The Impact of pH and Ion Exchange on 133Cs Adsorption on Vermiculite

Many studies have shown that the adsorption of ions like K and Cs on 2:1 clay minerals can prompt the collapse of their interlayers and render the adsorbing ions nonexchangeable. This study sought to better understand this unique adsorption mechanism through the generation of an adsorption envelope for Cs adsorption on vermiculite and the exploration of the kinetics of interlayer collapse. The collapse of the vermiculite interlayer was confirmed via X-ray diffraction (XRD), and the timing of interlayer collapse was determined by placing Cs in competition with K at different time intervals. The adsorption envelope for Cs on vermiculite showed that although H competition does affect the adsorption of Cs on vermiculite, the effect of this competition is quite limited, even at very low pH values. This hypothesis is supported by the fact that XRD demonstrated a significant decrease in interlayer dimension after Cs adsorption. Finally, kinetics experiments showed that the irreversible adsorption of K and the collapse of the interlayer may take place on a much longer time scale than previously considered.

Extramammary Paget ’s disease Of Glans Penis: A Rare Case Report

We present the case of an 83-year-old man with Extramammary Paget’s disease (EMPD) of the penis. He underwent a total penectomy and histopathology confirms the association of underlying invasive high grade urothelial carcinoma. Penile EMPD is rare and can be misinterpreted for benign skin conditions. A high index of suspicion is required for correct diagnosis and appropriate treatment.

Predictors of live birth after vasectomy reversal in a specialist fertility centre

In a retrospective review of 106 consecutive vasectomy reversals (May 2002-April 2015) in our institution, patients were stratified according to post vasectomy obstructive interval (PVOI); less than 5 years, 5-10 years, 10-15 years and >15 years. Positive semen analysis and live birth rates were analysed. Logistic regression tested potential predictors for these outcomes. Overall patency rate (positive semen analysis) was 75% and live birth rate was 41%. Shorter PVOI was a significant predictor for positive semen analysis (p=0.028). Male smoking or male age at reversal had no significant correlation (p=0.99 and 0.95 respectively). For a live birth, PVOI and female age (threshold: 36 years) at reversal were significant predictors (p=0.007 and p=0.043 respectively). Outcomes compared favourably with international series yielding satisfactory pregnancy rates, particularly with a short obstructive interval and in females <36 years of age.

Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study

PURPOSE

Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries.

MATERIALS AND METHODS

This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated.

RESULTS

A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790).

CONCLUSIONS

Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved.

Evaluating the cost of iatrogenic urethral catheterisation injuries

INTRODUCTION

Technique is vital to prevent urethral trauma during urethral catheterisation (UC). Education programmes are helpful but are not compulsory and safe UC remains operator dependent. Traumatic UC is associated with increased morbidity, length of stay, resource utilisation and surgical intervention.

AIM

To determine the cost of iatrogenic urethral injuries managed in a tertiary referral centre over a 6-month period.

METHODS

A 6-month prospective study monitored iatrogenic urethral injuries secondary to traumatic UC. Included were referrals from district hospitals and inpatient consultations relating to urethral injury caused by traumatic UC. The added cost of management was estimated.

RESULTS

Thirteen iatrogenic urethral injuries were recorded in 6 months. Management included open surgery for a ruptured bladder (n = 1), flexible cystourethroscopy (n = 10), suprapubic catherisation (n = 4), 3-way catheterisation (n = 4) and catheter re-insertion under direct vision (n = 6). The cost of acute management of these injuries was approximately €50,000 including theatre costs, ambulance transfer, hospital stay, procedural and equipment costs and short-term follow-up care.

CONCLUSION

Iatrogenic injuries during UC represent a significant cost burden to the healthcare system. Training programmes should be compulsory for all healthcare professionals routinely involved in catheterisation procedures.

Post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testis cancer: the 16-year experience in an Irish setting

INTRODUCTION

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important tool in the management of advanced germ cell testis cancer, particularly non-seminoma.

AIM

We present the 16-year experience with PC-RPLND in a single Irish tertiary referral centre, and compare our results to the major speciality centres worldwide.

METHODOLOGY

All 78 patients undergoing PC-RPLND for the treatment of metastatic testis cancer between January 1996 and December 2011 were included. Medical records were reviewed and up to date follow-up obtained from primary referral centres, patient's GPs and individual patient interview.

RESULTS

The mean age at diagnosis was 28.5 ± 7 years. Initial pathology included non-seminoma 62.8 %, seminoma 6.4 % and combined 19.2 %. All patients underwent pre-operative chemotherapy. The resection template utilised was bilateral infra-hilar in 29.5 %, unilateral infra-hilar in 46.2 % and supra-hilar in 20.5 %. Complete abdominal remission was achieved in all but one patient. Additional procedures were required in 38.5 % of patients (n = 30). Clavien Dindo grade three or four complications were seen in 8.9 %, including five patients who required early reoperation. Histology of RPLND specimen showed mature teratoma (41 %) and active cancer (11.5 %). Follow-up data were available for 66 patients (85 %). Median follow-up was 101 (11-207) months. Nine patients relapsed with median time to relapse 15 (8-60) months. Overall 5-year survival rate was 95.2 % (four deaths).

CONCLUSION

In this relatively small series due to small population and low disease incidence, we have shown acceptable peri-operative course, morbidity and oncological outcomes with PC-RPLND compared to major international centres.

