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.

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.

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.

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.