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Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: We determined the relation between promoter methylation and mRNA expression of the p53 target genes APAF-1 and DAPK-1 in 55 consecutive tumor and corresponding normal tissue samples. Materials and Methods: Tissue was taken from nonmetastatic clear cell renal cell carcinoma at a median followup of 75 months. Quantitative methylation specific real-time polymerase chain reaction and quantitative real-time reverse transcriptase-polymerase chain reaction were used. Results: The mRNA expression levels of APAF-1 and DAPK-1 were significantly higher in tumor vs nontumor tissue from the same kidney (p = 0.003 and 0.0001, respectively). Expression levels of the 2 genes did not correlate with tumor stage but they were significantly lower in high grade (G3) tumors (p = 0.018 and 0.05, respectively). In patients with positive lymph node staging mRNA expression of APAF-1 and DAPK-1 was significantly lower. On matched pair analysis of tumor tissue the methylation level of the APAF-1 gene correlated inversely with the mRNA expression level (p = 0.02). In tumor and normal kidney tissue from patients with lesions 4 cm or greater mRNA expression levels of DAPK-1 were significantly lower in those who later had metastatic disease (p = 0.04 and 0.02, respectively). Conclusions: These data demonstrate decreased tumor suppressor gene expression in more aggressive subtypes of clear cell renal cell carcinoma. The lower mRNA level of the DAPK-1 gene in tumor and normal tissue from patients with an unfavorable clinical outcome suggests the organ specific loss of tumor suppressor gene expression, predisposing to metastatic tumor disease and shorter overall survival. [Copyright &y& Elsevier]

Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Locally confined prostate cancer (PCa) can be treated by various treatment options (e.g. radical prostatectomy or radiation therapy) with comparable results but different possible side effects. Therefore, treatment recommendations can vary between urologists and radiation oncologists. In 2001 the Charité-Campus Benjamin Franklin (CBF, Berlin), established the first interdisciplinary consulting service for prostate cancer patients in Germany. The aim was to offer a comprehensive and neutral consultation on all treatment options and to make treatment recommendations. The study examines what benefits may be derived from this type of consultation. A total of 362 patients presented to the consulting service between May 2001 and April 2003. Two questionnaires were used. The first one contained epidemiological questions as well as questions covering information already available on PCa. It also examined feelings and fears about the disease and possible treatment options. The second questionnaire was completed 2 weeks after the consultation to evaluate the treatment decision, determine the patient’s satisfaction with the consultation and trace the development of feelings and fears. Of the patients, 334 (92.2%) were completely assessable. All patients had already obtained information about the disease and possible treatment options and wished to be involved in the decision-making process through objective and neutral consultation. Nearly all of them had a great fear of the possible side effects of therapy. Such a comprehensive consultation is time-consuming (average of 35 min) but largely received a very positive assessment in that a total of 66% found it either helpful (n=74, 22%) or very helpful (n=147, 44%). Patients felt they had been completely informed in 92% of the cases. Only 22 (9.7%) had still failed to make a decision after 2 weeks, 115 patients had stage T1c, PSA<10 ng/ml and a Gleason score =7. In these cases an equivalent recommendation for radical prostatectomy, percutaneous radiotherapy or permanent seed implantation was given. Of these, 49 (43.4%) decided on the surgical intervention, 48 (42.5%) on a type of radiotherapy and only 18 (15.6%) remained undecided. The histological examination of prostatectomy specimens from patients who had decided to undergo radical surgery at CBF showed a significant decrease in the rate of extracapsular disease extension (=T3) from 38% to 20% during the observation period. The interdisciplinary approach has made the process of deciding on an appropriate treatment much easier for the patient. The time-consuming consultation enables better selection of individual treatment modalities and their possible side effects from the point of view of both the patients and the attending physicians. In this study, patients chose either radical surgery or radiotherapy with equal frequency. [ABSTRACT FROM AUTHOR]

