromocytoma). In addition, two patients had a tumor invading the urinary bladder. Although the cohort included 63 men aged 60 or above (median 71 ± 8.7 years, range 60-94), none demonstrated clinical prostatic carcinoma. Data was compared to 69 systematic review articles. We report the rare association between GIST tumors and primary genitourinary cancer, mainly RCC and adrenal tumors. Also, we identified a secondary invasion of the urinary bladder. Unlike the reported series, none of the older male patients had clinical prostate cancer.

A comparison of the perineal and penoscrotal approaches in artificial urinary sphincter implantation for the control of male stress urinary incontinence.

BACKGROUND: The two most common surgical approaches to treat stress urinary incontinence in men are the traditional perineal and the new penoscrotal approach for artificial urinary sphincter (AUS) implantation. Each method carries its own advantages and disadvantages. The few reports that compare the approaches have disparate outcomes. OBJECTIVE: Compare the outcome of first time AUS implantation by the perineal versus the penoscrotal approach. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS AND METHODS: We included all male patients who underwent primary perineal or penoscrotal AUS placement between June 2004 and October 2018 at our tertiary care hospital. Patients were followed at least one year postoperatively. MAIN OUTCOME MEASURES: Rates of dry, infection, erosion, malfunction, atrophy, revision. SAMPLE SIZE: 44 males who underwent 68 procedures. RESULTS: Twenty-five (56.8%) patients underwent a perineal and 19 (43.2%) underwent a penoscrotal approach. The patients had 68 procedures: 36 (52.9%) perineal and 32 (47.1%) penoscrotal approaches. The median (25th-75th percentiles) age at the time of surgery was 61.0 (51.0-68.0) years (n=68 procedures). The median (25th-75th percentiles) operative time was significantly shorter for the penoscrotal approach, 87 (69-140), vs. 93 (72-210) minutes for the perineal approach (P=.016). The 44 patients were followed up for a mean (SD) of 52.5 (20.3) months for the 68 procedures. Postoperative complications occurred in 16 (36.36%) patients; 11 (44%) perineal approach patients and 5 (26.3%) penoscrotal. There were no significant differences in complications of infection, erosion, malfunction, or urethral atrophy between the two groups. Only removal/revision was significantly more common with the perineal approach (10 patients perineal and two patients penoscrotal, P=.042). At the last follow-up, dryness was comparable among groups. CONCLUSION: The outcomes of AUS placement are comparable between perineal and penoscrotal approaches in terms of complications and one year dryness. The penoscrotal approach however has shorter operative time and less need for revision and removal. LIMITATIONS: Small sample size, single-center. CONFLICT OF INTEREST: None.

Intraoperative cell salvage transfusion in patients undergoing posterior urethroplasty: Its efficacy of reducing allogeneic blood transfusion, safety, and cost.

Background: A significant blood loss may be encountered with complex urethroplasty surgery. Blood management aims at reducing allogeneic blood transfusion (ABT) because of limited supply, associated risks, and cost. Intraoperative cell salvage (ICS) has been used in different urological and nonurological surgeries to achieve this goal. However, no study evaluated its role in perineal urethroplasty. Objectives: We set out to determine the efficacy of reducing ABT, safety, and cost of ICS in posterior urethroplasty. Methods: We reviewed the charts of all patients who underwent posterior urethroplasty between 2012 and 2017. We collected data for patients' demographics, pre- and postoperative hemoglobin level, ICS volume, complications, equivalent ABT units saved, and cost. Results: Seventy patients with a median age of 27.5 ± 10.2 years underwent posterior urethroplasty. Of the 70 patients, 20 (28.57%) required ICS intraoperatively with a median of 441 ml/patient, equivalent to 1.47 units per patient of allogenic blood. No patient needed intraoperative ABT, whereas two patients required transfusions postoperatively. The median pre- and postoperative hemoglobin levels were 124.2 ± 9.2 and 110.3 ± 12.6 g/dl, respectively. There were no significant complications noted while using ICS. There was a 41% cost reduction of equivalent ABT units. Conclusions: ICS is safe and effective in reducing ABT during posterior urethroplasty. In our hospital, it is associated with a significant cost reduction of blood transfusion.

A retrospective cohort study on the use of machine learning to predict stone-free status following percutaneous nephrolithotomy: An experience from Saudi Arabia.

