Urological Emergencies

Mustafa Basim Zwain

M.B.Ch.B
• Non traumatic
• 1. Hematuria
• 2. Renal Colic
• 3. Urinary Retention
• 4. Acute Scrotum
• 5. Priapism
• Traumatic
• 1.Renal Trauma
• 2. Ureteral Injury
• 3.Bladder Trauma
• 4. Urethral Injury
• 5.Testicular Trauma
 1. Acute urinary retention
• Painful inability to void, with relief of pain following drainage of the
bladder by catheterization.
• The combination of reduced or absent urine output with lower
abdominal pain is not, in itself, enough to make a diagnosis of acute
retention.
• Many acute surgical conditions cause abdominal pain and fluid depletion,
the latter leading to reduced urine output, and this reduced urine output
can give the erroneous impression that the patient is in retention.
• Central to the diagnosis is the presence of a large volume of urine which,
when drained by catheterization, leads to resolution of the pain. What
represents ‘large’ has not been strictly defined, but volumes of 500800mL
are typical.
 Pathophysiology
➢ Four broad mechanisms can lead to urinary retention:
1) Increase urethral resistance (i.e. Bladder outlet obstruction (BOO)
is a blockage at the base of the bladder).
2) Low bladder pressure (i.e. impaired bladder contractility).
3) Interruption of sensory or motor innervation of the bladder.
4) Central failure of coordination of bladder contraction with
external sphincter relaxation.
 Causes acute urinary retention in men
1) Prostatic problem: Benign prostatic hyperplasia (BPH), prostate
cancer, prostatic abscess.

2) Urethral stricture.

➢ Risk factors for retention in men;-

1) Advancing age is a strong predictor of the risk of urinary retention
in men.
2) Other factors that predict risk of urinary retention are the
presence of LUTS (higher symptom scores), previous episodes of
spontaneous retention, and larger prostate volume.
 Causes acute urinary retention in women
1) Pelvic prolapse (cystocele, rectocele, uterine); urethral stricture;
urethral diverticulum.
2) Post- surgery for ‘stress’ incontinence.
3) Pelvic masses (e.g., ovarian masses).
4) Fowler’s syndrome: difficulty in passing urine and urinary
retention due to the bladder's sphincter muscle's failure to relax,
electromyographic (EMG) activity can be recorded in the external
urethral sphincters of these women and is hypothesized to cause
impaired relaxation of the external sphincter; occurs in
premenopausal women, often in association with polycystic
ovaries.
 Causes of acute urinary retention in Both sex
❖ Hematuria, leading to clot retention.
❖ Pain (adrenergic stimulation of the bladder neck).
❖ Post- operative retention: Precipitating events include:
➢ Anesthetic and other drugs (anticholinergics, sympathomimetic
agents such as ephedrine in nasal decongestants, antihistamine).
➢ Non- prostatic abdominal or perineal surgery.
➢ Immobility: following surgical procedures.
❖ Pelvic fracture rupturing the urethra (more likely in men than
women).
❖ Drugs ex; drugs with anticholinergic activity (e.g. antipsychotic
drugs, antidepressant agents, Buscopan…….etc
❖ Neurogenic:
➢ Sacral cord (S2– 4) injury or compression or damage, resulting in
detrusor areflexia.
➢ Radical pelvic surgery damaging the pelvic parasympathetic plexus
(radical hysterectomy, abdominoperineal resection): unilateral
injury to the pelvic plexus denervates motor innervation of the
detrusor muscle.
➢ Neurotropic viruses involving sensory dorsal root ganglia of S2,4
(herpes simplex or zoster).
➢ Diabetic cystopathy (causes sensory and motor dysfunction).
 Management
➢ Initial management
• Urethral catheterization to relieve pain (suprapubic catheterization if
the urethral route not possible). Record the volume drained, this
confirms the diagnosis, determines subsequent management.
➢ Definitive management in men
• Precipitated retention often does not recur; spontaneous retention
often does.
• 50% of spontaneous retention will experience a second episode of
retention within the next week or so, and 70% within the next year.
• Treat the cause.
 2.Phimosis
• A condition in which the foreskin can’t be retracted (pulled back) from
around the tip of the penis. A tight foreskin is common in baby boys who
aren’t circumcised, but it usually stops being a problem by the age of 3.

