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Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) referrals result in Urological cancer diagnosis. The majority are bladder cancers, for which flexible cystoscopy is regarded the “gold standard” diagnostic procedure. Recent changes to suspected cancer referral guidelines, public information campaigns and reduced smoking prevalence may have changed this percentage. We retrospectively calculated cancer detection rates from NVH referrals to assess whether flexible cystoscopy,an invasive and morbid procedure, remains necessary.Patients and methods: All patients referred to our University teaching hospital on a suspected (“two-week”) cancer pathway with NVH over a 16-week period were included. Clinical and demographic data were collected for a series of 200 patients (96 male, age range 27–92, median 68).Results: Only eight patients had urological malignancy found (two renal and six bladder cancers). Both renal, and four bladder cancers, were identified on imaging prior to flexible cystoscopy. Only two bladder cancers were therefore detected by cystoscopy; one low-risk non-muscle invasive (patient has already been discharged) and one in a patient that was unfit for treatment (died of heart failure). Only seven (3.5%) of the patients were offered the option of not undergoing flexible cystoscopy.Conclusion: Our analyses suggest that flexible cystoscopy is rarely of benefit in patients with NVH. We suggest that patients should be given an accurate risk of bladder cancer diagnosis during the consent process. We advocate that flexible cystoscopy can be avoided for the majority of NVH referrals, particularly in patients without strong risk factors for urothelial cell carcinoma. Avoidance of flexible cystoscopy would reduce patient risks from procedural morbidity, reduce risks of acquiring coronavirus from hospital attendance, and there could be huge reductions in financial and service delivery demands in an overstretched secondary-care service.

OBJECTIVES To analyze our practice of drainless and catheterless day-case minimal-access pyeloplasty with regard to feasibility, safety and long-term outcomes. METHODS Patients undergoing minimal-access pyeloplasty (laparoscopic, with or without robotic assistance) in a single center between 2007 and 2020 were included in this retrospective observational study. Patient demographics and the success rate of day-case discharge along with postoperative outcomes were analyzed. RESULTS A total of 129 patients underwent minimal-access pyeloplasty in this time period, of whom 116 met the inclusion criteria. The mean patient age was 48 years. A total of 65% of the patients (n = 75) were discharged on the same day and 88% (n = 101) were discharged within 23 h of surgery. Of the 14 patients with a hospital stay of >24 h, pain was the most common reason (60%) for delayed discharge. The overall subjective (pain-free status) and objective (unobstructed drainage) success rates were 91% and 86%, respectively. CONCLUSION This study demonstrates that routine drains or urethral catheters are not necessary in minimal-access pyeloplasty, and their omission could facilitate early recovery and day-case discharge without compromising long-term surgical outcomes. Large randomized controlled studies are required to prospectively evaluate outcomes.

Context Adrenal incidentalomas (AIs) are increasingly being identified during unrelated imaging. Unlike AI clinical management, data on referral patterns in routine practice are lacking. Objective This work aimed to identify factors associated with AI referral. Methods We linked data from imaging reports and outpatient bookings from a large UK teaching hospital. We examined (i) AI prevalence and (ii) pattern of referral to endocrinology, stratified by age, imaging modality, scan anatomical site, requesting clinical specialty, and temporal trends. Using key radiology phrases to identify scans reporting potential AI, we identified 4097 individuals from 479 945 scan reports (2015-2019). Main outcome measures included prevalence of AI and referral rates. Results Overall, AI lesions were identified in 1.2% of scans. They were more prevalent in abdomen computed tomography and magnetic resonance imaging scans (3.0% and 0.6%, respectively). Scans performed increased 7.7% year-on-year from 2015 to 2019, with a more pronounced increase in the number with AI lesions (14.7% per year). Only 394 of 4097 patients (9.6%) had a documented endocrinology referral code within 90 days, with medical (11.8%) more likely to refer than surgical (7.2%) specialties (P Conclusion While overall AI prevalence appeared low, scan numbers are large and rising; the number with identified AI are increasing still further. The poor AI referral rates, even in centers such as ours where dedicated AI multidisciplinary team meetings and digital management systems are used, highlights the need for new streamlined, clinically effective systems and processes to appropriately manage the AI workload.