Dilemmas in diagnosis and natural history of renal oncocytoma and implications for management

INTRODUCTION

Oncocytomas have traditionally been treated with surgical excision; however, their excellent long-term prognosis has popularized conservative and minimally invasive ablative techniques. We evaluated the evolving management and natural history of renal oncocytomas and investigated the relationship between radiological and histopathological diagnosis.

METHODS

We performed a 17-year retrospective cohort study on all patients with a confirmed histopathological diagnosis of renal oncocytoma. The primary outcome variables were long-term outcomes, coexistence with renal cell carcinoma, and development of metastatic disease.

RESULTS

A total of 38 oncocytomas were reported in 36 patients. Of the 36 patients, 29 (81%) were diagnosed incidentally. Oncocytoma was considered in the differential diagnosis in 4 oncocytomas (10.5%). In total, 34 patients underwent early surgical intervention; of these, 27 (79.4%) underwent radical nephrectomy and 7 underwent partial nephrectomy (20.6%). Four patients (11.1%) were managed conservatively with surveillance. No patients developed recurrence or metastatic disease after a median follow-up of 84 months (range: 4-178).

CONCLUSIONS

The diagnostic accuracy for imaging modalities in renal oncocytoma is poor. Surveillance or minimally invasive ablative techniques are appropriate in selected patients with biopsy-proven oncocytoma that are not increasing in size.

Testicular Sperm Extraction and Intracytoplasmic Sperm Injection: Outcomes in a specialist fertility centre

Assisted reproduction with testicular sperm extraction (TESE) and intra-cytoplasmic sperm injection (ICSI) are fertility treatment options for couples with severe oligospermia or azoospermia. A retrospective review was performed of 146 TESE procedures in a specialist fertility centre in Ireland. The indication for TESE was obstructive azoospermia (OA) in 59% (n = 80) and non-obstructive azoospermia (NOA) in 41% (n = 56). Sperm retrieval rates after TESE were determined and the pregnancy rates per ICSI cycle number were evaluated. Sperm retrieval rates were 99% (n = 79/80) and 32% (n = 18/56) for OA and NOA men respectively. Fifty-eight couples proceeded to ICSI. Overall 114 ICSI cycles were performed and 33 cycles resulted in fertilisation (29%). Our sperm retrieval and pregnancy rates are consistent with international studies and support the ongoing role for TESE and ICSI as successful assisted reproductive techniques for male factor infertility in Ireland.

Conversion rates of abstracts to publications from the Irish Society of Urology Annual Meeting (2005–2011) – Questioning the scientific value of national urological meetings for smaller European nations

Background:

Large annual scientific meetings such as the American Urological Association (AUA) and the European Association of Urology (EUA) have abstract conversion rates into publication of 37%−48%. There are no data on the conversion rates from national meetings of smaller European countries. Our objective was to present the conversion rates and manuscript characteristics of the Irish Society of Urology (ISU) annual meeting over a seven-year period (2005–2011), and to demonstrate the value, viability and sustainability of such a meeting as a model for other small national research programmes.

Methods:

All abstracts presented at the ISU annual meeting between 2005 and 2011 were identified. The subsequent publication rate following the meetings was established for the corresponding studies based on a Medline scan. A range of characteristics associated with subsequent publication were analysed using the logistic regression of the dichotomous variable of publications vs. non-publication of each factor.

Results:

Overall, 46% of the 322 abstracts presented at the ISU meeting were followed by publication into Medline-indexed journals with a mean impact factor of 2.6. A total of 74% abstracts were published within two years. Oral presentations were more likely to be published than posters ( p < 0.0001), and prospective clinical research was more likely to be published in a journal with a higher impact factor than retrospective analyses ( p = 0.033); the mean time to publication was 16.7 months.

Conclusions:

Almost half the abstracts presented at the ISU were subsequently published in peer-reviewed journals, the majority within two years. This compares favourably with larger urological meetings, and provides an incentive to other smaller countries within Europe to continue with national research programmes.

Transurethral resection of the prostate--"now and then"

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

Is citation index a good indicator of landmark papers in urology?

Objective:

Knowledge of landmark papers in urology is essential both for the practise of evidence-based medicine and for trainees requiring a syllabus for the FRCS Urology examination. Citation index (CI) is seen as a direct measure of the quality of a scientific paper. The aim of this study was to compare papers with the highest CI in each urologic sub-speciality with the landmark papers in urology.

Methods:

Seventy-nine of the highest impact factor journals in urology, medicine and urologic sub-specialities were identified from the Journal of Citation Reports: Science edition 2012. Urology papers with the highest CI were identified from these journals using the database of the Science CI (1965–2012). Forty-four landmark papers in urology were then identified from textbooks, recommended reading lists for the FRCS Urology examination, and publications on landmark urology papers. High CI papers were then compared to landmark papers.

Results:

The top 10 cited papers in each urologic sub-speciality were identified. A total of 31.8% ( n = 14) landmark papers were among the top 10 cited papers. Urinary tract infection had the highest proportion of landmark papers in the top 10 cited articles. Kidney cancer papers had the highest mean CI while urinary tract trauma had the lowest.

Conclusion:

This study shows that CI alone is a poor indicator of landmark papers in urology. This paper gives a comprehensive overview both of landmark papers in urology and those with the highest CI, and may be used as an adjunct to the FRCS Urology syllabus.

