Persistent storage symptoms following Y-V plasty reconstruction for the treatment of refractory bladder neck contracture.

PURPOSE: Refractory bladder neck contracture (BNC) following transurethral prostatectomy is rare and difficult to manage. Success rate of endoscopic treatment decline considerably after repeated treatments. Bladder neck reconstruction are often the last resort to treat refractory BNC failing endoscopic treatments. In general, experience is limited with this type of bladder neck reconstruction, particularly in adult patients. This study aims to determine the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral prostatectomy. The study also aims to determine the rate, and potential predictors of persistent storage symptoms after Y-V plasty. MATERIALS AND METHODS: Between January 2016 and February 2021, 18 consecutive patients with refractory BNC who underwent open Y-V plasty were included in this study. All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments followed by a 3-month period of outpatient serial dilation program. Clinicopathological data were extracted from medical records including baseline demographics, aetiology of BNC, previous endoscopic treatment, operative time, length of stay, complications, uroflow findings, International Prostate Symptom Score (IPSS) and OAB-V8. Primary outcome was the success of open YV plasty, defined as no need for further instrumentation such as indwelling catheterization, urethral dilatation, urethrotomy, or open surgery. Simple linear regression analysis was performed to determine predictor factors for postoperative OAB-V8. Variables that showed p < 0.25 were included in the multiple linear regression analysis. RESULTS: Most common aetiology of BNC was transurethral resection of prostate gland (n = 18, 100%). Mean age at surgery age (SD) was 65.5 (7.3) years. Mean follow-up was 14.8 (7) months. Success rate was 100%. Postoperative Qmax improved significantly [pre-OP 6.7 (8.1) ml/s vs. post-OP was 14.8 (7.3) ml/s, p < 0.001]. Mean postvoid residual decreased significantly [pre-OP 223.3 (254.3) ml vs. post-OP 45.1 (71.0) ml, p < 0.01)]. Persistent storage symptoms were reported in 61% of patients. BMI and baseline IPSS score are significant predictors for the postoperative OAB V8 change (adjusted b (95% confidence interval) = 1.037 (0.2-1.9), 0.64 (0.28-0.99), respectively, R2 = 0.59). CONCLUSION: Y-V plasty reconstruction for refractory BNC represents a feasible and successful option with high success rate and favorable outcomes. While functional and patient-reported outcomes had significantly improved post-operatively, persistent storage symptoms after this procedure still exist. BMI and baseline IPSS score are significant predictors for persistent storage symptoms after bladder neck reconstruction.

Lower risk of pelvic metalware infection with operative repair of concurrent bladder rupture.

BACKGROUND: Patients with traumatic bladder rupture frequently have associated pelvic fracture. With increasing numbers of pelvic fractures fixed internally, there are concerns that conservative management of bladder rupture may increase the risk of pelvic metalware infection. This study aims to determine if operative repair of bladder rupture in comparison to conservative management with catheter drainage alone is associated with a lower rate of infection of internal fixation device for concurrent pelvic fracture. METHODS: This is a retrospective cohort study of level IV evidence. From July 2001 through June 2013, 45 multi-trauma patients at a level 1 trauma centre were identified to have sustained bladder rupture with concurrent pelvic fracture requiring internal fixation. Clinicopathological data were extracted from the TraumaNET database, medical records and health-coding database. Patients were stratified into two retrospective cohorts, management with surgical repair and management with catheter drainage alone. Fischer's exact test was used to determine whether the rate of pelvic metalware infection was different in the two cohorts. RESULTS: Of the 45 patients, 13 had intraperitoneal bladder rupture, 28 had extraperitoneal bladder rupture and four had combined intra-extraperitoneal bladder rupture. The median age for this cohort was 31. Bladder rupture was surgically repaired in 36 patients and managed conservatively with catheter drainage in nine patients. The rate of pelvic internal fixation device infection was lower in patients managed with surgical repair compared with conservative management (5.6% versus 33.3%, P = 0.047). CONCLUSION: Operative repair of bladder rupture is associated with a lower rate of pelvic orthopaedic hardware infection in the presence of concurrent pelvic fracture requiring internal fixation.

Incidence of normal white cell count and C-reactive protein in adults with acute appendicitis.

BACKGROUND: Normal C-reactive protein (CRP) and white cell count (WCC) are often used to exclude a diagnosis of acute appendicitis in the Emergency Department (ED). Retrospective review of 281 adult patients with acute appendicitis was performed to study the incidence of normal CRP and WCC on admission and examine any possible predisposing factors. METHOD: Retrospective analysis of patient clinical records yielded CRP, WCC, operative diagnosis, time of symptom onset, imaging results and history and examination features. Case-control analysis was performed with patients with normal CRP and WCC considered the case group and those with raised CRP or WCC considered controls. Groups were compared using Mann-Whitney U-test and chi-squared analysis. RESULTS: Of 281 consecutive patients with histologically proven appendicitis, 24 (8.54%) had normal CRP and WCC on presentation to ED. There were no significant differences in age, sex or time to blood collection between groups. Three patients had normal WCC and CRP and an Alvarado score of 4 or less on presentation. Three patients had persistently normal CRP and WCC on repeated testing. There was a trend towards earlier presentation in patients with normal CRP and WCC with 75.0% versus 58.4% presenting within 24 h of symptom onset (OR 2.14, P = 0.112). CONCLUSION: Acute appendicitis remains diagnostically challenging and cannot be excluded on the basis of normal CRP and WCC. Serial clinical and biochemical assessment is warranted in patients with acute abdominal pain, particularly in those presenting early after symptom onset.

