Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta".

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if "Trifecta" and "Pentafecta" outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008-2019) was analysed. "Pentafecta" was defined as achievement of "Trifecta" (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres' outcomes.

Does stigma curvature promote delayed selfing? An experimental investigation in Triodanis perfoliata (Campanulaceae).

Self-fertilisation that is delayed until after opportunities for outcrossing have ceased has been argued to provide both the reproductive assurance benefits of selfing and the genetic advantages of outcrossing. In the Campanulaceae, presentation of pollen on stylar hairs and progressive stigma curvature have been hypothesised to facilitate delayed selfing, but experimental tests are lacking. Stigma curvature is common in Campanula, a genus largely characterised by self-incompatibility, and therefore is unlikely to have initially evolved to promote self-fertilisation. In derived self-compatible species, however, stigma curvature might serve the secondary function of delayed selfing. We investigated delayed selfing in Triodanis perfoliata, a self-compatible relative of Campanula. Using floral manipulation experiments and pollen tube observations, we quantified the extent and timing of self-pollination. Further, we hypothesised that, if stigma curvature provides the benefit of delayed selfing in Triodanis, selection should have favoured retention of self-pollen through the loss of a stylar hair retraction mechanism. Results of a stigma removal experiment indicated that autonomous selfing produces partial seed set, but only some selfing was delayed. Pollen tube observations and a flower senescence assay also supported the finding of partial delayed selfing. Scanning electron microscopy revealed that pollen-collecting hairs retract during anthesis, which may limit the extent of delayed selfing. Delayed selfing appeared to be only partially effective in T. perfoliata. The stylar hair retraction in this species would seem to contradict selection for selfing. We suggest that caution and rigour are needed in interpreting floral traits as adaptive mechanisms for delayed selfing.

Comparative pathogenicity of reniform nematode on root-knot resistant and susceptible bidi tobacco.

Comparative pathogenicity of reniform nematode on root-knot resistant ABT 10 and susceptible bidi tobacco A119 revealed that ABT 10 was found significantly superior to A119 with respect to plant growth characters and as good as A119 with respect to multiplication of reniform nematode. Initial inoculum of 1,000 J4 of the nematode found damaging to both ABT 10 and A119 varieties of bidi tobacco.

Estimation of loss and analysis of nicotine, reducing sugar and chloride in bidi tobacco due to reniform nematode under pot conditions.

Estimation of avoidable loss in yield of bidi tobacco due to reniform nematode under pot conditions revealed that variety A 119 suffered heavily than ABT 10 due to reniform nematode. Inoculation of reniform nematode @ 2000 J4 per plant significantly reduced the plant growth characters and increased nematode multiplication preferring A 119 variety. Estimation of avoidable loss in cured shoot yield of bidi tobacco due to infection of reniform nematode in individual variety ABT 10 and A 119 has been estimated to the tune of 30.5 and 34.2 per cent with overall loss 31.9 per cent in both the variety 60 DAI. Simply growing of ABT 10 variety irrespective of infection of reniform nematode avoided 29.5 per cent loss in cured shoot yield. ABT 10 recorded significantly high nicotine, reducing sugar and chloride than A 119; inoculation of reniform nematode significantly increased nicotine, reducing sugar and chloride compared to no inoculation. Interaction indicated that inoculation of 2000 J4 of reniform nematode significantly increased nicotine, reducing sugar and chloride in A 119 compared to no inoculation; while significantly reduced reducing sugar and increased chloride in ABT 10. There was no significant impact of infection of reniform nematode on nicotine in ABT 10.

Role of miRNAs and alternative mRNA 3'-end cleavage and polyadenylation of their mRNA targets in cardiomyocyte hypertrophy.

