Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study

Background
Renal trauma is present in 0.5–5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes.

Methods
We analysed “Towards Improved Trauma Care Outcomes in India” cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details.

Results
A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144).

Conclusion
Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.

Data on histological characteristics, survival patterns and determinants of mortality among colorectal, esophageal and prostate cancer patients in Ethiopia

This article describes data collected retrospectively on a cohort of esophageal, colorectal and prostate cancer patients registered in the patient log book of Tikur Anbessa Specialized Hospital, Ethiopia, from January 1, 2012 to December 31, 2017. The key variables studied include histological characteristics of each type of cancer, clinical and TNM stages, baseline laboratory results (Carcinoembryonic antigen (CEA) for colorectal cancer, Prostate-Specific Antigen (PSA) for prostate cancer, hemoglobin level, etc.), clinical characteristics including sign and symptoms, family history of cancer, diagnostic and treatment modalities a patient received for each type of cancer. The event status (death) was also collected using death certificates (whenever available) and supplemented by telephone interviews with the patient or attendant. Furthermore, lifestyle characteristics of patients including tobacco use, alcohol consumption, khat (‘Catha edulis’) chewing, etc. and socioeconomic characteristics including age, sex, region of residence, marital status, and educational level were also collected. The aim that led to conduct the study that generated these data was to describe clinical presentation, histological characteristics, survival pattern, and to identify determinants of mortality among cancer patients in Ethiopia. Thus, independent survival analyzes were performed using Kaplan-Meier estimates and life table analysis. Furthermore, Cox’s proportional hazards regression was developed to investigate the survival pattern and determinants of cancer specific mortality among colorectal, esophageal and prostate cancer patients.

Practical considerations for prostate hypofractionation in the developing world

External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8–9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.

Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas

Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the national average is about 800 in most of the rural areas in India, in the North-eastern states it varies from 30 to 300. We look at the various models and options available for empowering the surgeons in the rural areas. Short Term Medical Missions have been used for a long time including those with structured programs. Pioneering long term medical missions are few and difficult to sustain. Empowering surgeons working in rural areas with modern surgical techniques is a sustainable solution with high impact. Empowering the rural surgeons with training in Gas Insufflation Less Laparoscopic Surgeries and Endoscopic Urology surgeries helped the surgical coverage in the target population of the 8 rural hospitals studied go up from 1287 per 100000 per year to 2880 the next year and 3739 the following year. It is a financially sustainable model that could be scaled up by funding travel of the trainers and equipment for the trainees.

The role of Mitrofanoff appendicovesicostomy in the management of a pelvic fracture distraction defect in a 24- year-old man after multiple failed reconstruction attempts

Failed Pelvic Fracture Distraction Defect repairs present a considerable challenge for management. Re-do urethroplasties for failed repairs are associated with higher recurrence and morbidity rates. The case presented describes a male patient with a pelvic fracture urethral distraction defect (PFUDD) who had undergone multiple failed repairs. The Mitrofanoff appendicovesicostomy was successfully carried out and the patient remains continent to date. The Mitrofanoff appendicovesicostomy is not commonly employed in the management of adult urethral stricture disease. We present our experience with managing a pelvic fracture urethral disruption defect (PFUDD) after multiple failed urethroplasties using a continent catheterisable urinary diversion techniqu

Consensus on Prostate Cancer Treatment of Localized Disease With Very Low, Low, and Intermediate Risk: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC)

PURPOSE
A group of international urology and medical C developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed.

METHODS
A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript.

RESULTS
The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time.

CONCLUSION
The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Consensus on Treatment and Follow-Up for Biochemical Recurrence in Castration-Sensitive Prostate Cancer: A Report From the First Global Prostate Cancer Consensus Conference for Developing Countries

PURPOSE
To present a summary of the treatment and follow-up recommendations for the biochemical recurrence in castration-sensitive prostate cancer (PCa) acquired through a questionnaire administered to 99 PCa experts from developing countries during the Prostate Cancer Consensus Conference for Developing Countries.

METHODS
A total of 27 questions were identified as related to this topic from more than 300 questions. The clinician’s responses were tallied and presented in a percentage format. Topics included the use of imaging for staging biochemical recurrence, treatment recommendations for three different clinical scenarios, the field of radiation recommended, and follow-up. Each question had 5-7 relevant response options, including “abstain” and/or “unqualified to answer,” and investigated not only recommendations but also if a limitation in resources would change the recommendation.

RESULTS
For most questions, a clear majority (> 50%) of clinicians agreed on a recommended treatment for imaging, treatment scenarios, and follow-up, although only a few topics reached a consensus > 75%. Limited resources did affect several areas of treatment, although in many cases, they reinforced more stringent criteria for treatment such as prostate-specific antigen values > 0.2 ng/mL and STAMPEDE inclusion criteria as a basis for recommending treatment.

CONCLUSION
A majority of clinicians working in developing countries with limited resources use similar cutoff points and selection criteria to manage patients treated for biochemically recurrent castration-sensitive PCa.

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Genitourinary reconstructive surgery curriculum and postgraduate training program development in the Caribbean

Objectives: To describe the development of a genitourinary reconstructive fellowship curriculum and the establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the Caribbean.

Methods: In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We sought accreditation via a well-established local university, and fellowship candidates were selected. A database was maintained to track outcomes. Subjective and objective reviews were performed of the fellows.

Results: The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum was created and implemented. The fellowship has been successfully integrated into the health system, and the fellows performed 199 and 235 cases, respectively, during the program, completing all rotations successfully. They have been appointed to the national health system. Both graduates are now docents in the program and in the public system. Additional staff including radiologists, radiology technicians, nurses, urology residents (both Dominican and American), urology attendings, operating room staff, and anesthesia residents were trained as a result of the program.

Conclusions: To our knowledge, this is the first fellowship of its kind in the Caribbean. A novel curriculum was created and implemented, and the first 2 fellows have successfully completed all rotations. This training model may be transferable to additional sites.

Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay