Nurse-led coordinated surgical care pathways for cost optimization of robotic-assisted partial nephrectomy: medico-economic analysis of the UroCCR-25 AMBU-REIN study.

PURPOSE: Robot-assisted partial nephrectomy (RAPN) reduces morbidity, enabling development of Enhanced Recovery After Surgery (ERAS) and day-case protocols. Additional financial costs limit its integration into clinical practice. We evaluated the medico-economic impact of RAPN using a nurse-led coordinated pathway of care (NLC-RAPN). METHODS: All tumor RAPNs performed in 2017 were prospectively included in nurse-led protocols: NP-RAAC (ERAS) or Ambu-Rein (day case). Clinico-biological and pathological data were prospectively collected within the French Research Network for Kidney Cancer database (NCT03293563). Estimated costs were compared to "average" patients at the national level operated by open partial nephrectomy (OPN) or RAPN, using data from the 2017 French hospital discharge database and the national cost scale. RESULTS: The NLC-RAPN cohort (n = 151) included 27 (18%) outpatients and the average hospital length of stay (LOS) was 2.4 days. In the national control cohorts for OPN (n = 2475) and RAPN (n = 3529), the average LOS were 8.0 and 5.2 days, respectively. The mean incomes per group were €7607 for NLC-RAPN, €9813 for OPN, and €8215 for RAPN. The mean daily cost of stay was €659 for NLC-RAPN, €838 for OPN, and €725 for RAPN. The overall cost for NLC-RAPN was €6594, €8733 for OPN, and €8763 for RAPN. The best operational margin was obtained for day-case NLC-RAPN (€1967). CONCLUSION: Combining RAPN with nurse-led coordinated pathways of care led to a shorter hospital stay and reduced costs versus OPN. This may facilitate the economic sustainability of robotic assistance for hospitals where the extra cost is not covered by the healthcare system.

3D-Image guided robotic-assisted partial nephrectomy: a multi-institutional propensity score-matched analysis (UroCCR study 51).

PURPOSE: Robot-assisted partial nephrectomy (RAPN) is a difficult procedure with risk of significant perioperative complications. The objective was to evaluate the impact of preoperative planning and intraoperative guidance with 3D model reconstructions on perioperative outcomes of RAPN. METHODS: We conducted a retrospective analysis of all patients who underwent RAPN for kidney tumor by three high-volume expert surgeons from academic centers. Clinical data were collected prospectively after written consent into the French kidney cancer network database UroCCR (CNIL-DR 2013-206; NCT03293563). Our cohort was divided into two groups: 3D-Image guided RAPN group (3D-IGRAPN) and control group. A propensity score according to age, pre-operative renal function and RENAL tumor complexity score was used. Both surgical techniques were compared in terms of perioperative outcomes. RESULTS: The initial study cohort included 230 3D-IGRAPN and 415 control RAPN. Before propensity-score matching, patients in the 3D-IGRAPN group had a larger tumor (4.3 cm vs. 3.5 cm, P < 0.001) and higher RENAL complexity score (9 vs. 8, P < 0.001). Following propensity-score matching, there were 157 patients in both groups. The rate of major complications was lower for patients in the 3D-IGRAPN group (3.8% vs. 9.5%, P = 0.04). The median percentage of eGFR variation recorded at first follow-up was lower in the 3D-IGRAPN group (- 5.6% vs. - 10.5%, P = 0.002). The trifecta achievement rate was higher in the 3D-IGRAPN group (55.7% vs. 45.1%; P = 0.005). CONCLUSION: Three-dimensional kidney reconstructions use for pre-operative planning and intraoperative surgical guidance lowers the risk of complications and improve perioperative clinical outcomes of RAPN.

Towards automatic recognition of pure and mixed stones using intra-operative endoscopic digital images.

