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Background The majority of patients with primary hyperparathyroidism (PHPT) have a single overactive adenoma. Advances in preoperative imaging and surgical adjuncts have given rise to minimally invasive parathyroidectomy (MIP), with lower complication rates in comparison with bilateral neck exploration. Misdiagnosis and undertreatment of multiglandular disease, leading to potentially higher recurrence rates, remains a concern. This study evaluated risks of long‐term (1 year or more) recurrence following ‘targeted’ MIP in PHPT. Methods Multiple databases were searched for studies published between January 2004 and March 2017, looking at long‐term outcomes (1 year or more) following targeted MIP for PHPT. English‐language studies, with at least 50 patients and a mean follow‐up of 1 year, were included. Results A total of 5282 patients from 14 studies were included. Overall mean recurrence and cure rates were 1·6 (range 0–3·5) and 96·9 (95·5–100) per cent respectively. Mean follow‐up was 33·5 (1–145) months. When intraoperative parathyroid hormone (PTH) measurements were not done, cure rates were higher (99·3 per cent versus 98·1 per cent with use of intraoperative PTH measurement; P

Objectives The roles of Allied Health Care Professionals (AHPs) in Head and Neck Cancer (HNC) are wide ranging but not clearly defined. Inter-regional variability in practice results from a lack of standardisation in approaches to the Multidisciplinary Team (MDT) make-up and structure. Traditionally, the follow-up of HNC patients is clinician led with multiple scheduled follow-up appointments. The increasing population of HNC patients provides logistical, monetary and efficiency challenges. This systematic review presents the roles of the multiple AHP sub-groups in HNC with the aim of presenting how their differing skill sets can be integrated to modernise our approach in follow-up. Design We searched MEDLINE, Embase, the Cochrane Library, NIHR Dissemination Centre, The Kings Fund Library, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify multiple subgroups of AHPs (Dentists, Speech and Language Therapists, Dieticians, Physiotherapists, Psychologists, Clinical Nurse Specialists) and evidence of their role in HNC follow-up. Evidence not directly relating to HNC follow-up was excluded. Setting and participants This Systematic Review was undertaken online by the Integrate (UK ENT Trainee National Collaborative) Head and Neck Subcommittee. Main outcome measures Most evidence was of low-quality, and the broad nature of the protocol provided a wide variety of study models. Two authors screened the articles for relevance to the topic before final analysis. Results The main role identified was improvement in Quality of Life and symptom control rather than detecting recurrence. We also demonstrate that it is possible to stratify HNC follow-up patients using their received treatment modality and Distress Thermometers to identify groups who will require more intensive AHP input. Conclusions HNC follow-up covers a broad group of patients with differing needs. As such, a blanket approach to this phase of treatment is likely to be less effective than a patient-led model where the group of AHPs are employed on a needs basis rather than at set time points. This will likely lead to greater patient satisfaction, earlier detection of recurrence and efficiency savings.

Background and purpose The advances in both video games and minimally invasive surgery have allowed many to consider the potential positive relationship between the two. This review aims to evaluate outcomes of studies that investigated the correlation between video game skills and performance in laparoscopic surgery. Methods A systematic search was conducted on PubMed/Medline and EMBASE databases for the MeSH terms and keywords including "video games and laparoscopy," "computer games and laparoscopy," "Xbox and laparoscopy," "Nintendo Wii and laparoscopy," and "PlayStation and laparoscopy." Cohort, case reports, letters, editorials, bulletins, and reviews were excluded. Studies in English, with task performance as primary outcome, were included. The search period for this review was 1950 to December 2014. Results There were 57 abstracts identified: 4 of these were found to be duplicates; 32 were found to be nonrelevant to the research question. Overall, 21 full texts were assessed; 15 were excluded according to the Medical Education Research Study Quality Instrument quality assessment criteria. The five studies included in this review were randomized controlled trials. Playing video games was found to reduce error in two studies (P 0.002 and P 0.045). For the same studies, however, several other metrics assessed were not significantly different between the control and intervention group. One study showed a decrease in the time for the group that played video games (P 0.037) for one of two laparoscopic tasks performed. In the same study, however, when the groups were reversed (initial control group became intervention and vice versa), a difference was not demonstrated (P for peg transfer 1 - 0.465, P for cobra robe - 0.185). Finally, two further studies found no statistical difference between the game playing group and the control group's performance. Conclusion There is a very limited amount of evidence to support that the use of video games enhances surgical simulation performance.

