Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma.

CONTEXT: The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care. OBJECTIVE: To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma. EVIDENCE ACQUISITION: A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series. EVIDENCE SYNTHESIS: Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance. CONCLUSIONS: The guidelines provide an evidence-based approach for the management of urological trauma. PATIENT SUMMARY: Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review.

CONTEXT: The management of high-grade (Grade IV-V) renal injuries remains controversial. There has been an increase in the use of (NOM) but limited data exists comparing outcomes with open surgical exploration. OBJECTIVE: To conduct a systematic review to determine if NOM is the best first-line option for high-grade renal trauma in terms of safety and effectiveness. EVIDENCE ACQUISITION: Medline, Embase, and Cochrane Library were searched for all relevant publications, without time or language limitations. The primary harm outcome was overall mortality and the primary benefit outcome was renal preservation rate. Secondary outcomes included length of hospital stay and complication rate. Single-arm studies were included as there were few comparative studies. Only studies with more than 50 patients were included. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: Seven nonrandomised comparative and four single-arm studies were selected for data extraction. Seven hundred and eighty-seven patients were included from the comparative studies with 535 patients in the NOM group and 252 in the open surgical exploration group. A further 825 patients were included from single-arm studies. Results from comparative studies: overall mortality: NOM (0-3%), open surgical exploration (0-29%); renal preservation rate: NOM (84-100%), open surgical exploration (0-82%); complication rate: NOM (5-32%), open surgical exploration (10-76%). Overall mortality and renal preservation rate were significantly better in the NOM group whereas there was no statistical difference with regard to complication rate. Length of hospital stay was found be significantly reduced in the NOM group. Patients in the open surgical exploration group were more likely to have Grade V injuries, have a lower systolic blood pressure, and higher injury severity score on admission. CONCLUSIONS: No randomised controlled trials were identified and significant heterogeneity existed with regard to outcome reporting. However, NOM appeared to be safe and effective in a stable patient with a higher renal preservation rate, a shorter length of stay, and a comparable complication rate to open surgical exploration. Overall mortality was higher in the open surgical exploration group, though this was likely due to selection bias. PATIENT SUMMARY: The data of this systematic review suggest nonoperative management continues to be favoured to surgical exploration in the management of high-grade renal trauma whenever possible. However, comparisons between both interventions are difficult as patients who have surgery are often more seriously injured than those managed nonoperatively, and existing studies do not report on outcomes consistently.

Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel.

CONTEXT: The most recent European Association of Urology (EAU) guidelines on urologic trauma were published in 2014. OBJECTIVE: To present a summary of the 2014 version of the EAU guidelines on urologic trauma of the lower urinary tract with an emphasis on diagnosis and treatment. EVIDENCE ACQUISITION: The EAU Trauma Panel reviewed the English-language literature via a Medline search for lower urinary tract injury (LUTI) up to November 2013. The focus was on newer publications and reviews, although older key references could be included. EVIDENCE SYNTHESIS: A full version of the guidelines is available in print (EAU Guidelines 2014 edition, ISBN/EAN 978-90-79754-65-6) and online (www.uroweb.org). Blunt trauma is the main cause of LUTI. The preferred diagnostic modality for bladder and urethral injury is cystography and urethrography, respectively. In the treatment of bladder injuries, it is important to distinguish between extra- and intraperitoneal ruptures. Treatment of male anterior urethral injuries depends on the cause (blunt vs penetrating vs penile-fracture-related injury). Blunt posterior urethral injuries can be corrected by immediate/early endoscopic realignment. If this is not possible, such injuries are managed by suprapubic urinary diversion and deferred (>3 mo) urethroplasty. Treatment of female urethral injuries depends on the location of the injury and is usually surgical. CONCLUSIONS: Correct treatment of LUTIs is important to minimise long-term urinary symptoms and sexual dysfunction. This review performed by the EAU trauma panel summarises the current management of LUTIs. PATIENT SUMMARY: Patients with trauma to the lower urinary tract benefit from accurate diagnosis and appropriate treatment according to the nature and severity of their injury.

EAU guidelines on iatrogenic trauma.