Background: Machine learning techniques have been used extensively in the field of clinical medicine, especially when used for the construction of prediction models. The aim of the study was to use machine learning to predict the stone-free status after percutaneous nephrolithotomy (PCNL). Materials and methods: This is a retrospective cohort study of 137 patients. Data from adult patients who underwent PCNL at our institute were used for the purpose of this study. Three supervised machine learning algorithms were employed: Logistic Regression, XGBoost Regressor, and Random Forests. A set of variables comprising independent attributes including age, gender, body mass index (BMI), chronic kidney disease (CKD), hypertension (HTN), diabetes mellitus, gout, renal and stone factors (previous surgery, stone location, size, and staghorn status), and pre-operative surgical factors (infections, stent, hemoglobin, creatinine, and bacteriuria) were entered. Results: 137 patients were identified. The majority were males (65.4%; n = 89), aged 50 years and above (41.9%; n = 57). The stone-free status (SFS) rate was 86% (n = 118). An inverse relation was detected between SFS, and CKD and HTN. The accuracies were 71.4%, 74.5% and 75% using Logistic Regression, XGBoost, and Random Forest algorithms, respectively. Stone size, pre-operative hemoglobin, pre-operative creatinine, and stone type were the most important factors in predicting the SFS following PCNL. Conclusion: The Random Forest model showed the highest efficacy in predicting SFS. We developed an effective machine learning model to assist physicians and other healthcare professionals in selecting patients with renal stones who are most likely to have successful PCNL treatment based on their demographics and stone characteristics. Larger multicenter studies are needed to develop more powerful algorithms, such as deep learning and other AI subsets.

A Primary Urothelial Carcinoma Presenting as a Mid-Bulbar Urethral Stricture in a 30-Year-Old Male.

The bulbar urethra is the most common site of anterior urethral strictures. In this case report, we present a 30-year-old male who was referred to us as a case of mid-bulbar urethral stricture. Urethroplasty was booked and a papillary lesion was found on routine diagnostic cystoscopy. An open biopsy was taken which showed invasive high-grade papillary urothelial carcinoma with squamous differentiation. This case is rare in terms of a young age of incidence, a lack of risk factors, an absence of suspicious symptoms, and a short duration of signs and symptoms. Urologists should consider workup for malignancy even in young patients who present with an idiopathic urethral stricture and a short duration of symptoms.

The grasper-integrated disposable flexible cystoscope is comparable to the reusable, flexible cystoscope for the detection of bladder cancer.

Flexible cystoscopy under local anaesthesia is standard for the surveillance of bladder cancer. Frequently, several reusable cystoscopes fail to reprocess. With the new grasper incorporated single-use cystoscope for retrieval of ureteric stents, we explored the feasibility of using it off-label for diagnosis and the detection of bladder cancer. Consecutive diagnostic flexible cystoscopies between Mar 2016 and Nov 2018 were reviewed comparing the reusable versus the disposable cystoscopes. A total of 390 patients underwent 1211 cystoscopies. Median age was 61.5 years (SD 14.2, 18.8-91.4), males 331 (84.9%) and females 59 (15.1%). Indication for cystoscopy was prior malignancy in 1183 procedures (97.7%), haematuria 19 (1.6%) or bladder mass 7 (0.6%). There were 608 reusable and 603 disposable cystoscopies. There was no significant difference between groups at baseline in age, sex, BMI, smoking status, or prior tumor risk category. There was no significant difference in positive findings (123/608, 20.2% vs 111/603, 18.4%, p = 0.425) or cancer detection rates (95/608, 15.6% vs 88/603, 14.4%, p 0.574) among the two groups, respectively. We conclude that the disposable grasper integrated cystoscope is comparable to reusable cystoscope in the detection of bladder cancer.

Organ-sparing procedures in GU cancer: part 1-organ-sparing procedures in renal and adrenal tumors: a systematic review.

PURPOSE: Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors. MATERIALS AND METHODS: PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer". RESULTS: Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys. CONCLUSIONS: Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors.

Operative outcomes of robotic partial nephrectomy. A report of the first 101 cases from a single center in Saudi Arabia.