OBJECTIVE: To assess automatic computer-aided in situ recognition of the morphological features of pure and mixed urinary stones using intra-operative digital endoscopic images acquired in a clinical setting. MATERIALS AND METHODS: In this single-centre study, a urologist with 20 years' experience intra-operatively and prospectively examined the surface and section of all kidney stones encountered. Calcium oxalate monohydrate (COM) or Ia, calcium oxalate dihydrate (COD) or IIb, and uric acid (UA) or IIIb morphological criteria were collected and classified to generate annotated datasets. A deep convolutional neural network (CNN) was trained to predict the composition of both pure and mixed stones. To explain the predictions of the deep neural network model, coarse localization heat-maps were plotted to pinpoint key areas identified by the network. RESULTS: This study included 347 and 236 observations of stone surface and stone section, respectively; approximately 80% of all stones exhibited only one morphological type and approximately 20% displayed two. A highest sensitivity of 98% was obtained for the type 'pure IIIb/UA' using surface images. The most frequently encountered morphology was that of the type 'pure Ia/COM'; it was correctly predicted in 91% and 94% of cases using surface and section images, respectively. Of the mixed type 'Ia/COM + IIb/COD', Ia/COM was predicted in 84% of cases using surface images, IIb/COD in 70% of cases, and both in 65% of cases. With regard to mixed Ia/COM + IIIb/UA stones, Ia/COM was predicted in 91% of cases using section images, IIIb/UA in 69% of cases, and both in 74% of cases. CONCLUSIONS: This preliminary study demonstrates that deep CNNs are a promising method by which to identify kidney stone composition from endoscopic images acquired intra-operatively. Both pure and mixed stone composition could be discriminated. Collected in a clinical setting, surface and section images analysed by a deep CNN provide valuable information about stone morphology for computer-aided diagnosis.

Toward improved endoscopic examination of urinary stones: a concordance study between endoscopic digital pictures vs microscopy.

OBJECTIVE: To improve endoscopic recognition of the most frequently encountered urinary stone morphologies for a better aetiological approach in lithiasis by urologists. MATERIALS AND METHODS: An expert urologist intraoperatively and prospectively (between June 2015 and June 2018) examined the surface, the section, and the nucleus of all encountered kidney stones. Fragmented stones were subsequently analysed by a biologist based on both microscopic morphological (i.e. binocular magnifying glass) and infrared (i.e. Fourier transform-infrared spectroscopy) examinations (microscopists were blinded to the endoscopic data). Morphological criteria were collected and classified for the endoscopic and microscopic studies. The Wilcoxon-Mann-Whitney test was used to detect differences between the endoscopic and microscopic diagnoses. A diagnosis for a given urinary stone was considered 'confirmed' for a non-statistically significant difference. RESULTS: A total of 399 urinary stones were included in this study: 51.4% of the stones had only one morphological type, while 48.6% were mixed stones (41% had at least two morphologies and 7.6% had three morphologies). The overall matching rate was 81.6%. Diagnostics were confirmed for the following morphologies: whewellite (Ia or Ib), weddellite (IIa or IIb), uric acid (IIIa or IIIb), carbapatite-struvite association (IVb), and brushite (IVd). CONCLUSIONS: Our preliminary study demonstrates the feasibility of using endoscopic morphology for the most frequently encountered urinary stones and didactic boards of confirmed endoscopic images are provided. The present study constitutes the first step toward endoscopic stone recognition, which is essential in lithiasis. We provide didactic boards of confirmed endoscopic images that pave the way for automatic computer-aided in situ recognition.

Classification of the renal papillary abnormalities by flexible ureteroscopy: evaluation of the 2016 version and update.

INTRODUCTION: To assess the use of the 2016 proposed classification of the renal papillary abnormalities during flexible ureteroscopy that aims to standardize their description. PATIENTS AND METHODS: We performed a prospective monocentric single operator collection of the data using this classification during 88 consecutive flexible ureteroscopies required for renal stones treatment. Outcome measurements and statistical analysis: data of stones analysis (microscopy and infrared spectrophotometry) and of serum and urines biochemical samples have been compared with the results of the classified endoscopic descriptions. RESULTS: Mean duration of description was 81.4 s. We reported that 83% of the patients had Randall plaques (RP), as only 4.5% of the patients had no abnormality. Concerning the papillary stones and anchored stones were observed in 30.7% and aspect of intraductal crystallization (Sc) in 15.9%. Erosions were present in 55.7% and extrophic papillae in 8%. Sa1 and Pa2 were significantly correlated to RP, anchored stones (Sa) to papillary erosions and calcium phosphate stones to intraductal crystallization. Hypercalciuria was significantly higher in Sa2 than Sa1 stones. CONCLUSIONS: The different descriptions in the 2016 classification were confirmed by the results of this study. Papillary abnormalities are consequences of stones development. Their descriptions could also improve the follow-up and the diagnosis of a metabolic lithogenesis. We recommend their systematic description during ureteroscopy. Some improvements are proposed to update this classification.

