Penectomy Research Articles

Replantation following complete penile amputation: Summary of perioperative experience and treatment strategies.

To date, there are only case reports of penile amputation, a rare urological emergency with a low-treatment successful rate, and there are still no advanced, detailed surgical or perioperative treatment plans. Effective treatments for these rare diseases are urgently needed. The researchers summarized the perioperative experience of 20 patients who underwent replantation after complete penile amputation at several hospitals over the past 5 years and shared experience in detail. Only 1 of the 20 surgeries failed, and both urinary and erectile functions were successfully restored in other cases, indicating that the surgical methods and perioperative treatments summarized by researchers are feasible and highly successful for replantation following complete penile amputation. Researchers have summarized the method and perioperative plan for replantation following penile amputation based on a summary of 20 cases, thereby providing guidance for urologists and andrologists.

Traumatic penile amputation managed at Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria: a case series

BackgroundTraumatic penile amputation is a rare surgical emergency and a cause of anxiety and psychological distress to patients, spouses, or parents, especially when it occurs in children. Several mechanisms are involved in penile amputation and the management options also vary. We report two cases of penile amputation that our institution handled in the past year to draw attention to the risks associated with firearm confrontations and grinding machines as causes of genital injuries. In a similar vein, we look over the literature for management options.Case presentationIn the first case, a grinding machine resulted in an isolated total penile amputation of a 6-year-old boy. In contrast, the second patient was a 25-year-old man who had bilateral testicular injuries and near-total penile amputation as a result of gunshot injury as part of polytrauma. Both patients had a history of profuse bleeding from the penile stump associated with severe pain. Both patients were resuscitated and subsequently underwent emergency wound debridement and stump refashioning/meatoplasty. The first patient had a satisfactory outcome and was discharged home on follow-up visits while the second patient died from overwhelming sepsis with pulmonary embolism as a differential.ConclusionPenile injuries may increase in tandem with civilian firearm-related incidents. Similarly, grinding machines are an important cause of penile injuries. In emergencies, wound debridement followed by stump refashioning is an appropriate treatment option.

Sildenafil-induced priapism in a dog : an unusual case report

BackgroundPriapism is defined as erection that lasts for more than 4 h without sexual stimulation. There are various causes of priapism, but there are no reports of sildenafil-induced priapism in dogs. In human medicine, there were no pre-marketing reports of priapism caused by sildenafil, but post-marketing surveillance has shown that it is rare. In cases of pulmonary hypertension in dogs, sildenafil is the first-line drug of choice for symptomatic relief.Case presentationAn 11-year-old neutered male Maltese dog that presented with tachypnea and cough was diagnosed with myxomatous mitral valve disease, American College of Veterinary Internal Medicine (ACVIM) stage C, and was treated medically. Eighteen months after the diagnosis, severe pulmonary hypertension occurred due to left heart disease. At 20 months postdiagnosis, pleural effusion occurred, and sildenafil (2 mg/kg twice daily) was added to the existing treatment. Two weeks later, the dyspnea recurred, confirming pleural fluid recurrence, and sildenafil was increased to 2 mg/kg thrice daily. One day later, the patient developed persistent erections and penile pain. Penile amputation and urethrostomy were recommended but were refused; therefore, analgesia and palliative care were provided. The patient died of acute dyspnea 22 months after the first presentation, with no specific priapism recurrence at the time of death.ConclusionTo the best of our knowledge, this is the first report of sildenafil-induced priapism in a dog with pulmonary hypertension.

Penile Replantation: A Review of Microsurgical Techniques, Patient Outcomes, and Solutions to Complex Reconstructive Challenges