Schostak M, Wloch H, Müller M, Schrader M, Offermann G, Miller K. Optimizing open live-donor nephrectomy – long-term donor outcome. Clin Transplant 2004: 18: 301–305. © Blackwell Munksgaard, 2004 The technique of laparoscopic or retroperitoneoscopic donor nephrectomy has been increasingly propagated in recent years. The central advantage is supposed to be a reduction of perioperative discomfort. However, there have not been many reports describing the subjective feeling associated with an open donor nephrectomy, particularly with respect to the pain level in the perioperative and long-term course. This retrospective study examines the perioperative pain and morbidity and long-term outcome of living kidney donors from 35 yr of experience at the University Hospital Benjamin Franklin of the Free University of Berlin. A total of 102 living kidney donors were asked to fill out a questionnaire. Five epidemiological questions were posed and the rest dealt mainly with lasting subjective and objective surgical impairments. There were also questions relating to the perioperative pain level (VAS/NAS-Score). In addition, basic information was obtained regarding the donor's current health status (physical examination, serum creatinine; sometimes also ultrasound, protein IU, blood pressure), and/or examinations were performed. The mean age at the time of donation was 45.5 and 55% were women. Donor nephrectomies were left-sided in 78 cases and right-sided in 24. There was a total complication rate of 53%, but serious complications only occurred in two cases (1.9%). A total of 53 donors could be reached. Although 41.5% felt they had a lasting impairment, somatic sequelae like respiratory, abdominal or scar problems were rare, affecting a maximum of only four patients in each case. Fifteen patients reported neurological problems such as sensory disturbances. The mean serum creatinine was 89.9 μmol/L in female and 114.2 μmol/L in male donors. Microalbuminuria was found in 22.6% of the donors, hypertension in 35.8%. Persistent pain was reported by 20.7%, its occurrence being permanent in two of the donors and very frequent in one. All the others rarely have pain. The median perioperative VAS/NAS score was 8 on the first day after surgery, 5 after 1 wk and 1 after 1 month. The analgesia was rated as good or very good by 71%. Everyday life was managed as well as before surgery after 2–4 wk by the highest percentage (42%) of patients, but working capacity was only regained after 1–3 months by a comparable percentage (44%). Forty-six percent had a very good and 33% a good feeling after the kidney donation. The relationship to the recipient had intensified in most cases. Ninety-one percent would again decide in favor of a donation. Donor nephrectomy in an open technique is a safe and reliable procedure with low morbidity. After a median post-operative period of 7 yr, however, 42% of the donors still report general impairment due to the intervention, although concrete somatic problems were only detected in a few cases. Nearly all these patients underwent surgery in a full flank position. Wound-healing impairments were also significantly more frequent with this surgical technique. This positioning should thus be avoided. The post-operative pain level was relatively high, but a marked improvement was achieved in the course of the observation period by optimizing analgesic management. [ABSTRACT FROM AUTHOR]

Objectives. To examine, in a prospective, randomized study, the effect of different anesthetic techniques versus no anesthesia in a 10-core prostate biopsy. Reports thus far have shown a high variability in assessing the pain intensity of prostate biopsies and the effectiveness of anesthesia.Methods. Ultrasound-guided 10-core prostate biopsy was performed. Patients were prospectively randomized into four groups: no local anesthesia (group 1); anesthetic block of the prostatic plexus (group 2); local anesthesia onto the capsula of the apex (group 3); and a combination of the anesthesia used for groups 2 and 3 (group 4). The degree of pain was recorded using the visual analog scale/numeric analog scale (VAS/NAS) score.Results. The study included 187 patients. Results were assessed in 170 patients: 44 in group 1, 44 in group 2, 40 in group 3, and 42 in group 4. In group 1 (no anesthesia), 2 (4.5%) of 44 patients had no pain during biopsy (VAS/NAS = 0); the pain was mild (VAS/NAS of 1 to 4) in 38 (86.4%), moderate (VAS/NAS of 4 to 7) in 3 (6.8%), and severe (VAS/NAS of greater than 7) in 1 (2.3%) of 44 patients. The mean pain scores were 2.33 in group 1, 1.68 in group 2 (P = 0.05), 1.07 in group 3 (P <0.001), and 1.23 in group 4 (P <0.001). Pain caused by the local anesthesia itself was 0 in group 1, 1.52 in group 2 (P = 0.001), 1.05 in group 3 (P = 0.001), and 1.79 in group 4 (P = 0.001).Conclusions. Local anesthesia significantly reduces pain. An injection onto the capsule at the apex was the most effective technique. It is technically easier to perform than an anesthetic block of the prostatic plexus and can be recommended. [Copyright &y& Elsevier]