With a rising incidence of obesity and urolithiasis, we wanted to look at the outcomes of ureteroscopy (URS) for stone management in this group of patients.We did a systematic review of literature in accordance with Cochrane review and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines on all English language articles between 1990 and June 2015 for URS and stone treatment in obese patients. Data were retrieved for patient and stone demographics, outcomes of URS, complications, and follow-up.Fifteen studies (835 patients) were identified with a mean age of 49 years and a mean body mass index (BMI) of 40.5 kg/m(2). The overall stone size was 14.2 mm (range: 3-72 mm) with almost a third of the stones in the lower pole. The initial and final stone-free rate (SFR) was 76.9% and 82.5%, respectively, with an overall complication rate of 9.3% (n = 78). Except one patient with myocardial infarction, all other complications were Clavien grade I-III. The complication rate for morbidly obese patients (17.6%) was twice that of the obese patients (8.4%), although they were all graded as Clavien I or II.URS and stone fragmentation are safe and efficient treatment methods in obese patients with a good SFR and a relatively low complication rate, although the complications tend to be higher in the morbidly obese patients.

The aim of this study was to analyse prospective data on flexible ureteroscopy and laser fragmentation (FURSL) of large stones ( 2 cm) to assess whether a ureteral access sheath (UAS) is necessary for the treatment of large renal stones.Between March 2012 and October 2014, 43 patients with large stones underwent FURSL. Data were collected on a prospective database for patient demographics, stone characteristics and outcomes of FURSL with and without a UAS.There were 27 men and 16 women with a mean age of 54 years (range 7-84 years). The cumulative stone diameter was 2.92 cm (range 2-5 cm), with an overall stone-free rate (SFR) of 83.7%. A total of 68 procedures was needed (average 1.58 procedures/patient). The overall complication rate was 8.8% (n = 6); these were Clavien class II complications associated with urinary tract infections treated with additional antibiotics. UAS was not used in 28 procedures (41.2%). Comparing outcomes in those who had a UAS versus those who did not, there were no statistical differences in SFR, complication rate or average number of procedures per patients.Use of a UAS does not make any difference to the SFR or complication rate for FURSL in large stones ( 2 cm) and may not be routinely needed in all cases.

The aim of the present review was to look at the role of ureteroscopy (URS) for treatment of paediatric stone disease. We conducted a systematic review using studies identified by a literature search between January 1990 and May 2013. All English-language articles reporting on a minimum of 50 patients aged ≤18 years treated with URS for stone disease were included. Two reviewers independently extracted the data from each study. A total of 14 studies (1718 procedures) were reported in patients with a mean (range) age of 7.8 (0.25–18.0) years. The mean (range) stone burden was 9.8 (1–30) mm and the mean (range) stone-free rate (SFR) 87.5 (58–100)% with initial therapeutic URS. The majority of these stones were in the ureter (n = 1427, 83.4%). There were 180 (10.5%) Clavien I–III complications and 38 cases (2.2%) where there was a failure to complete the initial ureteroscopic procedure and an alternative procedure was performed. To assess the impact of age on failure rate and complications, studies were subcategorized into those that included children with either a mean age 6 years. (10 studies, 1377 procedures). A higher failure rate (4.4 vs 1.7%) and a higher complication rate (24.0 vs 7.1%) were observed in children whose mean age was