Three Dimensional Printing Technology Used to Create a High-Fidelity Ureteroscopy Simulator: Development and Validity Assessment (Rein-3D-Print-UroCCR-39).

OBJECTIVE: To create and assess the validity of a high-fidelity, three dimensional (3D) printed, flexible ureteroscopy simulator resulting from a real case. METHODS: A patient's CT scan was segmented to obtain a 3D model in .stl format, including the urinary bladder, ureter and renal cavities. The file was printed and a kidney stone was introduced into the cavities. The simulated surgery consisted of monobloc stone extraction. Nineteen participants split into 3 groups according to their level (6 medical students, 7 residents and 6 urology fellows) performed the procedure twice at a 1-month interval. They were rated according to a global score and a task-specific score, based on an anonymized, timed video recording. RESULTS: Participants demonstrated a significant improvement between the 2 assessments, both on the global score (29.4 vs 21.9 points out of 35; P < .001) and the task-specific score (17.7 vs 14.7 points out of 20; P < .001) as well as procedure time (498.5 vs 700 seconds; P = .001). Medical students showed the greatest progress for the global score (+15.5 points (mean), P = .001) and the task-specific score (+6.5 points (mean), P < .001). 69.2% of participants considered the model as visually quite realistic or highly realistic and all of them judged it quite or extremely interesting for intern training purposes. CONCLUSION: Our 3D printed ureteroscopy simulator was able to enhance the progress of medical students who are new to endoscopy, whilst being valid and reasonably priced. It could become part of a training program in urology, in line with the latest recommendations for surgical education.

The impact of single-use digital flexible cystoscope for double J removal on hospital costs and work organization: A multicentric evaluation.

BACKGROUND: Isiris-α® is a single-use digital flexible cystoscope with an integrated grasper designed for double J (DJ) stent removal. Aim of this study was to conduct a multicentric evaluation of the costs and criticalities of stent removals performed with Isiris®-α in different hospitals and health systems, as compared to other DJ removal procedures. METHODS: After gathering 10 institutions worldwide with experience on Isiris-α®, we performed an analysis of the reported costs of DJ removal with Isiris-α®, as compared to the traditional reusable equipment used in each institution. The cost evaluation included instrument purchase, Endoscopic Room (EnR)/ Operatory Room (OR) occupancy, medical staff, instrument disposal, maintenance, repairs, decontamination or sterilization of reusable devices. RESULTS: The main factor affecting the costs of the procedure was OR/EnR occupancy. Decontamination and sterilization accounted for a less important part of total costs. Isiris-α® was more profitable in institutions where DJ removal is usually performed in the EnR/OR, allowing to transfer the procedure to outpatient clinic, with a significant cost saving and EnR/OR time saving to be allocated to other activities. In the only institution where DJ removal was already performed in outpatient clinics, there is a slight cost difference in favor of reusable instruments in high-volume institutions, given a sufficient number to guarantee the turnover. CONCLUSION: Isiris-α® leads to significant cost benefit in the institutions where DJ removal is routinely performed in EnR/OR, and brings significant improvement in organization, cost impact and turnover.

Consequences of SARS-CoV-2 pandemic on urological surgery in France: a nationwide analysis of the healthcare system database.