CONTEXT: The European Association of Urology (EAU) Trauma Guidelines Panel presents an updated iatrogenic trauma section of their guidelines. Iatrogenic injuries are known complications of surgery to the urinary tract. Timely and adequate intervention is key to their management. OBJECTIVE: To assess the optimal evaluation and management of iatrogenic injuries and present an update of the iatrogenic section of the EAU Trauma Guidelines. EVIDENCE ACQUISITION: A systematic search of the literature was conducted, consulting Medline and the Cochrane Register of Systematic reviews. No time limitations were applied, although the focus was on more recent publications. EVIDENCE SYNTHESIS: The expert panel developed statements and recommendations. Statements were rated according to their level of evidence, and recommendations received a grade following a rating system modified from the Oxford Centre for Evidence-based Medicine. Currently, only limited high-powered studies are available addressing iatrogenic injuries. Because the reporting of complications or sequelae of interventions is now increasingly becoming a standard requirement, this situation will likely change in the future. CONCLUSIONS: This section of the trauma guidelines presents an updated overview of the treatment of iatrogenic trauma that will be incorporated in the trauma guidelines available at the EAU Web site (http://www. uroweb.org/guidelines/online-guidelines/).

Prospective comparative study of endoscopic management of bladder lithiasis: is prostate surgery a necessary adjunct?

OBJECTIVES: To present the results of a prospective study comparing transurethral cystolithotripsy and simultaneous transurethral resection of the prostate (TURP), with transurethral cystolithotripsy and medical treatment of benign prostatic hyperplasia. The traditional dogma that bladder lithiasis constitutes an absolute indication for prostatic surgery has recently been questioned. METHODS: A total of 64 patients with bladder calculi were included in the present study. In all patients, stone clearance was achieved transurethrally. The patients in group 1 (n=32) underwent TURP during the same session, and the patients in group 2 (n=32) underwent medical therapy for benign prostatic hyperplasia (tamsulosin plus finasteride). RESULTS: The mean follow-up was 28.23±8.84 months. No statistically significant differences were found between the 2 groups regarding the preoperative parameters (age, International Prostate Symptom Score, prostatic volume, peak urinary flow rate, postvoid residual urine volume, prostate-specific antigen level, and bladder stone characteristics). Both groups experienced statistically significant postoperative improvements in the International Prostate Symptom Score, peak urinary flow rate, and postvoid residual urine volume. However, patients in group 1 experienced a more pronounced improvement in the International Prostate Symptom Score (P=.02) and peak urinary flow rate (P=.001). In total, 11 patients in group 2 underwent TURP during follow-up, with medical management considered to have failed. Multivariate logistic regression analysis revealed the postvoid residual urine volume as an independent risk factor that predicted the need for TURP in group 2 patients (odds ratio 1.033, 95% CI for odds ratio 1.007-1.060, P=.014). CONCLUSIONS: The findings of the present study have provided useful information on the natural history of bladder lithiasis, particularly in the context of improved patient consultation.

EAU Guidelines on Urethral Trauma.

CONTEXT: These guidelines were prepared on behalf of the European Association of Urology (EAU) to assist urologists in the management of traumatic urethral injuries. OBJECTIVE: To determine the optimal evaluation and management of urethral injuries by review of the world's literature on the subject. EVIDENCE ACQUISITION: A working group of experts on Urological Trauma was convened to review and summarize the literature concerning the diagnosis and treatment of genitourinary trauma, including urethral trauma. The Urological Trauma guidelines have been based on a review of the literature identified using on-line searches of MEDLINE and other source documents published before 2009. A critical assessment of the findings was made, not involving a formal appraisal of the data. There were few high-powered, randomized, controlled trials in this area and considerable available data was provided by retrospective studies. The Working Group recognizes this limitation. EVIDENCE SYNTHESIS: The full text of these guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article comprises the abridged version of a section of the Urological Trauma guidelines. CONCLUSIONS: Updated and critically reviewed Guidelines on Urethral Trauma are presented. The aim of these guidelines is to provide support to the practicing urologist since urethral injuries carry substantial morbidity. The diversity of urethral injuries, associated injuries, the timing and availability of treatment options as well as their relative rarity contribute to the controversies in the management of urethral trauma.

Expression of transforming growth factor beta in renal cell carcinoma and matched non-involved renal tissue.

TGFbeta1 is one of several cytokines produced by proximal tubular and renal cancer cells. Previous studies have been mainly focused on determining plasma or serum TGFbeta levels, its effect on RCC cultures, and the expression of TGFbeta mRNA. Cancerous and autologous normal kidney samples were obtained from 24 patients treated by radical nephrectomy. TGFbeta1 expression was determined using a semi quantitative Western blot analysis and immunohistochemistry. Blot densities and immunohistochemical expression intensities in normal and neoplastic tissue were compared, and subsequently correlated to tumor stage, histological type and nuclear grade. All tissue samples examined expressed TGFbeta1; mean tumor to non-involved kidney spot density ratio correlated with advancing stage and higher nuclear grade. The overexpression of TGFbeta1 in certain RCCs may partially explain their resistance to the growth suppression action of TGFbeta. The correlation with tumor stage and grade indicates a possible role in the development of metastatic potential as well as in host's immune response modulation.