The clinic-pathological characteristics of prostate cancer in an Irish subpopulation with a serum PSA less than 4.0ng/ml

Background:

Prostate specific antigen (PSA) has been used as a biomarker for prostate cancer for the last 20 years. Traditionally, a serum PSA <4 ng/ml has been used as a general cut-off between normal and abnormal readings. There is evidence to demonstrate that men with a normal serum PSA can develop prostate cancer. The aim of this study was to investigate the clinico-pathological features of prostate cancer in a non-screened Irish cohort with serum PSA <4 ng/ml.

Methods:

A retrospective analysis was performed of all patients who underwent radical retropubic prostatectomy (RRP) in a tertiary referral unit over a 10-year period (2000–2010). Clinico-pathological characteristics were collated including those from trans-rectal ultrasound-guided (TRUS) prostate biopsies and radical prostatectomy specimens.

Results:

Between 2000 and 2010, 651 men underwent an RRP, with 43 (6.6%) having a serum PSA <4 ng/ml. The median PSA was 3.2 ng/ml (range 0.8–4.0). Nineteen (44.2%) had palpable disease on direct rectal examination (DRE). Following prostatectomy, 28 (65.12%) had Gleason 6 disease, 14 (32.56%) had Gleason 7 disease and one (2.32%) had Gleason 8 disease. Five (11.63%) patients were upgraded from TRUS biopsy to final histopathology. Six (13.95%) patients had pathological evidence of extracapsular extension on final pathology. Three (6.98%) patients experienced biochemical recurrence and received salvage radiation therapy after a median time of 24 months. The median follow-up was 106 months (range 36–158). Twenty (46.51%) patients had a first-degree family history of prostate cancer.

Conclusions:

A PSA cut-off of 4 ng/ml has commonly been used in the detection of prostate cancer. Our study emphasizes that this cut-off is inappropriate and that no specific level of PSA can be used. Management decisions need to be individualized based on index of suspicion with concomitant counselling and rectal examination.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

A 30-year experience of Millin's retropubic prostatectomy: Has this classic operation derived by a President of the College in Ireland stood the test of time?

INTRODUCTION

In patients with large gland volume, open prostatectomy/adenoma enucleation remains a valuable surgical option in treating large obstructing prostates. We report our series of open prostatectomies spanning 32 years from a single institution.

PATIENTS AND METHODS

We retrospectively reviewed all patients who underwent open prostatectomy between 1980 and 2012. Patient demographical, clinical, pre- and postoperative data and final histology were retrieved from hospital in-patient enquiry system and chart review.

RESULTS

A total of 161 patients underwent Millin's prostatectomy by seven surgeons between 1980 and 2012. The mean blood loss was 1,381 mls (range 300-3,675 mls). One-third (34%) of patients (n = 55) received a blood transfusion. The mean weight of prostate tissue removed was 119 g (median 112 g, range 17-372 g). 6.6 % of pathological specimens revealed incidental prostate cancer, of which 78% were well differentiated (Gleason score ≤ 6). The mean weight of prostate tissue removed in patients who received a transfusion was 124 g. Trial of micturition (TOM) was performed at a mean of 9 days (median 9 days, range 5-25 days) with 94% of patients having a successful trial of voiding. 6% of cases early in the series failed to void initially, but did so at later removal of catheter while still in hospital. 45 patients (28%) of patients developed peri- or postoperative complications. There were three deaths (1.9%).

CONCLUSION

Open Millin's prostatectomy popularized over half a century ago continues to be a valuable option for the surgical treatment of high-volume prostate glands with excellent outcomes for patients.

Percutaneous nephrolithotomy in adult patients with spina bifida, severe spinal deformity and large renal stones

AIMS

To present our experience in patients with spina bifida with severe spinal abnormality undergoing percutaneous nephrolithotomy (PCNL) for large stone burden.

PATIENTS AND METHODS

A retrospective review identified five spina bifida patients with abnormal spinal curvature who had a PCNL for large kidney stones. The mean age was 28 years. In two patients, stones were on the concave side of the scoliotic spine further limiting percutaneous access. Mean stone burden was 940 mm2. All patients were paraplegic, three patients had symptomatic stone disease. We performed initial percutaneous renal access in radiology department and staged nephrolithotomy in operating room. Tract dilatation was accomplished using Amplatz dilators and a 24 Ch or 26 Ch nephroscope was used. Fragmentation and stone removal were accomplished in all patients using pneumatic and or ultrasound lithotripter and a retrieval grasper.

RESULTS

No anaesthetic complications were recorded. One patient required multiple percutaneous tracts, four had single tract to access stones. Three patients were stone free after PCNL. One required second PCNL through the same tract and another patient had multiple adjunctive ESWL. All five patients were stone clear after the final procedure. Two patients required blood transfusion. No patient had major complication or admission to intensive care unit.

CONCLUSIONS

Percutaneous nephrolithotomy in patients with spina bifida is challenging but safe. Detailed pre-operative anaesthetic assessment and precise uroradiological evaluation of renal anatomy is essential. Second-look PCNL and additional ESWL/URS treatment may be required to completely clear stones.

Emergency management of acute urinary retention: results from an all-Ireland urologist practice survey

INTRODUCTION

Anecdotal evidence suggests that current service restrictions and operative cancellations are resulting in increased numbers of catheterized men in the community awaiting definitive management of their bladder outlet obstruction. We wished to analyse current admission policies and management strategies of acute urinary retention (AUR) secondary to benign prostatic enlargement (BPE) in Ireland.