The general advances made in minimal invasive surgery in the last 15 years has also led to the introduction of several new techniques for treating female incontinence. In the further development of bladder neck suspension according to Stamey-Pereyra, the use of miniature bone anchors received considerable support. Bladder neck suspension according to Stamey-Pereyra yields good initial results with a low complication rate but achieves permanent continence in only 40-71%. The anterior percutaneous implantation of miniature bone anchors with the attached suspension effects continence rates between 24% and 94%. Healing rates for transvaginal application of miniature bone anchors range from 52% to 100%. Reactions to foreign bodies are particularly common with synthetics but also occur with autologous materials. They are often associated with detrusor instability or sensory urge symptoms. Though these minimally invasive techniques can reduce the severity of stress incontinence, long-term healing is only achieved in about half the cases. The techniques described appear to be particularly unsuitable for treating grade III stress incontinence. The morbidity is unacceptable, especially when synthetic material is used in combination with bone anchors. Impaired vaginal wound healing often occurs in conjunction with irritative symptoms. [ABSTRACT FROM AUTHOR]

Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

One of the oldest methods used in minimally invasive surgeries is the transurethral resection. This is an operation technique in which diseased tissue from the bladder or the prostate is removed using a resectoscope through the urethra [Schostak M, Blana A, Hrsg. Alternative operative Therapien in der Uroonkologie. Berlin, Heidelberg, Springer Berlin Heidelberg; 2016]. A resectoscope has a channel for the view of the surgeon, a liquid supply, a working channel and a hand piece which could rotate up to 360 degrees. A RF- electrode on the tip of the resectoscope is used to cut out pathological growths. For diseased tissue which is located in the bladder on the ventral side, a rotation of the resectoscope up to 180 degrees is necessary. This means on the one side tiring of the hands, wrist pain and a change of the position of the operating surgeon. On the other side a reorganization of the connected tubes and cables is necessary. To avoid these problems and integrate additional features a standard resectoscope was adapted with an easy to use twist mechanism. After discussion with experienced urological surgeons a complete new design of the resectoscope with a twist mechanism in combination with a gyro sensor and a reference display was realized.

Operative approaches to solve severe urinary incontinence following radical prostatectomy include artificial urinary sphincters, bulking agents, urethral sling procedures, and the ProACT device (Uromedica Inc.). Previously reported complications of the ProACT procedure comprise ruptures and dislocations of balloons as well as erosions and perforations of the bladder or urethra. We report the case of a rectal perforation as a late complication of the ProACT procedure after prostatectomy and adjuvant radiotherapy. To the best of our knowledge this complication has not been described before. [ABSTRACT FROM AUTHOR]

Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background In spite of excellent cure rates for prostate cancer patients with favorable tumor characteristics, patients with unfavorable characteristics after radical prostatectomy are still at a significantly increased risk of tumor progression. Early adjuvant hormonal therapy (AHT) has been shown to be of prognostic benefit in these patients. Unfortunately initiation and duration of early AHT in the individual patient is based on statistic data. PSA, as the standard prostate marker is neither able to reliably indicate minimal residual tumor disease in the early postoperative phase, nor can it be used for therapy monitoring due to the suppressive effect of hormonal therapy on PSA production. Promoter hypermethylation of the detoxifying glutathione-S-transferase P1 gene (GSTP1-HM) has been shown to be the most common DNA alteration of primary prostatic carcinoma which, when used as a marker, is supposed to be able to overcome some of the disadvantages of PSA. However until now information on the impact of hormonal therapy on the detection of GSTP1-HM is lacking. The purpose of our study was to assess the impact of endocrine therapy on the detection of GSTP1-HM by methylation-specific PCR (MSP) in prostate cancer. Methods Paraffin embedded tumor samples from the radical prostatectomy (RP) specimens from 15 patients after hormonal therapy (HT) (mean 8 months) were assessed by MSP. In 8 of the patients the GSTP-1 status of the tumors before HT was assessed on the corresponding initial diagnostic biopsies. Results Following HT MSP showed GSTP1-HM in 13/15 of the RP specimens. In two patients analysis of the RP specimens failed to show GSTP1-HM. All initial tumor samples (8/8 biopsy specimens) showed GSTP1-HM, including both patients negative for GSTP1 HM in the corresponding RP specimen. Conclusion In most cases hormonal therapy appears to not alter GSTP1 HM detection. However the change from a positive to a negative GSTP1 HM status in a subset of the patients may point to an, at least partial androgen dependency. Further studies on a larger cohort of patients are necessary to assess its frequency and the exact hormonal interactions.

Background: In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. Methods: The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. Results: Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4–5) are now treated by interventional radiology. Conclusion: Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology. [ABSTRACT FROM AUTHOR]

Abstract Background The activity of the ribonucleoprotein enzyme telomerase is detectable in germ, stem and tumor cells. One major component of telomerase is human telomerase reverse transcriptase (hTERT), which encodes the catalytic subunit of telomerase. Here we investigate the correlation of telomerase activity and hTERT gene expression and the differentiation status of primary testicular germ cell tumors (TGCT). Methods Telomerase activity (TA) was detected by a quantitative telomerase PCR ELISA, and hTERT mRNA expression was quantified by online RT-PCR in 42 primary testicular germ cell tumors. The control group consisted of benign testicular biopsies from infertile patients. Results High levels of telomerase activity and hTERT expression were detected in all examined undifferentiated TGCTs and in the benign testicular tissue specimens with germ cell content. In contrast, differentiated teratomas and testicular control tissue without germ cells (Sertoli-cell-only syndrome) showed no telomerase activity and only minimal hTERT expression. Conclusions These findings demonstrate an inverse relationship between the level of telomerase activity and hTERT mRNA expression and the differentiation state of germ cell tumors. Quantification of telomerase activity and hTERT mRNA expression enables a new molecular-diagnostic subclassification of germ cell tumors that describes their proliferation potential and differentiation status.

Objectives: To determine cytokeratin 20 (CK 20) expression in tumor tissue, normal urothelial tissue, bladder washings, and urine from patients with urothelial carcinoma by real-time reverse transcriptase-polymerase chain reaction using the LightCycler Instrument.Methods: Urine, bladder washings, tumor, and normal urothelial tissue were obtained from 33 patients with bladder carcinoma. RNA was subsequently extracted. Twenty tissue samples from healthy volunteers were used as controls. Real-time reverse transcriptase-polymerase chain reaction with the LightCycler was performed using fluorescence-labeled CK 20 primers as the target gene and the porphobilinogen deaminase housekeeping gene as the internal standard.Results: CK 20 mRNA expression was detected in all samples investigated. CK 20 expression in the tissue and urine samples from patients with tumor was significantly increased compared with that in normal urothelial tissue (P = 0.028) or urine from the negative control group (P = 0.012). The average CK 20 expression was 70,140 arbitrary units (AU) in tumor tissue (30,533 AU in urine from patients with tumor) and 8460 AU in normal urothelial tissue (2234 AU in normal urine). A stage-related difference in CK 20 mRNA expression was observed in tumor tissue (P = 0.027) and for tumor grade G1-G2 versus G3 (P = 0.03).Conclusions: CK 20 mRNA expression levels in tissue and urine were elevated in patients with urothelial carcinoma compared with the levels in healthy individuals. CK 20 expression was also detectable in normal urine or normal urothelial tissue, but at significantly lower levels than in tumor samples. Fluorescence-labeled quantitative polymerase chain reaction using the LightCycler helped to differentiate between low-level CK 20 expression in normal urothelial tissue and the levels in tumor tissue samples. CK 20 might be an excellent and sensitive marker for tumor monitoring and routine follow-up in patients with transitional cell carcinoma. [Copyright &y& Elsevier]

