High grade renal injuries: application of Parkland Hospital predictors of intervention for renal hemorrhage.

PURPOSE: Investigators from Parkland Hospital proposed substratification of the AAST (American Association for the Surgery of Trauma) grading scale based on 3 risk factors, including active vascular extravasation, a medial laceration and a perinephric hematoma of greater than 3.5 cm. We hypothesized that these characteristics would also be associated with intervention for renal hemorrhage in our large trauma series. MATERIALS AND METHODS: From January 2005 to January 2011 we retrospectively reviewed the renal trauma records at adult level 1 trauma centers in Utah. AAST grade 3 and 4 injuries were characterized based on the mentioned 3 risk factors. Our primary outcome was intervention to control renal hemorrhage. RESULTS: AAST grade 3 or greater injury was identified in 147 patients, including 115 who had grade 3 and 4 injuries as well as imaging available for review. There were 63 grade 3 (53%) and 52 grade 4 (43%) renal injuries. Eight patients (7%) underwent intervention for renal hemorrhage. Vascular extravasation (OR 16.4, 95% CI 2.6-179.8, p <0.001) and perinephric hematoma greater than 3.5 cm (OR 8.4, 95% CI 1.4-52.5, p = 0.0099) were associated with intervention, while a medial laceration was not (p = 0.454). Patients with 1 or fewer, 2 and 3 risk factors had an intervention rate of less than 2.9%, 18% and 50%, respectively (p <0.001). CONCLUSIONS: Vascular extravasation, a perinephric hematoma greater than 3.5 cm and the number of risk factors (0 to 3) were associated with intervention for renal hemorrhage. Our findings are similar to those at Parkland Hospital. These imaging features may serve as useful prognostic indicators for renal trauma.

Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature.

BACKGROUND: Robot-assisted laparoscopic prostatectomy (RALP) is displacing radical retropubic prostatectomy as the gold standard surgical approach for clinically localised prostate cancer in the United States and is also being increasingly used in Europe and other parts of the world. This trend has occurred despite the paucity of high-quality evidence to support its relative superiority to more established treatment modalities. OBJECTIVE: We performed this study to critically assess the quality of published evidence on RALP to support this major shift in practice patterns. DESIGN, SETTING, AND PARTICIPANTS: We conducted a systematic review of the published literature through Medline and Embase (1966 to December 2008). All original research publications on RALP were included. Editorials, letters to the editor, and review articles were excluded. MEASUREMENTS: Two reviewers independently performed the data abstraction using a standardised form derived from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. RESULTS AND LIMITATIONS: Seventy-five original research publications met eligibility criteria. Fifty-five (73.3%) studies were published between 2005 and 2008, and 20 studies (26.7%) were published between 2001 and 2004. Approximately three-quarters of the studies were case series (74.7%), and only two (2.7%) randomised, controlled trials (RCT) were identified. Twelve authors cowrote 72% (54 of 75) of the published studies. Reporting of STROBE criteria ranged from 100.0% (scientific rationale/background explained) to 1.3% (consideration of sample size), with no improvement over time. The study was limited to published literature in the English language. CONCLUSIONS: The published RALP literature is limited to observational studies of mostly low methodologic quality. Our findings draw into question to what extent valid conclusions about the relative superiority or equivalence of RALP to other surgical approaches can be drawn and whether published outcomes can be generalised to the broader community. There is an urgent need to raise the methodologic standards for clinical research on new urologic procedures and devices.