Predictors for adverse events following intravesical botulinum toxin injections in men.

INTRODUCTION: Intravesical botulinum toxin A (BTX-A) has been long established as treatment for overactive bladder and neurogenic bladder dysfunction. However, most published data are reported among a female cohort. Adverse events such as intermittent self-catheterization (ISC) and urinary tract infections (UTIs) play a large role in discontinuation of therapy. There is currently limited information regarding predictive factors to appropriately counsel male patients. MATERIALS AND METHODS: We retrospectively collected data on male patients undergoing their first intravesical BTX-A therapy from January 2016 to July 2021 in two high-volume centers. Data included demographics, past medical and surgical history, and urodynamic parameters. Patients were excluded if they had a long-term catheter or ISC before initiation of therapy. RESULTS: A total of 69 men were included in the study with a median age of 66 years. There were 18 patients with neurogenic bladder dysfunction. Thirty men had urge incontinence secondary to radical prostatectomy or bladder outflow surgery. Overall rates of ISC were 43.5%. Predictors for ISC included a baseline postvoid residual (PVR) ≥ 50 mL (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.36-13.03, p = 0.01), BTX-A dose >100 units (OR: 4.2, 95% CI: 1.36-13.0, p = 0.01). Stress urinary incontinence was protective against ISC (OR: 0.20, 95% CI: 0.04-1.00, p = 0.049) as well as history of prostatectomy/bladder outflow obstruction (BOO) surgery (OR: 0.16, 95% CI: 0.05-0.47, p < 0.001). A multivariable logistic regression model with these factors yielded a c-statistic of 0.80 (optimism-adjusted = 0.75). An enlarged prostate was the only predictor for UTI among our male cohort (OR: 8.0, 95% CI: 2.03-31.5, p = 0.003). CONCLUSIONS: This is the first study assessing risk factors of adverse events among men following BTX-A injection. High PVR and BTX-A dose of >100U were predictors of requiring ISC after BTX-A. Stress incontinence, previous radical prostatectomy, and BOO surgery were all protective against needing ISC post-BTX-A. An enlarged prostate was associated with development of UTI. These factors can be used to assist in counseling male patients regarding their risk of ISC and UTI.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE: To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection. METHODS: We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre. RESULTS: Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25). CONCLUSION: Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Intravesical onabotulinumtoxinA injections in patients on antiplatelet and anticoagulation therapy.

AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.

Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence.

PURPOSE: To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation. MATERIALS AND METHODS: A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation. RESULTS: One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations. CONCLUSION: Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.

Lessons Learned from a Decade of Investigations of Shiga Toxin-Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada.

Shiga toxin-producing Escherichia coli (STEC) cause substantial and costly illnesses. Leafy greens are the second most common source of foodborne STEC O157 outbreaks. We examined STEC outbreaks linked to leafy greens during 2009-2018 in the United States and Canada. We identified 40 outbreaks, 1,212 illnesses, 77 cases of hemolytic uremic syndrome, and 8 deaths. More outbreaks were linked to romaine lettuce (54%) than to any other type of leafy green. More outbreaks occurred in the fall (45%) and spring (28%) than in other seasons. Barriers in epidemiologic and traceback investigations complicated identification of the ultimate outbreak source. Research on the seasonality of leafy green outbreaks and vulnerability to STEC contamination and bacterial survival dynamics by leafy green type are warranted. Improvements in traceability of leafy greens are also needed. Federal and state health partners, researchers, the leafy green industry, and retailers can work together on interventions to reduce STEC contamination.

Listeria monocytogenes Associated with Pasteurized Chocolate Milk, Ontario, Canada.

In an investigation of a listeriosis outbreak in Ontario, Canada, during November 2015-June 2016, pasteurized chocolate milk was identified as the source. Because listeriosis outbreaks associated with pasteurized milk are rare in North America, these findings highlight that dairy products can be contaminated after pasteurization.

The use of urethral bulking injections in post-prostatectomy stress urinary incontinence: A narrative review of the literature.

AIMS: Post-prostatectomy stress urinary incontinence (PPI) is a common condition with significant impact on patient quality of life. With rising numbers of prostatectomies performed, recognition of incontinence during survivorship care is growing. With increasing hesitance of the use of suburethral mesh in females, urethral bulking injections in this patient population as a minimally invasive alternative to surgery are evaluated. This review aims to evaluate the existing evidence base for urethral bulking therapy in PPI and provide a summary of its efficacy, durability, and side-effect profile. METHODS: A literature search of Medline/Pubmed and Cochrane databases was conducted to identify publications reporting the clinical outcomes of urethral bulking injections in patients with PPI, up to and including October 1st, 2018. Case reports, letters and reviews were excluded. RESULTS: We identified 25 studies that fit our inclusion criteria, comprised of one RCT, two large retrospective cohort studies, and 22 case series. The success rates reported varying widely from 13%-100% with reports of symptomatic control deterioration. Complication rates remain low. This review highlighted a poor performance using the more historic bulking agents (BA), and the lack of strong evidence with the more novel BA in PPI and discussed challenges regarding optimal patient selection and techniques. CONCLUSIONS: There exists poor clinical evidence base concerning the use of urethral bulking in PPI with few high-level studies and a significant lack of consistency between studies. Further study in this area is required to evaluate the role of BA in this patient population.