Error rates in a clinical data repository: lessons from the transition to electronic data transfer--a descriptive study.

OBJECTIVE: Data errors are a well-documented part of clinical datasets as is their potential to confound downstream analysis. In this study, we explore the reliability of manually transcribed data across different pathology fields in a prostate cancer database and also measure error rates attributable to the source data. DESIGN: Descriptive study. SETTING: Specialist urology service at a single centre in metropolitan Victoria in Australia. PARTICIPANTS: Between 2004 and 2011, 1471 patients underwent radical prostatectomy at our institution. In a large proportion of these cases, clinicopathological variables were recorded by manual data-entry. In 2011, we obtained electronic versions of the same printed pathology reports for our cohort. The data were electronically imported in parallel to any existing manual entry record enabling direct comparison between them. OUTCOME MEASURES: Error rates of manually entered data compared with electronically imported data across clinicopathological fields. RESULTS: 421 patients had at least 10 comparable pathology fields between the electronic import and manual records and were selected for study. 320 patients had concordant data between manually entered and electronically populated fields in a median of 12 pathology fields (range 10-13), indicating an outright accuracy in manually entered pathology data in 76% of patients. Across all fields, the error rate was 2.8%, while individual field error ranges from 0.5% to 6.4%. Fields in text formats were significantly more error-prone than those with direct measurements or involving numerical figures (p<0.001). 971 cases were available for review of error within the source data, with figures of 0.1-0.9%. CONCLUSIONS: While the overall rate of error was low in manually entered data, individual pathology fields were variably prone to error. High-quality pathology data can be obtained for both prospective and retrospective parts of our data repository and the electronic checking of source pathology data for error is feasible.

Haemostasis in neurosurgery: what is the evidence for gelatin-thrombin matrix sealant?

Strict intra-operative haemostasis is essential in the practice of neurosurgery. Over the last century, haemostatic methods have advanced significantly and the modern surgeon is now faced with an array of haemostatic agents, each with subtly different qualities and proven in different contexts with various levels of evidence. The popularity of endoscopic and laparoscopic procedures in other surgical specialties has encouraged the introduction of novel agents to achieve haemostasis where conventional methods have proven difficult. These agents are beginning to find a role in routine use for surgery in both the elective and emergent settings. This article reviews the mechanisms of different haemostasis methods and the current evidence for their use in neurosurgery, with a focus on the more recently introduced gelatin-thrombin matrix sealant (Floseal [Baxter, Hayward, CA, USA]).

Using age-referenced prostate-specific antigen percentile to predict survival outcomes in screened Taiwanese men.

The survival outcomes of Asian men with elevated prostate-specific antigen (PSA) levels at screening are largely unknown. We present the clinical outcomes of Taiwanese men based on their screening PSA levels. Between 1994 and 2006, 27,761 men aged over 40 years underwent PSA screening in a self-funded health examination. The clinical database was linked with the national cancer and death registry databases to generate prostate cancer incidence, prostate cancer mortality (PCM) and overall mortality (OM). Participants were followed until the end of 2009. Survival analyses were performed for the participants' outcomes, and were stratified by five 10-year age strata (age 40-<50, 50-<60, 60-<70, 70-<80 and ≥ 80), and six age-referenced PSA percentile groups, divided by the 50th, 75th, 90th, 95th and 99 th percentile of PSA values for each 10-year age stratum. The median age of the 27,761 men was 54.7 years. The median PSA level at cancer diagnosis was 4.46 ng ml(-1) . Specifically, the PSA levels for the five 10-year age strata in order of respectively increasing ages were 1.93, 3.50, 4.10, 6.94 and 12.4 ng ml(-1) . After a median follow-up of 8.4 years, 2,463 men died and 337 were diagnosed with prostate cancer. Among the 337 patients, 29 (8.6%) died of prostate cancer. The prostate cancer incidence, PCM and OM rates were higher in men with higher age-referenced PSA percentile values. The 10-year PCM rate for men with ≥ the 99th age-referenced PSA percentile was 3.9%, which was significantly higher than the rate of ≤ 0.5% in the lower percentile groups.

Prostate weight is the preferred measure of prostate size in radical prostatectomy cohorts.

OBJECTIVE: To evaluate the accuracy of calculated prostate volume variables in a radical prostatectomy (RP) cohort, as many recent studies use these measures of prostate size instead of prostate weight. To determine whether this accuracy could be improved by modifying the mathematical model used in the volume estimation. PATIENTS AND METHODS: Patients who underwent RP for prostate cancer at our associated institutions had calculated specimen volumes and weights from RP specimens determined at one pathology institution and transrectal ultrasonography (TRUS) volumes were recorded preoperatively (n= 236). Correlation analysis was performed and errors were determined for calculated volume variables when compared with prostate weight. Bland-Altman plots were drawn and concordance coefficients calculated. Analysis was repeated with smaller prostates mathematically modelled as bullet-shaped rather than ellipsoid (n= 165). RESULTS: Although correlation was good for both TRUS and specimen volumes, they equally underestimated prostate weight with a large range of errors and poor concordance coefficients. Only 22% of TRUS volumes and 11% of calculated specimen volumes were within 10% of weight measurements. Application of a bullet-shaped mathematical model for prostates <55 g did not correct the large individual variation seen within these values. CONCLUSION: Calculated prostate volume variables are prone to a large range of individual error regardless of the mathematical model used and should be avoided in statistical studies involving RP cohorts, and the more accurate prostate weight variable should instead be used as a size variable or correction factor.