Survival and quality of life outcomes of high-intensity focused ultrasound treatment of localized prostate cancer.

BACKGROUND: To evaluate the survival and quality of life (QoL) outcomes of high-intensity focused ultrasound (HIFU) whole-gland ablation for localized prostate cancer. METHODS: Over 8 years, men with localized prostate cancer treated with whole-gland HIFU were prospectively followed. Transrectal prostate ablation was performed under general anesthesia with Sonablate-500® (Sonacare Medical©, Charlotte, North Carolina, USA). The primary outcome was failure-free survival defined as no transition to any of the following: (1) local salvage therapy (surgery or radiotherapy), (2) systemic therapy, (3) metastases, or (4) prostate cancer-specific mortality. Secondary outcomes included both survival outcomes and QoL measures. RESULTS: Of 70 men, 29.7% had International Society of Urological Pathology (ISUP) grade 1, 43.8% ISUP 2, 10.9% ISUP 3, and 15.6% ISUP 4 disease. At median follow-up of 83.4 months, overall mortality was 8.6% and prostate cancer-specific mortality 0%. Failure-free survival was 78.2% at 5 years and 71.2% at 7 years. Of all men, 7.1% of men developed metastases, with median metastasis-free survival of 75.4 months. There was negligible post-HIFU urinary incontinence or lower urinary tract symptom with a median Male Urogenital Distress Inventory score of 32 at 6 months and 33 at 12 months and median IPSS of 4 at 6 months and 3 at 12 months. Median Radiation Therapy Oncology Group rectal toxicity score was 0 throughout. In men who had mild or no erectile dysfunction at baseline (International Index of Erectile Function ≥17), the mean International Index of Erectile Function score declined to 37% from 23.5 at baseline to 14.7 at 12 months. CONCLUSION: At median follow-up of 7 years, whole-gland HIFU appears to have comparable survival outcomes with other cohort studies involving radical prostatectomy and radiotherapy patient. It has low impact on QoL, preserved urinary continence, and erectile function approximate to nerve-sparing prostatectomy. Whole-gland HIFU presents a potential alternative minimally invasive and safe option for the treatment of localized prostate cancer.

Lower risk of pelvic metalware infection with operative repair of concurrent bladder rupture.

BACKGROUND: Patients with traumatic bladder rupture frequently have associated pelvic fracture. With increasing numbers of pelvic fractures fixed internally, there are concerns that conservative management of bladder rupture may increase the risk of pelvic metalware infection. This study aims to determine if operative repair of bladder rupture in comparison to conservative management with catheter drainage alone is associated with a lower rate of infection of internal fixation device for concurrent pelvic fracture. METHODS: This is a retrospective cohort study of level IV evidence. From July 2001 through June 2013, 45 multi-trauma patients at a level 1 trauma centre were identified to have sustained bladder rupture with concurrent pelvic fracture requiring internal fixation. Clinicopathological data were extracted from the TraumaNET database, medical records and health-coding database. Patients were stratified into two retrospective cohorts, management with surgical repair and management with catheter drainage alone. Fischer's exact test was used to determine whether the rate of pelvic metalware infection was different in the two cohorts. RESULTS: Of the 45 patients, 13 had intraperitoneal bladder rupture, 28 had extraperitoneal bladder rupture and four had combined intra-extraperitoneal bladder rupture. The median age for this cohort was 31. Bladder rupture was surgically repaired in 36 patients and managed conservatively with catheter drainage in nine patients. The rate of pelvic internal fixation device infection was lower in patients managed with surgical repair compared with conservative management (5.6% versus 33.3%, P = 0.047). CONCLUSION: Operative repair of bladder rupture is associated with a lower rate of pelvic orthopaedic hardware infection in the presence of concurrent pelvic fracture requiring internal fixation.

HIV and renal cell carcinoma: Experience in an Australian statewide HIV center.