• Phimosis can occur naturally or be the result of scarring. Young boys may
not need treatment for phimosis unless it makes urinating difficult or
causes other symptoms.

• Cause: Inflammation or an infection of the foreskin or head of penis

(glans).
Treatment: Depending on the severity of the condition.
• A topical steroid ointment can be used to help soften the foreskin
and make retraction easier. The ointment is massaged into the area
around the glans and foreskin twice a day for several weeks.
• daily gentle retraction may be enough to treat the problem.
• In more serious cases, circumcision
 3.Paraphimosis
• foreskin is retracted from over the glans of the penis, becomes
edematous, and cannot then be pulled back over the glans into its
normal anatomical position. It occurs most commonly in teenagers or
young men and also in elderly men (in uncircumcised male).
• Paraphimosis is usually painful.
• Treatment: The ‘iced glove’ method: apply topical lidocaine gel to the
glans and foreskin for 5min. Place ice and water in a rubber glove, and tie
a knot in the cuff of the glove to prevent the contents from pouring out.
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• Using a 25G needle; make punctures into the edematous foreskin.
Squeeze the oedema fluid out of the foreskin, and return to its normal
position. If this fails, the traditional surgical treatment is a dorsal slit
under GA or ring block.
 4.Priapism
➢ Definition: Prolonged, unwanted erection, in the absence of sexual
desire or stimulus, lasting >4h.
➢ Classification :-
❖ Low- flow (ischaemic) priapism:
• due to veno- occlusion (intracavernosal pressures of 80– 120mmHg).
• Commonest form (accounts for 95%), which manifests as a painful,
rigid erection, with absent or low cavernosal blood flow.
• Ischaemic priapism for >4h requires emergency intervention. Blood
gas analysis shows hypoxia and acidosis.
❖ High- flow (non- ischaemic) priapism: due to unregulated arterial
blood flow, presenting with a semi- rigid, painless erection. Caused
by trauma (or surgery) to the penis or perineum, resulting in
cavernosal artery laceration and subsequent formation of an
arteriovenous fistula. It is often self- limiting. Blood gas analysis
shows similar results to arterial blood.

❖ Recurrent (or stuttering) priapism: intermittent, recurrent

ischaemic episodes of priapism, of relatively short duration, which
are often painful. Most commonly seen in sickle- cell disease.
 Aetiology of ischemic priapism
• primary (idiopathic).
• secondary, including:
1) Oral drugs:a) Recreational drugs: cocaine, marijuana.b)
Hormones: GnRH; testosterone.
2) Thromboembolic: sickle- cell disease, leukaemia, thalassaemia.
3) Infection: malaria, rabies, scorpion sting.
4) prostate or bladder cancer extending into the penis.
 Management
• High- flow priapism: This is not an emergency, as the penis is not
ischemic. Conservative treatment is recommended in most cases, as
the fistula can close spontaneously.
• Low- flow priapism: Decompress urgently with aspiration of blood
from the corpora. Second-line therapy (if aspiration fails),
decompression of the penis by creating a shunt between the corpus
cavernousum and either the glans or the corpus spongiousum.
 5.Hematuria
• What is the definition of HEMATURIA? anything >3 RBCs per High
Power Field.
• How can hematuria be distinguished from hemoglobinuria &
myoglobinuria?
• Microscopy of centrifuged urine } presence of large number of
erythrocytes = hematuria .
• Serum exam } pink supernatant after centrifugation =
hemoglobinuria.
• clear supernatant after centrifugation = myoglobinuria
 What are some causes of a FALSE +VE
DIPSTICK reading for hematuria?
• contamination of urine with menstrual blood.

• vigorous exercise.

• dehydration.

• hemoglobinuria/myoglobinuria.
What are the signs suggestive of hematuria of
a nephrologic origin?
• Nephrological hematuria has more significant proteinuria (minimal
seen in urologic hematuria).
• Glomerular:1. dysmorphic erythrocytes (seen on light phase
microscopy)2. RBC casts.3. proteinuria.
• Non-glomerular (tubulointerstitial, renovascular, systemic) uniformly
round erythrocytes, no RBC casts, proteinuria.

➢ What is the most common cause of glomerular hematuria?

✓ IgA nephropathy (Berger’s disease) :30%
 Management of Hemorrhagic Cystitis
• The management may occasionally be guided by the cause for the
condition (treatment of infection), although in most cases no cause-
directed therapy can be offered and instead a sequential approach,
depending on the severity of the condition, should be undertaken.
• Supportive management represent the mainstay of first-line therapy and
typically suffice for mild cases.
1) increasing urine output via hydration.
2) Catheter placement with continuous bladder irrigation.
3) Blood transfusion as needed.
• If hematuria continues and/or clotting of the urine cannot be controlled
with bladder irrigation, cystoscopy under anesthesia with clot evacuation
and fulguration of discrete bleeding sites is then recommended.
 Acute scrotum
• Acute scrotum is defined as “the constellation of new onset pain, swelling, and/or
tenderness of the intrascrotal contents.
• The acute scrotum is an umbrella term that includes a wide variety of unique disease
processes.
• Rapid evaluation and diagnostics are necessary due to the time dependency of
certain morbid but reversible conditions, such as acute testicular torsion.
• The vascular anatomy of the scrotal contents is also important to review. The testes
receive a joint supply of blood from the testicular artery, deferential artery, and the
cremasteric artery. While the deferential artery and the cremasteric artery are
branches of the inferior vesical and inferior epigastric artery, respectively, the
testicular artery branches directly from the abdominal aorta.
• The testes are drained via small branching veins forming the pampiniform plexus
and ultimately the testicular vein. Notably, the testicular vein drains directly into the
inferior vena cava on the right while it drains into the left renal vein contralaterally
 TORSION OF THE TESTIS (Torsion of spermatic cord)

• Rotation of the testis around the vertical axis of the cord.