METHODS

A total of 58 consultant urologists practicing in Ireland were sent a questionnaire about their management of AUR secondary to BPE. Data was collected relating to initial emergency management, timing of trial without catheter (TWOC), their use of alpha-blockers and follow-up policy.

RESULTS

Urethral catheterization is the initial management of choice by all 42 respondents. The patient is routinely admitted after catheterization by 20/42 consultants (48 %) and 22/42 (52 %) discharge the patient home with a urinary catheter (UC). TWOC is performed on day 2 in 11/20 (55 %) and on day 3 in 9/20 (45 %). In terms of individuals who admit patients presenting with AUR one failed TWOC is an indication for transurethral resection of the prostate in 10/20 (50 %), with 6/20 (30 %) performing a second TWOC on the same admission and 4/20 (20 %) discharging the patient for interval TURP. A total of 83 % of respondents, all of whom work in public institutions, expressed concerns relating to elective admission difficulties for definitive management of catheterized patients following AUR.

CONCLUSION

There is variation in the admission policy for AUR in Ireland. Elective admission and operative restrictions for catheterized patients following episodes of AUR are causing concern to the urologists in Ireland.

The Distribution of PSA Age-Specific Profiles in Healthy Irish Men between 20 and 70

Background. Ireland is estimated to have the highest European incidence rate of prostate cancer (Pca) in 2006 which will increase by 275% by 2025. This study aimed to determine PSA cutoff values in different age groups of healthy male patients without Pca. Methods. 660 men in a pilot men's health programme, aged 18–67, had PSA assayed. Men were grouped into 8 age groups at 5-year intervals: 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, and 64–70. Results. Linear regression demonstrates a PSA velocity of 0.024 ng/ml/year. The 95% confidence interval demonstrates a near flat line of PSA values from age 20 to 50 and rises after. When transformed logarithmically, PSA correlates highly with expected values from the normal distribution (0.98). A fractional polynomial quantile regression model was used to predict median and 95th percentile for PSA as follows: 30–34 (0.73, 1.57), 35–39 (0.71, 1.65), 40–44 (0.73, 1.85), 45–49 (0.78, 2.17), 50–54 (0.88, 2.63), 55–59 (1.01, 3.25), 60–64 (1.20, 4.02), and 64–70 (1.43, 4.96). Conclusions. PSA levels are similar to other racial groups but not as high as US Caucasians until 65 years. These data define the predicted PSA for the Irish population and provide a reference for future screening programmes.

The pitfalls of treating anorectal conditions after radiotherapy for prostate cancer

We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.

Prostate cancer knowledge in Irish men

Men require prostate cancer (Pca) knowledge to practice health-seeking behaviours. Nine hundred seventy-nine men participated in a Pca screening programme comprising IPSS, bother score and health belief questionnaire. Men with private insurance had greater knowledge. Forty-nine percent (481) assessed their health status as average. Seventy-five percent (735) visited the GP at least once per year. The majority (576) felt well informed about health matters. Fifty-five percent (542) knew the prostate location but only 319 (33%) could identify it on a diagram. Forty-one percent (401) could not name a symptom. Few knew risk factors but 98% would attend a Pca screening clinic and sought more information. Men lack knowledge to pursue healthier behaviours and should be targeted possibly through a men's health initiative.

Survival after incidental prostate cancer diagnosis at transurethral resection of prostate: 10-year outcomes

BACKGROUND

The most appropriate management of incidental prostate cancers diagnosed at transurethral resection of prostate has been debated. It is important to determine the long-term outcomes to establish an appropriate management in patients with incidental prostate cancer.

AIMS

We aim to determine 10-year survival and to identify the factors of worse prognosis of incidental prostate cancers diagnosed at transurethral resection of prostate.

METHODS

A retrospective analysis of patients with pT1a-pT1b prostate cancers diagnosed between 1998 and 2003. Medical notes, PSA and pathology results were reviewed. Overall and cancer specific survival was calculated at mean 10-year follow-up.

RESULTS

Sixty patients with incidental prostate cancer were identified (pT1a = 18, pT1b = 42). Fifty-one percents of the patients were managed on a watchful waiting strategy with overall 84% survival and 9.7% cancer specific mortality. Twenty patients (all with pT1b) received hormone therapy. Overall survival in this cohort was 50% with 20% cancer specific mortality. Nine patients received curative therapy (Radical prostatectomy = 4, Radiotherapy = 5). In this group, overall survival was 88% with no cancer specific mortality.

CONCLUSIONS

Stage pT1a disease and preoperative low PSA were associated with favourable survival. However, for pT1b and/or high Gleason score (≥7), mortality was comparatively higher. Hence, patients with high Gleason score and/or pT1b disease should be considered for curative therapy. Additionally, active surveillance may have a role in selected men with incidental prostate cancer.

Extended long term functional outcome of inflatable penile prosthesis in a single institution

We sought to evaluate the extended long term functional outcome of the AMS700 three piece inflatable prosthesis in men with erectile dysfunction in a single urological department and assess our revision rates. Patients that underwent first-time insertion or revision of an AMS700 3 piece inflatable penile prosthesis between 1984-2007 were included. Data was obtained from medical records and long term follow up of patients was conducted by telephone interview. The medical records of 38 patients were available for review. Of these 38 men, 56 prostheses were inserted. The mean follow up was 8.4 years (101 months). The revision rate at 50 months postoperatively was 7/38 (18%). The overall revision rate was 18/38 (47%). The mean time to revision in these 18 patients was 72 months (12-156 months) after initial insertion of AMS700 penile prosthesis. This study highlights that with longer follow u revision rates markedly increase after 72 months.