Managing penetrating renal trauma: experience from two major trauma centres in the UK.

OBJECTIVES: To present our series of patients with penetrating renal trauma treated at two urban major trauma centres and to discuss the contemporary management of such injuries. METHODS: We reviewed prospective urological trauma databases for all patients presenting with penetrating renal trauma between January 2005 and October 2016. Patient demographics, clinical characteristics, imaging, management and follow-up data were analysed. RESULTS: Over the 11-year period, 63 patients presented with penetrating renal injuries. The vast majority of patients were male (n = 61; 96.8%), with a mean (range) age of 27.4 (14-71) years. Injuries were equally common on either side (31 left, 32 right). The most common mechanism of injury was stabbing (n = 55; 87.3%), followed by gunshot (n = 7; 11.1%) and crossbow injuries (n = 1; 1.6%). All patients underwent contrast-enhanced computed tomography. Using the American Association for the Surgery of Trauma renal injury grading system, 11 (17.5%) had grade II, 26 (41.3%) had grade III and 26 (41.3%) had grade IV injury. The most common associated injuries were thoracic (n = 23; 36.5%), liver (n = 11; 17.5%), splenic (n = 10; 15.9%), gastrointestinal tract (n = 8; 12.7%) and musculoskeletal (n = 6; 9.5%). At presentation, 16 patients (25.4%) were haemodynamically unstable. The majority of patients did not require blood transfusion (n = 56; 88.9%), while transfusion of >5 units was rare (n = 4; 6.3%). Fifty-two patients (82.5%) were managed by observation alone, while 10 (15.9%) underwent emergency angiography and embolization. Patients with grade IV injury were more likely to require embolization than those with grade III injury; however, the difference was not significant (26.9% vs 15.4%; P = 0.29). One patient (1.6%) underwent retroperitoneal exploration of their renal injury and was managed conservatively. Eight patients underwent laparotomy for other visceral injuries while their renal injury was managed conservatively. Renal artery pseudoaneurysm developed in five patients (7.9%) and one patient (1.6%) developed renal arteriovenous malformation. No patients underwent nephrectomy and no mortality was reported. CONCLUSIONS: The vast majority of patients with penetrating renal injuries can be safely managed non-operatively in this setting. Selective renal artery embolization is an effective option for patients in an unstable condition, with excellent outcomes. Associated thoracic or visceral injuries requiring operative management are common in penetrating renal trauma, while urologists should limit or have a high threshold for surgical intervention.

A study into the association between local recurrence rates and surgical resection margins in organ-sparing surgery for penile squamous cell cancer.

OBJECTIVE: To evaluate the significance of close surgical margins in organ-sparing surgery (OSS) in the treatment of penile squamous cell carcinoma (pSCC) and clinicopathological factors that may influence local recurrence. PATIENTS AND METHODS: At our tertiary referral centre, between March 2001 and September 2012, 332 patients treated with OSS for pSCC had clear surgical margins. As the focus was the impact of close clear margins on local recurrence, patients with positive margins were excluded for the purpose of this study. Our overall positive margin rate for OSS in penile cancer is 7.6% (42 patients). Analysis was carried out on an on-going prospective database, including prospective accurate pathological recording of surgical margins. Patients underwent OSS after multidisciplinary team (MDT) discussion. Local recurrence was the primary outcome measured and Fisher's exact test and time-to-recurrence curves were used in the analysis. All local recurrences were scrutinised by the MDT and were categorised into: true recurrences or metachronous new occurrences (i.e. tumours arising from a background of penile intraepithelial neoplasia and forming on an epithelial surface not related to the site of initial resection). A multivariate analysis was also conducted to elucidate other factors influencing local recurrence. RESULTS: In all, 64% of the patients had a <5 mm clear deep surgical margin, with 16% clear by <1 mm. Overall, 4% of patients had a true local recurrence, with a median time to recurrence of 6 months. In all, 53% were due to embolic spread, with residual occult local disease accounting for 47%. There was a statistically significant relationship between cavernosal involvement (P = 0.014) and lymphovascular invasion (LVI; P = 0.001) and local recurrence. Although multivariate analysis revealed that the extent of clear margin was not a predictor of disease (P = 0.405), we found an increased risk of local recurrence in the clear margin cohort of <1 mm compared to those of >1 mm (P < 0.001). Those patients considered to have metachronous tumours were scrutinised by our MDT, and eight patients (2.4%) were found to have new occurrences. Our overall proportion of patients therefore needing further treatment for either new occurrences or recurrent disease after OSS stands at 6.4%. CONCLUSIONS: Overall the presence of local recurrent disease in OSS in our experience is low (4%). We report an embolic mechanism of local recurrence, strongly suggested by the presence of cavernosal involvement and LVI. We conclude that a deep clear margin of >1 mm has a very low risk of local recurrence in penile OSS.