• It is time limited due to arterial obstruction & the patient might lose
his testis by ischemia (gangrene) if the diagnosis is delayed (6 hours).
• It may develop spontaneously during sleep.
• Straining at stool, lifting a heavy weight, trauma, and coitus are all
possible precipitating factors.
 Clinical features
• Most common between 10 and 25 years of age.
• Sudden agonizing pain in the groin and the lower abdomen.
• The patient feels nauseated and may vomit.
• The testis lies transversely high and the tender twisted cord can be
palpated above it.
• Testicular elevation does not relief pain.
• Loss of cremasteric reflex.
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• Diagnosis:-
• Doppler ultrasound scan will confirm the absence of the blood
supply to the affected testis.
• Treatment:-
• Exploration for torsion.
• If the testis is viable when the cord is untwisted then it is fixed
(orchiopexy).
• An infarcted testis (gangrenous) should be removed
(orchidectomy).
• The other testis should also be fixed because the anatomical
predisposition is likely to be bilateral.
• N.B: In the first hours it may be possible to untwist the testis
manually, then early orchiopexy to avoid recurrent torsion.
 Testicular Appendage Torsion
• Testicular appendage torsion is the twisting of a small piece of tissue
above a testicle.
• The appendage doesn’t have a function in the body. But it can twist
and cause pain and swelling that gets worse over time.
• It is not the same as testicular torsion. It is not a medical emergency
like testicular torsion.
• The symptoms can be similar in both conditions. But the pain of
testicular torsion is often more severe.
➢ Symptoms can include:
• Pain in one testicle, on one side of the scrotum.
• Swelling and redness of the scrotum.
• A blue dot at the top of the scrotum. This shows that the twist is in
the appendage, not the testicle.
➢ How is testicular appendage torsion diagnosed?
• Imaging test of your scrotum. This may include an ultrasound.
• In some cases, you may need surgery right away if it appears you
may have testicular torsion.
➢ Treatment for testicular appendage torsion includes:
1) Rest.
2) Scrotal elevation.
3) Analgesia (NSAID).
 EPIDIDYMO-ORCHITIS
• Inflammation confined to the epididymis is epididymitis.
• Infection spreading to the testis is epididymo-orchitis.
• Mode of infection:-
• Infection reaches the epididymis via the vas from a primary
infection of the urethra, prostate or seminal vesicles.
• Blood-borne infections of the epididymis are less common.
• Acute epididymo-orchitis can follow any form of urethral
instrumentation.It is particularly common when an indwelling
catheter is associated with infection of the prostate.
 Causes of Acute epididymo-orchitis
➢ acute bacterial orchitis:
• secondary to UTI
• secondary to STD
➢ acute non-bacterial infectious orchitis: viral (Mumps is
most common cause of viral orchitis, have associated
parotitis (mumps - paramyxovirus).
➢ acute non-infectious orchitis ; idiopathic, traumatic,
autoimmune.
 Clinical features
• The initial symptoms are those of urinary tract infection.
• The epididymis and testis swell and become painful.
• Fever.
• The scrotal wall, at first red, edematous and shiny, may become
adherent to the epididymis.
• Resolution may take 6–8 weeks to complete.
• Acute epididymo-orchitis develops in about 10-30% of males
suffering from mumps. The main complication is testicular atrophy,
which may cause infertility if the condition is bilateral.
 Investigations
• Urinalysis.
• Urine C&S.
• WBC count.
• RBS.
• Scrotal U/S: rule out torsion and malignancy (in chronic
orchitis/orchialgia)
 Treatment
• Rule out Testicular torsion.
• Bed rest + Scrotal support+ hydration.
• Broad spectrum antibiotics for 2 weeks (3 rd generation cephalosporin or
quinolones).
• Supportive therapy (analgesics, antipyretics, anti-emetics, IV. fluid.).
• If suppuration occurs (Abscess): drainage is necessary.
➢ Potential complications of acute Acute epididymo-orchitis is
• abscess formation.
• testicular infarction & atrophy.
• chronic scrotal pain.
• infertility.
The history of present illness (HPI)
 Scrotal gangrene (Necrotizing fasciitis, Fournier’s gangrene)
• Fulminating inflammation of the subcutaneous tissues, which results in an
obliterative arteritis of the arterioles to the scrotal skin.
• Most commonly occurs in immunocompromised patients (DM).
• Causative organisms: mixed infection of Hemolytic streptococci(sometimes
microaerophilic), Staphylococcus, E. coli, Clostridium welchii.
➢ Clinically:
• Sudden scrotal inflammation. The condition can follow minor injuries or
procedures in the perineal area, such as a bruise, scratch, urethral dilatation,
injection of haemorrhoids or opening of a periurethral abscess.
• Cellulitis spreads, Rapid onset of gangrene and loss of scrotal skin leading to
exposure of the scrotal contents,
• entire scrotal coverings slough, leaving the testes exposed but healthy.
• The absence of any obvious cause in over half the cases.
 Treatment
• Immediate treatment consists of aggressive surgical debridement,
combined with broad-spectrum intravenous antibiotics.
• Because the extent of tissue involvement is often not apparent at initial
debridement, patients should undergo “second look” procedures, with
additional debridement if necessary.
• Coordination with general surgery colleagues is critical as perirectal tissue
can be involved and in some cases, may be the source of the infection.
• Excision of affected tissue is a necessary component of treatment;
treatment with antibiotics alone typically has a 100% mortality. After
surviving the initial infection, many patients will need multiple
reconstructive procedures.
• Treatment with hyperbaric oxygen may preserve healthy tissue and
reduce the amount of debridement necessary
Debridement for Fournier's gangrene wound.
Hyperbaric oxygenation (HBO) improves tissue perfusion and promotes
angiogenesis and collagen synthesis

A: Necrosis extends to the B: good granulation after C: Final appearance of right