miRNAs play critical roles in heart disease. In addition to differential miRNA expression, miRNA-mediated control is also affected by variable miRNA processing or alternative 3'-end cleavage and polyadenylation (APA) of their mRNA targets. To what extent these phenomena play a role in the heart remains unclear. We sought to explore miRNA processing and mRNA APA in cardiomyocytes, and whether these change during cardiac hypertrophy. Thoracic aortic constriction (TAC) was performed to induce hypertrophy in C57BL/6J mice. RNA extracted from cardiomyocytes of sham-treated, pre-hypertrophic (2 days post-TAC), and hypertrophic (7 days post-TAC) mice was subjected to small RNA- and poly(A)-test sequencing (PAT-Seq). Differential expression analysis matched expectations; nevertheless we identified ~400 mRNAs and hundreds of noncoding RNA loci as altered with hypertrophy for the first time. Although multiple processing variants were observed for many miRNAs, there was little change in their relative proportions during hypertrophy. PAT-Seq mapped ~48,000 mRNA 3'-ends, identifying novel 3' untranslated regions (3'UTRs) for over 7000 genes. Importantly, hypertrophy was associated with marked changes in APA with a net shift from distal to more proximal mRNA 3'-ends, which is predicted to decrease overall miRNA repression strength. We independently validated several examples of 3'UTR proportion change and showed that alternative 3'UTRs associate with differences in mRNA translation. Our work suggests that APA contributes to altered gene expression with the development of cardiomyocyte hypertrophy and provides a rich resource for a systems-level understanding of miRNA-mediated regulation in physiological and pathological states of the heart.

APOE*E2 allele delays age of onset in PSEN1 E280A Alzheimer's disease.

Alzheimer's disease (AD) age of onset (ADAOO) varies greatly between individuals, with unique causal mutations suggesting the role of modifying genetic and environmental interactions. We analyzed ~50 000 common and rare functional genomic variants from 71 individuals of the 'Paisa' pedigree, the world's largest pedigree segregating a severe form of early-onset AD, who were affected carriers of the fully penetrant E280A mutation in the presenilin-1 (PSEN1) gene. Affected carriers with ages at the extremes of the ADAOO distribution (30s-70s age range), and linear mixed-effects models were used to build single-locus regression models outlining the ADAOO. We identified the rs7412 (APOE*E2 allele) as a whole exome-wide ADAOO modifier that delays ADAOO by ~12 years (ß=11.74, 95% confidence interval (CI): 8.07-15.41, P=6.31 × 10(-8), PFDR=2.48 × 10(-3)). Subsequently, to evaluate comprehensively the APOE (apolipoprotein E) haplotype variants (E1/E2/E3/E4), the markers rs7412 and rs429358 were genotyped in 93 AD affected carriers of the E280A mutation. We found that the APOE*E2 allele, and not APOE*E4, modifies ADAOO in carriers of the E280A mutation (ß=8.24, 95% CI: 4.45-12.01, P=3.84 × 10(-5)). Exploratory linear mixed-effects multilocus analysis suggested that other functional variants harbored in genes involved in cell proliferation, protein degradation, apoptotic and immune dysregulation processes (i.e., GPR20, TRIM22, FCRL5, AOAH, PINLYP, IFI16, RC3H1 and DFNA5) might interact with the APOE*E2 allele. Interestingly, suggestive evidence as an ADAOO modifier was found for one of these variants (GPR20) in a set of patients with sporadic AD from the Paisa genetic isolate. This is the first study demonstrating that the APOE*E2 allele modifies the natural history of AD typified by the age of onset in E280A mutation carriers. To the best of our knowledge, this is the largest analyzed sample of patients with a unique mutation sharing uniform environment. Formal replication of our results in other populations and in other forms of AD will be crucial for prediction, follow-up and presumably developing new therapeutic strategies for patients either at risk or affected by AD.

Surgical anatomy of the pudendal nerve and its branches in South Africans.

Dissection of the pudendal nerve (PN) and its branches in 71 cadavers revealed anatomic variations not previously described. Knowledge of this variation is necessary to prevent nerve injury resulting in sexual of sensory dysfunction. Because descriptions vary, this study re-evaluated the anatomy of the PN as implicated in perineal procedures in South Africans. The course of the PN from the gluteal region into the perineum was dissected in an adult sample of both sexes and of African and European ancestry. Distances between PN and branches to applicable landmarks were measured. Basic descriptive statistics and comparisons were carried out between groups. In 5/13 African females, the inferior rectal nerve (IRN) entered the gluteal region separately and in 12/13 cases it passed medial to the ischial spine with the PN. The dorsal nerve of the clitoris or penis (DNC/DNP) was closer to the bony frame in those of European ancestry. The IRN branches were more superficial in females, but deeper in males of European ancestry. In African females, a PN block and Richter stitch should be placed more medial. Outside-in transobturator tape procedures might endanger the DNC/DNP in obese individuals. In females of European ancestry the IRN branches are compromised during ischioanal abscess drainage. In males of European ancestry, the dorsal penile nerve block might be less effective. Predictions should be verified clinically.