Introduction: Penile amputation is a rare urological emergency with varying etiologies, ranging from psychiatric disorders to traumatic injuries, and requires precise microsurgical replantation techniques to restore function and appearance. The popularization of microsurgery has greatly improved outcomes by enabling accurate vascular and nerve reattachments, which are crucial for erectile function and sensation. This comprehensive study reviews advancements in microsurgical penile replantation, perioperative, and postoperative care, focusing on the nuances of surgical interventions and potential complications such as ischemia and necrosis. Methods: The PubMed, EMBASE, and Cochrane databases, were queried for studies published between 2015 and 2023 that discussed preoperative conditions, surgical techniques, and postoperative outcomes in penile replantation cases. Resulting studies that reported preoperative and postoperative outcomes of at least one case of penile replantation after amputation were included. Case parameters of interest were then extracted and categorized to determine the most common complications as well as solutions utilized in penile replantation. Results: Our findings from 46 cases across 37 studies revealed a common occurrence of postoperative necrosis (56.5%) and highlighted the importance of timely vascular reconnection and innovative surgical strategies to manage complications. Three cases were complicated by scrotal hematomas and 23 cases reported at least one psychiatric comorbidity. Some innovative solutions mentioned include hyperbaric oxygen therapy, laser angiography, leech therapy, PDE inhibitors, and penile splints. Conclusion: The outcomes suggest a critical need for standardized protocols and further research into optimizing techniques and therapies to enhance the success rates as well as quality of life post-replantation. This review aims to guide future practices and encourage collaborative efforts to refine the complex microsurgical procedures involved in penile replantation.

Urologic Trauma Management for Military Providers.

Genitourinary (GU) trauma resulting from combat and the treatment of these injuries is an inadequately explored subject. While historically accounting for 2 to 5% of combat-related injuries, GU-related injuries escalated considerably during U.S. involvements in Iraq and Afghanistan due to improvised explosive devices (IEDs). Advanced body armor increased survivability while altering injury patterns, with a shift toward bladder and external genitalia injuries. Forward-deployed surgeons and military medics manage treatment, with Role 2 facilities addressing damage control resuscitation and surgery, including GU-specific procedures. The review aims to provide an overview of GU trauma and enhance medical readiness for battlefield scenarios. This review examined urologic trauma management in combat, searching PubMed, Cochrane Central, Scopus, and Web of Science databases with search terms "wounds" OR "injuries" OR "hemorrhage" AND "trauma" AND "penile" OR "genital" AND "combat." Records were then screened for inclusion of combat-related urologic trauma in conflicts after 2001 and which were English-based publications. No limits based on year of publication, study design, or additional patient-specific demographics were implemented in this review. Ultimately, 33 articles that met the inclusion criteria were included. Included texts were narrowed to focus on the management of renal injuries, ureteral trauma, bladder injuries, penile amputations, urethral injuries, testicular trauma, Central nervous system (CNS) injuries, and female GU injuries. In modern conflicts, treatment of GU trauma at the point of injury should be secondary to Advanced Trauma Life Support (ATLS) care in addition to competing non-medical priorities. This review highlights the increasing severity of GU trauma due to explosive use, especially dismounted IEDs. Concealed morbidity and fertility issues underscore the importance of protection measures. Military medics play a crucial role in evaluating and managing GU injuries. Adherence to tactical guidelines and trained personnel is vital for effective management, and GU trauma's integration into broader polytrauma care is essential. Adequate preparation should address challenges for deploying health care providers, prioritizing lifesaving and quality-of-life care for casualties affected by GU injuries.

Subtotal traumatic penile amputation of unknown origin in a canine

AbstractCases with a fracture of the os penis in dogs have been reported rarely, and to the authors’ knowledge, traumatic penile amputation has only been reported once. The dog presented in this case report sustained subtotal traumatic penile amputation of unknown origin. Before the presentation, the dog had been in a boarding facility, where no trauma was witnessed. The patient presented with haematuria, discharge from the prepuce, and lethargy. Upon examination, traumatic subtotal penile amputation was diagnosed, and a complete blood count revealed severe regenerative anaemia. Surgical debridement was performed, and the wound healed by second intention. During the recovery period, a urinary catheter was placed to aid in preventing urethral stenosis. Though the animal sustained extensive trauma to its genitals and subsequent anaemia, it survived with a good quality of life and acceptable urinary function.