AIM: To report on the presentation, management and outcomes of renal cell carcinoma (RCC) among people with human immunodeficiency virus (HIV). METHODS: We retrospectively reviewed patients with HIV and RCC in a statewide HIV referral center in Australia. Patients' medical records were reviewed to collect data on the HIV parameters at the time of RCC diagnosis, as well as presentation, management and outcomes of RCC. RESULTS: Seven patients with HIV and RCC were included in the current study. The median age at RCC diagnosis was 56 years (range: 44-62 years). At RCC diagnosis, six patients were on combination antiretroviral therapy (ART), and five had virological suppression. Three patients were symptomatic at presentation, while the rest were diagnosed incidentally. Two patients had metastatic RCC at diagnosis. All five patients with clinically localized RCC had radical/partial nephrectomies, of which two patients with pT3a disease developed recurrence (pulmonary and bone) at 5 and 30 months postnephrectomies. One patient with metastatic RCC was treated with vascular endothelial growth factor (VEGF) inhibitors while continuing on ART. Four patients died of RCC at a median of 9 months (range: 4-16 months) following diagnosis of metastatic disease. Three patients were alive at a median follow-up of 16 months (range: 10-80 months). CONCLUSION: Our experience suggests that patients with HIV should be offered all treatment options in the same manner as the general population, taking into account their prognosis from HIV. Curative surgery should be considered for localized RCC. Potential drug interactions between ART drugs and targeted therapies for metastatic RCC need to be considered.

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.

OBJECTIVES: 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. PATIENTS AND METHODS: We retrospectively reviewed all patients with HIV in the State-wide HIV referral centre in Victoria, who were diagnosed with prostate cancer from 2000 onwards. In all, 12 patients were identified, and the medical records were reviewed to collect data on HIV parameters at the time of prostate cancer diagnosis, as well as prostate cancer clinicopathological characteristics, treatment details and outcomes. RESULTS: At the time of prostate cancer diagnosis, eight patients had undetectable viral load, and the median cluster of differentiation 4 (CD4) count was 485 cells/µL. The average age at diagnosis of prostate cancer was 63 years and the median prostate-specific antigen (PSA) level of 11.1 ng/mL. Four patients had Gleason 6 prostate cancer, four Gleason 7, one Gleason 8 and three Gleason 9. Seven of the 12 patients had a positive family history for prostate cancer. Of the patients with clinically localised prostate cancer (10), most were treated with radiotherapy (RT): one permanent seed brachytherapy (BT), five external beam RT (EBRT), two open radical prostatectomies (RP), one active surveillance (AS), and one on watchful waiting (WW). For the two patients with metastatic disease, one had androgen-deprivation therapy and EBRT, while the other had a combination of EBRT and chemo-hormonal therapy with doxetacel. All patients were followed for a median of 46 months, with three deaths reported, none of which was a prostate cancer-specific death. CONCLUSIONS: This is the first Australasian series on prostate cancer management in a HIV population. With the prolonged survival among HIV-positive men in the highly active anti-retroviral therapy era, PSA testing should be offered to this group of patients, especially those with a positive family history. HIV-positive men should also be offered all treatment options in the same manner as men in the general population.

Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate--A Single Institution Experience.

PURPOSE: To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications. PATIENTS AND METHODS: Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables). RESULTS: There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17%; P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients. CONCLUSION: Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.

A Whole of Population, Multiuser Series of High-Intensity Focused Ultrasound for Management of Localized Prostate Cancer: Outcomes and Implications.