Purpose: The aim of this study was to assess the post biopsy infection rate, feasibility and prostate cancer (PCa) detection rate (CDR) by performing transperineal MRI-TRUS fusion biopsy of the prostate (TPBx) under local anesthesia (LA) without antibiotic prophylaxis (AP). Methods: We prospectively screened 766 men with suspicious lesions on mpMRI, an elevated PSA level or a suspect digital examination undergoing MRI-TRUS-TPBx in LA, from May 2019 to July 2020. Patients with the need for antibiotic prophylaxis or without a PI-RADS target lesion were excluded from final analyses. We reported CDR, perioperative pain (0–10) and postoperative complications. PCa with an ISUP grade ≥ 2 was classified as clinically significant PCa (csPCa). Results: We included 621 patients with a median age of 68 years (IQR 62–74), a PSA of 6.43 ng/mL (IQR 4.72–9.91) and a prostate volume of 45 cc (IQR 32–64). In median, 4 targeted (TB) (IQR 3–4) and 6 (IQR 5–7) systematic biopsies (SB) detected in combination overall 416 (67%) PCa and 324 (52%) csPCa. Overall CDR of TB for PI-RADS 3, 4 and 5 was 26%, 65% and 84%, respectively. Patients reported a median perioperative pain level of 2 (IQR 1–3). Four patients (0.6%) developed a post biopsy infection, one experienced urosepsis. Conclusion: Our results demonstrate that transperineal MRI-TRUS fusion-guided prostate biopsy under LA without AP is feasible, safe and well tolerated. [ABSTRACT FROM AUTHOR]

Purpose: To investigate focal therapy using High Intensity Focused Ultrasound (HIFU) for the treatment of localized prostate cancer (CaP), we analyzed the safety and complications of this procedure.Methods: Patients (pts) eligible for this multicenter prospective cohort study suffered from low to intermediate risk localized CaP with no prior treatment. After tumor identification on multiparametric MRI and in prostate biopsy, the lesions were treated with HIFU observing a safety margin of 8 to 10 mm. Adverse events (AE) after 30 and 90 days, as well as the required interventions were assessed and stratified for treatment localizations.Results: Of the 98 men included in the study in two European centers, 35 (35.7%) experienced AEs in the first 30 days after HIFU intervention with Clavien-Dindo grade ≤ II: 15 pts (15.3%) had a postoperative urinary tract infection and 26 pts (26.5%) a urinary retention. Four pts (4.1%) underwent subsequent intervention (Clavien-Dindo grade IIIa/b). The number of late postoperative complications occurring between 30 and 90 days after intervention was low (2.0%). The highest complication rate was associated with tumors located at the anterior base (50.0%). The inclusion of the urethra in the ablation zone led to AEs in 20 out of 41 cases (48.8%) and represented a significant risk factor for complications within 30 days (odds ratio = 2.53; 95% confidence interval: 1.08-5.96; P = 0.033).Conclusions: Focal therapy of CaP lesions with a robotic HIFU-probe is safe and renders an acceptable rate of minor early AEs. The inclusion of the urethra in the ablation zone leads to an increase in early complications and should be avoided whenever possible. [ABSTRACT FROM AUTHOR]