Inlay osmotic pump tablets containing metformin and glipizide.

The goal of diabetes therapy today is to achieve and maintain as near normal glycemia as possible to prevent the long-term microvascular and macrovascular complications of an elevated blood glucose. A newly developed inlay osmotic pump tablet (IOPT) can deliver glipizide (GLZ) and metformin HCl (MET) gradually in controlled manner. The aim of present investigation was to prepare the IOPT that can deliver >75% of GLZ in 2 h, whereas MET released after 2 h and sustained up to 12 h. In the present work, HP-ß-CD was used to modify the solubility of GLZ before incorporating in the osmotic system and MET was spray-dried with HPMC A15C to modify its release profile, flow property, and compressibility. Various parameters mainly G(75%) (75% GLZ release), t(LMET) (lag time of MET release from device), Q(10 h) (percent of MET released within 10 h), and RSQ(ZERO) (R(2) of release data fitted to zero-order equation) were used to compare different formulations. The effects of different formulation variables, that is, osmagents, concentration of hydrophilic polymer, diameter of drug releasing orifice, and coating composition on the drug release profile were investigated. The release rate of GLZ could be effectively modified by the addition of sodium carbonate and sodium chloride, whereas the release rate of MET was adjusted by dual-coating system and by addition of hydrophilic polymer. The developed inlay osmotic system could be effective in the multidrug therapy of diabetes by delivering both drugs in a controlled manner.

Synthesis and Antibacterial and Antifungal Studies of Novel Nitrogen Containing Heterocycles from 5-Ethylpyridin-2-ethanol.

A novel series of chalcones, pyrimidines and imidazolinone is described; chalcones (4a-o) were prepared from the lead molecule 4-[2-(5-ethylpyridin-2-yl)ethoxy]benzaldehyde. Pyrimidine (5a-o) derivatives were prepared from the reaction of chalcones and guanidine nitrate in alkali media. Imidazolinones (6a-o) were synthesized from reaction of pyrimidine and oxazolone derivatives (prepared by Erlenmeyer azlactone synthesis). The structures of the synthesized compounds were assigned on the basis of elemental analysis, IR, (1)H and (13)C NMR spectral data. All the products were screened against different strains of bacteria and fungi. Most of these compounds showed better inhibitory activity in comparison to the standard drugs.

Robotic laparoscopic surgery: cost and training.

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

Trans-obturator tape: a single centre experience.

AIM: To assess the clinical outcome of TOT tape for stress and mixed urinary incontinence in a single centre. METHODS: From March 2002 to October 2006, 82 patients completed the study, all were evaluated at 3 and 12 months by physical examination and validated questionnaires. Seventy nine patients had the procedure under epidural anaesthesia and all women received antibiotics starting before surgery. RESULTS: TOT was mostly performed as a day case surgery with short operative time of 22 minute (range 15-38 minute). A total of 62 (70.4%) patients were discharged from the hospital within a few hours (4.3 +/- 1.7 hours). CONCLUSION: The TOT tape can safely be performed as a day-case procedure, which has a continence cure rate of approximately 80%. This figure is comparable with the more established TVT, however the TOT tape has a significantly lower morbidity in our experience.

The first cytogenetic map of the tuatara, Sphenodon punctatus.

Tuatara, Sphenodon punctatus, is the last survivor of the distinctive reptilian order Rhynchocephalia and is a species of extraordinary zoological interest, yet only recently have genomic analyses been undertaken. The karyotype consists of 28 macrochromosomes and 8 microchromosomes. A Bacterial Artificial Chromosome (BAC) library constructed for this species has allowed the first characterization of the tuatara genome. Sequence analysis of 11 fully sequenced BAC clones (approximately 0.03% coverage) increased the estimate of genome wide GC composition to 47.8%, the highest reported for any vertebrate. Our physical mapping data demonstrate discrete accumulation of repetitive elements in large blocks on some chromosomes, particularly the microchromosomes. We suggest that the large size of the genome (5.0 pg/haploid) is due to the accumulation of repetitive sequences. The microchromosomes of tuatara are rich in repetitive sequences, and the observation of one animal that lacked a microchromosome pair suggests that at least this microchromosome is unnecessary for survival. We used BACs bearing orthologues of known genes to construct a low-coverage cytogenetic map containing 21 markers. We identified a region on chromosome 4 of tuatara that shares homology with 7 Mb of chicken chromosome 2, and therefore the orthologous region of the snake Z chromosome. We identified a region on tuatara chromosome 3 that is orthologous to the chicken Z, and a region on chromosome 9 orthologous to the mammalian X. Since the tuatara determines sex by temperature and has no sex chromosomes, this implies that different tuatara autosome regions are homologous with the sex chromosomes of mammals, birds and snakes. We have identified anchor BAC clones that can be used to reliably mark chromosomes 3-7, 10 and 13, some of which are difficult to distinguish based on morphology alone. Fluorescence in situ hybridization mapping of 18S rDNA confirms the presence of a single NOR located on the long arm of chromosome 7, as previously identified by silver staining. Further work to construct a dense physical map will lead to a better understanding of the dynamics of genome evolution and organization in this isolated species.