Background The prevalence of adrenal incidentaloma (AI) is increasing, with pressure on healthcare systems. While earlier guidelines recommended repeat endocrine testing to ensure stability, the recent European guidelines suggest that is not necessary if initial tests were reassuring. Aim To explore the utility of this guidance on repeat endocrine testing of AI. Methods Retrospective unselected review of AI cases reviewed before the European guidelines, based on local protocol (baseline overnight dexaethasone suppression test [ONDST] and plasma metanephrines +/- aldosterone: renin ratio [ARR] if hypertension or hypokalemia were present). At two years, the endocrine tests were repeated. We compared the baseline with the two-year follow-up data. Results We collected data on 54 patients initially identified (2011-2016). Post-ONDST cortisol (nmol/L): At baseline, 37/52 (71.1%), 12/52 (23.1%) and 3/52 (5.8%) had values 138 respectively. After 2 years, 20/28 (71.4%) had results of 0.33 nmol/L). Of these 8, 7 had values between 0.33 and 0.46, with the remaining one having a single markedly raised value at 206.8 nmol/L. At 2 years, we had data on 23 of these 43 patients, out of whom 20 had normal levels at both baseline and 2 years, 2 had abnormal results at baseline but normal at 2 years and one normal baseline value but slightly raised (0.36 nmol/L) at two years, with normal normetanephrines (0.33 nmol/L). Normetanephrine: Of the 43 cases with baseline results, only one was abnormal at 802 nmol/L (the same patient with a plasma metanephrine of 206.8 nmol/L). In this case, the normetanephrine became unremarkable after 2 years indicative of successful surgery. The remaining 22 cases with data at 2 years all had values within the reference range. Conclusion There was no significant change in function after two-year follow up, as defined by abnormal endocrine test results. Therefore, our findings support the European guidelines advice that repeat testing is not warranted. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Background Adrenal incidentaloma (AI) is an increasingly recognised finding, with pressure on healthcare systems. Earlier guidelines recommended interval scanning and testing to ensure stability. However, the recent European guidelines do not recommend the need for repeat scanning if initial assessment is reassuring. Aim To explore the utility of this guidance on need for interval scanning of benign AI. Methods A retrospective unselected review of AI cases seen in our unit before the launch of the European guidelines was conducted. At that time, a local protocol was in use to characterise scan and test adrenal functions at baseline, and at two years, the scan and endocrine tests were repeated. We compared the baseline scan results with those at two-years. Results We collected data on 54 patients initially identified between 2011 and 2016. Of these, 31 had left-sided lesions, 15 had right-sided lesions and 8 bilateral. Of the left-sided lesions, 16 increased in size over the 2.2-year follow-up period, 4 decreased in size and 17 remained the same. Of the right-sided lesions, 3 increased in size over the follow-up period, 6 decreased in size and 13 remained the same. Of those that increased (left- or right-sided), the largest increase was 5mm. Taking 2 mm as the cut-off for a significant change: on the left, 32/37 (86%) had a change ≤2mm (P Conclusion We found that there was no significant change in size after two years. Therefore, our data support the European guidelines that repeat scanning is unnecessary. This should be reassuring to patients and provide a more cost-effective service. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Whilst the estimated prevalence of adrenal incidentaloma is 0.5-2% following abdominal CT scan (1), little is known about subsequent endocrine referral patterns according to clinical specialty. We therefore examined the range of specialties that were responsible for requesting CT and MRI scans that led to reporting potential adrenal lesions. We also explored the referral pattern to endocrinology following identification. We extracted data from all radiology reports for all CT and MRI scans from Jan 2018-Oct 2019. We utilised a key phrase search strategy (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal). Where possible we excluded false hits (eg no adrenal lesion). These were lined to the referral patterns as identified by a referral logged or an attendance (new or follow-up) to endocrine clinic 3 months post index scan. These data were stratified by requesting specialty. Preliminary data showed that, out of 127878 scans, 2021 patients were identified to have a potential adrenal incidentaloma. These requests came from a total of 45 different clinical specialities (medical and surgical). The top 12 specialties accounted from 82.8% of these referrals. Medical specialties (renal, gastroenterology, respiratory, general medicine, acute medicine and geriatric medicine) accounted for 50.2%. The remaining 32.6% were via surgical specialities. The overall referral pattern in these cases was 8.5% with no difference between medical (8.6%) and surgical (8.4%) specialties. In conclusion, adrenal incidentalomas are potentially identifiable across a wide range of specialties. Currently, despite a dedicated adrenal multidisciplinary team and nationally-acknowledged quality improvement programme for the management of adrenal incidentalomas (2), the majority of cases are overlooked and not referred for endocrine review as suggested in current guidelines. We expect the findings in our centre to be reproducible elsewhere. We are considering innovative approaches to improve the process and cope with the additional workload cost-effectively. 1. Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol. 2003;149:273-285. Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Quality. 2019;In press.

