Peter Royce

Predictors of Outcome for Blunt High Grade Renal Injury Treated With Conservative Intent

PURPOSE Management for blunt high grade renal injury is controversial with most disagreement concerning indications for exploration. At our institution all patients are considered candidates for conservative treatment regardless of injury grade or computerized tomography appearance with clinical status the sole determinant for intervention. We define clinical factors predicting the need for emergency intervention as well the development of complications. MATERIALS AND METHODS We analyzed the records of 117 patients with high grade renal injury (III to V) secondary to blunt trauma who presented to our institution in an 8-year period. Patients were categorized by the need for emergency intervention and, in those treated conservatively, by complications. We generated logistic regression models to identify significant clinical predictors of each outcome. RESULTS Grade III to V injury occurred in 48 (41.1%), 42 (35.9%) and 27 patients (23%), respectively. Of the 117 patients 20 (17.1%) required emergency intervention. On multivariate analysis only grade V injury (RR 4.4, 95% CI 1.9-10.5, p = 0.001) and the need for platelet transfusion (RR 8.9, 95% CI 2.1-32.1, p < 0.001) significantly predicted the need for intervention. A total of 90 patients (82.9%) who did not require emergency intervention underwent a trial of conservative treatment, of whom 9 (9.3%) experienced complications requiring procedural intervention. On multivariate analysis only patient age (RR 1.06, 95% CI 1.02-1.1, p = 0.004) and hypotension (RR 12, 95% CI 1.9-76.7, p = 0.009) were significant predictors. CONCLUSIONS High grade injury can be successfully managed conservatively. However, grade V injury and the need for platelet transfusion predict the need for emergency intervention while older patient age and hypotension predict complications.

What to do for prostate cancer patients with a rising PSA?--A survey of Australian practice.

PURPOSE To document current Australian management of asymptomatic prostate cancer patients with prostate-specific antigen (PSA) relapse after radical treatment or considered unsuitable for radical treatment. MATERIALS AND METHODS Four case scenarios-postprostatectomy PSA relapse, postradiotherapy (RT) with a slow or a rapidly rising PSA level, or no radical treatment-were presented. Management preferences, including (where relevant) RT, androgen ablation either immediate or delayed until a PSA rise or symptomatic progression, and other approaches, were identified. The preferred methods of androgen ablation were noted. RESULTS One hundred eighteen informative replies out of 324 e-mailed surveys were received. For postprostatectomy PSA relapse, 59% of respondents favored salvage RT. For post-RT with a slow or a rapidly rising PSA level and treatment of nonradical patients, there was no clear consensus of opinion, with respondents divided among the different options. A diverse range of PSA levels was cited for delayed intervention, with values ranging from 0.8 to 100 ng/mL. PSA doubling time proved a more consistent criterion for determining intervention. Most respondents favored the use of a luteinizing hormone-releasing hormone agonist as first-line androgen ablation, although patient choice was recognized as important in all decision making. CONCLUSIONS A lack of available evidence underlies the diversity of opinion regarding the management of asymptomatic prostate cancer patients with a rising PSA. The need for randomized controlled trials in this area is highlighted.

The diagnosis of acute urethral trauma

BACKGROUND During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury. METHODS A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted. RESULTS There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma. DISCUSSION Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.

A 9-year experience of renal injury at an Australian level 1 trauma centre

To detail the 9‐year experience of renal trauma at a modern Level 1 trauma centre and report on patterns of injury, management and complications.

Assessing the Usefulness of Delayed Imaging in Routine Followup for Renal Trauma

PURPOSE Renal trauma is often managed conservatively. Repeat imaging within 48 hours of injury is recommended but to our knowledge the value of further delayed imaging is unknown. We determined the usefulness of routine followup imaging beyond 48 hours in cases of conservatively managed renal trauma. MATERIALS AND METHODS Of 377 patients who presented to our institution with renal injury in the last 8 years we identified 138 who underwent a trial of conservative treatment and repeat imaging more than 48 hours after injury. Followup imaging was categorized as routine in 108 patients (group 1) and indicated in 30 (group 2), and assessed for complications and the need for subsequent intervention. RESULTS Of the patients 121 (76%) were male. Mean age was 36 years. All except 4 injuries were the result of blunt trauma, predominantly due to road traffic accidents. Injury was grade 1 to 5 in 26, 24, 44, 33 and 11 cases, respectively. We identified 108 patients with routine followup imaging (group 1) while 30 were re-imaged due to a clinical indication. The rate of progression was 0.93% in group 1 with only 1 complication requiring a management change. In contrast, 20% of group 2 patients had progression requiring a treatment change (p = 0.0004). CONCLUSIONS Routine re-imaging in patients with renal trauma outside the initial 48-hour window in the absence of a clear clinical indication had little benefit and changed treatment in less than 1%.

