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Objective: Robot-assisted radical cystectomy (RARC) is considered the gold-standard for patients who fail Bacillus Calmette–Guérin (BCG) treatment for high-grade non-muscle-invasive bladder cancer. We reviewed our histopathological outcomes to assess whether we are proceeding to cystectomy at an appropriate time. Methods: A retrospective analysis of the RARC database (2015–2020) was performed to identify patients who received intravesical BCG before cystectomy. Data regarding demographics, number of BCG instillations and staging were collected. Histopathological stage at cystectomy was compared between patients who received an induction course of BCG only (group A), and those who had continued maintenance doses (group B). Results: A total of 73 patients (57 males and 16 females) met the final inclusion criteria, with 24 patients in group A and 49 patients in group B. At cystectomy, 19 patients had ⩾T2 disease (group A: 7; group B: 12). There was no significant difference between groups ( p=0.78). Pelvic lymph node dissection was performed in 68 patients, with six patients found to have lymph node metastases. Conclusion: RARC plays a key role in managing BCG failure, considering the number of patients with muscle-invasive disease at final staging. However, prolonged BCG treatment was not associated with more advanced disease in our case series. Thus, persistence with intravesical treatment warrants consideration for selected patients. Level of evidence: Level 4.

Background The comparative effectiveness of robotic-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) in terms of perioperative outcomes is still a matter of debate affecting payors, physicians, and patients. Objective To evaluate comparative perioperative and longer-term morbidity of RARC versus ORC in a multicenter contemporary retrospective cohort of patients. Design, setting, and participants This retrospective multicenter study included patients with bladder cancer treated with radical cystectomy at 10 academic centers between 2000 and 2017. Outcome measurements and statistical analysis Intraoperative outcomes including blood loss and operative time as well as postoperative outcomes including time to discharge, complication, readmission, reoperation, and mortality rates at 30 and 90 d were assessed. Multiple imputation and inverse probability of treatment weighting (IPTW) were used. IPTW-multivariable-adjusted regression and logistic analyses were performed to evaluate the associations of RARC versus ORC with perioperative outcomes at 30 and 90 d. Results and limitations Overall, 1887 patients (1197 RARC and 690 ORC) were included in the study. After IPTW-adjusted analysis, no differences between the groups in terms of preoperative characteristics were observed. RARC was associated with lower blood loss (p Conclusions While RARC was associated with less blood loss and shorter hospital stay, it also led to longer operation times and more readmissions. There were no differences in 30- and 90-d complications. Because there are no apparent differences in safety between ORC and RARC in expert centers, differences in oncologic and cost-effectiveness outcomes are likely to drive decision making regarding RARC utilization. Patient summary In this study we investigated the differences between RARC and ORC in terms of perioperative outcomes. We found no difference in early and late complications. We concluded that, to date, differences in oncologic and cost-effectiveness outcomes should drive decision making regarding RARC utilization.

INTRODUCTION AND OBJECTIVE:The European Association of Urology recommend post-operative venous thromboembolic prophylaxis for 28 days for patients following radical cystectomy. Currently, subcutane...

OBJECTIVES To report clinical and functional outcomes for patients who have undergone salvage robot-assisted seminal vesicle excision (RA-SVE) for the focal treatment of isolated seminal vesical (SV) recurrence after treatment for prostate cancer by low-dose-rate brachytherapy. PATIENTS AND METHODS Patients with rising prostate-specific antigen (PSA) after low-dose-rate prostate brachytherapy (LDR-PB) underwent multi-parametric magnetic resonance imaging (mp-MRI) of the prostate and 11 C-Choline or 68 Ga-prostate-specific membrane antigen (68 Ga-PSMA) positron emission tomography/computed tomography (PET/CT) scan, followed by targeted transperineal biopsy of the prostate and SVs. Isolated SV recurrence were identified in 17 (0.38%) LDR-PB patients. These 17 patients were offered RA-SVE. RESULTS The median total operative time was 90 min and blood loss 50 mL with no postoperative transfusions required. The median hospital stay was 1 day. No intra- or postoperative complications were documented. Continence status was unaffected, no patient required urinary pads. Postoperative pathology confirmed SV invasion in all specimens. Surgical margins were positive in seven (41%) patients. All patients had at least one positive imaging study, although three (18%) mp-MRI and five (29%) PET/CT assessments were negative. One (6%) pre-SVE biopsy was also negative but with positive imaging. Salvage SVE failure, defined as three consecutive PSA rises or the need for further treatment, occurred in six patients of whom three had a positive margin. Overall failure-free survival rates were 86%, 67%, and 53% at 1, 2, and 3 years after SVE, respectively. CONCLUSIONS Salvage RA-SVE appears to be a safe focal treatment, with very low morbidity, for patients with localised SV recurrence after LDR-PB. It permits deferral of androgen deprivation therapy in selected patients. Bilateral SVE is mandatory. This surgical option should be considered in patients with isolated prostate cancer recurrence to the SV.