It is estimated that the prevalence of adrenal incidentaloma increases with age: ~3% of those aged 50 years, rising to 10% in those >70 years (1). Given the aging population together with increased utilisation of cross-sectional imaging in the UK (eg CT urogram, MR angiogram), we explored the proportion of patients with adrenal incidentaloma by age based on current imaging trends. Furthermore, there is no information currently available on the relationship between age and pattern of endocrine referrals. We extracted data for all CT and MRI scans from Jan 2018-Oct 2019 and used key phrases in radiology reports (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal) to identify potential lesions. We also extracted data on patient age and referral patterns as identified by a logged referral or an attendance (new or follow-up) to endocrine clinic 3 months post index scan, stratified by 10 year age groups. Where possible, we excluded false hits (eg no adrenal lesion). Preliminary data showed that, of the 2604 potential lesions identified by CT and MRI scans, 78.7% were on patients aged over 60 years. The numbers of identified lesions gradually increased with age to a peak in the 71-80 year age group after which these declined. Whilst patients younger that 60 years had fewer potential lesions identified, they were more likely to be referred to endocrine services (73 out of 55 patients; 13.2%) than those in the older age group (168 out of 2049; 8.2%; p

The estimated prevalence of adrenal incidentaloma at abdominal CT scan is 0.5-2% (1). However, from clinical practice, we noticed that incidentalomas are referred from other imaging modalities (eg MRI) and of other sites (eg thorax, spine). We therefore explored the relationship between prevalence rates and (i) imaging modality and (ii) its change over time, in a real world clinical setting from a large UK teaching hospital/trauma centre. We also examined the referral pattern of potential lesions to endocrinology. We extracted data from all radiology reports for all CT and MRI scans from Jan 2018-Oct 2019. We utilised a key phrase search strategy (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal). Where possible we excluded false hits (eg no adrenal lesion). These were linked to the referral patterns as identified by a referral logged or an attendance (new or follow-up) to endocrine clinic 3 months post index scan. Preliminary data showed that, from a total of 127878 scans performed, 2604 potential lesions were reported (prevalence 2.0%), comprising 2496/88838 (2.8%) CT scans and 108/39040 (0.3%) MRI scans. The number of scans/month increased in 2019 vs 2018 (6.9% for CT and 12.6% for MRI). Only 9.0% and 15.7% of reported potential lesions detected by CT and MRI, respectively, were referred for endocrine review. Hence, MRI patients were more likely to be referred than those with CT scans (p=0.018). Referral rates were lower in 2019 than 2018 (8.6% vs 14.4%; p less than 0.001). This approach has its limitations but allows efficiently review of large cohorts. Adrenal incidentalomas pose a rising challenge in view of increasing reliance on scanning. Despite a dedicated adrenal multidisciplinary team with a national track record in improving management of incidentalomas (2), the referral rate of potential lesions is worryingly low and not improving, with >90% of cases overlooked. This work is part of on-going innovation to enhance the pick-up rate for these cases whilst addressing the increased endocrine workload in a cost-effective manner. 1. Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol. 2003;149:273-285. 2. Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Quality. 2019;In press.

IntroductionAdrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients.MethodsWe developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability.ResultsImplementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs.ConclusionsThe system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.