Ureterocystoplasty is safe and effective in patients awaiting renal transplantation.

OBJECTIVES: Surgical outcomes and bladder function were assessed in a group of patients who had undergone ureterocystoplasty while awaiting renal transplantation. METHODS: An observational cohort study was performed. A chart review was performed of 16 patients who had undergone ureterocystoplasty between 1997 and 2006. The postoperative assessment included measurement of bladder capacity and voiding cystourethrography findings. RESULTS: The median patient age at operation was 17 years (range, 3 to 44 years). The median follow-up was 38 months (range, 3 to 60 months). All patients achieved continence. The median increase in bladder capacity was 162 mL (range, 65 to 265 mL), representing a median proportional increase of 226% (range, 167% to 340%) of the original bladder capacity. None of the patients developed vesicoureteral reflux. Only 4 patients required subsequent intermittent catheterization to fully empty their bladders. Seven patients underwent renal transplantation within 3 to 7 months of ureterocystoplasty. CONCLUSIONS: Ureterocystoplasty in patients awaiting renal transplantation is safe and effective. Good results can be achieved when care is taken to preserve the blood supply of the ureter. The results of this study have confirmed the desirability of preserving the ureters in patients awaiting transplantation who might require bladder augmentation.

Predictors of success in surgical ligation of painful varicocele.

INTRODUCTION: Surgical ligation is used in the treatment of painful varicocele. We conducted this retrospective study to establish the effectiveness of varicocele ligation for the treatment of pain and to examine the factors that might predict outcomes. PATIENTS AND METHODS: Eighty-three patients underwent varicocele ligation for pain during the study period. Review of medical records and postal questionnaires were used to document patient age, grade and location of varicocele, duration and quality of pain, surgical approach, complications and the resolution of pain. RESULTS: Follow-up was available for 68 (82%) patients. In 76.5% patients there was marked or complete resolution of pain and 14 had partial resolution. Only 9% patients had persistent pain and 1.5% patient reported worsening pain. The quality of pain, dull ache or dragging, was the only factor that correlated with the resolution of pain following surgery. CONCLUSIONS: Surgical ligation is an effective treatment for the painful varicocele. The quality of pain at presentation may predict outcomes in selected patients.

Trans-obturator tape for incontinence: a 3-year follow-up.

AIM: To assess operative and functional outcomes, including morbidity, after using the trans-obturator tape for stress incontinence. PATIENTS AND METHODS: The first 24 consecutive patients undergoing trans-obturator tape insertion in a single centre were included in this retrospective study. All patients were female with a mean age of 63 (range 40-83) years. Fifteen patients (62.5%) suffered from pure stress incontinence, and 9 patients (37.5%) had mixed incontinence. Of the latter, 2 patients also had nocturnal enuresis. Each patient was followed up for between 3 and 12 months postoperatively and again at 36 months. The patients were assessed by clinical examination, ultrasound for residual urinary volume, and subjective satisfaction which was assessed at 3 and 12 months. At 36 months, all patients completed a validated incontinence questionnaire (International Consultation on Incontinence Questionnaire: ICIQ) which assessed female lower urinary tract symptoms and their impact on the quality of life. RESULTS: All operations were performed under epidural anaesthesia in day surgery, and the mean operative time was 20 (range 15-38) min. Nineteen patients (79.2%) showed significant improvement postoperatively, with 16 of those (66.6%) being completely cured of their incontinence. The remaining 5 patients (20.8%) were considered to have had failed procedures. There were no vascular, bladder, or urethral injuries. One patient had perforation of the vaginal fornix, and 3 patients developed vaginal erosion. CONCLUSIONS: The trans-obturator tape is a safe and effective treatment for stress incontinence and has a low morbidity after a 3-year follow-up period; however, it should only be performed by clinicians with the relevant surgical expertise and experience in treating female incontinence.