Ureteroscopic management of urolithiasis in pregnancy has been on the rise. Technological advancements such as the development of the semi-rigid or flexible ureteroscope, improvements in the design of baskets used for retrieval and the availability of laser have enabled atraumatic fragmentation of stones. We did a systematic review of literature from January 1990 to December 2012. Data were analysed separately for the time period from January 1990 to June 2010 (Period 1) and for last 2.5 years from July 2010 to December 2012 (Period 2). Inclusion criteria were all English language articles with at least three patients reported. Data were extracted on the outcomes and complications reported in the literature. A total of 271 procedures (116 in period 1, 155 in period 2) across 21 studies were reported in the last 22 years. General anaesthesia was used in 38% (44/116) in period 1 and in 64% (99/155) in period 2. The average stone size (7.6 mm) and stone-free rate (SFR) (85%) were similar in both time periods. Fluoroscopy was used in 20% (23/116) and 24% (38/155) in period 1 and 2, respectively. There were fewer complications in period 1 (n = 9) than period 2 (n = 25). These complications were divided into obstetric (n = 5) and non-obstetric complications (n = 29). There were no maternal or foetal deaths during the 22 years. Stone treatment using ureteroscopic techniques in pregnancy can achieve a high success rate. Evidence suggests a rise in the risk of complications with increasing number of these procedures in pregnancy.

The treatment of bilateral renal and/or ureteric stones can be challenging due to concerns about its safety and efficacy compared to staged ureteroscopy. This review evaluates the current evidence to look at the outcomes of bilateral simultaneous ureteroscopy (BS-URS) for urinary stone disease.A systematic review using studies identified by a literature search between January 1990 and August 2013. All English language articles reporting on outcomes of BS-URS for urolithiasis were included. Two reviewers independently extracted the data from each study.A total of seven studies (312 patients) were identified with a mean age of 40 years. Of the reported stone location, two thirds of the stones were in the ureter. With a mean operative time of 58 minutes, stone free status was achieved in 87.1% after the first look and 91.6% after a re-look for pure ureteric stones. Nearly 86% of patients had a postoperative stent inserted with a mean hospital stay of 2 days. In the pure ureteric stone cohort a total of 134 (50.8%) complications were reported. Around three quarters of the complications were Clavien I grading (hematuria, lower urinary symptoms and flank pain) and under a quarter were Clavien III complications.Although BS-URS achieved a high overall stone free rate; the complication rate seemed to be high. The quality of included studies in this review was weak and future research with good methodology is required to evaluate the feasibility and safety of BS-URS procedure.

INTRODUCTION: Renal lower pole stones pose difficulty in management due to anatomical variation, stone size, hardness and patient demographics. Flexible ureterorenoscopy and laser lithotripsy (FURSL) and shock wave lithotripsy (SWL) are preferred for stones 1-2 cm in size. We wanted to compare the outcomes of FURSL and SWL for lower pole stones during the same time period. MATERIAL AND METHODS: All patients who were treated for lower pole stones with FURSL and SWL during a 19-month period were included. The stone free rate (SFR) was defined as ≤3 mm fragments on follow-up imaging or stone free endoscopically. Data was recorded in an excel spreadsheet with SPSS version 21 used for statistical analysis. RESULTS: A total of 161 lower pole procedures were done (93 SWL and 63 FURSL). The mean stone size for SWL (7.4 mm; range: 4-16 mm) was significantly smaller than for FURSL (13.4 mm; 4-53 mm). The mean operating time and hospital stay for FURSL was 65 minutes (range: 30-160 minutes) and 0.5 days (range: 0-7 days) respectively. The SFR was significantly better (p