Renal arteriovenous malformations (AVMs) are rare, with an incidence of approximately 0.04%. Diagnosis is often challenging due to mimics of AVMs. We report a case of renal AVM mimicking hydronephrosis on ultrasound and unenhanced computed tomography (CT). A 24-year-old female with background of recurrent urinary tract infections (UTIs) presented to the Accident and Emergency department with 1 day history of bilateral flank pain, dysuria, rigors and pyrexia. Urine dipstick showed microscopic haematuria and blood tests showed mild neutrophilia. Dilated right renal pelvis was seen on ultrasound. Unenhanced CT of the urinary tract demonstrated right hydronephrosis with no evidence of calculi. Subsequent Uro-radiology meeting discussion concluded that renal pelvis might be pus-filled and recommended an urgent nephrostomy. However, ultrasound Doppler scan performed at the time of the planned nephrostomy demonstrated colour flow within dilated renal pelvis suggestive of an AVM. Nephrostomy was abandoned and subsequent CT angiogram confirmed a large congenital AVM. The patient was referred for embolization.Colour flow ultrasound imaging is a simple and quick technique to diagnose AVMs. However, as in our case, when colour flow Doppler imaging was not used at the initial ultrasound, the opportunity to obtain an accurate diagnosis was missed. If the subsequently planned nephrostomy had taken place, this may have led to potentially serious outcomes. We suggest that colour flow imaging should be used prior to nephrostomy insertion to differentiate hydronephrosis from vascular abnormalities.

Background: Adrenal incidentalomas (AI) are incidentally identified lesions whilst scanning for other purposes. They are mostly benign and hormonally inactive but about 20% are hormonally-active or malignant, requiring prompt intervention. The overall reported AI prevalence is 3-5% but increases with age (up to 7% of those above 70 years). Guidelines stipulate that patients with AI should be investigated, but only a small proportion of patients are referred for an endocrine work up.. We are not aware of any work that systematically looked at the proportion of missed cases of AI. Aim: To identify the proportion of missed cases with AI.Methods: Data on adrenal lesions reported on CT scans were collected, utilising pre-agreed key phrases to identify AI. These included the terms: Adrenal adenoma, Adrenal incidentaloma, Adrenal lesion, Adrenal mass, Adrenal nodule, Incidental adrenal, Indeterminate adrenal. These data were collected from 2014-2016, focusing on the referral for the month of November each year as a representative sample. Patients with known cancer were excluded and those with genuine AIs were then checked (based on MDT note entry and/or review of endocrinology letters) to confirm whether they were appropriately identified and then referred to endocrinology for further assessment or not.Results: November 2014: Out of a total 57 cases, identified using the key phrases, 30 had previously known malignancies and hence were excluded. This left a net of 27 genuine AI cases. Out of those, only 8 (29.6%) were referred for further assessment. November 2015: Out of a total 76 cases, 35 had genuine AIs (with 41 cases of known malignancy). Only 10 AIs were referred on (28.6%) November 2016: Out of a total 77 cases, 62 had genuine AIs (with 15 cases of known malignancy). Only 20 AIs were referred on (32.3%) The missed cases are equivalent to approximately one third of the endocrinology workload for our unit. Conclusion: Despite an established and dedicated MDT, only a third of cases are referred for further evaluation, with 70% are being overlooked. The potential for missing functional or malignant cases is a serious patient safety risk. Paradoxically, the financial implication for managing this work load is - to our knowledge - significant and has never been considered in a systematic way.

Objective: The objective of this article is to review the outcomes of our updated single-centre extended experience of an innovative enhanced recovery pathway to perform catheter- and drain-free laparoscopic pyeloplasties, achieving safe discharge within 23 hours of surgery. Patients and methods: We conducted a retrospective review of patients who underwent a standard trans-peritoneal laparoscopic pyeloplasty repair over an antegrade stent in our centre by a single surgeon, between 1 September 2007 and 1 February 2015. Patients who had a urinary catheter and/or peri-nephric drain inserted intraoperatively and were not planned for day-case discharge were excluded. Data were collected for duration of in-patient stay, readmission rates and reasons for these. Successful outcome was deemed both in subjective improvement of patient symptoms and/or objective improvement in post-operative MAG-3 renogram curve. Results: Fifty-eight patients were included. A total of 74% ( n = 43) were successfully discharged as day-case, and four of these were readmitted. Fifteen patients required in-patient stay, of whom two were readmitted. Successful outcome was recorded in 93% ( n = 54). Conclusion: The insertion of a drain and catheter are not essential in laparoscopic pyeloplasty. Avoidance of unnecessary tubes facilitates day-case surgery with no adverse effect on outcome. At our institute all patients are now offered the enhanced recovery protocol for laparoscopic pyeloplasty with resulting benefits both to patients and the local health economy.

