1191 The Use of CT Urography to Diagnose Upper Tract Urothelial Carcinomas (UTUC); Managing Surgical Resources During The COVID-19 Pandemic

Introduction

Upper tract urothelial carcinomas (UTUC) account for 5-10% of urothelial malignancies. Rapid diagnosis is essential as 60% are invasive at diagnosis and confer poor prognoses. European Association of Urology (EAU) guidelines recommend CT urography (CTU) for initial diagnosis and staging of UTUCs. Diagnostic ureteroscopy (URS) is used second line where diagnosis is unclear. The COVID-19 pandemic has limited theatre access and may delay diagnosis of suspected UTUC. Our aim was to evaluate specific CTU findings in predicting UTUC to aid prompt diagnosis and risk stratification in a tertiary centre.

Method

A retrospective analysis was performed on 122 patients who underwent CTU with diagnostic URS over two years from 2018-2019 for possible UTUC. Data including demographics, imaging and histology were collected from our electronic database.

Results

57 patients had confirmed UTUC, all had CT changes. CTU had an overall positive predictive value (PPV) of 45%. CT findings were divided into: hydronephrosis; filling defect/lesion; urothelial thickening; normal; or other. The PPV was highest for filling defects/lesions at 60%, hydronephrosis was 38%, urothelial thickening was 30%, and other was 33%. Of those with high-grade histology, 61% had evidence of filling defects/lesions and 24% had hydronephrosis.

Conclusions

A specific CTU finding of filling defect/lesion in combination with cytology can aid diagnosis and risk stratification of UTUC. This may enable us to reduce use of diagnostic URS, as well as associated risks of intravesical seeding, necessary in the COVID-19 pandemic. With other CTU findings of hydronephrosis or urothelial thickening, a diagnostic URS may be required.

1393 The Impact of Using A Virtual Reality Surgical Curriculum to Train Scrub Practitioners in Complex Orthopaedic Surgery

Background

The training scrub practitioners receive varies considerably in comparison to their surgical counterpart, although their performance is key to a proficient surgical team. For infrequent procedures that require specific and often intricate equipment such as revision total knee arthroplasty (RTKA), their training may be limited to an initial guidance session by company representatives. This study aims to evaluate the impact of using a virtual reality (VR) curriculum to train scrub practitioners in the performance of a RTKA.

Method

Ten orthopaedic scrub practitioners were enrolled into VR training across four sessions. Each VR session consisted of training where participants were guided through the assembly of equipment and steps of the surgery. In the concluding three sessions, each training session was supplemented by an assessment session in VR without guidance. The outcomes measured in VR assessment were incorrect procedural sequence, duration of surgery and efficiency of movement. The transfer of skills outside VR were assessed pre-training and post-training by the participants performance in a sequence of tasks using real equipment.

Results

All participants enhanced their surgical performance in successive assessed VR sessions reducing their operative time by 47%, assistive prompts by 75% and dominant hand motion by 28%. Improvements in VR showed effective transfer when assessed using real equipment with participants achieving superior scores post-training (11.3% versus 83.5%).

Conclusions

VR enables safe learning and provides measurable feedback of procedural steps and technical skills of complex orthopaedic surgery. VR is an effective training tool for scrub practitioners, with transfer to the real world.

Femoral stem tip orientation and surgical approach in total hip arthroplasty

INTRODUCTION

A posterior entry point, a neutral tip position and neutral stem alignment are recommended to avoid a thin cement mantle and ensure an optimal outcome in total hip arthroplasty (THA). Our aim was to highlight any influence of surgical approach in obtaining an optimal stem orientation.

METHODS

We examined the post-operative, digitised radiographs of 100 (50 each group) polished, tapered Exeter THA, inserted via the antero-lateral or posterior approaches. Stem tip position was assessed in both coronal and sagittal planes and stem alignment was assessed in the coronal plane.

RESULTS

There was a significant difference between the two approaches in the sagittal stem tip position only (p=0.01).

DISCUSSION

Our results illustrate that a neutral stem tip position in THA is significantly more difficult to obtain with an antero-lateral approach, when compared to the posterior approach. A posterior approach to the hip avoids the cuff of glutei that can lever the proximal stem anteriorly causing an anterior entry point and a posterior stem tip position. We also illustrate how the anatomy of the proximal femur in the sagittal plane makes a neutral stem alignment difficult to achieve with either approach.

Laparoscopic Management of Cryptorchidism in Adults

OBJECTIVES

Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group.

PATIENTS AND METHODS

Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition.

RESULTS

The mean age was 29 yrs (range: 19-36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice.

CONCLUSIONS

Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes.

Urinary tract infections: new insights into a common problem

This review discusses recent advances in the understanding of how the common pathogen, uropathogenic Escherichia coli, interacts with the host to lead to infection.

Diagnosis and immediate care of fractures of the knee

In the UK the three commonest bony injuries around the knee are tibial plateau fractures, supracondylar and intercondylar fractures of the femur and patellar fractures. This review will summarize the initial management of these injuries and of rarer but significant more minor fractures that must not be missed. The review will concentrate on the injury to the knee, but every trauma patient must be assessed fully following advanced trauma life support guidelines.