Irreversible electroporation (IRE), a new tissue ablation procedure available since 2007, could meet the requirements for ideal focal therapy of prostate cancer with its postulated features, especially the absence of a thermal ablation effect. Thus far, there is not enough evidence of its effectiveness or adverse effects to justify its use as a definitive treatment option for localized prostate cancer. Moreover, neither optimal nor individual treatment parameters nor uniform endpoints have been defined thus far. No advantages over established treatment procedures have as yet been demonstrated. Nevertheless, IRE is now being increasingly applied for primary prostate cancer therapy outside clinical trials, not least through active advertising in the lay press. This review reflects the previous relevant literature on IRE of the prostate or prostate cancer and shows why we should not adopt IRE as a routine treatment modality at this stage. [ABSTRACT FROM AUTHOR]

Abstract: Hypermethylation of tumor-suppressor genes has been implicated in the pathogenesis of human cancers. This study was designed to examine the methylation profiles of a selected group of p53 target genes (APAF-1, CASP-8, DAPK-1, IGFBP-3) and to correlate the findings with the histopathological characterization of testicular germ cell tumors (TGCT). Promoter methylation status was analysed by highly sensitive real-time methylation-specific PCR in 46 primary TGCTs (26 seminomas and 20 nonseminomas) and 15 normal testicular tissue samples. APAF-1 methylation was detected in all of the seminomatous and nonseminomatous TGCTs as well as in 60% of normal testicular tissue. Methylation of DAPK-1 was frequent in seminomas (50%) and nonseminomas (20%), but not in normal testicular tissue (6%). The degree of DAPK-1 methylation correlated with the clinical stage of the disease (P=0.05) and was useful in differentiating seminomatous from nonseminomatous, and malignant from nonmalignant testicular tissue (P=0.04 and 0.02, respectively). The APAF-1 methylation index achieved a highly significant differentiation between seminomatous or nonseminomatous tissue and nonmalignant testicular tissue (P=0.0001). In testicular tumorigenesis, promoter methylation of specific p53 target genes occurs at early stage but to varying degrees. Methylation also occurs in normal testicular tissue, which is in contrast to findings in other urogenital malignancies. Further studies will be necessary to determine whether the methylation level may be used as marker for risk estimation, especially in clinical stage I disease. [Copyright &y& Elsevier]

Purpose: Blunt abdominopelvic trauma frequently results in injuries to the urinary organs, especially in polytrauma. The urotrauma is rarely an acute life-threatening event; however, it may lead to severe complications. Methods: This review addresses the under-representation of urological trauma management in interdisciplinary medical training and its impact on patient outcomes. It compiles evidence-based recommendations and guidelines from multiple specialties, focusing on common challenges in managing these injuries. The resource is tailored for primary care physicians in radiology, trauma surgery, internal medicine, urology, and nephrology. Results: Urinary tract injuries can occur even if the patient's condition initially appears normal. An exclusion diagnosis is obligatory by contrast medium tomography of the entire urinary tract and, if suspected, an additional uroendoscopic examination. Interventional therapy by catheterisation of the urinary tract is often required. Urosurgical treatment is not commonly needed, but when there is a demand, it must be administered via an interdisciplinary approach with visceral and trauma surgery. Over 90% of life-threatening kidney injuries (usually up to grade 4-5 AAST) are presently treated by interventional radiologists. Acute kidney injury (AKI) as a complication in trauma patients may complicate clinical management and often worsens the outcome. The incidence of trauma-associated AKI in patients admitted to an intensive care unit is high. Conclusions: Patients suffering from blunt abdominopelvic trauma should ideally be referred to certified trauma centres with subspecialised or fully specialised care provided by visceral/vascular surgery, trauma surgery, interventional radiology, urology, and nephrology. This recommendation is based on the complex nature of most damage patterns.