Scrotal signs and symptoms in the general population, the value of testis self-examination and the pitfalls of a scrotal screening programme: is the two-week rule relevant?

PURPOSE

Testicular symptoms/lumps are a cause of concern, anxiety and possible diagnostic dilemma for patient and general practitioner. The majority of scrotal pathology is benign in nature and results in a huge workload. The main aim of this study was to determine the relationship between scrotal symptoms, previous scrotal surgery, testicular self-examination and awareness of scrotal abnormalities. Secondarily, we sought to determine the scrotal findings in men enrolled in a consultant urologist-directed screening programme.

METHODS

There were 677 men surveyed on their performance of TSE. They were also asked about scrotal symptoms and prior surgery, before undergoing blinded physical examination by one of four consultant urologists.

RESULTS

Among the participants, 9.8% of men had scrotal symptoms with 55% of these having a normal scrotal examination and the rest having benign pathology. A number of men who had undergone previous scrotal surgery (13%) had no clinical findings detected on scrotal examination. No subject was found to have testis cancer; 20.9% had a benign scrotal or inguinal condition detected with the majority (65%) not aware of the abnormality. Men who demonstrate a superior awareness of their scrotal abnormalities were more likely to perform TSE.

CONCLUSIONS

Increased awareness of scrotal abnormalities combined with TSE may have a role in improving detection of significant testicular pathology. However, the high prevalence of benign scrotal conditions, of which most men were unaware, may serve to raise anxiety in the patient and general practitioner. We believe there is no role for a one-stop scrotal anxiety clinic, as the costs do not justify the benefits.

A prospective 10 year audit of a single Irish centre's experience of retroperitoneal lymph node dissection for metastatic testis cancer

BACKGROUND

Retro-peritoneal lymph node dissection (RPLND) following chemotherapy is critical in advanced germ cell tumours with residual retro-peritoneal masses. Post-chemotherapy RPLND is more extensive, may require adjacent organ resection and has higher morbidity. The study aim was to analyse patient demographics, clinical stage, surgical procedures and cure rates following RPLND.

METHODS

An RPLND database (1994-2005) was analysed prospectively for demographics, pre/post-RPLND staging, chemotherapy regimen, cure, follow-up and early/late morbidity and mortality.

RESULTS

73 patients were identified (range 17-49 median 25.7). The mean hospital stay was 14.3 days (range 6-50). Clinical stage at presentation was; IV (16), III (19), II (27), I (11) and prior to RPLND was IV (12), III (6), II (55), I (0). Eleven patients with stage I disease progressed prior to RPLND. Seventy-one patients received cisplatin-based chemotherapy with partial response (49), minimal response (14), no response (7), disease progression (3) and 13 patients required salvage chemotherapy. RPLND was bilateral (26), unilateral (36) and suprahilar (11) with nerve sparing in 10. Other major procedures included nephrectomy (22), aortic graft (1), ureterectomy (1) and caval dissection (1). RPLND histology was mature teratoma (MT) (37), fibrosis/necrosis (26), NSGCT (6), seminoma (1), mixed NSGCT/teratoma (1), sarcoma (1) and mixed seminoma/teratoma (1). Early (n = 26) and late (n = 13) morbidity was significant but expected. There was no mortality. Ninety-five per cent had complete remission following RPLND (mean follow-up 30 months). One patient is deceased following relapse.

CONCLUSIONS

The decision to perform post-chemotherapy RPLND depends on the possibility of viable tumour or teratoma and surgical morbidity. Appropriate case selection and timely intervention in an experienced centre permits optimum outcome.

The effects of drugs, ions, and poly-l-lysine on the excretory system of Schistosoma mansoni

We have been able to label the excretory system of cercariae and all forms of schistosomula, immature and adult worms with the highly fluorescent dye resorufin. We have shown that the accumulation of the resorufin into the excretory tubules and collecting ducts of the male adult worm depends on the presence of extracellular calcium and phosphate ions. In the adult male worms, praziquantel (PZQ) prevents this accumulation in RPMI medium and disperses resorufin from tubules which have been prelabelled. Female worms and all other developmental stages are much less affected either by the presence of calcium and phosphate ions, or the disruption caused by PZQ. The male can inhibit the excretory system in paired female. Fluorescent PZQ localises in the posterior gut (intestine) region of the male adult worm, but not in the excretory system, except for the anionic carboxy fluorescein derivative of PZQ, which may be excreted by this route. All stages of the parasite can recover from damage by PZQ treatment in vitro. The excretory system is highly sensitive to damage to the surface membrane and may be involved in vesicle movement and damage repair processes. In vivo the adult parasite does not recover from PZQ treatment, but what is inhibiting recovery is unknown, but likely to be related to immune effector molecules.

The forgotten ureteric JJ stent and its prevention: a prospective audit of the value of a ureteric stent logbook

BACKGROUND

Temporary ureteric stent insertion is an integral part of modern endo-urological practice. Delayed stent removal or forgotten stents are associated with increased patient morbidity and complications which are often difficult to manage.

