Pelvic fracture-related urethral and bladder injury.

Major pelvic ring fracture (PRF) due to blunt trauma results in lower urinary tract injury (LUTI) in up to 10% of cases. Significant comorbidity may result and this is particularly the case for unrecognised injury. The increase in military injuries due to improvised explosive devices in recent conflicts has revealed a complex injury cohort. The incidence of pelvic fracture related LUTI in these casualties is up to three times higher than that seen in civilian patients with pelvic fracture. A complete understanding of LUTI following pelvic fracture is still lacking. Complex fractures of the anterior pelvic arch are associated with LUTI and initial management is largely conservative. In battlefield injuries, the combination of the blast wave, penetrating fragment and bodily displacement results in open pelvic fracture combined with gross perineal and pelvic soft-tissue destruction and traumatic femoral amputations. These are some of the most challenging injuries that any surgical team will manage and life saving measures are the priority. There are established pathways for the management of LUTI following blunt trauma related pelvic fracture. Military injuries are more complex and require a significantly different approach. This paper outlines the developments in the understanding and management of pelvic fracture-related LUTI, focussing primarily on injury mechanisms and early management. Recent military surgical experience is discussed, highlighting the significant differences to civilian practice.

Trial of ligation versus coagulation of lymphatics in dynamic inguinal sentinel lymph node biopsy for staging of squamous cell carcinoma of the penis.

INTRODUCTION: The principal advantage of dynamic sentinel lymph node biopsy (DSNB) over modified inguinal node dissection is the lower complication rate. The aim of this study was to identify factors associated with short-term complications of DSNB in order to lower morbidity of the procedure. METHODS: Retrospective and prospective cohort studies were performed on patients undergoing DSNB between April 2005 and March 2010. Patients were categorised into three groups of 50 (from a total of 250 patients on the database). The patients of Group A, on whom ligaclips were the lymphovascular control technique, were compared with those of Group B, in whom diathermy was used. Incision length, operative time, number of nodes removed, antibiotics and co-morbidities were recorded. A prospective study on Group C, using ligaclips, was also performed. RESULTS: Groups A (88 groins), B (75 groins) and C (68 groins) were explored with complication rates of 5.7%, 24.0% (p =0.0018) and 8.8% (p =0.0277). Co-morbidities, antibiotics (co-amoxiclav 1.2g intravenous as per protocol) and the mean number of nodes removed were similar in all groups. The mean incision length was 4.1cm (standard deviation [SD]: 1.0 cm) for Group A, 5.6 cm (SD: 1.0 cm) for Group B (p =0.0001) and 5.6 cm (SD: 0.8 cm) for Group C (p =0.979). The mean operative times for Groups A, B and C were 15.8 (SD: 8.1), 19.3 (SD: 7.4) (p =0.0043) and 22.1 (SD: 7.7) (p =0.0301) minutes respectively. CONCLUSIONS: Lymphovascular control with diathermy is associated with a statistically higher short-term complication rate compared with ligaclip usage (ie 'permanent' ligation). Lymphocoeles are the principal complication and can result in delayed wound infection and breakdown. A small but statistical increase in operative time and wound length is likely to be related to registrar training.

Clinicopathological and molecular study of penile melanoma.

AIMS: To examine the clinicopathological features of a series of penile melanomas and screen for mutations in the BRAF and KIT genes, which are seen in melanomas from other sites. METHODS AND RESULTS: 12 patients with penile melanoma were identified over a 10-year period in two supra-regional networks in the UK. The 2- and 5-year survival was 61% and 20%, respectively. Half the patients had lymph node involvement at presentation; this was a poor prognostic indicator. KIT exons 11, 13, 17 and 18, and BRAF codons 600 and 601 were analysed for mutations by Sanger sequencing and pyrosequencing, respectively. None of the tumours showed either KIT mutations or the BRAF V600E mutation. CONCLUSION: Penile melanomas are extremely rare and have a similar prognosis to melanomas elsewhere, but they often present late, leading to a poor outcome. The mutations seen in melanomas from other sites appear to be rarely present in these tumours.

Sentinel lymph node biopsy using dynamic lymphoscintigraphy combined with ultrasound-guided fine needle aspiration in penile carcinoma.