right inguinal region with hyperbaric oxygen therapy. inguinal region after suture.
substantial necrotic tissue on the
fascia and muscle layer.
Urological
Trauma
 Renal Trauma
• The kidneys relatively protected from traumatic
injuries.Considerable degree of force is usually required to injure a
kidney.
➢ Mechanisms and cause:
• Blunt : direct blow or acceleration/ deceleration (road traffic
accidents, falls from a height, fall onto flank).
• Penetrating : knives, gunshots, iatrogenic, e.g., percutaneous
nephrolithotomy (PCNL)
➢ Renal US:
• Advantages: – can certainly establish the presence of
two kidneys – the presence of a retroperitoneal
hematoma – power Doppler can identify the
presence of blood flow in the renal vessels.
• Disadvantages: – cannot accurately identify
parenchymal tears, collecting system injuries, or
extravasations of urine until a later stage when a
urine collection has had time to accumulate.
➢ Contrast-enhanced CT: The imaging study of choice,
accurate, rapid, images other intra-abdominal
structures
 Indications for renal imaging CT scan:
• Macroscopic hematuria.
• Penetrating chest, flank, and abdominal wounds.
• Microscopic [>5 red blood cells (RBCs) per high powered field] or
dipstick hematuria a hypotensive.
• patient (SBP <90mmHg ).
• A history of a rapid acceleration or deceleration.
• Any child with microscopic or dipstick hematuria who has sustained
trauma.
 Management
➢ Conservative:
• Over 95% of blunt injuries.
• 50% of renal stab injuries and 25% of renal gunshot wounds (specialized
center).
✓ Management Include :
• Wide Bore IV line.
• IV antibiotics.
• Bed rest.
• serial CBC (Htc).
• Follow up with US &/or CT.
• 2-3 wks.
➢ Surgical exploration:
• Persistent bleeding (persistent tachycardia and/orhypotension failing
to respond to appropriate fluid and blood replacement.
• Expanding perirenal haematoma (again the patient will show signs of
continued bleeding).
• Pulsatile perirenal haematoma
 URETERIC INJURIES
• The ureters are protected from external trauma by surrounding
bony structures, muscles and other organs.
• Causes and Mechanisms : External Trauma , Internal Trauma.
• External Trauma: – Rare and severe force is required.
• Blunt or penetrating.
• Blunt external trauma severe enough to injure the ureters will
usually be associated with multiple other injuries .
• Knife or bullet wound to the abdomen or chest may damage the
ureter, as well as other organs.
• Internal Trauma :- Uncommon, but is more common than external
trauma.
• Surgery: Hysterectomy, oophorectomy, and sigmoidcolectomy.
• Ureteroscopy.
• Caesarean section.
• Aortoiliac vascular graft placement,
• Laparoscopic procedures,
• Orthopedic operations
 Diagnosis
• Requires a high index of suspicion – Intraoperative:
• Late:
1) An ileus: the presence of urine within the peritoneal
cavity.
2) Prolonged postoperative fever or overt urinary sepsis.
3) Persistent drainage of fluid from abdominal or pelvic
drains, from the abdominal wound, or from the vagina.
4) Flank pain if the ureter has been ligated.
5) An abdominal mass, representing a urinoma.
6) 6. Vague abdominal pain.
 Treatment options
• JJ stenting – Primary closure of partial transection of the ureter.
• Direct ureter to ureter anastomosis – Reimplantation of the ureter
into the bladder.
• (ureteroneocystostomy), either using a psoas hitch or a Boari flap.
• Transureteroureterostomy.
• Autotransplantation of the kidney into the pelvis.
• Replacement of the ureter with ileum.
• Permanent cutaneous ureterostomy – Nephrectomy
 BLADDER INJURIES
• Causes:
❖ Iatrogenic injury :
1) Transurethral resection of bladder tumour (TURBT).
2) Cystoscopic bladder biopsy.
3) Transurethral resection of prostate (TURP).
4) Cystolitholapaxy.
5) Caesarean section, especially as an emergency.
6) Total hip replacement (very rare).
❖ Penetrating trauma to the lower abdomen or back.
❖ Blunt pelvic trauma —in association with pelvic fracture or
❖ Rapid deceleration injury —seat belt injury with full bladder in the
absence of a pelvic fracture.
❖ Spontaneous rupture after bladder augmentation.

• Presentation: – Iatrogenic Recognized intraoperatively.

• Trauma ( blunt or penetrating ).
• The classic triad of symptoms and signs that are suggestive of a
bladder rupture. Suprapubic pain and tenderness, difficulty or
inability in passing urine, and haematuria
 Diagnosis
• Hx.
• Physical examination.
• u/s.
• VOIDING CYSTOGRAM is the standard
imaging study to evaluate patient with
suspected bladder injury.
 Types of Perforation
• intraperitoneal perforation the peritoneum overlying the bladder,
has been breached along with the wall of the bladder, allowing
urine to escape into the peritoneal cavity.