Anastomosing variant of capillary haemangioma is a rare and recently described vascular tumour with a proclivity for the genitourinary tract. Here we present the case of a 64-year-old man with incidental finding of 3.4 cm renal mass on CT who had laparoscopic nephrectomy with a good postoperative recovery. Histopathological diagnosis of anastomosing haemangioma of the kidney was made and the patient was followed up for 10 months without evidence of tumour recurrence.

To determine whether day-case surgery (DS) laparoscopic pyeloplasty (LP) is feasible and safe.Thirty-two consecutive patients, planned for DS LP between March 2006 and January 2010 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LP after a standard pathway of care for DS. We collected demographic and medical information, including renographic data. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated.There were 20 (62.5%) females and 12 (37.5%) males with a median age of 37 years (range 11 to 69 y). The pelviureteral junction obstruction was on the left side in 19 (59.3%) patients and on the right side in 13 (40.6%) patients. The most common symptom was loin pain (68.75%). The majority of patients were classified according to their physical status as American Society of Anesthesiologists (ASA) 1 (59.37%), ASA 2 (37.5%), and only one patient (3.1%) as ASA 3. Surgical time varied from 90 to 210 minutes (mean 148.9 min, standard deviation 34.70). Twenty-five (78.12%) patients were successfully discharged on the same day. Two (6.25%) patients were readmitted after surgery. On follow-up renography, 96.15% had improved drainage. This is a small retrospective study reporting initial experience.The DS LP is feasible and safe. To improve the success rate and to decrease the readmission rate, objective preoperative, intraoperative, and discharge criteria should be developed for DS and validated in randomized studies.

To report our initial experience with day case surgery (DS) laparoscopic nephrectomy (LN) and to assess its feasibility and safety.Twenty-six consecutive patients, planned for DS LN between January 2006 and December 2009 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LN after a standard pathway of care for DS. We collected data regarding demographic information, medical comorbidities, preoperative and postoperative symptoms, admission as well as discharge time and date. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated.There were 12 (46.15%) women and 14 (53.84%) men with a median age of 46 years (range 11-77 y). The LN was on the left side in 15 (57.7%) patients and on the right side in 11 (42.3%) patients. Fifteen (57.7%) patients had benign diseases associated with nonfunctioning kidney and 11 (42.3%) patients had renal masses. The most common symptom was loin pain-53.3% for the patients with nonfunctioning kidneys; the majority of patients with tumors (45.6%) were asymptomatic. Twenty-two (84.61%) patients were successfully discharged the same day. Six (23.07%) patients were readmitted after surgery.The DS LN is feasible and safe. We believe that the results should be easily reproducible. Increasing experience may help to develop more rigorous preoperative, intraoperative, and discharge criteria to increase the success rate and to decrease the readmission rate for DS LN.

The current first-line recommended modality for nephrectomy is by the laparoscopic approach. This is one of the most frequent laparoscopic interventions conducted in urology. From a skills acquisition and delivery perspective in minimally invasive urologic surgery, there is a paucity of objective scoring systems for advanced laparoscopic urologic procedures. We developed a system of direct observation with structured criteria to evaluate the surgical conduction of laparoscopic nephrectomy (LN). We tested the application and preliminary validity of the scoring system.Sixty cases of prerecorded LN performed in four teaching hospitals were each analyzed by four mentors. Each mentor scored each case based on a 100-point scoring systemthat comprised 20 key steps for LN (each step ranging 0 to 5). Steps included port placement and safety checks in addition to the actual case. In addition, a negative marking system based on a 50-point index scoring system was deployed such that technically unsound techniques were penalized. The sum of the two resulted in the final score. The final scores independently submitted for each recorded case were analyzed and compared. The system was then used to predict the experience of a surgeon for 10 pilot cases. The cases included a mix of five fellows and five experienced laparoscopic urologic surgeons. The cases were blinded to the independent assessors. A further 20 cases involving 10 cases performed by a trainee who sufficiently completed training (as deemed by the recent award of a certificate of specialist training in urology) vs one who is not ready were reviewed.There was no significant difference in the scores submitted by each of the four mentors for each of the cases observed. There was a strong correlation between overall score and seniority/experience of the performing surgeon of each case; ie, it was able to predict whether an experienced surgeon or laparoscopic fellow performed the case. It was able to predict accurately between a trainee who sufficiently completed training vs one who is "not ready."The scoring system was a reliable tool for assessing the performance of LN and accurately predicts the level of experience of the surgeon. This system could be a useful supplementary tool for assessing the baseline skill and progress of trainees.