METHODS AND RESULTS

We prospectively audited our ureteric stent insertion and removal logbook system to determine the value and effectiveness of our stent follow-up. Over a 1-year period, 210 ureteric stents were inserted in our urological unit. Of these, 47 (22.4%) patients were unaccounted as having their stents removed within the stent logbooks. One patient was lost to follow-up and re-presented with stent encrustation 10 months later.

CONCLUSIONS

Our results in this audit suggest that our system of ureteric stent follow-up is not effective. We have now introduced a new system that we feel is a safer and a satisfactory alternative to the stent logbooks. This includes a patient education leaflet and removal date scheduling prior to discharge from hospital.

Urology out-patient non-attenders: are we wasting our time?

BACKGROUND

Out-patient non-attendance leads to inefficiency and patient morbidity.

AIMS AND METHODS

A phone survey of urology out-patient non-attenders over 1-month was performed to determine reasons for non-attendance, to identify patients who could be discharged, and the manner in which patients want reminders.

RESULTS

Seventy-six non-attenders were contacted. Fourteen were GP referred new patients. The reason for non-attendance (n = 10) was due to patient issues. Of the patients due for review (n = 62), it was a first non-attendance in 56. Only 41 (66%) claimed to have received notification or appointment cards. Eight patients said they were written to and 13 (21%) denied either receiving a written notification or an appointment card. Only eight patients rang to confirm/change their appointment. Ninety-nine percent said that they would like a further appointment by text message (34%), phone (37%), letter (36%) or email (6%).

CONCLUSIONS

We now hope to implement a number of methods to further reduce non-attendance rates based on the findings in this study.

An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi

BACKGROUND

At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol.

PATIENTS AND METHODS

A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years.

RESULTS

Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus.

CONCLUSION

A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

A study of the effect of surface damage on the uptake of Texas Red-BSA by schistosomula of Schistosoma mansoni

In this paper we describe the effect of poly-L-lysines of different molecular weight on the schistosomula. In the control sample, the schistosomula of Schistosoma mansoni take up fluorescent Texas Red conjugated to bovine serum albumin (TxR-BSA) into the gut. Following slight damage by 24.0 kDa poly-L-lysine, a high proportion of schistosomula take up fluorescent TxR-BSA into the excretory system. Subsequently, the dye diffused into the bodies of the schistosomula. We suspected that this diffusion involved the process of endocytosis so we investigated this with the use of endocytosis inhibitor, Latrunculin A. Addition of the endocytosis inhibitor Latrunculin A following poly-L-lysine treatment inhibited gut uptake of TxR-BSA as well as the diffusion of excretory-ingested TxR-BSA molecules.

Acidic vesicles of Schistosoma mansoni

The fluorescent probe LysoTracker Red was used to examine for the presence of acidic vesicles in cercariae and schistosomula of Schistosoma mansoni. Acidic vesicles were widely distributed throughout the body of freshly transformed schistosomula and 24-h-old schistosomula but were absent from cercariae. The vesicles of freshly transformed schistosomula were undetectable after incubation with drugs that affect the functionality of acidic vesicles including monensin, ouabain, primaquine, and amiloride. In 24-h transformed schistosomula, the same effect was observed with monensin but not with ouabain, primaquine or amiloride. Praziquantel also affected the acidic vesicles of the schistosomula. We suggest that these acidic vesicles could be large lysosome-like organelles.

Rupture of the male membranous urethra

BACKGROUND

Management of traumatic rupture of the male membranous urethra remains controversial. Long-term morbidity can include urinary incontinence, urethral stricture and erectile dysfunction.

AIMS

To review management and outcome of urethral rupture to improve treatment protocols.

METHODS

A retrospective study of 47 patients presenting with traumatic urethral rupture over 25 years was performed.

RESULTS

All patients underwent emergency suprapubic catheterisation, 32 patients had open surgical realignment at 1-2 weeks; 78% of whom developed strictures. Ten patients unsuitable for early repair underwent delayed transabdominal transpubic urethroplasty at three months: 40% of whom developed strictures. Five patients with partial rupture were managed by cystoscopy and urethral catheter. Erectile dysfunction correlated to initial injury rather than treatment.

CONCLUSIONS

If the patient is stable and requires emergency laparotomy for other abdominal injuries, he should have immediate realignment of the urethra. Early realignment of the urethra at laparotomy at 1-2 weeks can be combined with orthopaedic fixation of pelvic fractures. Patients who remain unstable due to associated injuries should have delayed urethroplasty at three months.

Schistosomes: Unanswered Questions on the Basic Biology of the Host–Parasite Relationship

As is the case in many parasite infections, research into schistosomiasis has not yet yielded a vaccine and, although chemotherapy with praziquantel is very effective, the mechanism of action of this drug is unknown. John Kusel and colleagues here suggest that an understanding of basic biological phenomena, such as the role of Ca(2+) in skin penetration and the function of the adult excretory system, might lead to important breakthroughs. Other crucial questions are also addressed, with the hope of stimulating debate. They invite suggestions and correspondence from others working in related fields.