OBJECTIVES: To report robotic partial nephrectomy (RPN) outcomes from a single tertiary hospital in Saudi Arabia. Methods: We retrospectively reviewed consecutive cases of patients undergoing RPN at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of  Saudi Arabia, between January 2008 and January 2018. The study reports patient's demographics, tumor characteristics, operative details, and perioperative outcomes, using descriptive statistics of median and range values. Results: One hundred and one patients underwent RPN during the study period. Average tumor size was 3 (1.3-6.4) cm and average radius exophytic nearness anterior/posterior location (RENAL) score was 6 (4-10). Perioperative parameters were blood loss 200 (5-1500) ml and warm ischemia time 17 (8-40) minutes, excluding off-clamp surgery in 12 (11.9%); operative time was 166 (66-381) minutes. Conversion to open partial nephrectomy occurred in 9 (8.9%) patients, major complications in 3 (3%) patients, positive surgical margins in 5 (5%) patients, and the hospital stay was 4 (2-14) days. A total of 73 (73%) patients achieved a trifecta of freedom from any complication, negative surgical margins, and ischemia time ≤25 minutes. Study limitations included the retrospective design and small cohort size. Conclusions: The initial experience of robotic partial nephrectomy was associated with a surgical outcome comparable to that reported by higher-volume centers.

The Risks of Renal Angiomyolipoma: Reviewing the Evidence.

Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.

Hypospadias repair during adulthood: Case series.

PURPOSE: We report our complications and success rate in adult hypospadias repair. PATIENTS AND METHODS: This was a retrospective study of patients aged ≥17 years who underwent hypospadias repair during 2006-2014. We analyzed two groups, one with primary repair and the other that had secondary repair after failed childhood hypospadias surgery. Outcome was compared between the two groups and among different surgical procedures. Descriptive statistics and Fisher's exact test were used and significance level was set at P < 0.05. RESULTS: Forty patients were included, of which 26 presented for a secondary repair and 14 for primary repair. The meatus was distal in 15 patients, mid-penile in 16, and penoscrotal in 9. The median age of patients at the time of surgery was 21 years (standard deviation [SD] =4, range 17-30). The median follow-up period was 37 months (SD = 8, range 5-75). In the primary repair group, the success rate was 71% (10/14), whereas in the secondary repair group, the success rate was 55% (14/26). The overall complication rate was 60%. Following a subsequent repair, the overall success rate reached 95% (38/40). There was no significant difference in success or complications between patients who presented with primary or secondary hypospadias or between methods of repair. CONCLUSION: Delayed hypospadias repair in adults is associated with a high success rate of 95% with no difference between primary and secondary repair. Secondary repair however may require more than one procedure most of the time.

Factors Predicting Renal Function Outcome after Augmentation Cystoplasty.

We determined the cause of renal deterioration after augmentation cystoplasty (AC). Twenty-nine adult patients with refractory bladder dysfunction and who underwent ileocystoplasty from 2004 to 2015 were studied. Patients with a decline in glomerular filtration rate (GFR) after augmentation were reviewed. The primary outcome was to determine the factors that might lead to deterioration of estimated GFR. Median follow-up was 7.0 ± 2.6 years. Significant bladder capacity, end filling pressure, and bladder compliance were achieved from median 114 ± 53.6 to 342.1 ± 68.3 ml (p = .0001), 68.5 ± 19.9 to 28.2 ± 6.9 cm H2O (p = .0001), and 3.0 ± 2.1 to 12.8 ± 3.9 (p = .0001), respectively. Renal function remained stable and improved in 22 (76%) patients from median eGFR 135 ± 81.98 to 142.82 ± 94.4 ml/min/1.73 m2 (p = .160). Significant deterioration was found in 7 (24%) patients from median eGFR 68.25 ± 42 to 36.57 ± 35.33 (p = .001). The causes of renal deterioration were noncompliance to self-catheterization (2 patients), posterior urethral valve/dysplastic kidneys (2 patients), and reflux/infection (2 patients). On multivariate analysis, recurrent pyelonephritis (OR 3.87, p = 0.0155) and noncompliance (OR 30.78, p = 0.0156) were significant. We concluded that AC is not the cause of progression to end-stage renal disease in patients with renal insufficiency.

The impact of renal angiomyolipoma on estimated glomerular filtration rate in patients with tuberous sclerosis complex.