Surgical management of squamous cell carcinoma of the canine male external genitalia: 15 cases (1994-2020)

Fifteen male dogs with squamous cell carcinoma of the external genitalia were admitted for further investigation and surgical management between 1994 and 2020. The dogs belonged to various breeds. Thirteen dogs were intact and two were castrated with a median age of 8 years and a median weight of 28 kg. Seven dogs were white-coated and eight nonwhite coated. Scrotal ablation and orchiectomy were performed in four dogs, partial penile amputation in two, partial penile amputation plus partial preputial ablation in one, penile amputation, and scrotal urethrostomy in seven, and local preputial excision in one dog. Postoperative complications included hemorrhage in 10 dogs, bruising at the urethrostomy site in seven, and urethrostomy dehiscence in one dog. Tumor recurrence was recorded in six dogs. Dogs with poorly differentiated tumors that had tumor recurrence had shorter survival and worse prognosis compared to those with well and moderately differentiated tumors. The mean survival time was 48.132 months. After a median follow-up of 23 months (range: 8 to 72 months), eight dogs were alive, five were euthanized and two dogs died from unrelated causes. Surgical excision seems to be a treatment option for dogs with squamous cell carcinoma of the external genitalia.

Penile Injury: Four Years’ Experience of a Single Surgeon in a Limited Resources Setting

Background: Penile injuries (PIs) are uncommon, with the management of severe cases being difficult. This study aims to examine the causes of PIs and present experience for their management using the limited facilities available in a hospital with low-resource settings. Methods: The management of PIs in a limited-resource hospital in eastern Sudan was recorded over four years. Records of 32 cases of emergency penile surgical conditions between January 2016 and March 2020 were retrospectively reviewed, and 17 cases of significant PI were included in the study and divided into pediatric and adult groups with further subdivision of each group according to the nature of the injury. Results: Seventeen patients with PIs were treated during the study period. The pediatric group (n = 4) were victims of traditional circumcision; two of them presented with glans penis (GP) amputation, one with gangrenous GP, and one with mild GP injury. The patients in the adult group were divided into three subgroups; the first group had penile fractures (n = 8), the second group had degloving PIs (n = 2), and the third group had penile amputation injuries (n = 3). Management included various surgical techniques tailored to the individual patients. The outcome of the intervention was presented on a case-by-case basis. Conclusion: Severe PIs should be managed using a case-by-case approach. To enhance the effectiveness of surgical interventions, the field of reconstructive penile surgery must be established and developed. Community orientation and work safety measures should be implemented to avoid PIs that may result from traditional circumcision and machinery trauma.

Quality of Life Evaluation after Partial Penile Amputation for Penile Cancer.

Penile cancer is most prevalent in developing countries. Both the physiological and psychological consequences for the patient are critical. These consequences result from both the cancer diagnosis and the treatment's effects. The objective of this study was to evaluate the quality of life (QoL) of patients who have undergone partial penile amputation in terms of general well-being, sexual function, and urinary function. This retrospective observational study included 32 patients who underwent partial penile amputation. The european organisation for research and treatment of cancer core quality of life questionnaire (EORTC QLQ C-30) questionnaire was completed postoperatively. Erectile function and satisfaction were assessed retrospectively after partial penile amputation using the International Index of Erectile Function-15. The mean age of the patients was 54.03 ± 16.02 years. The mean scores for erectile function, orgasm, sexual desire, satisfaction, and overall satisfaction were 16.28 ± 10.83, 7.50 ± 3.30, 5.72 ± 3.35, 8.84 ± 4.77, and 9.12 ± 0.83 preoperatively, and 14.03 ± 8.61, 6.88 ± 2.97, 5.72 ± 3.35, 7.94 ± 4.09, and 7.81 ± 1.00 postoperatively. Mean erectile function, orgasm, satisfaction, and overall satisfaction were significantly decreased postoperatively compared with preoperatively. Erectile function and overall satisfaction improved more in younger years from the preoperative to the postoperative period, whereas they improved less in older years. Although partial penile amputation for penile cancer provides adequate local disease management, appropriate counseling is crucial, especially when the QoL concerns general well-being, sexual function, and urinary function.

(PM-17) THE ROLE OF PHOSPHODIESTERASE-5 INHIBITORS IN THE TREATMENT OF COMPLEX PENILE WOUNDS: A CASE REPORT AND LITERATURE REVIEW