PURPOSE: To determine the oncologic and complication outcomes of treatment of patients with localized prostate cancer by high intensity focused ultrasound (HIFU) for primary management of prostate cancer in a whole of population, multiuser series. PATIENTS AND METHODS: We created a centralized database-accessible only by nonurologist researchers-within a cancer epidemiology center, after ethics approval from that institution. A single researcher prospectively entered baseline, treatment, and clinical/biochemical follow-up data from all patients treated with HIFU in the state of Victoria over the study period. RESULTS: We accrued 108 patients, of whom 103 had been staged as having clinically localized disease. Ninety-three patients (86.1%) had low- or intermediate-risk prostate cancer. Forty-four patients (40.5%) had persistent mild urinary incontinence at 3 months after treatment, and 3 of these ultimately underwent further surgical procedures to correct incontinence. Twenty-seven patients (25%) additionally experienced occasions of urinary retention in the first 3 months after treatment because of passage of tissue. Twenty-nine patients had achieved a prostate-specific antigen level of <0.2 ng/mL at 3 months after HIFU. Fifty-six patients underwent post-HIFU prostate biopsy, and this was positive for residual cancer in 51 cases. Forty-five of the patients who had a positive post-HIFU biopsy underwent secondary treatment for prostate cancer. CONCLUSION: Oncologic control and complication outcomes in this cohort were inferior to those previously reported for HIFU in single-user series. Given the population-based multiuser nature of our series, we believe our observations are more likely to reflect the community outcomes that might be expected from widespread adoption of HIFU than generalizing from single-operator series.

In vivo characterization and numerical simulation of prostate properties for non-thermal irreversible electroporation ablation.

BACKGROUND: Irreversible electroporation (IRE) delivers brief electric pulses to attain non-thermal focal ablation that spares vasculature and other sensitive systems. It is a promising prostate cancer treatment due to sparing of the tissues associated with morbidity risk from conventional therapies. IRE effects depend on electric field strength and tissue properties. These characteristics are organ-dependent, affecting IRE treatment outcomes. This study characterizes the relevant properties to improve treatment planning and outcome predictions for IRE prostate cancer treatment. METHODS: Clinically relevant IRE pulse protocols were delivered to a healthy canine and two human cancerous prostates while measuring electrical parameters to determine tissue characteristics for predictive treatment simulations. Prostates were resected 5 hr, 3 weeks, and 4 weeks post-IRE. Lesions were correlated with numerical simulations to determine an effective prostate lethal IRE electric field threshold. RESULTS: Lesions were produced in all subjects. Tissue electrical conductivity increased from 0.284 to 0.927 S/m due to IRE pulses. Numerical simulations show an average effective prostate electric field threshold of 1072 ± 119 V/cm, significantly higher than previously characterized tissues. Histological findings in the human cases show instances of complete tissue necrosis centrally with variable tissue effects beyond the margin. CONCLUSIONS: Preliminary experimental IRE trials safely ablated healthy canine and cancerous human prostates, as examined in the short- and medium-term. IRE-relevant prostate properties are now experimentally and numerically defined. Importantly, the electric field required to kill healthy prostate tissue is substantially higher than previously characterized tissues. These findings can be applied to optimize IRE prostate cancer treatment protocols.

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.

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

OBJECTIVE: 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. PATIENTS AND METHODS: We analysed 338 patients with renal injuries who presented to our institution over a 9-year period. Data on demographics, clinical presentation, management and complications were recorded. RESULTS: Males comprised 74.9% of patients with renal injuries and the highest incidence was amongst those aged 20-24 years. Blunt injuries comprised 96.2% (n = 325) of all the renal injuries, with road trauma being the predominant mechanism accounting for 72.5% of injuries. The distribution of injury grade was; 21.6% grade 1 (n = 73), 24.3% grade 2 (n = 82), 24.9% grade 3 (n = 84), 16.6% grade 4 (n = 56), and 12.7% grade 5 (n = 43). Conservative management was successful in all grade 1 and 2 renal injuries, and 94.9%, 90.7% and 35.1% of grade 3, 4 and 5 injuries respectively. All but one of the 13 patients with penetrating injuries were successfully managed conservatively. CONCLUSIONS: Road trauma is the greatest cause of renal injury. Most haemodynamically stable patients are successfully managed conservatively.