Bifacial photovoltaic (PV) modules can absorb light from both front and rear sides of the module, resulting in an additional gain of ~ 10-15% in output. The additional gain depends on the amount of reflected light (albedo) reaching the rear side. This is highly depended on the local site layout, ground cover, distance between modules and the ground, distance between modules in a row and the distance between the rows. There is lot of uncertainty in energy forecast due to the variabilities of albedo due to all these factors. These uncertainties are a hindrance in adoption of bifacial modules in the industry and hence have attracted lot of research interest recently. Measurement of soiling loss in bifacial modules is another area that is very important and suffers from uncertainties in the albedo at a site. The problem is compounded due to a slight spectral mismatch between the front and rear side, and anticipated differences in the rate of soiling on two sides. In this paper we report on experiments using two identical half cut cell bifacial PV modules in Logan, UT for about 6 months during June-December 2020. The short circuit current of the two modules has been measured along with the supporting measurements of incident and reflected light intensity underneath each module. A method is proposed to separate the contributions to module output from front and rear sides. The soiling loss on both sides can also be calculated separately, using this method. The soiling loss is dominated by soiling on the front side as expected. The soiling loss on the rear side is minimal and may be affected by the spatial variations in the albedo across the two modules under comparison.

Objective To evaluate urology patient satisfaction with telephone consultations during the COVID-19 pandemic. Methods All patients who received a telephone appointment in a 1-month period were invited to complete a questionnaire. An adaption of the Telehealth Satisfaction Scale (TeSS) was used. Patient responses were compared based on type of clinic, age and gender. Results 119 questionnaires were completed. The majority of responses to the adapted TeSS (Q1–7) were graded as ‘Excellent’, ranging from 79 (66%) to 112 (94%). ‘Agree’ responses ranged from 92 (77%) to 117 (98%) for questions (Q8–12), indicating high satisfaction. Patients consulted in post radical prostatectomy and PSA surveillance clinics gave a significantly greater number of ‘Excellent’ or ‘Agree’ responses. Older age was associated with a significantly greater number of ‘Agree’ responses to one item only. Responses were not affected by gender. Conclusion Our study demonstrates high overall satisfaction with the use of telephone consultations among urology patients. For some patients, telephone consultations are more suitable and may be utilised more frequently in the future. However, it is clear that in selected cases face-to-face consultations are required for safe, comprehensive clinical assessment.

OBJECTIVE To assess treatment satisfaction and decision regret post robot-assisted radical prostatectomy (RARP) and correlate these with clinical, demographic and quality of life indicators. Our study took place at a high-volume United Kingdom center and patients were assessed at a minimum of 18 months postsurgery. METHODS Patients who underwent RARP between June 2011 and May 2016 were invited to participate through mailed questionnaires. A total of 207 patients formed our cohort. The questionnaires included European Organization for Research and Treatment of Cancer Quality of Life of Cancer patients 30 and PR25 modules, sexual health inventory in men and Likert decisional regret scale. A Decisional Regret Scale score of >15 was used to define an outcome of high decision regret. RESULTS The mean patient age was 63 years and the mean duration of follow up was 36 months. Of the 106 responders, 51 (48%) were fully satisfied with the decision to undergo RARP and 32 (30%) recorded high regret. The mean Decisional Regret Scale score was 11.3. High decision regret associated with the length of time from RARP to questionnaire administration, higher prostate specific quality of life symptom scores and lower sexual and erectile function scores. CONCLUSION Our study represents the first contemporary United Kingdom series assessing decision regret following the management of localised prostate cancer with RARP. Higher regret was seen in one third of patients and was associated with worse disease-specific quality of life, sexual and erectile function measures. To minimize regret, collaborative and detailed discussion should take place pre-operatively when counselling patients about RARP. The potential longevity and impact on quality of life of these side effects should be made clear.

Paramedics have progressed in many developed nations from being primarily a medical transportation service into independent prehospital practitioners, leading to some unique solutions to various issues in public health care policy. Issues such as how to manage increasing Emergency Department (ED) demand have given rise to paramedics establishing specialist roles in non-traditional practice settings (Raven, Tippett, Ferguson, & Smith, 2006).. This is contrasted by the situation in some developing health care systems (according to the WHO), where prehospital care services remain under developed. The more recent contribution to wider public health outcomes made by the emerging paramedic profession needs to be viewed within the context in which it developed. More work needs to be done to describe and understand the contextual nature of the profession, particularly where different roles are performed and training undertaken by prehospital care practitioners. When this context is established, interpreting research conducted in developed systems for use in developing nations may become possible. Furthermore this paper discusses the difficulties in establishing internationally relevant research.

We aim to outline our technique of performing a robotic-assisted bladder diverticulectomy at our institution and report our surgical outcomes. We report the cases of three robotic-assisted bladder diverticulectomies, performed at the Royal Surrey County Hospital during the period of January 2014 to December 2015. Patient was positioned in low dorsal lithotomy position. A 6Fr double-J stent was prophylactically inserted at the start of the procedure. Foley catheter was placed over guide wire into the diverticulum and balloon inflated on the diverticulum neck. We used a transperitoneal extravesical approach to mobilise the distended bladder diverticulum, dissected en bloc and transected at the diverticulum neck in all cases. The bladder was closed in two layers with absorbable sutures. The procedures were uneventful, without post-operative complications and minimal blood loss. The median length of stay was 3 days and all three patients reported a significant improvement in all symptoms with non-significant post-void residuals. Robotic-assisted bladder diverticulectomy is a safe and effective procedure that results in both symptom relief and minimal post-void residuals.

Thalidomide was used in the late 1950s and early 1960s as a sedative for morning sickness in pregnant women. It resulted in thousands of babies being born with various congenital anomalies, such as phocomelia. Subsequently, the drug was banned for this indication. Most of the survivors have become thalidomide adults and now they are in their fifties. We report the first case of a robot-assisted radical prostatectomy in a 54-year-old male with prostate cancer and phocomelia as a result of thalidomide embryopathy. He presented with a PSA of 3.3 and was diagnosed with Gleason 3 + 4 prostate cancer. An extra peritoneal approach was chosen due to his body habitus and to avoid extreme Trendelenburg tilt. Side docking with the da Vinci robot was employed and the prostatectomy was carried out in the standard extra peritoneal fashion. At 6 months' follow-up his PSA is unrecordable and he is voiding well with minimal urinary incontinence, requiring 1 pad/day. We aim to outline our approach and highlight the technical modifications in this rare physically disabling condition.

Background: Paramedics occupy an ever-increasing role within healthcare and the development of this role should be informed by the voice of patients. This systematic literature review seeks to explore patient experience during a paramedic intervention. Methods: Using a ‘state of the art’ review style, a systematic search was conducted of the literature published between 2006 and 2018. Following PRISMA guidelines, a total of seven articles meeting the inclusion criteria were identified. A definition of experience which incorporates several dimensions was used to frame the search. Results: Three themes were identified, with the available literature focusing mainly on satisfaction. Satisfaction is improved through certainty and clarity of the progression through treatment and is high among patients of paramedics. Conclusion: Our understanding of patient experience in paramedic interventions is largely limited to an understanding of satisfaction. While this may provide some useful insights, other facets such as the lived experience and physiologic aspects are underrepresented in the current evidence base.

The aim of this work is to produce probabilistic forecasts of solar power for the Global Energy Forecasting Competition 2014 (GEFCom2014). The task involves predicting the outputs from three solar farms at an hourly resolution using data from the ECMWF numerical weather prediction model. The annual cycle of solar radiation and power is modelled using a low-pass filter built using a Fourier transformation. The diurnal cycle is handled by fitting separate models for each hour of the day with the positive solar radiation. A model for simulating PV power production, taking the effect of temperature into account, is also included. The forecasting methods were gradient boosting for the deterministic forecasting of solar power and k -nearest neighbors regression for estimating prediction intervals in order to provide probabilistic forecasts. A cross-validation strategy, splitting the data into monthly folds, was employed for comparing the performances of alternative methods and in an attempt to avoid overfitting issues.

Objective This is a prospective trial comparing the impact of intraoperative flexible, rigid, and no cystoscopy on dysuria immediately after permanent seed prostate brachytherapy (PB). It prospectively documents the time course and characteristics of dysuria, as well as the rates of urinary retention post-PB. Furthermore, this study attempts to establish the utility of routine, post-PB cystoscopy, by documenting the incidence of finding significant pathology on cystoscopy. Materials and methods Between January 2003 and January 2007, 225 patients deemed by their physician to be candidates for PB alone were recruited to the study. Patients who had external beam radiation therapy and/or androgen deprivation therapy were excluded. Preimplant International Prostate Symptom Score (IPSS), urinary quality of life score, urine leakage score, Sexual Health Inventory for Men score, and Radiation Therapy Oncology Group Bowel Health Inventory Scores were obtained. Patients were assigned to one of the following three groups: intraoperative rigid cystoscopy, flexible cystoscopy, or no cystoscopy following PB. Patient self-administered questionnaires were given to the patient in the recovery room after PB. These questionnaires evaluated the intensity, type, and duration of urinary symptoms associated with the first four urinations post-PB. All patients were seen on postoperative Day 1 when the surveys were retrieved. Patients were then followed up every 3 months. Acute urinary retention (AUR) was documented in the follow ups. Frequencies of significant pathology (defined as bladder tumor, urethral stricture, or large blood clots) were documented at the time of cystoscopy. AUR rates were also evaluated by the isotope used (I 125 , Pd 103 , or Cs 131 ). Results A total of 225 patients were enrolled into this study, but only 194 patients could be analyzed for dysuria. Thirty-one patients were excluded from analysis (6, 13, and 12 patients from the rigid, flexible, and no cystoscopy groups, respectively). These patients did not return the questionnaire, or were in retention, and thus did not have dysuria scores to report. Baseline characteristics for the 194 patients in terms of preimplant IPSS, quality of life, prostate volume, and isotope used were well balanced between all three groups. There were no significant differences in dysuria between the three cystoscopy groups at any time point following PB. The mean dysuria score across all time points was 5.5 of 10, with 0 representing “no pain” and 10 representing “the worst possible pain.” Pain was most often characterized as “burning” (78%), whereas dysuria most commonly was “only during urination” (56%). AUR rates (6.8–9.5%) and duration of catheter dependence (10.5–19 days) were not found to be significantly different between the assigned groups. When results were stratified by isotope, patients treated with I 125 , Pd 103 , and Cs 131 seeds experienced a 6%, 14%, and 0% retention rate, respectively. The I 125 and Pd 103 patients had similar pretreatment IPSS and prostate volumes. Seven percent of patients undergoing cystoscopy had significant findings. The most common finding was “clots thought too large to void” (3%). Seeds in the bladder/urethra occurred in 1% of cases. Only 0.7% of patients were found to harbor unsuspected bladder tumors. Conclusion There was no significant difference in dysuria in the first four urinations post-PB between patients in the rigid, flexible, and no cystoscopy groups. Larger blood clots that may have been difficult to void, seeds in the bladder and/or urethra, and other abnormalities were found in 7% of patients who had cystoscopy. This may suggest that cystoscopy may be worthwhile post-PB. The incidence of AUR was not significantly different between the three cohorts.

Introduction & Objectives: We present our experience on managing our robotic cancer service during the lock down period of COVID 19 pandemic to ensure safety of both staff and patients, reducing waiting list times and re-initiating robotic training. Materials & Methods: In keeping with government guidance all non-emergent operations were suspended in the Royal Surrey County Hospital (RSCH), Guildford, UK on the 9th April till the 29th July. In collaboration between RSCH and the Nuffield Private Hospital, innovative solutions were proposed and implemented to set up a robotic hub for cancer surgeries in a “clean” area. This included risk assessment, team allocations, moving of equipment, correspondence with various teams, reinstating logistics using remote access, screening and training of staff and patients along with setting a protocol for procedures and emergencies based on national and international guidelines. Results: 76 Robot Assisted Radical Prostatectomy (RARP) and 13 (Robot Assisted Radical Cystectomy (RARC) were performed between 21st April and 29th July at RSCH. After a month of service, when all procedures were conducted by expert surgeons, robotic training was initiated in a phased manner. None of the patients or staff members developed COVID 19 infection or were off sick during this time. Our waiting list at the end of this period was down to single figures for both RARPs and RARCs. Conclusions: With adequate planning, robotic surgery can be safely carried out to confront the barriers for return to pre-pandemic practice, preventing a ripple effect on waiting list times for cancer surgeries. Good patient and trainee satisfaction can also be achieved using this approach.

Aerosols produced by fire burns can have marked impacts on PV power production. Here we take advantage of an isolated, short-lived but well monitored fire burn event during an otherwise clear sky day – a case of a serendipitous ‘earth experiment’ – to study its impact on both solar irradiance and solar power recorded at the nearby solar lab. The local council controlled burns happened at Black Mountain in Canberra, Australia. Evidence from the solar lab sky-camera images was used to confirm that the sky was clear of clouds during the late afternoon of 4th March 2014 so that the effect of the smoke plume could be isolated, and to observe the development of the plume. Global and direct irradiance observations were compared with those from analogous clear days, as well as with values obtained from a clear sky model, in order to estimate the reduction in irradiance due to the smoke plume. The results showed that global irradiance was reduced by 6.5% and direct irradiance by 9% during a 140 min afternoon period, with one-minute reductions of up to 26% and 32% respectively. The spectral global irradiance showed that the smoke had the greatest impact in the wavelength range from 400 to 500 nm. A spectral analysis of the impact of smoke on six different PV technologies revealed that the least impact was on the mono-silicon cells used in this study. The resulting effect of solar power output was an overall reduction of 7% during the study period and a peak reduction of 27%.

Ramping is the practice of requiring paramedics to continue to care for patients rather than hand over clinical responsibility to the ED. It arose as an alternative to admitting patients to EDs that are deemed to be already operating at or beyond capacity. This paper analyses the ethics of ramping. Ramping has been embraced by some ED practitioners and policymakers as a solution to the problem of ED patients suffering increased risks of harm as a result of waiting times within ED. However, this perspective fails to adequately consider the implications, especially the opportunity cost of requiring paramedics to remain at the hospital rather than make themselves available for other patients. From this perspective, ramping negatively impacts the wider provision of emergency medical services, with potentially serious consequences for people's health. Advocates of ramping must consider people in the community who require a medical emergency response.

Aim: The aim of this study was to determine the added value of robotic surgery for radical cystectomy in the context of an established enhanced recovery programme (ERP). Background: We have previously reported on ERP in open radical cystectomy (ORC) and shown that it is safe and not associated with an increase in complications or readmissions. Further, it is associated with reductions in ICU stay, length of hospital stay and duration of postoperative ileus. The recent introduction of robotic-assisted radical cystectomy (RARC), with its perceived benefit of minimal invasiveness, has led to the question of whether patients who have their radical cystectomy in the environment of ERP would experience an added benefit if the surgery were performed robotically. We implemented the ERP for all patients undergoing radical cystectomy in 2008. In 2010 we started to offer RARC as the first line treatment for all bladder cancer patients with an indication for bladder extirpation. In this study we compare the perioperative results of the last 50 RARC patients with the last 50 ORC. The same ERP protocol was implemented in all patients. Patients and methods: We used our prospectively kept electronic database to identify the last 50 ORC and 50 RARC patients (we excluded the first 10 RARC in our series to reduce learning curve effect). We compared preoperative (age, sex, comorbidity), intraoperative (diversion type, fluid loss, blood transfusion, conversion and number of lymph node dissections (LND)) and post-operative (length of stay LOS, nodal yield and pathological T stage) variables. We also reported on the 30 day complications according to Clavien–Dindo classification. Results: The two groups did not differ significantly in their preoperative variables, number of LND performed and pathological T and N stage. Patients in the RARC arm were more likely to have continent diversion and had significantly less intraoperative fluid loss. LOS and lymph nodal yield was no worse in the RARC cohort in comparison to the ORC patients. The RARC patients had significantly lower transfusion rates and overall 30-day complication rates. Conclusions: We have shown that robotic surgery offers an added value to patients undergoing radical cystectomy for bladder cancer in addition to the benefits gained from enrolling in an ERP. This is likely due to the minimally invasive nature of robotic surgery, and thus an attenuation of its physiological insult, which is the cornerstone of ERP theory.

Lyme disease is a common disease that is faced by the physician but also acts a mimicker of many other disease processes. Facial palsies, especially bilateral, are a relatively rare presenting symptom of Lyme disease and may warrant further investigation. A thorough history and physical examination coupled with precision testing may aid the physician when faced with a patient with the diagnostic dilemma of facial diplegia.

Recurrence following radical cystectomy often occurs early, with >80% of recurrences occurring within the first 2 yr. Debate remains as to whether robot-assisted radical cystectomy (RARC) negatively impacts early recurrence patterns because of inadequate resection or pneumoperitoneum. We report early recurrence patterns among 717 patients who underwent RARC with intracorporeal urinary diversion at nine different institutions with a minimum follow-up of 12 mo. Clinical, pathologic, radiologic, and survival data at the latest follow-up were collected. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method, and Cox regression models were built to assess variables associated with recurrence. RFS at 3, 12, and 24 mo was 95.9%, 80.2%, and 74.6% respectively. Distant recurrences most frequently occurred in the bones, lungs, and liver, and pelvic lymph nodes were the commonest site of local recurrence. We identified five patients (0.7%) with peritoneal carcinomatosis and two patients (0.3%) with metastasis at the port site (wound site). We conclude that unusual recurrence patterns were not identified in this multi-institutional series and that recurrence patterns appear similar to those in open radical cystectomy series. Patient summary In this multi-institutional study, bladder cancer recurrences following robotic surgery are described. Early recurrence rates and locations appear to be similar to those for open radical cystectomy series.

Context Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials. Objective To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients. Evidence acquisition The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee. Evidence synthesis Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation. Conclusions This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs. Patient summary There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

This article suggests research should be undertaken to discover the extent of education in the out-of-hospital health workforce. This document is the Accepted Manuscript version of a Published Work that appeared in final form in Journal of Paramedic Practice, copyright © MA Healthcare, after peer review and technical editing by the publisher. To access the final edited and published work see https://www.magonlinelibrary.com/journal/jpar

OBJECTIVE To report on the largest series to date of ulceration of the external genitalia, related to treatment with nicorandil - a vasodilator for the prevention and long-term treatment of angina - and to review the literature on the subject, focusing on the clinical features and the pathogenesis of this rare, yet marked, side-effect. PATIENTS AND METHODS Three patients (aged 71-83 years) were referred for severe ulceration of the penis. A complete work-up was performed to exclude potential underlying causes, including malignancy and sexually transmitted diseases. After a careful review of the patients' medical history, a potentially causal relationship was noted; all patients had been taking nicorandil for at least 2 years before the development of penile ulceration. RESULTS Penile ulcers associated with nicorandil are characteristically large, deep, painful and have punched-out edges. They usually involve the prepuce or the penile shaft skin. Higher doses of nicorandil (at least 40 mg daily) and surgical procedures seem to increase the risk for nicorandil-related ulceration. Response to topical steroids is poor, but complete healing is achieved by discontinuation of nicorandil, while surgical treatment should be discouraged. CONCLUSION The growing body of literature showing the link between treatment with nicorandil and ulceration at multiple sites has led to the recognition of this side-effect by the World Health Organization. Nicorandil-related ulcers rarely involve the penile skin and constitute a diagnostic and therapeutic challenge. The pathogenesis of this rare side-effect is largely unknown, but mechanisms such as the 'vascular steal phenomenon' and the direct toxic effect of the drug or its metabolites have been implicated.

