Urology Bay of Plenty

Renal angiomyolipomas (AMLs) are benign mesenchymal tumours that may present with life-threatening haemorrhages when associated with underlying genetic conditions. AMLs are comprised of mature but disorganised vasculature, smooth muscle and fatty adipose tissue. Whilst the majority of intrarenal AMLs are sporadic and found incidentally as solitary lesions, there is a significant association with tuberous sclerosis complex (TSC).TSC results in the disruption of the mTOR pathway, leading to unregulated cell proliferation and subsequent benign tumour growth. Consequently, AMLs present in TSC are typically large, multiple and complex in nature.In this case, we report a 22-year-old woman with no significant past medical history, who presented with right‑sided abdominal pain and was initially investigated for cholecystitis. Imaging revealed bilateral renal AMLs, a right renal artery pseudoaneurysm and acute retroperitoneal haemorrhage. The patient was stabilised with a transfusion and proceeded to undergo emergency super‑selective embolisation. Physical examination and radiological clues raised further suspicion of TSC.Follow-up interval imaging revealed a 9 mm intra-tumoral aneurysm in the contralateral kidney, which was prophylactically embolised, and neuroimaging revealed subependymal nodules. Subsequent treatment is anticipated to involve pharmaceutical mTOR inhibition, definitive neurological assessment and follow-up at the regional Genetics Centre.In patients with complex AMLs and clues of genetic disease, evaluation for TSC should be prompt. The presence of secondary features should raise suspicion and initiate assessment of underlying genetic conditions in young patients. Evaluation may then unmask serious complications, such as haemorrhage, and early recognition enables targeted intervention, surveillance and holistic patient counselling.

ABSTRACT Across the globe suicide rates are creating concern, and the World Health Organisation (WHO) argues that suicide is the responsibility of everyone. The WHO recognises that police have an important role in suicide prevention and the management of mental health crises. We suggest that police officers and staff are inevitably impacted by the emotional labour of meeting the demands of this aspect of the role. We argue for more research attention on the experiences and views of police who work with suicide. This study comprised qualitative reflective interviews with police in the UK, Guyana and New Zealand, with the focus on identifying commonalities in experience across the three locations. Four themes were generated through reflective thematic analysis: (1) the context; (2) the traumatic impact; (3) the difficult aspects of this work and (4) organisational opportunities for supporting police officers and staff. Our data illustrated that suicide is qualitatively different from other forms of death, and the nature of the work did have considerable emotional and traumatic impact on police. We conclude our paper with several recommendations for police forces to build their welfare support for staff. These recommendations could help promote a healthier workforce and recognise the specific issues associated with this part of the role.

This is the first reported case of lesser sac empyema secondary to a foreign body perforation in the posterior stomach. Although PubMed and Google Scholar search reports cases of lesser sac empyema alone and foreign body penetrations, there are currently no reported cases of a lesser sac abscess secondary to a foreign body. Patients with a lesser sac empyema present atypically with an insidious onset. The lesser sac should be examined in patients with peritonitis without a clear source.A 48-year-old female presented to the emergency department with acute onset epigastric pain. The patient was tender in the epigastrium and left upper quadrant with associated guarding. The patient had elevated white cell count and C-reactive protein, with a computed tomography scan identifying a foreign body posterior gastric wall perforation. The patient was managed with endoscopic drainage of the lesser sac empyema and surgical washout of the abdomen.Foreign bodies are investigated using different imaging modalities, with computed tomography being able to further evaluate the size, shape, and complications. Intra-abdominal collections can be managed through three different methods: percutaneous drainage, endoscopic drainage, and surgery. Patients with peritonitis would require a laparoscopic or open surgical washout of the abdomen and inspection of the lesser sac would be necessary if no obvious source is identified.Foreign body ingestion requires careful history taking and assessment. Patients with lesser sac empyema present atypically, and this can lead to delayed surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically.

ObjectivesTo assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand.DesignA retrospective cohort study of hospital inpatient records.SettingA tertiary children’s hospital in Auckland, New Zealand.Participants1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019.Outcome measuresThe outcome of assessment by the hospital’s multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code.ResultsThere were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor).ConclusionsThe ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition.

Outcomes of radical prostatectomy (RP) in men with history of lower urinary tract symptoms related to benign prostatic enlargement (LUTS/BPE) surgery represents a controversial issue. We performed an updated systematic review and meta- analysis evaluating oncological and functional outcomes of RP in this subset of patients. Eligible studies were identified from MEDLINE, Web of Science and the Scopus databases. The following outcomes were evaluated: incidence of positive surgical margins (PSM), incidence of biochemical recurrence (BCR), 3-mo and 1-year urinary continence (UC) rates, incidence of nerve-sparing (NS) procedures, 1-year erectile function (EF) recovery rates. We estimated pooled Odds ratios (OR) and 95% confidence intervals (CI) using random effects models. Sub-analyses were performed according to the type of RP and LUTS/BPE surgery. Twenty-five retrospective studies including 11,101 patients undergoing RP were included in the analysis (2113 with history of LUTS/BPE surgery, and 8898 controls). PSM rate was significantly higher in patients with history of LUTS/BPE surgery (OR 1.39, 95% CI 1.18-1.63, p < 0.001). No statistically significant difference in terms of BCR emerged between patients with or without history of LUTS/BPE surgery (OR 1.46, 95% CI 0.97-2.18, p = 0.066). Three-months and 1-year UC rates were significantly lower in patients with previous LUTS/BPE surgery (OR 0.48, 95% CI 0.34-0.68, p < 0.001 and OR 0.44, 95% CI 0.31-0.62, p < 0.001; respectively). Although not statistically significant differences between the two groups emerged in terms of adoption of NS procedures (OR 0.59, 95% CI 0.32-1.12, p = 0.107), 1-year EF recovery was significantly lower in patients with history of LUTS/BPE procedures (OR 0.60, 95% CI 0.40-0.89, p = 0.010). In conclusions, RP in patients with history of previous LUTS/BPE surgery is associated with increased incidence of PSM, lower UC rates at both 3-months and 1-year follow-up as well as lower rates of EF recovery at 1-year follow-up.

Global increases in opioid prescribing and misuse have prompted calls for closer regulation. Opioid prescription following surgery may lead to long term opioid use. A study was conducted evaluating opioid prescriptions on hospital discharge following common general surgery operations in the Bay of Plenty. Retrospective observational study over a two-year period in two regional New Zealand hospitals. Six hundred and eleven patients aged 18-64 years were assessed. Patients with complications, readmission, and a prescription of opioids in the preceding 3 months were excluded. A total of 460 patients (165 Laparoscopic Cholecystectomy (LC), 200 Laparoscopic Appendicectomy (LA) and 95 Open Inguinal Hernia Repair (OIHR)) were included in analysis. Opioids were prescribed to 53% of LC, 55% of LA, and 60% of OIHR patients, with a mean of 75.8 Morphine Milligram Equivalents (MMEs), 75.3 MMEs, and 82.8 MMEs respectively. Seven percent of patients (18/254) received a second opioid prescription within 3 months, and of those only 1.6% (4/254) received a further prescription between 3 and 6 months from discharge. Opioid prescribing did not correlate with operation, ethnicity, age, length of stay, or gender, except for males receiving a more MMEs than females following LC (mean 102.0 MMEs versus 65.4 MMEs, P= 0.017). This study shows a rate of opioid prescribing lower than the USA, and greater than seen in an Australian setting. Substantial amounts of opioids were prescribed following uncomplicated surgery, with significant variability. Improvements in training in post-operative opioid prescribing are needed. Fortunately, rates of ongoing opioid use were low.