The SARS-CoV-2 outbreak overwhelmed the healthcare systems worldwide. Saturation of hospitals and the risk of contagion led to a reduction in the care of other diseases. OBJECTIVE: To determine the impact of SARS-CoV-2 pandemic on urological surgery in France during the year 2020. DESIGN, SETTING AND PARTICIPANTS: An observational descriptive study was conducted on anonymised data collected from the national healthcare database established each year as part of the Program for the Medicalization of Information Systems in Medicine, Surgery, Obstetrics and Odontology. INTERVENTION: None. PRIMARY AND SECONDARY OUTCOME MEASURES: We gathered the number of urology surgical procedures carried out between 2010 and 2019, and we observed the difference between the forecast and actual number of urological surgeries performed in 2020. RESULTS: Urological surgeries decreased by 11.4%, non-oncological surgeries being more affected (-13.1%) than oncological ones (-4.1%). Among the most relevant surgeries, female urinary incontinence (-44.7%) and benign prostatic hyperplasia (-20.8%) were the most impacted ones, followed by kidney cancer (-9%), urolithiasis (-8.7%), radical cystectomy for bladder cancer (-6.1%), prostate cancer (-3.6%) and transurethral resection of bladder tumour (-2%). Public hospitals had a more reduced activity (-17.7%) than private ones (-9.1%). Finally, the distribution of the reduction in urological activities by region did not correspond to the regional burden of SARS-CoV-2. CONCLUSIONS: Urological care was severely affected during SARS-CoV-2 pandemic. Even if oncological surgeries were prioritised, the longer it takes to receive appropriate care, the greater the risk on survival impact. TRIAL REGISTRATION: The data collection and analysis was authorised by the French Data Protection Authority (CNIL) under the number1 861 282v2.

Deep morphological recognition of kidney stones using intra-operative endoscopic digital videos.

Objective.To assess the performance and added value of processing complete digital endoscopic video sequences for the automatic recognition of stone morphological features during a standard-of-care intra-operative session.Approach.A computer-aided video classifier was developed to predictin-situthe morphology of stone using an intra-operative digital endoscopic video acquired in a clinical setting. Using dedicated artificial intelligence (AI) networks, the proposed pipeline selects adequate frames in steady sequences of the video, ensures the presence of (potentially fragmented) stones and predicts the stone morphologies on a frame-by-frame basis. The automatic endoscopic stone recognition (A-ESR) is subsequently carried out by mixing all collected morphological observations.Main results.The proposed technique was evaluated on pure (i.e. include one morphology) and mixed (i.e. include at least two morphologies) stones involving 'Ia/Calcium Oxalate Monohydrate' (COM), 'IIb/Calcium Oxalate Dihydrate' (COD) and 'IIIb/Uric Acid' (UA) morphologies. The gold standard ESR was provided by a trained endo-urologist and confirmed by microscopy and infra-red spectroscopy. For the AI-training, 585 static images were collected (349 and 236 observations of stone surface and section, respectively) and used. Using the proposed video classifier, 71 digital endoscopic videos were analyzed: 50 exhibited only one morphological type and 21 displayed two. Taken together, both pure and mixed stone types yielded a mean diagnostic performances as follows: balanced accuracy = [88 ± 6] (min = 81)%, sensitivity = [80 ± 13] (min = 69)%, specificity = [95 ± 2] (min = 92)%, precision = [78 ± 12] (min = 62)% and F1-score = [78 ± 7] (min = 69)%.Significance.These results demonstrate that AI applied on digital endoscopic video sequences is a promising tool for collecting morphological information during the time-course of the stone fragmentation process without resorting to any human intervention for stone delineation or the selection of adequate steady frames.

Can Pre-Operative Neutrophil-to-Lymphocyte Ratio (NLR) Help Predict Non-Metastatic Renal Carcinoma Recurrence after Nephrectomy? (UroCCR-61 Study).