BACKGROUND: There is a growing concern that renal impairment may develop in patients with renal angiomyolipomas (AMLs) associated with tuberous sclerosis complex (TSC) as a consequence of the disease itself and/or the interventions to mitigate the risk of hemorrhage. OBJECTIVE: To assess the estimated glomerular filtration rate (eGFR) in patients with bilateral renal AMLs and the impact of tumor burden and intervention on renal function. DESIGN: Retrospective study. SETTING: Urology department of a tertiary care hospital. PATIENTS AND METHODS: All adult patients (>=18 years of age) with TSC-associated renal AMLs seen from October 1998 to June 2015. We included only patients with bilateral tumors or solitary kidneys at the last follow-up. MAIN OUTCOME MEASURES: The eGFR, renal volume, and number and type of interventions. RESULTS: We identified 12 patients (median age 27.6, interquartile range 23.7-39.9 years), a median follow-up period of 1266 days (33-3133), and a median renal size of 454.7 mL (interquartile range 344.7-1016.9 on the right side; 558.1 mL, interquartile range 253.7-1001.4 on the left). In 11 (91.7%) patients, the eGFR was > 60 mL/min/1.77 m2. Six patients had three total nephrectomies, one had a contralateral partial nephrectomy, and seven had selective arterial embolizations. Intervention was associated with a significantly reduced eGFR. The renal size did not correlate with the eGFR. CONCLUSIONS: TSC-associated renal AMLs may attain a large size but normal renal function is maintained in 92% of patients. Interventions to mitigate the risk of hemorrhage are associated with decreased renal function. LIMITATIONS: The renal size was used as a surrogate for tumor size. Other limitations were the limited number of patients and lack of split renal function testing.

Neurogenic bladder in spinal cord injury patients.

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

Isolated ureteric endometriosis presenting as a ureteric tumor.

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Penile autotransplantation in rats: An animal model.

CONTEXT: Penile allotransplantation might be a viable option for patients who need penile reconstruction. AIMS: A successful autotransplantation rat model is the first step toward proceeding for allotransplantation. We herein evaluate autotransplantation following transaction of the rat penis just distal to the urethral bulb. SETTINGS AND DESIGN: Experimental animal study. MATERIALS AND METHODS: Five Sprague-Dawely rats weighing 520 g (SD 19) were used. Utilizing a magnification of 6-40, transection and immediate anastomosis of the tunica albuginea, urethra, dorsal vein and nerves were carried out. Vesicostomy was made to divert urine. The glandular skin was sutured to the perineum and the abdominal wall was closed in layers. STATISTICAL ANALYSIS USED: Descriptive statistics. RESULTS: Average surgery time was 8 h. The first two rats had no vesicostomy and died in the first postoperative day from retention. Three rats tolerated well the procedure and survived to the end point. One rat was sacrificed at day 10 and histopathology showed 30-50% necrosis of the implanted penis. Another rat was sacrificed at day 20 and showed normal cavernous tissue. The fifth rat was sacrificed 3 months postoperatively and showed evidence of moderate corporal fibrosis. Urethral fistula and necrosis of corpus spongiosum, dorsal nerve necrosis and dorsal vein occurred in all animals. CONCLUSIONS: Penile autotransplantation in rats is feasible and provides the basis for evaluation of the corpora cavernosa in an allotransplantation model. Long-term urethral continuity and dorsal neurovascular bundle survival in this model is difficult to establish.

Long-term outcome of genital reconstruction of Middle Eastern women with congenital adrenal hyperplasia.

OBJECTIVES: There is a paucity of data on the long-term outcome of genital reconstruction of female children with congenital adrenal hyperplasia (CAH) as they become adult women. We report on the surgical outcome general condition and marriage status. MATERIALS AND METHODS: We reviewed the medical records of women 20 years or older with CAH who had genital reconstruction. We interviewed married patients utilizing the female sexual function index (FSFI-6) questionnaire and compared them to age-matched controls. RESULTS: We identified 43 women with CAH with a median age of 24.2 ± 3.9 years and a median follow-up of 23.4 ± 4.6 years. Salt wasting and the severity of virilization affected most patients, parents were commonly cousins, children were reared as boys for a protracted period and surgical reconstruction was usually complex. Only five women had married. Compared with single women, married women had significantly more frequent normal menses, emergency hospital admissions and number of repeated reconstructive surgery. There was no significant difference in FSFI score between patients and controls. Four women conceived and three gave birth to one healthy child. There was no significant difference in the number of children between patients and controls. CONCLUSIONS: CAH has a significant impact on adult women in our region. Most of the patients remain single. Few women get married and these are able to lead a nearly normal sexual life and give birth to healthy children.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men.

INTRODUCTION: A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed. OBJECTIVES: The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports. METHODS: A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded. RESULTS: A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options. CONCLUSION: There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.