The diagnosis of penile cancer can be devastating for a man and his partner. The fear of cancer is heightened by the prospect of penile amputation. While conventional radical surgery continues to be an effective approach to management, the emasculating nature of this treatment has serious psychological and sexual morbidity. Recent studies have challenged the traditional belief that a 2 cm margin was required for adequate oncological control.We review the current options and status of such penile preserving techniques in the modern day management of penile cancer, and assess the use of the different techniques according to the stage and grade of disease based upon the combined experience of two superregional centres in the United Kingdom.A range of organ preserving procedures matches the clinical spectrum of patients presenting with penile cancer. These demonstrate excellent oncological control whilst maximizing penile function and form.Innovative surgical techniques can now preserve as much penile tissue and functional integrity as possible, without compromising oncological control. This minimizes the impact of disease and its treatment on the quality of life of the patient.

Objective To establish the safety and toxicity of an allogeneic human tumour cell vaccine in patients with hormone-refractory prostate cancer, and to determine any biochemical, immunological or clinical response to vaccination. Patients and methods Sixty patients with hormone-refractory prostate cancer were recruited and randomly allocated into four equal groups. Three cell lines (from a bank of four) were administered initially every 2 weeks and then monthly, in conjunction with the immunostimulant Mycobacterium vaccae (SRL-172), each group receiving a different combination of the four cell lines. The patients' serum prostate-specific antigen (PSA) levels were monitored regularly, and the immune response to the vaccine measured using nonspecific intracellular cytokines and specific humoral and cell-mediated assays. Results The vaccine was safe and well tolerated with no major side-effects. Whilst several patients had a decline in PSA from the entry level, there was no significant decrease that could be attributed solely to the vaccine. However, the immunological data were more encouraging, with several patients from each arm of the trial having an increase in cytokine production, increases in specific antibodies and evidence of T-cell proliferation in response to the vaccinations. Conclusion The failure of the vaccine to produce a PSA response in the patients in the trial is not surprising considering the stage of the disease. The high PSA levels on entry indicate that the burden of disease was probably high and thus this was an extremely challenging group of patients in which to try and elicit a response through immunotherapy. However, the immunological evidence of a response to the vaccine was encouraging and suggests that further exploration of immunotherapy in less advanced disease may yield more encouraging clinical responses.

Objectives We present medium-term outcome data for patients with invasive penile cancer treated with glansectomy and reconstruction with a split-thickness skin graft. Methods A series of consecutive patients referred with penile malignancies over a 6-yr period were analyzed prospectively. A dedicated histopathologist reviewed all the specimens. After clinical staging, patients with tumours confined to the glans were offered glansectomy. Results A total of 72 patients (32% of patients, 31% of procedures) underwent glansectomy for penile carcinoma. Of these, 65 patients were new diagnoses and seven were recurrences after radiotherapy. The mean follow-up period was 27 mo (range: 4–68 mo). There have been three late local recurrences (4%). Conclusion Glansectomy appears to be an oncologically safe and effective procedure for patients with glans-confined squamous cell tumours. It preserves maximum phallic length and results in a very satisfactory cosmetic penile appearance after reconstruction.

OBJECTIVE To evaluate medium-term outcome data from patients with distal urethral cancers treated with penile-preserving surgery. PATIENTS AND METHODS We analysed prospectively 18 consecutive men referred for the management of urethral carcinoma. All had a specialist review in a supra-regional multidisciplinary team meeting, where the histology findings were reviewed by one pathology consultant. Tumours were staged according to the Tumour-Node-Metastasis classification and the patients offered penile-preserving surgery when tumours were limited to the glanular or penile urethra. RESULTS All 18 patients were suitable for penile-preserving surgery; the procedures were: three hypospadias formation with or without topical chemotherapy; four buccal mucosa urethroplasty; three glansectomy and reconstruction; six glansectomy, distal corporectomy, reconstruction and hypospadias formation; two urethrectomy with or with no excision of adjacent tunica albuginea. The mean (median, range) follow-up was 26 (20.5, 9–58) months. There were no local recurrences; four patients with regional nodal disease progressed and of these, two died from metastatic disease, and one died from an unrelated condition. CONCLUSION Medium-term data show that penile-preserving surgery is a feasible treatment for men with distal urethral carcinoma, providing excellent local control without prejudicing survival; a longer follow-up is needed.