With the increasing prevalence of prostate cancer and evolving methods for the definitive treatment of OCPCa, health economic analyses will be critically important, albeit difficult to carry out. Preliminary studies point to RPP as the most cost-effective treatment for OCPCa. The quickest postoperative recovery, in experienced hands, occurs in RARP and RPP, with ORPP having a slightly, but statistically in significant, shorter hospital stay. It should be stressed that initial treatment costs are not the only important factor in healthcare costs. Readmission for early and late complications and the loss of productivity resulting from variation in time to return to work, need also to be considered. Loss of productivity may also vary in cost between different institutions and countries depending upon the proportion of patients employed. Further large-scale multicentre studies are necessary to assess this.

s / International Journal of Surgery 8 (2010) 501–578 533 Aims: ERCP is usually performed in OGSD patients. Most patients are subsequently counselled for cholecystectomy. This may be associated with significant morbidity in elderly patients. This study aims to assess if cholecystectomy can be safely deferred in elderly patients following successful ERCP for OGSD. Methods: All patients >75 year-old with OGSD, who underwent ERCP (June 2004-2008) in 2 centres, were included. Information regarding stenting, complications (failure, bleeding, cholangitis and stent migration), 30-day mortality and symptoms recurrence was retrospectively collected. The median follow-up period was 9 (6-36) months. Difference in ERCP outcome between the 2 centres was assessed by two-tailed t-test. Results: Centre 1(n1⁄4 54) Centre 2(n1⁄4 51) Total (n1⁄4 105) Sphincterotomy only 33(61.1%) 29(56.9%) 62(59%) Stent insertion 21(38.9%) 22(43.1%) 43 (41%) Complications 3(5.6%) 7(13.7%) 10(9.5%) 30-day mortality 3(5.6%) 1 (2%) 4(3.8%) Symptoms recurrence 11(20.4%) 5(9.8%) 16(15.2%) Cholecystectomy 4(7.4%) 11(21.6%) 15(14.3%) Overall, 85.7% of patients did not require cholecystectomy during the follow-up period. There was no difference between centres regarding number of stents inserted and 30day mortality (p>0.05). Centre 2 had a higher cholecystectomy and ERCP complication rate (p < 0.05%). Conclusions: The preliminary data suggests that cholecystectomy is not required in themajority of elderly patients with OGSD following successful ERCP. Longer follow-up is needed to determine if ERCP offers definitive treatment. ROLE OF ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE (USTAP) BLOCK IN ANALGESIC SUPPLEMENTATION FOR LAPAROSCOPIC RADICAL PROSTATECTOMY. PRELIMINARY FINDINGS Sashi Kommu, Anna Crosby, Zafar Hashim, Anurag Golash, Christopher Luscombe, Albin Augustine. University Hospital of North Staffordshire Introduction: Ultrasound Guided Transversus Abdominis Plane (USTAP) Block is a new regional anaesthetic technique that aims to block the abdominal neural afferents by instillation of local anaesthetic into the neurofascial plane that lies between the transversus abdominis and internal oblique musculature. We conducted a preliminary evaluation of the analgesic efficacy of this approach for Laparoscopic Radical Prostatectomy (LRP). Methods: Forty men undergoing LRP were given different modes of analgesia. Group 1 had general anaesthetic (GA) alone, Group 2 had GA and epidural, Group 3 had GA and patient controlled analgesia and Group 4 had bilateral USTAP Block. Post-operatively all groups received acetaminophen and non-steroidal anti-inflammatories as required. Each patient was objectively assessed at 24 hours. Results: The percentages of patients requiring morphine in the first 24 hours / the mean visual analogue pain scores at 24 hours were: Group 1 – 47/3.5; Group 2 – 100/3.0; Group 3 – 100/2.0; Group 4 – 47/1.2. Conclusions: USTAP Block offers satisfactory analgesic effects for patients undergoing LRP and appears to be safe with no complications. The role of USTAP in LRP and other minimally invasive urological procedures should be explored further. THE ROLE OF BONE SCAN AND PSA IN PATIENTS WITH NEWLY DIAGNOSED PROSTATE CANCER A. Damola , C. Lockett , B. Pettersson . 1 Countess of Chester Hospital NHS Foundation Trust; 2 Edith Cavell Hospital, Peterborough and Stamford Hospitals, NHS foundation Trust. Objective: To determine if bone scanning is necessary in newly diagnosed cases of prostate cancer with PSA < 20ng/ml. Material and methods: We analyzed the data of all our 246 patients with newly diagnosed prostate cancer from January 2007 to January 2009. We excluded 18 of these patients without histology or bone scan leaving 228 patients. Results: 44 patients had a positive bone scan, of which 37 were confirmed with further radiological imaging. Out of these 37 patients; there were 11 (8%) with PSA