Recent studies suggested that the neutrophil-to-lymphocyte ratio (NLR) could play a key role in tumor initiation, progression and response to treatments. The main objective was to assess the prognostic value of the pre-operative NLR on recurrence-free survival (RFS) in patients with non-hereditary localized renal cell carcinoma. From the UroCCR database (NCT03293563), factors influencing the disease recurrence of consecutive patients who underwent nephrectomy for cT1-T4 N0M0 were analyzed using multi-variate cox regression and log-rank methods. We included 786 patients, among which 135 (17.2%) experienced a recurrence at a median time of 23.7 [8.5-48.6] months. RFS for patients with a pre-operative NLR of <2.7 was 94% and 88% at 3 and 5 years, respectively, versus 76% and 63% for patients with a NLR of ≥2.7 (p < 0.001, log-rank test). To predict the risk of post-operative recurrence, the NLR was combined with the UCLA integrated staging system (UISS), and we defined four groups of the UroCCR-61 predictive model. The RFS rates at 3 and 5 years were 100% and 97% in the very-low-risk group, 93% and 86% in the low-risk group, 78% and 68% in the intermediate-risk group and 63% and 46% in the high-risk group (p < 0.0001). The pre-operative NLR seems to be an inexpensive and easily accessible prognostic bio-marker for non-metastatic RCCs.

Feasibility of salvage robotic partial nephrectomy after ablative treatment failure (UroCCR-62 study).

BACKGROUND: Ablative therapies (AT) are increasingly being offered to patients with kidney tumors. In cases of failure or local relapse, salvage surgery may be required. Such procedures often require an open approach, are difficult and have received little attention in the literature. We aim to evaluate the feasibility of salvage robot-assisted partial nephrectomy (sRAPN) after AT. METHODS: We conducted a monocentric retrospective study of all patients who benefited from sRAPN. Clinical data were collected prospectively after written consent in the French UroCCR database. RESULTS: Between 2013 and 2020, 724 RAPN were performed in our center; of these, 11 patients underwent salvage RAPN and four (36.4%) had an imperative indication for a solitary kidney. The median patient age was 54 (49-72) years, median preoperative glomerular filtration rate (GFR) was 65.5 (42.9-88.4) mL/min/1.73 m2, and median tumor diameter was 34 (16-38) mm. Extensive perinephric fibrosis was present in 90.9% of cases. Postoperative complications occurred in 36.4% of patients, including major complications in 18.2%. The median GFR at three months (56.8 [45.9-63.9] mL/min/1.73 m2) and at last follow-up (52.1 [45.85-68.3] mL/min/1.73 m2) were not significantly different to the preoperative GFR (P=0.51 and P=0.65, respectively). During follow-up (median 12 months), three patients (all with Von Hippel Lindau disease) developed a recurrence, but none were on the sRAPN site. CONCLUSIONS: Our series of sRAPN following AT failure confirms that such surgery is feasible with good functional and oncological results. However, these surgeries remain difficult, are associated with significant complication rate and should be performed in expert centers.

Endoscopic Papillary Abnormalities and Stone Recognition (EPSR) during Flexible Ureteroscopy: A Comprehensive Review.

INTRODUCTION: The increasing efficiency of the different lasers and the improved performance of endoscopic devices have led to smaller stone fragments that impact the accuracy of microscopic evaluation (morphological and infrared). Before the stone destruction, the urologist has the opportunity to analyze the stone and the papillary abnormalities endoscopically (endoscopic papillary recognition (EPR) and endoscopic stone recognition (ESR)). Our objective was to evaluate the value for those endoscopic descriptions. METHODS: The MEDLINE and EMBASE databases were searched in February 2021 for studies on endoscopic papillary recognition and endoscopic stone recognition. RESULTS: If the ESR provided information concerning the main crystallization process, EPR provided information concerning the origin of the lithogenesis and its severity. Despite many actual limitations, those complementary descriptions could support the preventive care of the stone formers in improving the diagnosis of the lithogenesis mechanism and in identifying high-risk stone formers. CONCLUSION: Until the development of an Artificial Intelligence recognition, the endourologist has to learn EPSR to minimize the distortion effect of the new lasers on the stone analysis and to improve care efficiency of the stone formers patients.

Assessing deep learning methods for the identification of kidney stones in endoscopic images.

