Objective  To define the incidence, risk factors and complications of priapism in a large population of patients with sickle‐cell anaemia in five centres in the UK and Nigeria, as priapism is common among these patients, but the precise characteristics of the condition in this population are poorly documented.Patients and methods  A questionnaire was developed and administered to patients with sickle‐cell disease. Questions were designed to define the incidence, nature, precipitants, duration, treatment and complications of priapism. A distinction was made between acute (severe) priapism and the recurrent, ‘stuttering’ type.Results  The questionnaire was completed by 130 patients (mean age 25 years, sd 11, range 4–66) from the five centres; 102 (78%) were homozygous Hb SS genotype, 19 (15%) were Hb SC genotype and two (1.5%) were Hb Sα−thalassaemia. Of the patients, 46 (35%) reported a history of priapism, and of these, 33 (72%) had a history of stuttering priapism, while 24 (52%) had had an acute episode of priapism. The mean age of onset of priapism was 15 years, with 75% of patients having the first episode before their 20th birthday. Sexual activity was the most frequent precipitating factor, with fever and/or dehydration being the next most common. Of the 46 patients, 10 (21%) with a history of priapism reported having erectile dysfunction. A similar proportion reported dissatisfaction with sexual intercourse, including a fear of engaging in sexual activity.Conclusion  The incidence of priapism among patients with sickle‐cell anaemia is high (35%). The implications of priapism for erectile and sexual function are significant and documented in this large series. The treatment of this condition in these patients remains unstandardised. This study highlights the need for an increased awareness of the problems associated with priapism among patients, families and medical professionals.

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ObjectivesTo describe the frequency and nature of symptoms in patients presenting with suspected renal cell carcinoma (RCC) and examine their reliability in achieving early diagnosis.DesignMulticentre prospective observational cohort study.Setting and participantsEleven UK centres recruiting patients presenting with suspected newly diagnosed RCC. Symptoms reported by patients were recorded and reviewed. Comprehensive clinico-pathological and outcome data were also collected.OutcomesType and frequency of reported symptoms, incidental diagnosis rate, metastasis-free survival and cancer-specific survival.ResultsOf 706 patients recruited between 2011 and 2014, 608 patients with a confirmed RCC formed the primary study population. The majority (60%) of patients were diagnosed incidentally. 87% of patients with stage Ia and 36% with stage III or IV disease presented incidentally. Visible haematuria was reported in 23% of patients and was commonly associated with advanced disease (49% had stage III or IV disease). Symptomatic presentation was associated with poorer outcomes, likely reflecting the presence of higher stage disease. Symptom patterns among the 54 patients subsequently found to have a benign renal mass were similar to those with a confirmed RCC.ConclusionsRaising public awareness of RCC-related symptoms as a strategy to improve early detection rates is limited by the fact that related symptoms are relatively uncommon and often associated with advanced disease. Greater attention must be paid to the feasibility of screening strategies and the identification of circulating diagnostic biomarkers.

Priapism is defined as a prolonged, persistent, and purposeless penile erection. It is a common (35%) but frequently understated complication in young men and adults with sickle cell disease. We had previously demonstrated an association between stuttering attacks (,4 hours) and an acute catastrophic event with its consequent problems of erectile dysfunction and impotence. We describe a randomized, placebo-controlled, clinical study looking at medical prophylaxis with 2 oral a-adrenergic agonists, etilefrine and ephedrine, in preventing stuttering attacks of priapism. One hundred thirty-one patients were registered into a 2-phase (observational and intervention phase) study, and 86 patients (66%) completed Phase A diary charts. Forty-six patients (59%) completed a 6-month treatment phase (Phase B), and the remaining patients were lost to follow-up despite persistent efforts to contact them. Various reasons are postulated for the high attrition rates. The drugs were well tolerated, and no serious adverse events were reported. There was no significant difference among the 4 treatment groups in the weekly total number of attacks in Phase B (analysis of covariance P 5 .99) nor among the average pain score per attack after adjusting for attack rates and pain scores in Phase A (analysis of covariance P 5 .33). None of the patients who completed the study required penile aspiration at study sites while on medical prophylaxis. Young men with sickle cell disease are not comfortable engaging with health care providers about issues relating to their sexual health. The full impact of an improved awareness campaign and early presentation to hospital merits further standardized study. Priapism still contributes seriously to the comorbidity experienced by this previously inaccessible group of patients and medical prophylaxis with oral a-adrenergic agonists is feasible. Future international collaborative efforts using some of the lessons learnt in this study should be undertaken.

ports introduced to enable dissection and identification of the PUJ. The technical principles and goals are similar to those of open surgery. Depending on the type of procedure the PUJ is either incised or dismembered, and reductive pyeloplasty performed if indicated. The ureteric JJ stent is typically inserted retrogradely before (the authors' preference being 4.7 F, 26 cm) or during surgery. A drain is inserted to lie adjacent to the completed repair and a Foley catheter is left in the bladder.Patients typically commence free oral intake of fluids 8-12 h after surgery; the urethral catheter is removed after 1-2 days and the wound drain subsequently. The ureteric stent is typically removed by outpatient flexible cystoscopy at 4 weeks, after IVU. RESULTSThe results of LP are shown in Table 1 [4][5][6][7][8][9][10]; several early reports were excluded where updated results from the same institution were published more recently. Several points are worth specific comment. The success rates of LP are consistently high, at 87-98%; the rates are > 95% in series with a predominance of primary procedures, with only one exception. The 'success rate' is defined as the objective radiological success, i.e. with a patent and unobstructed PUJ (or an improvement in drainage) by either IVU or diuretic renography. Subjective improvement rates, e.g. from patient questionnaires, are invariably less than the radiological success rates by 10-30% for both open and endourological pyeloplasty. There are several possible reasons for this discrepancy, but the present discussion focuses on the objective radiological success rate, which is reported rather more consistently. The prolonged operative duration of reconstructive laparoscopy is significant, but there has been a trend towards a reduction, from a mean of 330 min in the original series to 164-252 min in contemporary series reported in the last 3 years [6][7][8][9]11]. This reflects increased confidence and ability in intracorporeal suturing and knot-tying. Laparoscopic suturing and knot-tying can be learned effectively and reinforced by regular repetition in a 'dry lab' environment. The effect of increasing experience is notable, with an experienced laparoscopist consistently performing the entire procedure (transperitoneal) in < 3.5 h [9]. The retroperitoneal approach (mean operative duration 175 min) is seemingly quicker than the transperitoneal approach (mean 246 min) in contemporary series reported since 2001. This is probably because it takes less time to dissect and identify the PUJ with the retroperitoneal technique. The low morbidity of LP is well reflected in the low incidence of complications during and after surgery even in the initial series. The risks of blood transfusion are remarkably low, being limited to anecdotal reports, in sharp contradistinction to endopyelotomy, where the transfusion rates are 3-11%. The hospital stay is short, averaging 3.8 days in the series reported since 2000.To our knowledge there has been at least one abortive attempt to compare laparosc...

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The aim of this review was to discuss the most recent data from current trials of diethylstilboestrol (DES) to identify its present role in advanced prostate cancer treatment as new hormonal therapies emerge. The most relevant clinical studies using DES in castration-refractory prostate cancer (CRPC) were identified from the literature. The safety, efficacy, outcomes and mechanisms of action are summarized. In the age of chemotherapy this review highlights the efficacy of oestrogen therapy in CRPC. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.