Outbreak of Vibrio parahaemolyticus Associated with Consumption of Raw Oysters in Canada, 2015.

There has been a steady increase in illness incidence of Vibrio parahaemolyticus (Vp). The majority of illnesses are associated with consumption of raw oysters. In the summer of 2015, Canada experienced the largest outbreak associated with the consumption of raw oysters harvested from British Columbia (BC) coastal waters. Case investigation of laboratory-confirmed cases was conducted to collect information on exposures and to assist traceback. Investigations at processors and oyster sampling were conducted. Eighty-two laboratory-confirmed cases of Vp infection were reported between January 1 and October 26, 2015. The majority of the cases were reported in BC, associated with consumption of raw BC oysters in restaurants. Sea surface temperatures were above the historical levels in 2015. This outbreak identified the need to improve surveillance and response to increases in human cases of Vp. This is of particular importance due to the potential for increasing water temperatures and the likelihood of additional outbreaks of Vibrio.

Multi-Province Listeriosis Outbreak Linked to Contaminated Deli Meat Consumed Primarily in Institutional Settings, Canada, 2008.

A multi-province outbreak of listeriosis occurred in Canada from June to November 2008. Fifty-seven persons were infected with 1 of 3 similar outbreak strains defined by pulsed-field gel electrophoresis, and 24 (42%) individuals died. Forty-one (72%) of 57 individuals were residents of long-term care facilities or hospital inpatients during their exposure period. Descriptive epidemiology, product traceback, and detection of the outbreak strains of Listeria monocytogenes in food samples and the plant environment confirmed delicatessen meat manufactured by one establishment and purchased primarily by institutions was the source of the outbreak. The food safety investigation identified a plant environment conducive to the introduction and proliferation of L. monocytogenes and persistently contaminated with Listeria spp. This outbreak demonstrated the need for improved listeriosis surveillance, strict control of L. monocytogenes in establishments producing ready-to-eat foods, and advice to vulnerable populations and institutions serving these populations regarding which high-risk foods to avoid.

The management of genitourinary war injuries: a multidisciplinary consensus.

Genitourinary injuries as a result of current warfare may be severe and result in significant long term morbidity. There is no high quality evidence to guide management and the logistics involved require the development of bespoke management strategies. The multidisciplinary Genitourinary Working Group (Trauma) has the remit of leading this service, primarily addressing the management of casualties in the medical evacuation chain of the Defence Medical Services of the UK. The recommendations made are based mainly upon expert opinion and are intended to provide guidance to the deploying surgeon and the teams that manage these casualties thereafter.

Immediate surgical management of combat-related injury to the external genitalia.

Patterns of survivable injury after combat injury have changed during recent years as wounding mechanisms have altered, ballistic protection has improved and the military chain of trauma care has evolved. Combat casualties now survive injuries that would have been fatal in previous wars and service personnel can be left with injuries that have significantly detrimental effects on their quality of life. Severe, destructive injuries to the external genitalia are rarely life-threatening, but can be profoundly life altering and the immediate management of these injuries deserves special scrutiny. The general principles of haemorrhage control, wound debridement, urinary diversion, and organ preservation should be observed. An up-to-date review of the management of these relative rare injuries is based on recent, albeit scanty literature and the experiences of managing casualties in the medical evacuation chain of the United Kingdom Defence Medical Services. The rationale behind the current emphasis on post-injury fertility preservation is also discussed.

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.

Haematuria in Sport: A Review.