The purpose of this study was to assess the utility of sentinel lymph node lymphoscintigraphy (SLNL) and ultrasound-guided fine needle aspiration cytology (FNAC) in patients with penile carcinoma. A prospective study was undertaken of 64 patients with stage T1 (or greater) clinically N0 squamous cell carcinoma of the penis. Patients underwent SLNL and bilateral groin ultrasonography with or without FNAC. Following intradermal blue dye, patients underwent unilateral or bilateral sentinel lymph node excision biopsy (SNB). 17 patients had sentinel nodes that contained metastases (21 nodal basins). Lymphatic drainage was demonstrated in all patients by lymphoscintigraphy. Bilateral drainage was seen in 57/64 patients. 61/64 patients had ultrasonography of the inguinal basins on the same day as FNAC of 38 basins. FNAC showed malignancy in eight basins. FNAC was negative in six basins, which were subsequently shown to be positive following SNB. 82 inguinal basins did not warrant FNAC by ultrasound criteria, of which 5 contained metastases at SNB. The sensitivity and specificity of ultrasonography was 74% and 77%, respectively. The positive and negative predictive values were 37% and 94%, respectively. Two patients had a negative initial SNB; however, ultrasonography identified a metastatic node and re-evaluation of the sentinel node confirmed micro-metastases. There has been no evidence of recurrence in any patients with negative SNB (during 6-28 months' follow-up). In conclusion, when investigating clinically stage N0 penile cancer, the combination of SNB and groin ultrasonography, with or without FNAC, identifies accurately those with occult nodal metastases. Ultrasonography alone is not adequate as a staging technique, and SNB alone might miss between 5% and 10% of metastases.

Squamous cell carcinoma of the penis in a patient with chronic isolated penile lymphoedema.

Squamous cell carcinoma arising in tissue affected by chronic lymphoedema is rare. We describe, to our knowledge, the first documented case of penile squamous cell carcinoma arising in a patient with a history of idiopathic chronic penile lymphoedema. Patients with chronic lymphoedema should be actively followed for possible malignant changes. We discuss the management and possible aetiology of this unusual case.

What is important to patients receiving extracorporeal shock-wave lithotripsy for urinary tract calculi?

INTRODUCTION: Patients' experience and expectations are paramount in the current era of clinical governance. However, there is lack of published information on patients' expectations from extracorporeal shock-wave lithotripsy (ESWL) treatment for renal stone disease. We conducted a survey to quantify what aspects of ESWL are important purely from the patients' prospective. PATIENTS AND METHODS: Postal questionnaires were sent out to all patients who attended our unit for ESWL treatment for renal stone disease. The questionnaire referred to 15 aspects of ESWL treatment. Patients were asked to rate each aspect based on a numerical scale from 1 to 10 (1--least important; 10--most important). RESULTS: We posted 340 questionnaires and received 208 valid replies (61%). Stone clearance was statistically the most important aspect of treatment. Staff attitude and explanation of the procedure and outcomes were rated highly. To our surprise, pain control was rated only 8th. CONCLUSIONS: Patients' priorities may be different to ours. Surveys like this allow ones to put the appropriate 'weight' on the results of patient satisfaction surveys in order to allocate resources and improve service appropriately.

A prospective audit of the implementation of the 2-week rule for assessment of suspected urological cancers.

INTRODUCTION: All urology departments are under considerable pressure to comply with the UK Government's implementation of the 2-week rule for suspected cancer referrals. A prospective audit was planned to begin 6 months after introduction of cancer referral guidelines and a central data collection process, to investigate the local workload generated by these referrals, and compliance with the 2-week rule. METHODS: Data were collected prospectively over an 8-week period. All referral letters were examined by an independent urologist for any of the criteria defined by the regional tumour working group as suspicious of urological cancer. For suspected cancer referrals, the patient journey was followed to assess efficiency of the referral process. Results were compared with figures for '2-week rule' referrals for the Trust obtained from the UK Department of Health (DoH) website. RESULTS: In all, 234 GP referrals were reviewed, 82 fitting regional criteria for suspected cancer. Of these, (i) 13% were either marked urgent with a clear statement of 'cancer' or included a clear request to be seen within 2 weeks; (ii) 23% included no implication of cancer; (iii) 72% were seen in haematuria clinic, median time to clinic visit being 56.5 days, none complying with the 2-week rule; and (iv) of referrals not seen in haematuria clinic, median time to clinic was 21 days, with 34% compliance. With more stringent definitions of a cancer referral, DoH figures for the Trust recorded just 18 referrals over 3 months, with 89% compliance. DISCUSSION: GP referral letters meeting guidelines for suspected cancer often failed to imply or mention this. Compliance with the 2-week rule was poor, especially for the haematuria clinic. This is variably attributable to wording of GP letters, communication issues, and the sheer load of patients to be seen. CONCLUSION: DoH criteria for cancer referrals grossly underestimate the true magnitude of workload demanded of the service.

What to do if it gets 'bigger'.

The problems associated with intra-operative erections are discussed. Present theory is reviewed to allow a better understanding of the available treatment options.

Morbidity and the impact on daily activities associated with catheter drainage after acute urinary retention.