s / International Journal of Surgery 12 (2014) S13eS117 S57 55yrs. Patients treated between April 2008 January 2013. A single incision approach was used and repaired with anchor sutures. Results: Time to surgery, mean of 13.6 days, follow up mean 13.5 weeks, range 9 26 weeks. 2 patients lost to follow up at 9 weeks. Full range of movement in 15/17 patients. Pre-injury strength regained in 12/17 patients. 2 patients had reasonable power at 12 weeks. Slow improvement in 2 patients at week 12. 2 patients had complications, 1 had injury to lateral cutaneous nerve of the forearm, and 1 had a superficial blister proximal to the wound. Conclusions: Single incision approach has a low complication rate and a high satisfaction outcome. It provides acceptable functional recovery of elbow and forearm mechanics and we believe it a safe repair for distal biceps tendon injuries. 0298: TOTAL HIP ARTHROPLASTY TO TREAT FRACTURE NECK OF FEMURS e ARE NICE GUIDELINES BEING IMPLEMENTED? Piyush Mahapatra , Edmund Leong, Chris Huber. West Middlesex University Hospital, London, UK. Introduction: In 2011 NICE suggested that a specific subset of patients with a displaced intracapsular neck of femur fracture (#NOF) should be offered a total hip arthroplasty (THA); a significant paradigm shift from the traditional treatment of hemiarthroplasty (HA). This audit aims to ascertain whether the guidelines have changed local practice in a busy urban district general hospital. Methods: A retrospective analysis was performed of the local #NOF registry data for all patients who were admitted to our institution with a #NOF in 2012. Results: 230 patients were admitted. In total, 119 patients had intracapsular fractures, of which 108 were displaced fractures. 82 patients were treated with an arthroplasty; 79 HAs and 3 THAs. Of those patients treated with HA,15 met the new NICE guidelines for THA but had a HA instead of a THA. There was no statistical difference in length of stay of patients undergoing THA or HA (median 10 vs 11, p1⁄40.164; Mann-Whitney U). Conclusions: NICE ‘moved the goalposts' with the release of their guidelines and this study shows that institutions are struggling to find the new target. We feel that systemic changes have to occur in order to allow these guidelines to be effectively implemented. 0301: THE USE OF TRANEXAMIC ACID RESULTS IN DECREASED BLOOD LOSS IN PATIENTS UNDERGOING PRIMARY LOWER LIMB ARTHROPLASTY Max Marsden , Hiro Ishii, James Logan, Philip Pettit. Salisbury District General Hospital, Salisbury, UK. Introduction: To assess the effect of tranexamic acid (TXA) on blood loss, transfusion rate and length of stay following lower limb arthroplasty. Methods: The study group included 81 patients who underwent lower limb arthroplasty with 1g of TXA given at induction of anaesthesia for total hip replacement (THR) and at deflation of the tourniquet for total knee replacement (TKR). Post-operative haemoglobin, length of stay and blood transfusion episodes were recorded. These figures were compared with a historical cohort of 88 patients. Results: At 24 hours post operation the mean (± SD) drop in haemoglobin decreased from 3.5 ± 1.5 g /dL to 2.5 ± 0.9 g/dL following administration of TXA in THR p

The aim of the present review was to look at the role of ureteroscopy (URS) for treatment of paediatric stone disease. We conducted a systematic review using studies identified by a literature search between January 1990 and May 2013. All English-language articles reporting on a minimum of 50 patients aged ≤ 18 years treated with URS for stone disease were included. Two reviewers independently extracted the data from each study. A total of 14 studies (1718 procedures) were reported in patients with a mean (range) age of 7.8 (0.25-18.0) years. The mean (range) stone burden was 9.8 (1-30) mm and the mean (range) stone-free rate (SFR) 87.5 (58-100)% with initial therapeutic URS. The majority of these stones were in the ureter (n = 1427, 83.4%). There were 180 (10.5%) Clavien I-III complications and 38 cases (2.2%) where there was a failure to complete the initial ureteroscopic procedure and an alternative procedure was performed. To assess the impact of age on failure rate and complications, studies were subcategorized into those that included children with either a mean age6 years (four studies, 341 procedures) or a mean age6 years. (10 studies, 1377 procedures). A higher failure rate (4.4 vs 1.7%) and a higher complication rate (24.0 vs 7.1%) were observed in children whose mean age was6 years. URS for paediatric stone disease is a relatively safe procedure with a reasonably good SFR, but there seems to be a higher failure and complication rate in children aged6 years.