CONTEXT: Haematuria is a common urological presentation associated with patient anxiety and clinically relevant underlying pathology. However, the prevalence and pathophysiology of haematuria following sporting exercise is less well documented. OBJECTIVES: This review paper seeks to clarify the prevalence of microscopic and macroscopic haematuria in association with sporting exercise reported in the literature, and the pathophysiology behind it. We review the relation of haematuria to injury to the urinary tract in sport, as well as the incidence of underlying disease, urological and incidental, following investigation for exercise-induced haematuria. EVIDENCE ACQUISITION: A non-systematic literature review was conducted of articles and studies using the Pubmed database. Articles were selected with preference for the highest level of evidence available, with relevant data extracted, analysed, and summarised. Supplementary information was collected by cross-referencing the reference lists. EVIDENCE SYNTHESIS: Multiple studies have shown that clinically significant haematuria is common after exercise. Physiological changes occurring during exercise result in increased glomerular permeability and microscopic haematuria in up to 95% of cases. The degree of haematuria is related to the intensity of the exercise. However, participating in contact sports increases the risk of macroscopic haematuria. Red cell haemolysis and rhabdomyolysis also play a role in urine discolouration following exercise and can be present in 30%. Haematuria following exercise-related trauma is regarded an important indication for further urological investigation. Haematuria may be absent in 44% of cases of urological injury. Renal trauma accounts for 80% of urological trauma, with 30% of these being due to sporting activity. Incidental findings on computed tomography for haematuria are common, with 50% showing positive extraurinary findings. Incidental malignancy, however, is rare. CONCLUSIONS: Haematuria is common following exercise and results from physiological changes and contact-related trauma to the urinary tract. All cases of haematuria should be investigated as underlying trauma and extraurinary disease are common incidental findings on investigation. PATIENT SUMMARY: Blood in the urine following exercise is a common phenomenon and occurs due to vascular responses to sports and trauma as well as blood and muscle cell breakdown. Although it may not be present in all cases of trauma, blood in the urine should be investigated due to the risk of discovering underlying injury to the urinary tract and other incidental findings.

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.

Outbreak of Escherichia coli O157:H7 Infections Linked to Aged Raw Milk Gouda Cheese, Canada, 2013.

Between 12 July and 29 September 2013, 29 individuals in five Canadian provinces became ill following infection with the same strain of Escherichia coli O157:H7 as defined by molecular typing results. Five case patients were hospitalized, and one died. Twenty-six case patients (90%) reported eating Gouda cheese originating from a dairy plant in British Columbia. All of the 22 case patients with sufficient product details available reported consuming Gouda cheese made with raw milk; this cheese had been produced between March and July 2013 and was aged for a minimum of 60 days. The outbreak strain was isolated from the implicated Gouda cheese, including one core sample obtained from an intact cheese wheel 83 days after production. The findings indicate that raw milk was the primary source of the E. coli O157:H7, which persisted through production and the minimum 60-day aging period. This outbreak is the third caused by E. coli O157:H7 traced to Gouda cheese made with raw milk in North America. These findings provide further evidence that a 60-day ripening period cannot ensure die-off of pathogens that might be present in raw milk Gouda cheese after production and have triggered an evaluation of processing conditions, physicochemical parameters, and options to mitigate the risk of E. coli O157:H7 infection associated with raw milk Gouda cheese produced in Canada.

Outcomes of Early Endoscopic Realignment Versus Suprapubic Cystostomy and Delayed Urethroplasty for Pelvic Fracture-related Posterior Urethral Injuries: A Systematic Review.

CONTEXT: The evidence base for optimal acute management of pelvic fracture-related posterior urethral injuries needs to be reviewed because of evolving endoscopic techniques. The current standard of care is suprapubic cystostomy followed by delayed urethroplasty. OBJECTIVE: To systematically review the evidence base comparing early endoscopic realignment with cystostomy and delayed urethroplasty regarding stricture rate, the need for subsequent procedures, and functional outcomes. EVIDENCE ACQUISITION: A systematic search in Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Review, and www.clinicaltrials.gov without time or language limitations. Both medical subject heading and free text terms as well as variations of root word were searched. Randomised controlled trials (RCTs), nonrandomised comparative studies and single-arm case series were included, as long as ≥10 patients were enrolled. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: No RCTs were found. Six nonrandomised comparative studies and met inclusion criteria and were selected for data extraction. Noncomparative studies with more than 10 participants were included resulting in seven eligible studies. From the comparative papers the results of 219 patients were reported: 142 in the realignment group and 77 in the group undergoing cystostomy with delayed repair. The noncomparative studies reported on a further 150 cases. An overall stricture rate of 49% was evident in the endoscopic realignment group. Of these patients, 50% (28.1% overall) could be managed by endoscopic procedures and 40.3% (18.5% of intervention group) required anastomotic repair. CONCLUSIONS: No RCTs were found and the included nonrandomised studies have heterogeneous populations and a high degree of bias. About half of the patients were free of stricture and thus did not undergo delayed urethroplasty in case early endoscopic realignment had been performed. PATIENT SUMMARY: This systematic review of literature of urethral trauma revealed there are no well conducted comparative studies of newer endoscopic treatments versus standard treatments which include more extensive surgery. The results of the reports we selected based on specific characteristics are often influenced by variable factors. After careful analysis of these results we can conclude that the newer endoscopic techniques might resolve the risk of urethral injury due to pubic fractures in about half of the patients. Because of various confounders we cannot identify those patients who would benefit from this procedure or who might be possibly harmed.