Introduction: Acquiring skills for Laparoendoscopic Single-Site Surgery (LESS) is complex and shown to have a very steep learning curve. We aimed to develop and test the novel concept of Time-Lag for LESS skill acquisition using an ex-vivo training module. Methods: We used a Time-Lag Camera-Monitor System that allows for a 2.0 second delay between real-time hand movement and the perception of the movement on the monitor. We tested the impact of time-lag on the time taken to learn to perform a simulated Vesicourethral Anastomosis (VUA) by taking two groups of 3 novices and training the first group to perform the procedure with the time-lag system, and the second without the time-lag. Once each novice could perform the procedure satisfactorily, each group was timed in performing the VUA in a real-time setting. Results: The group who had initially trained with the time-lag system performed the final VUA 1.8 times faster than the second group. Video analysis showed that novices who trained using the time-lag system had reduced intention anxiety compared to the second group. Conclusions: The Time-Lag model has potential application in acquiring skills for LESS. It could be used for preliminary skill acquisition in other laparoscopic procedures during training.

s / International Journal of Surgery 8 (2010) 501–578 517 Methods: We studied patients with colorectal cancer (n 1⁄4 11,74 11y) and age-matched healthy controls (n 1⁄4 8,64 3y). We measured plasma myoglobin concentration, leg muscle mass (LMM) by dual-energy X-ray absorptiometry (DXA) and psoas muscle cross-sectional area (CSA) by computerized axial tomography (CT) (at the L3 vertebra). Results: Plasma myoglobin concentration was 31.2 9.6 vs. 42.9 8.71 ng/ml in patients with cancers and healthy controls, respectively. LMM was 6.49 1.94 vs. 6.42 1.62 kg in patients and controls respectively; Psoas CSA in the patients with colorectal cancer was 3363 1631 mm2 i.e. not significantly different from that in 56 previously examined patients (2873 1103 mm2) in who had normal diagnostic CT. There was no significant correlation betweenmyoglobin and psoas CSA (r21⁄4 0.0074; P1⁄4 0.87) (CT) or LMM (r2 1⁄4 0.4684; P 1⁄4 0.80) in patients. Conclusion: In early colorectal cancer, the extent of muscle wasting cannot be assessed by measuring plasma myoglobin concentration. BLADDER SPHINCTER VERGE URETHRAL PRESSURE REDUCES PAIN SCORES IN MEN UNDERGOING FIRST EVER FLEXIBLE CYSTOSCOPY Sashi S. Kommu, Zafar Hashim, David Cartlidge, Thomas Finnigan, Anurag Golash, Christopher J. Luscombe, Samson Liu, Mark F. Saxby, Jerry B. Emtage. University Hospital North Staffordshire, Stoke-on-trent, UK Introduction: Flexible cystoscopy (FC) is the most common endourological procedure done and is a source of significant discomfort/pain in men. We previously developed a novel scoring system to establish those at high risk of pain (Kommu et al. J Endourol 2006). We developed and tested the technique of Bladder Sphincter Verge Urethral Pressure (BSVUP) and its impact on pain scores in high risk men undergoing FC. Methods: All patients were given a single shot of Instillagel . A fluid bag at a standard height had pressure applied it as the cystoscope passed the Bladder Verge. A total of 200 patients were studied (100 had no BSVUP;100 had BSVUP). Pain scores were recorded during the procedure via visual analogue score. Results: The mean pain score among patients who had BSVUP was 2 (range: 2–8) compared with 4 (range: 3–10) for those who had no BSVUP. Eight patients in the in the Non-BSVUP arm found the procedure