The defunctionalized bladder

Supravesical urinary diversion without cystectomy is a common procedure performed to manage a variety of lower urinary tract pathologies. The purpose of this article is to review the complications associated with the bladder left in situ and to relate this to the female patient. Complications related to the defunctionalized bladder include pyocystis, hemorrhage, pain/spasm and neoplastic transformation. The defunctionalized bladder also has implications for sexual function, pregnancy and undiversion. The risk factors for complications are chronic infection, inadequate drainage, interstitial cystitis and previous irradiation. The incidence of neoplastic change in the defunctionalized bladder is low, but long-term follow-up is advised, as carcinoma could develop many decades after diversion. Sexual function following urinary diversion is better preserved when the bladder is retained.

Epididymectomy in the management of intrascrotal disease: a critical reappraisal

OBJECTIVE

To assess the outcome of epididymectomy as a method of treating epididymal pathology.

PATIENTS AND METHODS

Forty-one patients who underwent epididymectomy between 1990 and 1995 were analysed retrospectively; their clinical records were reviewed and their satisfaction with the outcome and relief of symptoms assessed using a questionnaire and/or telephone interview.

RESULTS

Twenty-nine patients with pain were subdivided into three categories depending on the indication for epididymectomy, i.e. post-vasectomy epididymal engorgement (eight patients), complex cystic disease (11) or 'chronic epididymitis' (10). The outcome was satisfactory in 27 of the 29 patients. The best results were obtained in the group who underwent epididymectomy after vasectomy, where seven of eight improved after the procedure. Those with chronic epididymitis had the least favourable outcome, with only seven reporting any improvement in symptoms.

CONCLUSIONS

Epididymectomy has a valuable role in the management of epididymal pathology in appropriately selected patients.

The role of orchiectomy in the management of postpubertal cryptorchidism

PURPOSE

Owing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients.

MATERIALS AND METHODS

A total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically.

RESULTS

Histology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%).

CONCLUSIONS

This analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

The effect of age on susceptibility to hypoxic-ischemic brain damage

Stroke occurs in all age groups, ranging from the new-born to the elderly. Our current understanding of the mechanisms of ischemic brain injury suggests that, despite age, the underlying cascade of events includes the rapid depletion of energy reserves, lactate accumulation, release of excitatory amino acids, high intracellular concentrations of Ca2+, and the production of oxygen free radicals. The extent to which these events affect brain injury, however, is profoundly influenced by age. Hyperglycemia for example, markedly enhances hypoxic-ischemic brain damage in adults, but has a protective effect in new-born rats. Insulin-induced hypoglycemia, on the other hand, protects the adult brain, but may be detrimental to the new-born. Substrate utilization of ketone bodies is markedly enhanced in the new-born, and has now been shown also to protect the brain. The immature brain is generally believed to be more resistant to the damaging effects of cerebrovascular compromise compared to the more mature brain. However, recent experiments suggest that the correlation between brain damage and age is not linear. To further clarify the effects of age and development on hypoxic-ischemic brain damage, we developed a model whereby rats of increasing age received identical cerebrovascular insults. Neuropathologic assessment at 7 days of recovery showed that brain damage was most severe in the 1- and 3-week-old animals followed by those that were 6 months. The 6- and 9-week-old groups had significantly less injury than the other three age groups. Hippocampal damage was most severe in the 3-week and 6-month-old rats compared to all other age groups. These findings contrast previously held beliefs regarding the enhanced tolerance of the immature brain to hypoxic-ischemic damage and demonstrate that the immature brain is, in fact, less resistant to hypoxic-ischemic brain damage than its adult counterpart. The results emphasize the need for a greater understanding of the effects of ontogeny on hypoxic-ischemic brain damage, particularly as it pertains to the development of therapeutic interventions.

Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility

OBJECTIVES AND METHODS

The effects of double pigtail ureteric catheters (JJS) and percutaneous nephrostomies (PN) on ureteric motility and artificial stone transit was assessed in 12 dogs. Each animal underwent bilateral nephrostomies and an artificial stone insertion into each upper ureter (n = 20). A 4-Fr JJS was inserted on one side (group 1) while a PN was left on the contralateral side (group 2). In 4 stone-only 'control' ureters (group 3), the PN was sealed after 72 h. Stone passage was assessed by plain x-rays. Pelvic and ureteric motility was assessed prior to stone insertion and again at 2 weeks.

RESULTS

In group 1, only 1 of 8 stones (12.5%) passed completely. Four reached the midureter, 3 remained static. Six of 8 stones (75%) in group 2 passed completely. Two stones remained in the distal ureter. All 4 stones (100%) in group 3 passed by day 3 postoperatively. At laparotomy the J-stented ureters were dilated and both pelvic and ureteric contractions were diminished. Ureteric diameter was normal on the PN side. The ureters contracted with normal amplitude, but diminished rate of contraction above the stones in the ureters with residual calculi (n = 2), and in the 6 ureters from which spontaneous stone passage had occurred. A similar pattern was found in the 4 group 3 ureters.

CONCLUSIONS

Double J stents are associated with ureteric dilatation, diminished peristalsis and impaired stone passage. APN preserves ureteric peristalsis and facilitates stone passage. In the initial phase, raised hydrostatic pressure appears to the most important factor determining stone passage.

Incidentally detected renal cell carcinoma: pathological features, survival trends and implications for treatment

OBJECTIVES

To compare treatment outcomes in symptomatic and incidental renal cell carcinoma (RCC) with specific interest in the role of radical nephrectomy.

PATIENTS AND METHODS

The records of 189 patients with a clinical diagnosis of RCC were reviewed. The mode of presentation, tumour size, grade and stage at presentation were correlated with final outcome, as measured by the disease-free and overall survival of the patients.