Abstract Introduction/Objective Phosphodiesterase-5 inhibitors (PDE5i) are traditionally employed for the management of erectile dysfunction and lower urinary tract symptoms. However, their role in the healing of complex penile wounds remains scarcely discussed. This study aims to describe the case of a 27-year-old man who suffered from penile strangulation, treated with sildenafil. Additionally, a literature review concerning the use of PDE5i for the treatment of complex penile injuries will be conducted. Methods A 27-year-old man presented to the emergency room after a self-induced penile strangulation using a ring placed at the base of the penis. Extensive necrosis of the corpus cavernosum was identified through magnetic resonance imaging. Considering the psychosocial implications of penile amputation, organ preservation was chosen, and conservative treatment with sildenafil and daily local dressings was initiated. Thirty days after admission, Doppler ultrasound revealed symmetrical corpus cavernosum with normal echogenicity and usual blood flow patterns. Subsequently, the patient underwent superficial necrotic tissue debridement followed by partial skin grafting in a second stage, leading to hospital discharge after 55 days of hospitalization. Results PDE5 inhibitors enhance nitric oxide bioavailability, promoting vasodilation and improved tissue oxygenation, thereby facilitating various phases of the healing process. Evidence indicates their benefit in microvascular perfusion in skin and soft tissues. Reports suggest satisfactory outcomes of topical PDE5i application in radiation-induced lesions, implying their role in epidermal cell expansion, reduction of inflammatory infiltrates, enhanced vascularization, and decreased collagen deposition. Conclusion This study presents a successful case of sildenafil use in treatment of a complex penile wound, shedding light on an unconventional application of PDE5i. Financing No conflict.

Surgical management of urethral obstruction secondary to perineal liposarcoma in a dog: a case report

BackgroundSwelling of the perineal region in male dogs is most commonly caused by a perineal hernia. Clinical signs associated with perineal hernia are constipation, tenesmus or stranguria. This case report documents a rare cause of perineal swelling created by the growth of a malignant tumour leading to urethral obstruction and subsequent stranguria.Case presentationAn 11-year-old neutered male German Shepherd was presented for swelling in the perineal region and stranguria for three days. Complete blood count and serum biochemistry were unremarkable. Ultrasound revealed a heterogeneous mass in the perineal region. Retrograde urethrography showed a severe narrowing of the urethra caudal to the pelvis. A fine-needle aspirate of the mass was highly suspicious for liposarcoma. Staging was performed by computed tomography (CT) of the thorax and abdomen. Total penile amputation in combination with pubic-ischial pelvic osteotomy, transposition of the remaining urethra through the inguinal canal, V-Y-plasty cranial to the prepuce and preputial urethrostomy were performed to remove the tumour. Histopathology confirmed a well-differentiated liposarcoma with complete histological margins. Six months after the surgery the dog was doing well and there were no signs indicating local tumour recurrence.ConclusionsWide surgical excision is generally recommended for soft tissue sarcomas, however this is sometimes not feasible for large tumours. In the case reported here, tumour resection was achieved by a combination of several surgical techniques with a good clinical outcome.

Penile Cancer in the Region of Thies: Epidemiological, Diagnostic and Therapeutic Aspects

Aim This study aimed to determine the epidemiological, clinical, histopathological, and therapeutic characteristics of patients with penile cancer in hospitals in the Thiès region. Patients and Methods We conducted a retrospective descriptive study collecting all cases of penile cancer in the different urology departments in the Thies region from January 1st, 2015, to December 31st, 2020. Results We recorded 14 cases of penile cancer during the study period. The average age of the patients was 42.93-years (range: 26 to 82-years). The average consultation time was 18-months. All patients were circumcised during childhood. The circumstances of discovery were penile pain (64.3%), ulceration of the penis (26.6%), and hematuria (14.3%). Squamous cell carcinoma was found in 100% of patients. The cancer was locally advanced or metastatic in 64.3% of cases. Partial amputation of the penis was carried out in 50% of patients, and total amputation of the penis was carried out in 42.85% of patients. One patient refused a total penile amputation. After a 6-month follow-up, 35.7% of patients had died. Conclusion The presentation of penile cancers is often late in the Thiès region. Improving the technical platform will make it possible to better manage these cancers.

