Justin Amann

Fractured Penis: Diagnosis and Management (CME)

INTRODUCTION Penile fracture is a well-recognized clinical entity. It is relatively uncommon and is considered a urological emergency. Its management has been a subject of controversy. AIM In this article, we will review contemporary knowledge of the epidemiology, pathophysiology, evaluation, and evolving management strategies of penile fracture. METHODS A case report was discussed followed by an English-language Medline review. MAIN OUTCOME MEASURE Review of the available literature to establish best-practice management. RESULTS The injury is defined as the traumatic rupture of the corpus cavernosum secondary to a blunt trauma of the erect penis. The condition is underreported. The commonest causes were coital injuries and penile manipulation. The diagnosis was usually fairly straightforward because of the stereotypical clinical presentation. Associated injuries included urethral rupture. Imaging was helpful in selected cases. Conservative measures were associated with increased complications. Most authors advocated early surgical repair. False explorations have been reported. CONCLUSIONS Penile fracture is a clinical diagnosis. The ideal management has evolved and remains largely surgical. Preoperative imaging should not delay surgical repair.

Repeat Prostate Biopsy Accuracy: Simulator-based Comparison of Two- and Three-dimensional Transrectal US Modalities

PURPOSE To compare the accuracy of biopsy with two-dimensional (2D) transrectal ultrasonography (US) with that of biopsy with conventional three-dimensional (3D) transrectal US and biopsy with guided 3D transrectal US in the guidance of repeat prostate biopsy procedures in a prostate biopsy simulator. MATERIALS AND METHODS The institutional review board approved this retrospective study. Five residents and five experts performed repeat biopsies with a biopsy simulator that contained the transrectal US prostate images of 10 patients who had undergone biopsy. Simulated repeat biopsies were performed with 2D transrectal US, conventional 3D transrectal US, and guided 3D transrectal US (an extension of 3D transrectal US that enables active display of biopsy targets). The modalities were compared on the basis of time per biopsy and how accurately simulated repeat biopsies could be guided to specific targets. The probability for successful biopsy of a repeat target was calculated for each modality. RESULTS Guided 3D transrectal US was significantly (P < .01) more accurate for simulated biopsy of repeat targets than was 2D or 3D transrectal US, with a biopsy accuracy of 0.86 mm +/- 0.47 (standard deviation), 3.68 mm +/- 2.60, and 3.60 mm +/- 2.57, respectively. Experts had a 70% probability of sampling a prior biopsy target volume of 0.5 cm(3) with 2D transrectal US; however, the probability approached 100% with guided 3D transrectal US. Biopsy accuracy was not significantly different between experts and residents for any modality; however, experts were significantly (P < .05) faster than residents with each modality. CONCLUSION Repeat biopsy of the prostate with 2D transrectal US has limited accuracy. Compared with 2D transrectal US, the biopsy accuracy of both experts and residents improved with guided 3D transrectal US but did not improve with conventional 3D transrectal US.

Combining Mean and Standard Deviation of Hounsfield Unit Measurements from Preoperative CT Allows More Accurate Prediction of Urinary Stone Composition Than Mean Hounsfield Units Alone

INTRODUCTION AND OBJECTIVES The mineral composition of a urinary stone may influence its surgical and medical treatment. Previous attempts at identifying stone composition based on mean Hounsfield Units (HUm) have had varied success. We aimed to evaluate the additional use of standard deviation of HU (HUsd) to more accurately predict stone composition. METHODS We identified patients from two centers who had undergone urinary stone treatment between 2006 and 2013 and had mineral stone analysis and a computed tomography (CT) available. HUm and HUsd of the stones were compared with ANOVA. Receiver operative characteristic analysis with area under the curve (AUC), Youden index, and likelihood ratio calculations were performed. RESULTS Data were available for 466 patients. The major components were calcium oxalate monohydrate (COM), uric acid, hydroxyapatite, struvite, brushite, cystine, and CO dihydrate (COD) in 41.4%, 19.3%, 12.4%, 7.5%, 5.8%, 5.4%, and 4.7% of patients, respectively. The HUm of UA and Br was significantly lower and higher than the HUm of any other stone type, respectively. HUm and HUsd were most accurate in predicting uric acid with an AUC of 0.969 and 0.851, respectively. The combined use of HUm and HUsd resulted in increased positive predictive value and higher likelihood ratios for identifying a stones mineral composition for all stone types but COM. CONCLUSIONS To the best of our knowledge, this is the first report of CT data aiding in the prediction of brushite stone composition. Both HUm and HUsd can help predict stone composition and their combined use results in higher likelihood ratios influencing probability.

After-Hours Radiology Consultation in an Academic Setting, 2005-2009

After-hours radiology is an increasingly frequent topic for discussion and debate within the medical community; in the academic community, this topic centers around the role of the ‘‘on-call’’ radiology resident. Academic and nonacademic centres have been experiencing ballooning workloads and have had to introduce new and creative work paradigms to accommodate this extra burden [1]. Results of one representative study reported an increase in after-hours utilisation of computed tomography (CT) by 59%, magnetic resonance imaging (MRI) by 51%, and ultrasound by 30% over a 4-year period [2]. Furthermore, the use of crosssectional imaging, particularly CT, is increasing at a rate that far exceeds emergency department (ED) volumes and acuity [3]. Not only is the volume and breadth of on-call imaging growing, there is increasing pressure for ‘‘stat’’ or contemporaneous reports. These realities place a significantly increasing and changing load on radiology residents, who typically manage the department after hours. Hence, to optimally prepare residents for on-call commitments as well as to allocate manpower and resources optimally, it is important to be aware of the trends and variations in the current after-hours radiology landscape. This information would be particularly useful to the University of Western Ontario’s Diagnostic Radiology Residency program planners. The purpose of this study was to assess for any significant trends with regard to on-call radiology consultations in a Canadian academic health care setting (London Health Sciences Centre and St. Joseph’s Health Care in London, Ontario) between 2005 and 2009. Specifically, the following questions were analysed: � Has there been a significant increase in total number of after-hours radiology consultations? If so, by how much? Is there any variation based on modality? � Is there any variation based on the month? � Is there any variation based on day of the week? � Is there any variation based on resident level of training?

Today’s Radiology Student: What Every Radiology Training Program Director Needs to Know

Imagine that you have left a meeting with the Chair of the Radiology Department. Somehow you were persuaded to accept a new role as Director of Radiology Training. What exactly have you just agreed to? Feeling both apprehension and excitement, your mind begins to explore what you know and what you do not know about this role. You are certainly familiar with the position itself – after all, you are a radiologist, you have been a resident, and you have watched your colleague in another hospital serve in the role for the past 5 years. Now it is your turn. You make a mental note to visit the outgoing Director and find out what support and resources are in place that you need to become aware of in order to prepare for this new role. Since all programs have a residency, you consider that you will likely receive some direction from the Postgraduate Education (PGE) Office. Since all medical academic centers in Canada offering radiology programs are accredited by the same governing body (The Royal College of Physicians of Surgeons of Canada), you know that you will have provincial and national counterparts to call on for advice. You feel at once both overwhelmed and comforted by this thought and begin to wonder where you are going to find the time for all of this “networking” when you still have your own clinical work to do. You take a deep breath. You refocus on the various teaching hospitals within your own network, and you quickly recognize how important it will be to have a strong site director at each site that you can count on. In a very busy teaching hospital, you will need everyone to contribute to the academic mission through teaching rounds, reading cases, or offering weekly afternoon academic sessions. At the same time, you have to 3