RESULTS

The rate of incidental detection was 15%; incidental tumours were of a lower stage and patients with incidentally detected tumours had a significantly longer disease-free and overall survival than had those with symptomatic tumours (P < 0.05).

CONCLUSIONS

The increased detection of incidental tumours should further improve survival in RCC. We continue to advocate radical nephrectomy for incidentally detected tumours, as it offers the best outcome and simplifies the follow-up.

Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965-1989) using routine primary retroperitoneal lymph node dissection

Between 1965 and 1989, 1180 patients at Indiana University, U.S.A., underwent retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ cell (NSGC) testis cancer of whom 638 cases had primary RPLND. A subset of 174 cases were considered clinical stage B (or II) before surgery (retroperitoneal nodal metastases by clinical staging). Surgery revealed that 23% (n = 41) had pathological stage A disease (no cancerous nodes). This error rate in clinical staging has decreased somewhat with improved techniques, but remains approximately 20% over the last decade. The relapse rate in pathological stage A (n = 41) was 5% (n = 2), both of whom were cured by chemotherapy. The relapse rate in pathological stage B without postoperative adjuvant treatment (n = 54) was 35% (n = 19); 2 patients died. This indicates that 65% of pathological stage B cases were cured by RPLND alone. From 1979 to 1989, the 140 pathological stage B cases participated in a randomised prospective trial of post-RPLND adjuvant chemotherapy versus no postoperative treatment. Forty two per cent (n = 59) received postoperative platinum-based therapy (two cycles), and there has been no relapse after RPLND for stage B disease. While advances in chemotherapy for NSGC testis cancer have led to its application by several study groups to clinical stage B (or II) testis cancer (with surgery reserved only for those in partial remission), the equivalent cure rate with RPLND surgery with chemotherapy rescue reserved for those who relapse appears to have both cost and risk-benefit advantages.

'Firm' versus 'soft' double pigtail ureteric stents: a randomised blind comparative trial

It is generally considered that 'firm' double pigtail ureteric catheters, while easier to insert and less prone to migration, may cause more patient discomfort than the 'softer' variety of stent. Objective support for these perceptions is however lacking. The aim of this study was to compare firm and soft stents regarding their ease of insertion, positional stability, biocompatibility and patient tolerance. 155 patients were randomised to receive 'firm' (polyurethane, n = 78) or 'soft' (Sof-Flex, n = 77) stents. Ease and mode of insertion was recorded at time of initial placement. Positional stability, degree of bladder inflammation, stent encrustation and patient tolerance were recorded at the time of removal. Patient tolerance was assessed by symptom score in double-blind fashion. Results showed no significant difference in ease of insertion, positional stability, degree of bladder inflammation or stent encrustation between the two groups. There was a significantly higher incidence of dysuria, renal and suprapubic pain in the firm stent group. There was no significant difference in the incidence of urgency, frequency, nocturia or haematuria. Normal activity and return to work were reported in 67 and 45% of patients with soft and firm stents, respectively. The data indicates that patient tolerance appears to be related to the softness of the stent material.

The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University experience (1965 to 1989)

Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 underwent primary dissection). Of these patients, 174 were considered to have clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patients (23%) actually had pathological stage A disease (no cancerous nodes). This nonspecificity in clinical staging remains consistent despite advance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that primary retroperitoneal lymph node dissection for low stage metastatic nonseminomatous germ cell testis cancer (pathological stage B) not only had diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of primary chemotherapy alone for stage B disease, which are still relatively early reports. This cure rate with single modality therapy (retroperitoneal lymph node dissection alone) was accomplished within an average of 4 hours and, therefore, should be more time and cost-effective than prior reports of 3 and 4 courses of primary chemotherapy. In the post-cisplatin era (1979 to 1989), 140 patients with clinical stage B disease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relapse. Both patients are currently disease-free with subsequent chemotherapy. Of the remaining 108 patients with pathological stage B disease 49 received no adjuvant chemotherapy and 59 received cisplatin-based adjuvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuvant chemotherapy had relapse. The overall survival rate in these 140 clinical stage B cancer patients was 98%. There were 3 deaths, only 1 from cancer. The addition of cisplatin-based adjuvant chemotherapy postoperatively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retroperitoneal lymph node dissection as monotherapy is curative in two-thirds of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemotherapy. Future considerations in selecting therapy for clinical stage II nonseminomatous germ cell testis cancer will be risk-benefit, cost-benefit and quality of life issues. Several cooperative studies will examine these issues, involving European and United States groups.

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I--Vena cava

A total of 42 patients underwent inferior vena cava resection (n = 40) or intraluminal tumor thrombectomy (n = 2) during retroperitoneal lymph-node dissection (RPLND) for bulky abdominal metastatic nonseminomatous germ-cell cancer (7% of all postchemotherapy RPLND cases). The three indications for caval resection included tumor clearance (38%), caval scar occlusion (14%), and caval tumor thrombus (48%). En bloc caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of specimens, teratoma in 31% specimens). Caval resection in the presence of scar occlusion was required de facto by virtue of its incorporation in the specimen. Caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer, 35%; teratoma, 45%; fibrosis, 20%) reflected nodal pathology in 71% of cancer cases, 78% of teratoma cases, and 100% of fibrosis cases. The complications of caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapeutic options.