Knowing the type (i.e., the biochemical composition) of kidney stones is crucial to prevent relapses with an appropriate treatment. During ureteroscopies, kidney stones are fragmented, extracted from the urinary tract, and their composition is determined using a morpho-constitutional analysis. This procedure is time-consuming (the morpho-constitutional analysis results are only available after several weeks) and tedious (the fragment extraction lasts up to an hour). Identifying the kidney stone type only with the in-vivo endoscopic images would allow for the dusting of the fragments and eneable early treatments, while the morpho-constitutional analysis is ready. Only few contributions dealing with the in vivo identification of kidney stones have been published. This paper discusses and compares five classification methods including deep convolutional neural networks (DCNN)-based approaches and traditional (non DCNN-based) ones. Even if the best method is a DCCN approach with a precision and recall of 98% and 97% over four classes, this contribution shows that an XGBoost classifier exploiting well-chosen feature vectors can closely approach the performances of DCNN classifiers for a medical application with a limited number of annotated data.

Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73).

BACKGROUND: The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus. METHODS: We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed. RESULTS: A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes. CONCLUSIONS: Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.

Towards an automated classification method for ureteroscopic kidney stone images using ensemble learning.

Urolithiasis is a common disease around the world and its incidence has been growing every year. There are various diagnosis techniques based on kidney stone identification aiming to find the formation cause. However, most of them are time consuming, tedious and expensive. The accuracy of the diagnosis is crucial for the prescription of an appropriate treatment that can eliminate the stones and diminish future relapses. This paper presents two effective supervised learning methods to automate and improve the accuracy of the classification of kidney stones; as well as a dataset consisting of kidney stone images captured with ureteroscopes. In the proposed methods, the image features that are visually exploited by urologists to distinguish the type of kidney stones are analyzed and encoded as vectors. Then, the classification is performed on these feature vectors through Random Forest and ensemble K Nearest Neighbor classifiers. The overall classification accuracy obtained was 89%, outperforming previous methods by more than 10%. The details of the classifier implementation, as well as their performance and accuracy, are presented and discussed. Finally, future work and improvements are proposed.

[Migration of an intra uterine device into the bladder]. / Migration intravésicale d'un dispositif intra-utérin. Stratégies d'exploration et modalités thérapeutiques.

The migration of an intra uterine device (IUCD) into the bladder is a rare complication. The authors report a case of IUCD migrated into the bladder. The patient was asymptomatic. Diagnosis was made on abdominal X-ray performed for another reason. It was confirmed by ultrasound and cystoscopy. As the IUCD was only partially intra vesical, it's removal was made by laparoscopy and cystoscopy. The authors then discussed the frequency, the physiopathology, the diagnosis and the treatment with arguments from the literature.

[Spontaneous renal haematoma: diagnostic and therapeutic approach in 7 cases]. / Hématomes spontanés du rein: conduite à tenir diagnostique et thérapeutique. A propos de 7 cas.

OBJECTIVE: Spontaneous renal haematomas are rare. The authors discuss the aetiological diagnosis and management of these haematomas. MATERIAL AND METHODS: Seven cases (3 females and 4 males) of spontaneous renal haematoma were managed between July 1999 and December 2002 and the case files were studied retrospectively. RESULTS: The circumstances of discovery were nonspecific. One patient presented with haemorrhagic shock. Radiological work-up comprised abdominal ultrasound and CT scan in almost every case. Ultrasound failed to demonstrate the aetiological diagnosis. CT revealed the cause of bleeding in 7 cases. MRI was performed in 4 cases, but urgent angiography was not performed. Four total nephrectomies were necessary, while two patients were treated by conservative surgery. One patient was simply followed by repeat CT scan. The short-term course was favourable with a mean follow-up of 23 months. CONCLUSION: Spontaneous renal haematomas raise 2 problems, that of their aetiology: tumours are the commonest causes (angiomyolipoma and renal cell carcinoma), and that of their management. Three therapeutic approaches are possible: radical surgery in the case of uncontrollable bleeding, conservative surgery or surveillance in the absence of a life-threatening emergency and when the aetiological diagnosis has not been established. Rigorous and repeated radiological surveillance can identify the cause of the bleeding allowing conservative surgery to be performed when indicated.