This study demonstrates that men who used the penile compression device reduced their Incontinence Impact Questionnaire scores significantly. Further research into the side effect profile of the device is needed as its utility may be under appreciated.

ObjectivesTo determine if there is a Valsalva leak-point pressure (VLPP) threshold that predicts for retro-urethral transobturator sling (RTS) success in men with post-prostatectomy urinary incontinence (UI). Patients and MethodsThe preoperative urodynamic parameters of all patients undergoing RTS (AdVance™) sling surgery over the last 5 years were analysed and compared with the postoperative outcomes. The sling was defined as having been successful if the patient no longer had to wear pads or merely used a pad to provide a sense of security. ResultsIn all, 46 men with a mean (range) age of 65 (45-83) years, underwent AdVance™ sling surgery. 10 men had undergone holmium laser enucleation of the prostate, one a transurethral resection of the prostate and 35 radical prostatectomy. 11 men had a VLPP of ≤100 cmH2O. Of these 11 men, three had no, or minimal, improvement in their leakage and all three required a secondary procedure (artificial urinary sphincter, AUS). In the 35 men with a VLPP of >100cmH2O there were three failures. One of these was successfully salvaged with a repeat sling, another with an AUS and one with ProACT™ balloons. The hazard ratio (HR) for failure with a VLPP of ≤100 cmH20 compared with a VLPP of >100 cmH2O was 4 (95% confidence interval 0.68-23.7). ConclusionA VLPP of >100 cmH2O has a high degree of predictability for success for AdVance™ sling placement for men with post-prostatectomy UI.

Background: Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency.Methods: Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days).Results: Of a total of 5067 patients from 97 hospitals across the UK, 911 (18⋅0 per cent) fulfilled the criteria for sepsis, 165 (3⋅3 per cent) for severe sepsis and 24 (0⋅5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17⋅6-94⋅5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19⋅8 (i.q.r. 10⋅0-35⋅4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. Conclusion:Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent. * Members of the UK National Surgical Research Collaborative are co-authors of this study and can be found under the heading Collaborators Paper accepted 25 October 2016Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10432 IntroductionGeneral surgical patients presenting as an emergency account for over 7 per cent of hospital episodes in the USA and 14 000 ICU admissions per year in the UK 1 -3 . Sepsis is prevalent in this patient group. Early diagnosis of severe sepsis and initiation of goal-directed therapy can reduce mortality, irrespective of the need for surgery 4,5 . This evidence was used to develop a care bundle known as the Sepsis Six for managing patients with severe sepsis (Table 1) 6,7 . These standards have been endorsed by many professional organizations, including the Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the Royal Colleges of Surgeons of England and Ireland 1,2,8,9 . Complete application of these interventions is thought to be associated with as much as a one-third reduction in mortality from sepsis, although uptake is uncertain amongst surgical patients presenting as an emergency 4,6 .The main aims of the present study were to assess adherence to the Sepsis Six guidelines and identify the timing of source control in general su...

An otherwise fit and well 70-year-old man underwent elective radical retropubic prostatectomy (RRP) for low-grade prostate cancer. The cancer had been diagnosed on transperineal saturation biopsy after which he had significant perineal bruising. At the time of prostatectomy, it was noted that the posterior surface of the prostate was very adherent to the anterior wall of the rectum and particular care was taken during this part of the dissection. Immediately post-operatively the patient had a prolonged period of unexplained hypotension, which resolved spontaneously. He was discharged without further complication on the third post-operative day.Five days post-operatively he presented to his general practitioner with chest discomfort and fresh rectal bleeding. He had been constipated and had been straining to pass bowel motions, but had otherwise made a routine recovery following the surgery. On admission to the emergency department he was tachycardic and febrile with a normal blood pressure. He had obvious subcutaneous emphysema of the abdomen, thorax and neck. His wound was healing well and his abdomen was not peritonitic. There was a small amount of dark blood on digital rectal examination. His blood tests showed a mild leucocytosis (11.4) and a neutrophilia (9.5); blood tests were otherwise unremarkable. A chest X-ray revealed gross surgical emphysema of the chest wall and neck (Fig. 1) and a computed tomography (CT) scan showed extensive subcutaneous emphysema with a right pneumothorax, pneumomediastinum and also extensive pneumoperitoneum (Fig. 2). A CT scan revealed no evidence of oesophageal or tracheal perforation and there was no air in the bladder. Given the intraoperative difficulties in developing the plane between the rectum and the prostate, a further CT abdomen with rectal contrast was performed and this demonstrated a 1-cm rectal perforation (Fig. 3). Laparotomy with lavage of the pelvis, formation of a defunctioning loop colostomy, and over-sewing of the rectal injury were performed. His post-operative period was complicated by several runs of non-specific supraventricular tachycardia likely secondary to metabolic derangement and they resolved spontaneously. He made a good recovery and was discharged from the hospital in a comfortable condition 5 days after his laparotomy, and 7 days after presentation. This is an unusual presentation of a fortunately rare complication. Initial concerns were of a developing necrotizing fasciitis but he was systemically well and showed no significant abnormalities on his blood tests. The other concern was anaesthetic trauma to the major airways at the time of surgery. The delay in presentation made this unlikely, though a healed tracheal perforation could conceivably declare itself late given sufficient force, for example, with coughing or straining. 1 A comprehensive review of the medical literature failed to find any case reports of subcutaneous emphysema following RRP. One case reported subcutaneous emphysema following laparoscopic prostatectomy but the cause ap...

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