Renal angiomyolipoma.

• Renal angiomyolipomas (AMLs) are usually easy to diagnose with imaging alone. They have unique characteristics on ultrasonography, computerised tomography and magnetic resonance imaging that usually allow AMLs to be differentiated from other renal masses. • If this is not possible on imaging criteria then biopsy can be performed and AMLs have unique immunohistochemical staining that allows them to be accurately differentiated from other renal tumours.

Prognostic factors in malignant ureteric obstruction.

OBJECTIVE: To validate a model to stratify patients with obstructive nephropathy due to malignant ureteric obstruction, associated with a poor prognosis, into different prognostic groups, as a recent report identified low serum albumin, degree of hydronephrosis and number of events related to metastatic disease as prognostic indicators before palliative decompression. PATIENTS AND METHODS: We retrospectively review the charts to identify all patients who had a nephrostomy tube inserted for malignant ureteric obstruction. Laboratory and clinical factors that might influence prognosis were reviewed to attempt to externally validate the previously identified factors and model for risk stratification. RESULTS: The median (range) age of the 49 patients identified was 71 (36-91) years, and the median survival was 174 (14-602) days. Tumours were of urological origin in 66% of patients. Patients with prostate cancer had nephrostomy tubes indwelling for a mean of 279 days, vs 190 days (P = 0.07) for patients with tumours not of prostatic origin. A serum albumin level of >30 g/L (P ≤ 0.001), serum sodium <135 mmol/L (P = 0.019) and three or more events related to dissemination of cancer (P = 0.04) were factors associated with a significantly shorter mean survival. Complications related to the nephrostomy tube were experienced by 39% of patients. The model proved useful in stratifying these patients into different risk groups (P = 0.002). CONCLUSION: Consistent with a previous report we showed that a low serum albumin level and events related to metastatic disease were indicative of a poor prognosis. We also found that a low serum sodium level might be associated with a worse prognosis. We externally validated a model for stratifying patients into different prognostic groups. Palliative decompression is associated with significant morbidity.

Treatment of duodenal adenomas with endoscopic argon plasma coagulation.

BACKGROUND: Surgical resection has been the standard treatment for duodenal adenomas. It has a high associated morbidity rate and a significant recurrence rate. The aim of this study was to evaluate endoscopic treatment of these lesions with argon plasma coagulation. METHODS: We retrospectively identified patients with non-ampullary duodenal adenomas without a polyposis syndrome and who were treated endoscopically between 1st January 1999 and 31st December 2003. Their management, follow up and outcomes were reviewed. RESULTS: Fifteen patients were included, with mean age 72 years (range 46-85 years). All were treated with at least one session of argon plasma coagulation. Initially, 13 adenomas were macroscopically cleared. Of these, eight (61%) had no recurrence during mean follow up of 40 months (26-68 months). The mean time to recurrence was 14 months (6-30 months). Eradication was possible a second time in four of five recurrent adenomas. There was one complication, of haemorrhage, from 37 sessions of argon plasma coagulation. No patient developed duodenal adenocarcinoma during the study period. CONCLUSION: Argon plasma coagulation may be safe and effective for the treatment of duodenal adenomas, but further research is required. Progression of adenomas is slow and perhaps no treatment is required.

The role of laparoscopy and robotic surgery in the management of small renal masses.

Increased utilization of cross-sectional abdominal imaging has led to a significant increase in the incidence of small renal masses. There is a growing body of literature suggesting that these lesions have a low malignant potential, thus supporting surveillance as a therapeutic option, particularly in the elderly population. Over the last decade, there has been an explosion of minimally invasive techniques for managing these lesions, including laparoscopic nephrectomy, laparoscopic partial nephrectomy, cryotherapy, radiofrequency ablation and, more recently, robotic-assisted surgery. The aim of this article is to review recent literature and assess the role of laparoscopic and robotic-assisted surgery in the management of small renal masses.

The outcomes of transrectal ultrasound guided biopsy of the prostate in a New Zealand population.

INTRODUCTION: We aim to produce nomograms relating age, digital rectal examinations (DRE), and prostate specific antigen (PSA) to probability of a positive transrectal ultrasound guided (TRUS) prostate biopsy for a New Zealand population. Usefulness of age-adjusted PSA reference ranges and PSA density are also examined. METHODS: Data was extracted retrospectively from electronic records of prostate biopsies performed between 1995-2007 in Christchurch, New Zealand. Nomograms were created using logistic regression models. The area under the curve (AUC) for age-adjusted PSA ranges, PSA density, and PSA in predicting a positive biopsy was calculated and used to compare these methods. RESULTS: 4316 biopsies were available for analysis. Data was incomplete for 1177 (27%) of patients. Biopsy was positive in 54.4%. PSA level and DRE finding were strong predictors of a malignant biopsy in our multivariable model but age was not. PSA level and DRE were also predictors of a higher Gleason score (7 or greater). Nomograms are presented relating PSA and DRE to both a positive biopsy result and to biopsy with Gleason score 7 or greater. AUC for age adjusted reference ranges was no better than PSA using a single cutpoint of 4.0. (0.54 vs 0.53). AUC for PSA density using a cutpoint of 0.15 was 0.72. Receiver Operator Characteristic (ROC) curves showed a clear advantage for PSA density over PSA regardless of cutpoint. (AUC 0.80 vs 0.67). CONCLUSIONS: Nomograms are formulated to help inform New Zealand men how likely they are to have a positive TRUS prostate biopsy and also how likely they are to have a higher grade cancer detected by TRUS prostate biopsy. Age-adjusted reference ranges did not improve prediction of cancer in this population, but the use of PSA density may enhance prostate cancer diagnosis.

Closing the audit loop is necessary to achieve compliance with evidence-based guidelines in the management of acute pancreatitis.

AIM: The aim of this study was to assess the effect of the implementation of evidence-based guidelines and subsequent feedback to surgeons in the management of acute pancreatitis. METHOD: An evidence-based Pancreatitis Proforma was developed. Data were prospectively recorded (01/06/2005-30/09/2007). Audit feedback (AFB) was performed at 9 months. A final analysis was performed comparing outcomes pre- and post-audit feedback. RESULTS: 372 patients were included. Median age (range) was 57 (12-96) years. 168 (45.2%) patients were admitted pre-AFB. Post-AFB, there was a significant increase in the number of patients whose diagnosis was made within 48 hours (135/168 (80.4%) vs 189/204 (92.6%), p<0.001) and who underwent definitive treatment for mild biliary pancreatitis (33/61 (54.1%) vs 56/70 (80.0%), p=0.002). Post-AFB there was also a significant reduction in the number of computed tomography (CT) scans performed for patients with mild acute pancreatitis (23/85 (27.1%) vs 13/99 (13.1%), p=0.018). Mortality (9/168 (5.4%) vs 3/204 (1.4%), p=0.040) also decreased. On multivariate analysis, AFB was an independent factor for change in the use of CT scans (p=0.015) and management of patients with mild biliary pancreatitis (p=0.039). CONCLUSION: For evidence-based guidelines to be effective, feedback to surgeons is necessary.