• extraperitoneal perforation the peritoneum is intact and urine

escapes into the space around the bladder, but not into the
peritoneal cavity
 URETHRAL INJURIES
A) ANTERIOR URETHRAL INJURIES
• Rare.
• Mechanism:The majority a result of a straddle injury in boys or men.
• Direct injuries to the penis.
• Penile fractures.
• Inflating a catheter balloon in the anterior urethra.
• Penetrating injuries by gunshot wounds.
• Symptoms and signs:
• Blood at the end of the penis.
• Difficulty in passing urine.
• Frank hematuria.
• Hematoma may around the site of the rupture.
• Penile swelling.
• Diagnosis:
• Retrograde urethrography :
• Contusion: no extravasation of contrast.
• Partial rupture : extravasation of contrast, with contrast also present
in the bladder.
• Complete disruption: no filling of the posterior urethra or bladder.
 Management
• Contusion A small-gauge urethral catheter for one week.
• Partial Rupture of Anterior Urethra: No urethral catheterization.
• Majority can be managed by suprapubic urinary diversion for one
week.
• Penetrating partial disruption (e.g., knife, gunshot wound), primary
(immediate) repair.
• Complete Rupture of Anterior Urethra: patient is unstable a
suprapubic catheter.
• patient is stable, the urethra may either be immediately repaired or
a suprapubic catheter.
• Penetrating Anterior Urethral Injuries : qgenerally managed by
surgical debridement and repair.
 URETHRAL INJURIES
B) POSTERIOR URETHRAL INJURIES
• Great majority of posterior urethral injuries occur in
association with pelvic fractures.
• 10% to 20% have an associated bladder rupture.
• Signs :- Blood at the meatus, gross hematuria, and perineal
or scrotal bruising.
• Per rectal EXAM High-riding prostate
 Classification of posterior urethral injuries
• Type I: (rare ) stretch injury with intact urethra.
• type II : (25%) partial tear but some continuity remains).
• type III: (75%) complete tear with no evidence of continuity.
• In women, partial rupture at the anterior position is the
most common urethral injury associated with pelvic fracture.
❖ RUG: Retrograde UrethroGram: is the standard imaging
study to evaluate patient with suspected urethral injury.
 Management
• Stretch injury (type I) and incomplete urethral tears
(type II) are best treated by stenting with a urethral
catheter.
• Type III Patient is at varying risk of urethral stricture,
urinary incontinence, and erectile dysfunction (ED).
• Initial management with suprapubic cystotomy and
attempting primary repair at 7 to 10 days after injury
 Testicular trauma
• Blunt trauma (75%): assault, sports-related events, MVA.
• Penetrating trauma (25%): GSWs, explosions, impalement injuries.
➢ 30% are bilateral.
➢ 80% associated with non-GU injuries (thigh, perineum, femoral
vessels)
Perineal and scrotal ecchymosis accompanying testicular injury
 Diagnosis
• physical exam } swelling & ecchymosis are variable.
• degree of hematoma does not correlate with severity of testis
injury.
• absence of hematoma does not rule out testis rupture.
• rule out concomitant urethral injury.
• imaging} U/S is the investigation of choice, to assess integrity and
vascularity of testis, inhomogeneity of parenchyma + disruption of
tunica albuginea suggests testis fracture.
• if U/S is equivocal but physical exam is suspicious, always explore.
 Management
• Early exploration & repair is beneficial.
1) increased testis salvage.
2) Reduced convalescence time and disability.
3) earlier return to normal activities.
4) preservation of fertility and hormonal function.
❖ What is the management of penetrating scrotal injuries?
➢ explore to rule out vascular and vasal injury.
 Outcomes of testis rupture management
• non-operative management often complicated by:
1) Infection.
2) Atrophy.
3) Necrosis.
4) delayed orchiectomy} 3-9 fold higher.
➢ 90% testis salvage rate with exploration + repair within 3 days of
injury, 33% salvage rate with conservative management.
➢ salvage rate for penetrating testis trauma is only 30-60%.
 Case Study
• 57 year old man is brought to emergency department 30minutes
after motor vehicle accident . On arrival he was with disturbed level
of consciousness and in a shock state ( BP 70/40 , pulse rate 180
bpm) , on examination he had bruising in lower abdomen .
• CXR was normal while Pelvic X ray shows open book Pelvic fracture .
Ultrasound shows intact both kidneys and free intra peritoneal fluid
with pelvic heamatom . Foley catheter was inserted with 300 cc
fresh blood comes to the urine bag .
• Your initial action in this case ?
• Your professional diagnosis ?
• Imaging study of choice to confirm ?
This imaging study has been done for the patient . What is the name of this imaging
study ?Describe the steps of this imaging study procedure ? what are your findings ?
How you can manage this patient ?