The expression of xenobiotic-metabolizing enzymes in human prostate and in prostate epithelial cells (PECs) derived from primary cultures.

BACKGROUND: Dietary heterocyclic amines (HCAs) are carcinogenic in rodent prostate requiring activation by enzymes such as cytochrome P450 (CYP) and N-acetyltransferase (NAT). METHODS: We investigated by Western blotting and immunohistochemistry the expression of CYP1A1, CYP1A2, and NAT1 in human prostate and in prostate epithelial cells (PECs) derived from primary cultures and tested their ability to activate the dietary carcinogen 2-amino-3-methylimidazo[4,5-f]quinoline (IQ) and its N-hydroxy metabolite (N-OH-IQ) to DNA-damaging moieties. RESULTS: Western blotting identified CYP1A1, CYP1A2, and NAT1. Immunohistochemistry localized NAT1 to the cytoplasm of PECs. Inter-individual variation was observed in the expression levels of CYP1A1, 1A2, and NAT1 (11, 75, and 35-fold, respectively). PECs expressed CYP1A1 and NAT1 but not CYP1A2. When incubated with IQ or N-OH-IQ, PECs formed DNA adducts indicating their ability to metabolically activate these compounds. CONCLUSIONS: Prostate cells possess the capacity to activate dietary carcinogens. PECs may provide a useful model system to study their role in prostate carcinogenesis.

Robotic extraperitoneal radical prostatectomy: an alternative approach.

PURPOSE: Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded. RESULTS: Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured. CONCLUSIONS: The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Nonmyeloablative allogeneic stem-cell transplantation for metastatic renal cell cancer: a review and update.

Metastatic renal cell carcinoma (RCC) is resistant to conventional chemotherapy and radiotherapy. However, immunotherapy appears to be effective in 15-20% of cases, with interleukin-2 becoming the standard therapy for this disease. As a consequence of the immune susceptibility of RCC, other avenues of immunotherapy are being explored, such as nonmyeloablative allogeneic stem cell transplantation (NST). A number of trials have shown NST to be effective in varying degrees, causing partial or complete regression. Although nonmyeloablative conditioning is safer than myeloablative conditioning, its role has yet to be clearly proven as many studies have shown variable effect. Alongside this limitation, transplant-related toxicity also forms obstacles. Regardless of the limitation of NST, further refinement of the technique, with appropriate patient selection, may lead to this being an effective therapeutic choice for a significant number of individuals.

Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?

OBJECTIVES: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery. MATERIALS AND METHODS: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using 'Sign Test', calculating two-sided p values and 95% confidence intervals. RESULTS: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 +/- 0.94 and 21.13 +/- 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p < 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. CONCLUSIONS: Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process.

Tension-free vaginal tape: avoiding failure.

A prospective, single-centre study to assess the outcome of incontinence surgery in the first 120 consecutive patients who had tension-free vaginal tape (TVT) by a single surgeon. All patients were initially seen at 3 months postsurgery, with a cough provocation test, measurement of residual urine volume and a satisfaction survey. At a mean of 26 months (6-42 months) after surgery, a validated telephone interview was performed. The operation was performed in accordance with the original technique described by Ulmsten et al. [Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 81-5]. A total of 87 of 120 patients completed the study with the others either not complying or having died. Sixty-three (72.4%) patients were completely dry on cough provocation test. Of these, four (4.5%) had a slow stream and 10 (11.4%) suffered persistent urgency. The remaining 24 patients had varying degrees of leakage (operative failure). Sixteen (18.3%) patients subjectively considered the procedure to have failed at 3 months follow-up, either because leakage occurred once or more a day, and/or the persistence of the preoperative frequency/urgency syndrome. Of these 16 TVT failures, two had previous pelvic radiotherapy, two had double incontinence and eight had TVT for recurrent incontinence. Among the failures, 81.3% had mixed incontinence with predominant urge and nocturia three times per twenty four hours. Our study highlights the need for selection when performing TVT. We recommend that TVT be performed for those who have simple stress incontinence failing conservative measures (pelvic floor exercises and physiotherapy), with no history of incontinence surgery, pelvic radiotherapy, faecal or mixed incontinence.