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

OBJECTIVE: • To examine the effect of oral anticoagulation (OA) on the prevalence and inpatient management of haematuria in a contemporary Australian patient cohort. PATIENTS AND METHODS: • Patients across all inpatient units who had diagnosis-related group (DRG) coding for haematuria were identified from April 2010 to September 2011. • A retrospective chart review was performed to identify the type of anticoagulation (if any), requirement for bladder irrigation or blood transfusion, length of stay (LOS) and cause of haematuria. • Patients for whom the anticoagulation status was uncertain were excluded from analysis. • Statistical significance was determined by Pearson's chi-square tests and Student's t-tests. RESULTS: • In all, 335 admissions with DRG coding for haematuria were identified from hospital records, of which 268 admissions had clear documentation of anticoagulation. There were 118 emergency admissions and 150 elective admissions for day case cystoscopy. The mean age of the patients was 66 years and the male:female ratio was 5:1. In all, 123 admissions were for patients on some form of anticoagulation (46%). • Patients were on anticoagulation in 53% of the 118 emergency admissions for gross haematuria. These comprised patients on aspirin (28%), clopidogrel (4%), warfarin (10%), combined aspirin and warfarin (1%) and combined aspirin and clopidogrel (10%). • The use of OA was a significant predictor of the need for intervention among the 118 emergency admissions (86% vs 62%, P = 0.003). • In particular, dual antiplatelet therapy in the form of aspirin and clopidogrel was associated with an increased requirement for bladder irrigation (92%) when compared with patients on other forms of anticoagulation (84%) or none at all (62%, P = 0.01). • The mean LOS for patients admitted to hospital with haematuria was 5.6 days. Patients on warfarin had a statistically significant longer LOS than the other groups (13.7 vs 4.5 days, P < 0.001). A cause for haematuria was identified in 120 of the 234 patients (51%). Of these, the most common was benign prostatic hyperplasia (21%), followed by bladder urothelial carcinoma (17%). CONCLUSION: • In our cohort of patients, about half of all admissions with haematuria were for patients on some form of OA. • OA use increased the need for intervention, especially for patients on dual antiplatelet therapy.

Lower urinary tract injuries following blunt trauma: a review of contemporary management.

Lower urinary tract trauma, although relatively uncommon in blunt trauma, can lead to significant morbidity when diagnosed late or left untreated; urologists may only encounter a handful of these injuries in their career. This article reviews the literature and reports on the management of these injuries, highlighting the issues facing clinicians in this subspecialty. Also presented is a structured review detailing the mechanisms, classification, diagnosis, management, and complications of blunt trauma to the bladder and urethra. The prognosis for bladder rupture is excellent when treated. Significant intraperitoneal rupture or involvement of the bladder neck mandates surgical repair, whereas smaller extraperitoneal lacerations may be managed with catheterization alone. With the push for management of trauma patients in larger centers, urologists in these hospitals are seeing increasing numbers of lower urinary tract injuries. Prospective analysis may be achieved in these centers to address the current lack of Level 1 evidence.

Incidentally detected small renal masses - investigation and management.

BACKGROUND: With increasing use of imaging to diagnose other conditions, incidentally detected small renal masses and cysts are now a common clinical scenario for both the general practitioner and the urologist. OBJECTIVE: This article outlines a diagnostic and management approach to the incidental finding of a small renal mass or cyst. DISCUSSION: Renal cell carcinoma represent 2-3% of all cancers and more than 50% of these are detected incidentally. Small renal masses are defined as renal masses less than 4 cm in diameter. They comprise a heterogeneous group of lesions; 20% are benign and only 20-25% prove to be potentially aggressive kidney cancers at the time of diagnosis. Work-up involves a full history, looking for evidence of paraneoplastic syndromes and examination, which is usually normal. Recommended blood tests include basic biochemistry and haematology, and imaging. A four phase contrasted computerised tomography scan of the kidneys allows a detailed examination of each aspect of the functional anatomy of the kidney, which can help approximate risk of malignancy and direct management. Not all patients with small renal masses require a biopsy. However, biopsy is required in patients who opt for active surveillance or ablative therapy. Management options include surveillance, surgery and ablative techniques.

Contemporary management of renal trauma.