Surgical treatment of Paraphimosis in dogs: 4 Cases

Aim: The aim of this study was to evaluate the use of surgical methods concerning the severity of persistent paraphimosis and describe the surgical techniques. Materials and Methods: The study material consisted of 4 dogs with paraphimosis. Based on anamnesis and clinical examination, 3 dogs were diagnosed with idiopathic permanent and one dog with traumatic paraphimosis. According to diagnoses and findings, patients underwent preputial advancement, partial penile amputation, phallopexy, and total penile amputation. Results: Recurrence of disease 1 week following surgery was recorded as postoperative complication in the first patient with preputial advancement. Intermittent bleeding in the surgical field in the second patient undergoing partial penile amputation continued for 3 days. No complications were observed as a result of the preputial advancement and phallopexy procedures performed for the treatment of the third case. The surgical wound healing time was recorded as one week in the second and third cases. In the fourth case, intermittent bleeding persisted for 12 days postoperatively and mild dermatitis was noted at the surgical site. According to the information received from the patient owners on the 30th day after the surgery, it was noted that there was no recurrence of the disease and no complications were encountered. Conclusion: According to the results of our study preputial advancement surgery technique alone was unsuccessful when the length of the prolapsed penis from the prepuce was 1,5 cm or more in patients with permanent paraphimosis. In addition, in cases where the disorder of the penile shaft and urethra allows, partial penile amputation should be preferred to total penile amputation.

Spontaneous Penile Amputation in a HIV Patient: Case Presentation

Penile tumor is the rarest urogenital tumor in males (1%). Around 95% of penile tumors are squamous cell carcinomas. We report a case of penile squamous cell carcinoma in a 69-year-old male who presented spontaneous penile amputation with a necrotic stump. The patient was tested positive for HIV1. He benefitted from a total penectomy with a supra-pubic cystostomy (SPC) and antiretroviral therapy. The suprapubic catheter is changed monthly while awaiting perineal urethrostomy.

Penile Cancer at the Urology Department of Koutiala Reference Health Center. About Three Cases and Literature Review

Goal: Raise awareness among the population to be consulted early in the event of penile cancer and to accept the treatment proposed by the clinician, based on three observations of penile cancer treated in the urology department of the center of reference health Koutiala. Material and methods: This was a prospective review of three cases of penile cancer diagnosed and treated in the urology department of the Koutiala reference health center over a period of two years from January 1, 2021. As of December 31, 2022. The first case was a squamous cell carcinoma of the penile in a 67-year-old patient who suffered amputation of the glans during circumcision, having undergone an adenomectomy in December 2020. The second patient was 63 years old and circumcised; having had urinary bilharzia in childhood and also presenting squamous cell carcinoma. The third case was a 74-year-old circumcised patient with ulcerated swelling of the glans. A review of the literature made it possible to identify the frequency and risk factors and/or precancerous lesions of this cancer on both sides in the world in general and more particularly in Africa. Results: Over a period of two years, three cases of penile cancer were recorded and treated in the urology department of the Koutiala reference health center. The three patients were aged 67, 63 and 74 years respectively. They were all farmers, circumcised and one had his glans amputated during the circumcision. A cystotomy was performed in one patient but all refused amputation of the penis. No patient received radiotherapy or chemotherapy because they were all lost to follow-up. The histological type encountered in our patients was squamous cell carcinoma. Conclusion: Penile cancer remains the least common urological cancer in our practice, behind testicular cancer. Patients are seen late, at stages requiring penile amputation, which few patients accept.

Primary preputial reconstruction following surgical excision of cutaneous mast cell tumours without penile amputation in eight dogs

ABSTRACT Case history: Medical records from a single referral hospital (Davies Veterinary Specialists, Hitchin, UK) were reviewed to identify dogs (n = 8) with preputial cutaneous mast cell tumours (CMCT) that underwent surgical excision and primary preputial reconstruction, preserving the penis and urethra, after clients declined alternatives such as penile amputation and urethrostomy, from June 2017–June 2022. Clinical findings: Tumours had a median diameter of 21.5 (min 15, max 30) mm, were located cranioventrally (3/8), caudoventrally (1/8), laterally (2/8) and dorsally (2/8) relative to the prepuce and were diagnosed as CMCT based on cytology. No dogs had hepatic or splenic metastasis on cytology but inguinal lymph node metastasis was identified in 3/4 dogs sampled. Treatment and outcome: The owners of all dogs had declined penile amputation and scrotal urethrostomy. The CMCT were excised and primary reconstruction of the prepuce performed. Surgical lateral margins of 10, 20 or 30 mm were used and the deep margin excised the inner preputial lamina or underlying muscular fascia. The deep margin for caudoventral CMCT involved excision of the underlying SC adipose tissue. Preputial advancement was performed in 3/8 dogs to achieve adequate penile coverage. Histopathology confirmed all CMCT were Kiupel low grade, Patnaik grade II with complete margins in 6/8 dogs but identified metastasis only in one inguinal lymph node from one dog. Two dogs encountered minor complications (infection and a minor dehiscence) and one dog had a major complication (infection with major dehiscence). Median follow-up duration was 125 weeks, excluding one dog with 4 weeks of follow-up. None of the dogs experienced local recurrence or died of mast cell disease during the available follow-up period. Clinical relevance: This clinical study evaluated a surgical alternative to penile amputation and advanced reconstructive techniques for Kuipel low/Patnaik grade II preputial CMCT when these procedures were declined by owners. Surgical excision of preputial CMCT with lateral margins of 10, 20 or 30 mm with primary preputial reconstruction is achievable with low morbidity and a good outcome when penile amputation and scrotal urethrostomy is not an option.