The effect of oral anticoagulation on the prevalence and management of haematuria in a contemporary Australian patient cohort

Urologists are increasingly involved in the management of patients taking oral anticoagulation (OA) who present with haematuria. It is accepted practice that haematuria in the presence of concurrent anticoagulation requires a full diagnostic evaluation, as it is frequently precipitated by a significant pathological lesion. However, there is limited data on the impact of anticoagulation on the initial inpatient management of these patients. Much of the current evidence is either based around perioperative management of elective patients or, for emergency presentations, is focused on bleeding associated with high morbidity and mortality, such as in the neurosurgical population.

The medical consequences of vasectomy

Vasectomy is a widely used form of contraception worldwide. The data indicates that vasectomy is a safe procedure in terms of both general and sexual health. Studies reporting an increased risk of prostatic cancer are open to methodological criticisms and further research is required to resolve this important issue. Vasectomy reversal is sought by ∼4% of men as a result of new relationships, the death of children or a change of heart. About one quarter of these couples will not achieve a natural pregnancy due to surgical difficulties and/or poor sperm quality. Infertility after vasectomy reversal is now a leading cause of iatrogenic infertility. Vasectomy must be regarded as a permanent procedure and should not be performed on young men (e.g.

Predicting surgical exploration in renal trauma: assessment and modification of an established nomogram.

BACKGROUND This study aimed to externally validate a previously described nomogram that predicts the need for renal exploration in the trauma setting. METHODS The predicted probability of nephrectomy was manually calculated using prospectively collected data from consecutive patients with renal trauma who presented to our institution between May 2001 and January 2010. To assess nomogram performance, receiver operating characteristic curves against the observed exploration rate were generated, and areas under the curve were calculated. Calibration curves were generated to assess performance across the range of predicted probabilities. Logistic regression modeling was used to determine clinical factors predicting exploration in a contemporary setting, and a nomogram was derived and internally validated using bootstrapping. RESULTS The established nomogram was applied to the 320 patients who presented during the 9-year period. The global performance of the established nomogram was very high, with an area under the curve of 0.95. However, the model performance was poor for higher predicted probabilities, thus lacking predictive ability in the population where the model has the greatest potential utility. A clinical tool was generated to better predict trauma nephrectomy in our contemporary population, using platelet transfusion within the first 24 hours, blood urea nitrogen, hemoglobin, and heart rate on admission. The global accuracy for the new model was similar to the previous nomogram, but it was significantly better calibrated for patients with higher probabilities of nephrectomy, with good predictive accuracy even in patients with Grade 5 injuries. CONCLUSION Older nomogram fails to accurately predict renal exploration in high-grade injuries in the contemporary setting. A new nomogram that more accurately predicts the need for exploration is presented. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level III.

Significant impact of transperineal template biopsy of the prostate at a single tertiary institution.

Objective: The objective was to review the impact of transperineal biopsy (TPB) at our institution by assessing rates of cancer detection/grading, treatment outcomes and complications. Patients and Methods: A retrospective review of TPBs between 2009 and 2013 was performed. Variables included reason for TPB, age, prostate-specific antigen, previous histology, TPB histology, and management outcomes. Results: In total, 110 patients underwent 111 TPBs at our institution. On average, 22 cores were taken from each procedure. Disease-upgrade occurred in 37.5% of active surveillance patients, 35% of patients with previous negative transrectal ultrasound, and 58.8% in patients undergoing TPB for other reasons. Of these patients, anterior and/or transition zones were involved in 66%, 79%, and 80%, respectively. Involvement in anterior and/or transition zones only occurred in 40%, 37%, and 10%, respectively. About 77% of patients with disease-upgrading underwent treatment with curative intent. Complications included a 6.3% rate of acute urinary retention and 2.7% of clot retention, with no episodes of urosepsis. Conclusions: Transperineal biopsy at our institution showed a high rate of disease-upgrading, with a large proportion involving anterior and transition zones. A significant amount of patients went on to receive curative treatment. TPB is a valuable diagnostic procedure with minimal risk of developing urosepsis. We believe TBP should be offered as an option for all repeat prostate biopsies and considered as an option for initial prostate biopsy.

Clinicopathological characteristics and management of prostate cancer in the human immunodeficiency virus (HIV)-positive population: experience in an Australian major HIV centre.

To characterise clinicopathological characteristics of prostate cancer among human immunodeficiency virus (HIV)‐positive men and to evaluate the current practice patterns in the management of prostate cancer in these men.