Objective To understand the role, safety and efficacy of flexible ureterorenoscopy and lasertripsy (FURSL) for paediatric renal stones. Material and methods A systematic review was conducted using studies identified by a literature search between January 1990 and March 2014. All English language articles reporting on a minimum of five patients ≤18-years old, treated with flexible ureteroscopy and lasertripsy for stone disease were included. Results A total of six studies (282 patients) were reported, with a mean age of 7.3 years (range 0.25–17 years). The stone sizes ranged from 1 to 30 mm. The mean stone-free rate across the three studies was 85.5% (range 58.0–93.0%) after initial ureteroscopy, with a postoperative stent inserted in 81.8% (range 66.7–98.0%). There were a total of 35 complications (12.4%), with the most severe complication being a Clavien class III (five ureteral injuries, one urinoma). There were no deaths in any of the studies. Conclusion The present review shows that FURSL for management of renal calculi in the paediatric population is an effective and safe procedure. To ensure that outcomes keep on improving, these procedures should be undertaken by experienced surgeons who are familiar with the difficulties encountered in the paediatric population.

Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer.To compare early surgical outcomes for RRC and open radical cystectomy (ORC) with an emphasis on complications and postoperative mortality rates.A literature review was conducted from 2000 to 2013, including studies comparing RRC and ORC. The main outcome measures analyzed were the complications and mortality rates, in addition to patient demographics, pathological parameters, operating time, estimated blood loss (EBL), transfusion rates, and type of urinary diversion. A meta-analysis was conducted. For continuous data, the Mantel-Haenszel chi-square test was used, and for dichotomous data, inverse variance was used and each expressed as risk ratio with 95% CI.In total, 748 patients were included, 461 patients in the robotic group and 287 patients in the open group (seven studies). There were no significant differences in the demographic parameters of the two groups, except for age (age: p=0.03). There was no difference in the number of muscle-invasive diseases: p=0.47. No difference in positive surgical margin rates (p=0.21).The overall (p=0.32) and lower grade (Clavien I-II) (p=0.10) complication rates between the two cohorts did not achieve statistical significance. The high-grade (Clavien III-IV) (p=0.007) complication rates in the ORC group were significantly higher. The mortality rate (Clavien V) was higher in the ORC group (2.2%) compared with the RRC group (0.35%) and this did achieve statistical significance on a meta-analysis (p=0.04).The EBL and transfusion rates were statistically significantly lower in the RRC cohort (p0.00001). The operating time was statistically significantly higher in the RRC cohort (p0.00001). There was no statistically significant difference in the margin positivity between the two cohorts (p=0.08).In early experience, RRC appears to be feasible and a safe alternative to the ORC. RRC appears to have lower high-grade complications and mortality rates compared with the open approach. Although these results are promising, the authors would suggest caution while interpreting these results due to concerns with methodological flaws in the included studies in this review.

Diagnosing urinary infection in patients with chronic lower urinary tract symptoms without dysuria is a critical step. In this study we scrutinize the sensitivity and specificity of dipstick urinalysis and microscopic pyuria (10 or more white blood cells per microl) to identify infection in such patients.This was a prospective, blinded, observational cohort study of urological outpatients with painless lower urinary tract symptoms. Midstream and catheter urine samples were analyzed. A total of 508 midstream urine samples were used to compare leukocyte esterase, nitrite dipstick and urine microscopy with cultures seeking 10(5) cfu/ml. Similarly 470 catheter urine samples were used to compare the same surrogates with 10(5) cfu/ml and with an enhanced culture method seeking 10(2) cfu/ml. A comparison of leukocyte esterase against microscopic pyuria was made using the 508 midstream and 470 catheter specimens of urine. Midstream urine specimens were provided by 42 normal volunteers for comparison.For a midstream urine culture at 10(5) cfu/ml leukocyte esterase was 56% sensitive, nitrite was 10% sensitive and microscopic pyuria was 56% sensitive. Specificities were 66%, 99% and 72%, respectively. For a catheter specimen of urine culture at 10(5) cfu/ml leukocyte esterase was 59% sensitive, nitrite was 20% sensitive and microscopic pyuria was 66% sensitive. Specificities were 84%, 97% and 73%, respectively. The enhanced culture of catheter specimen of urine at 10(2) cfu/ml was positive in 29% of patients vs 15% at 10(5) cfu/ml.Despite official guidelines and widespread use these tests cannot be considered appropriate for diagnosing urinary tract infection in patients with lower urinary tract symptoms, and should be abandoned in this context.