OBJECTIVE: To evaluate the effect on quality of life of being discharged home with a catheter before definitive treatment in patients with acute urinary retention (AUR). PATIENTS AND METHODS: Patients attending the emergency department with AUR were assessed and discharged home with a catheter if they fulfilled predetermined criteria. They were admitted to the day-care unit for urological assessment and completed a disease-specific quality-of-life questionnaire. RESULTS: Of 101 patients presenting to the emergency department in AUR, 84 were sent home after catheterization (83%); 78 (93%) patients completed the questionnaire. The major side-effects reported were urinary leak (46%), mild haematuria (44%), urgency (42%), pain around the penis (42%), painful erection (31%) and catheter blockage (26%). Only 12% of patients felt having a catheter was very inconvenient and 93% would find it acceptable to have a catheter in future. CONCLUSION: A significant minority of patients discharged home with a catheter had side-effects related to their catheter but were not greatly inconvenienced, and their capacity to carry out normal daily activities was not impaired. The immediate discharge of patients in AUR and planned treatment will enable better use of inpatient urology resources.

High-intensity focused ultrasound ablation of the kidney in a large animal model.

The purpose of this study was to establish the feasibility of noninvasive treatment of small renal tumors with high-intensity focused ultrasound (HIFU). A 1.69-MHz extracorporeal HIFU transducer of 150-mm focal length was used. In vitro experiments with excised porcine kidneys allowed determination of suitable exposure parameters to be tested in vivo. For short exposure times (< 2 seconds), the minimum energy required to produce acute thermal damage was 500 +/- 100 Wcm-2 per second. Porcine kidneys (N = 18) were treated in vivo at a depth of 40 mm from the skin surface, with acute damage detected in 13. Damage was macroscopically and histologically discrete and confined to the target area within the kidney. Skin induration was observed after treatment in nine cases, and there was one skin burn. Transducer developments to prevent this morbidity and to improve energy deposition within the target are discussed.

A feasibility study for the non-invasive treatment of superficial bladder tumours with focused ultrasound.

OBJECTIVE: To determine whether high-intensity focused ultrasound can be used to ablate bladder wall tissue using a transabdominal approach in a large animal model, and whether it can be developed as a non-invasive treatment for superficial bladder tumours. MATERIALS AND METHODS: The bladder wall of 25 large white pigs was treated with a 1.7 MHz extracorporeal focused-bowl ultrasonic transducer. Animals were killed either 2 h, 3 days or 4 weeks after treatment and the bladder wall examined macroscopically and histologically. RESULTS: Acute bladder wall damage was detected in 15 of 16 animals at 2 h and in all six animals examined after 3 days. Areas of healing were seen in 10 of 12 animals at 4 weeks. Histological analysis of the treated areas revealed that the urothelium was denuded within 2 h and was associated with an acute inflammatory response in the bladder wall. At 4 weeks, the urothelium had regenerated over a maturing scar. CONCLUSIONS: Focused ultrasound can be used successfully to destroy regions of the bladder wall in a large animal model in vivo.

Is the conservative management of the acute scrotum justified on clinical grounds?

OBJECTIVE: To determine whether there is justification for a policy of conservative management of acute scrotal emergencies, based on the ability to exclude a twisted testicle or the assumption that there is a "missed torsion' when the duration of symptoms is prolonged. PATIENTS AND METHODS: The case notes of 209 consecutive emergency scrotal explorations, carried out in one district general hospital over a 7-year period, were reviewed. The decision to operate was based solely on a clinical diagnosis, with no information from additional radiological investigations. RESULTS: The commonest finding was testicular torsion (39.5%) with an orchidectomy rate of 22%. Only 5% of scrotal torsions occurred in patients < 12 years of age, whereas 26% occurred in those > 20 years of age. In five of 82 cases (6%) of confirmed testicular torsion, the surgeon did not consider this the most likely diagnosis. With a pain duration of < 16 h, 89% of testes were salvaged, but with pain for > 16 h this decreased to 25%. In three cases the testis was viable after pain had been present for > 24 h. CONCLUSION: In the absence of supportive radiological investigations, a small but significant number of twisted testes will be missed if conservative management is adopted.

The intensity dependence of the site of maximal energy deposition in focused ultrasound surgery.

The relationship between spatial peak intensity and the position of ultrasound induced tissue damage was studied in in vitro tissue models, using a 1.69 MHz spherical bowl transducer. The models corresponded to the transabdominal route to the bladder and prostate, which are potential target sites for focused ultrasound surgery. The results confirm that there is a relationship between lesion position and intensity, with lesions forming, under some exposure conditions, ahead of the geometric focus. Forward growth of lesions appears to be due to changes in the absorption characteristics of the tissue in the beam path. Using a computer model, we have demonstrated that the absorption coefficient of the tissue must increase significantly in front of the focus to enable lesions to form ahead of the predicted position. A possible mechanism for this is bubble formation as a result of acoustic cavitation. The effect of nonlinear propagation in the tissue, at the intensities studied, is shown to be relatively small.