unbearable and a general anaesthetic cystoscopy. Conclusions: Bladder Sphincter Verge Urethral Pressure during flexible cystoscopy in ‘high risk for pain’ men, halves the pain scores. This is a simple readily applicable technique with no additional morbidity to the patient and at no additional cost. PLANNED COMPUTED TOMOGRAPHY AND ENDOSCOPY DURING FOLLOW UP OF PATIENTS WHO HAVE HAD RESECTION FOR OESOPHAGEAL CARCINOMA – IS THERE A SURVIVAL BENEFIT? N.C. Carter, S. Mercer, T. Geldart, M. Bayne, N. Davies. Royal Bournemouth Hospital Aims: Follow-up practice varies for patients undergoing osophagectomy and there is no published evidence about the contribution of planned imaging and endoscopy to survival. This paper aims to assess their contribution to survival. Methods: Patients undergoing oesophagectomy during a 6 year period were studied. Roughly half had “Planned” endoscopy and CT carried out at 1 year and CT alone at 2 years. Differences between the two groups were compared. Results: 127 patients had a minimum of 12 months follow-up. 26 developed symptomatic recurrence proven by CT within the first year. 59 asymptomatic patients underwent CT at 1 year, of which 53 (90%) were normal and 6 (10%) detected a recurrence. 47 asymptomatic patients underwent OGD at 1 year, none revealed any recurrence. 35 asymptomatic patients underwent CT at 2 years, of which 34 (97%) were normal and 1 (3%) detected recurrence. Long-rank analysis did not show any survival difference between the two groups at 1 and 2 years (p 1⁄4 0.318 and 0.447). Conclusions: The yield of CT scanning and OGD during follow-up after oesophagectomy is low for asymptomatic patients and does not appear to improve survival. Our data suggests that post operative imaging and endoscopy should be symptom-driven rather than planned. THE EFFECT OF DIETARY INTAKE OF OMEGA 3 AND OMEGA 6 POLYUNSATURATED FATTY ACIDS ON EARLY-ONSET PROSTATE CANCER RISK Joanna Lobaz, Nicholas Baylem, John Britton. University of Nottingham Background: In theUK, prostate cancer accounts for 24%of allmale cancers. Incidence varies globally, suggesting that modifiable risk factors exist. Objectives: Examine the effect of consuming omega 3 and 6 (U3&6) polyunsaturated fatty acids (PUFAs) on risk of early onset prostate cancer. It is hypothesized that high dietary intake of U3 decreases risk, while U6 increases risk. Methodology: 2088 patients were recruited into this case-control study. 805 men, aged 0.43 g /100 g food, OR 1⁄4 1.45, 95%CI 1⁄4 1.08-1.95, p 1⁄4 0.01). Conclusions: Omega3 derivatives may protect against early onset prostate cancer. Omega6 derivatives may increase risk. Further study is warranted. OSTEOGENIC DIFFERENTIATION OF HUMAN EMBRYONIC STEM CELLS IN-VITRO; FUTURE PROSPECTS FOR BONE TISSUE ENGINEERING IN ORTHOPAEDIC SURGERY Omair Shariq , Stephen Adshead , Eleftherios Tsiridis , Athanasios Mantalaris . 1 Imperial College London, UK; University of Leeds, UK Background and Aims: Replacing irreversible bone loss poses a significant challenge for orthopaedic surgeons. With an ageing population and shortage of donor material worldwide, tissue engineering has emerged as a state-of-the-art approach to providing 'off-the-shelf' bone substitutes. Human embryonic stem cells (hESCs) have a capacity for unlimited selfrenewal and pluripotency, making them an ideal material for tissue engineering. However, the osteogenic differentiation of hESCs is a labourintensive process, complicated further by unpredictable apoptosis in-vitro. This study reports the techniques used to differentiate hESCs into the