Penile Cancer Mortality in Brazil: Are We Making Progress?

This study aims to analyze the trends in mortality rates from penile cancer (PeC) and the treatment modalities adopted in Brazil over recent years. Death records for PeC cases (International Classification of Diseases, version 10 C60) and treatment modalities were extracted from the DATASUS database. A joinpoint regression analysis was conducted to examine the data. A total of 7,848 deaths due to PeC were recorded in Brazil between 1996 and 2020. Increasing mortality trends were observed, with an average annual percentage change (AAPC) of 0.91 (0.6-1.2; P < .001). The North and Northeast regions had the highest age-standardized mortality rates (ASMRs) and AAPCs. From 2008 to 2020, the ASMR in the Northeast region remained stable, whereas the North region surpassed it. The Southeast region exhibited a significant downward trend, with an AAPC of -0.91 (-1.3 to -0.5; P < .001). Penile biopsies declined and were more frequent in the southeastern region. A total of 8,498 penile amputations were performed, with 39.4% and 29.1% conducted in the Southeast and Northeast regions, respectively. Brazil has experienced increasing mortality trends in PeC over the past 2 decades. Low schooling, married, and young men from the North or Northeast regions represent the majority of deaths. Urgent efforts are needed to enhance the diagnosis and treatment of PeC to prevent and reduce mortality rates in the country.

Late management of traumatic complete penile amputation: A Case Report

Late management of traumatic complete penile amputation: A Case Report

Successful management of near-total penile amputation secondary to neglected hair tourniquet syndrome

Successful management of near-total penile amputation secondary to neglected hair tourniquet syndrome

Oncological Outcomes of Thulium–Yttrium–Aluminum–Garnet (Tm:YAG) Laser Ablation for Penile Cancer

ObjectivesTo report oncological outcomes after Thulium–yttrium–aluminium–garnet (Tm:YAG) laser ablation for penile cancer patients. Materials and MethodsWe retrospectively analysed 71 patients with ≤cT1 penile cancer (2013-2022). All patients underwent Tm:YAG ablation with a RevoLix 200 W continuous-wave laser. First, Kaplan-Meier plots and multivariable Cox regression models tested local tumor recurrence rates. Second, Kaplan-Meier plots tested progression-free survival (≥T3 and/or N1-3 and/or M1). ResultsMedian (IQR) follow-up time was 38 (22-58) months. Overall, 33 (50.5%) patients experienced local tumor recurrence. Specifically, 19 (29%) vs. 9 (14%) vs. 5 (7.5%) patients had 1 vs. 2 vs. 3 recurrences over time. In multivariable Cox regression models, a trend for higher recurrence rates was observed for G3 tumors (HR:6.1; p=0.05), relative to G1. During follow-up, 12 (18.5%) vs. 4 (6.0%) vs. 2 (3.0%) men were re-treated with 1 vs. 2 vs. 3 Tm:YAG laser ablations. Moreover, 11 (17.0%) and 3 (4.5%) patients underwent glansectomy and partial/total penile amputation. Last, 5 (7.5%) patients experienced disease progression. Specifically, TNM stage at the time of disease progression was: 1) pT3N0; 2) pT2N2; 3) pTxN3; 4) pT1N1 and 5) pT3N3, respectively. ConclusionTm:YAG laser ablation provides similar oncological results as those observed by other PSS procedures. In consequence, Tm:YAG laser ablation should be considered a valid alternative for treating selected penile cancer patients.