In the management of renal trauma, surgical exploration inevitably leads to nephrectomy in all but a few specialized centers. With current management options, the majority of hemodynamically stable patients with renal injuries can be successfully managed nonoperatively. Improved radiographic techniques and the development of a validated renal injury scoring system have led to improved staging of injury severity that is relatively easy to monitor. This article reviews a multidisciplinary approach to facilitate the care of patients with renal injury.

Prostate-specific antigen bounce after permanent iodine-125 prostate brachytherapy--an Australian analysis.

PURPOSE: To report on prostate-specific antigen (PSA) "bounces" after (125)I prostate brachytherapy to review the relationship to biochemical control and correlate both clinical and dosimetric variables. METHODS AND MATERIALS: We analyzed 194 hormone-naive patients with a follow-up of ≥ 3 years. Four bounce definitions were applied: an increase of ≥ 0.2 ng/mL (definition I), ≥ 0.4 ng/mL (definition II), ≥ 15% (definition III), and ≥ 35% (definition IV) of a previous value with spontaneous return to the prebounce level or lower. RESULTS: Using definition I, II, III, and IV, a bounce was detected in 50%, 34%, 11%, and 9% of patients, respectively. The median time to onset was 14-16 months, the duration was 12-21.5 months, and the magnitude of the increase was 0.5-2 ng/mL. A magnitude of >2 ng/mL, fulfilling the criteria for biochemical failure (BF) according to the American Society for Therapeutic Radiology and Oncology Phoenix definition, was detected in 11.3%, 16.9%, 47.6%, and 50% using definitions I, II, III, and IV, respectively; 11 patients (5.7%) had true BF. The PSA bounces occurred earlier than BF (p < 0.001). The prediction of BF remains controversial and is probably unrelated to biochemical control. The only statistically significant factor predictive of a PSA bounce was younger age (definitions I and II). CONCLUSION: PSA bounces are common after brachytherapy. All definitions resulted in a high number of false-positive calls for BF during the first 2 years. The definition of an increase of ≥ 0.2 ng/mL should be preferred because of the lowest number of false-positive results for BF. Patients experiencing a PSA bounce during the first 2 years after brachytherapy should undergo surveillance every 3-6 months. Additional investigations are recommended for elevated postimplant PSA levels that have not corrected by 3 years of follow-up.

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.

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.

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%.

Factors predicting for urinary morbidity following 125iodine transperineal prostate brachytherapy.

PURPOSE: To assess factors related to the risk of acute urinary retention and other morbidity indices in patients undergoing transperineal seed implantation of the prostate. MATERIALS AND METHODS: One hundred and seventy-three consecutive patients treated with (125)Iodine transperineal interstitial permanent prostate brachytherapy (TIPPB) were evaluated. Various demographic, pathological, symptomatic, urodynamic and dosimetric values were assessed in relation to the incidence of acute urinary retention as well as the International Prostate Symptom Score (IPSS) dynamics. Patients were routinely placed on alpha-blockade postimplant. Dosimetry was based on CT scan one month postimplant. RESULTS: Acute urinary retention developed in thirty-four patients (19.7%), at a median time of four days. Peak urinary flow rate was the only independent factor which varied significantly between those suffering retention and those not (median of 16 and 19.5 ml/s respectively, P=0.005). Median preimplant IPSS was 4.0, with a median peak of 16 at 3 months. Actuarial median time to return to baseline IPSS was at 15 months. The peak IPSS above preimplant levels was correlated significantly in multivariate analysis with the number of seeds implanted superior to the physician-nominated anatomical base level of the prostate (P<0.009), as well as lower preimplant IPSS values. CONCLUSIONS: In our series, preimplant urinary flow rate was the most important factor predictive of postimplant acute urinary retention. The patients' risk of having heightened IPSS change following implantation was correlated to a lower preimplant IPSS and an increased number of seeds implanted above the level of the prostatic base, possibly reflecting bladder base rather than urethral irritation in the development of acute urinary morbidity.