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Objective: This case series aimed to demonstrate that flexible cystoscopy and laser stone fragmentation via a Mitrofanoff stoma is possible and an effective treatment for symptomatic bladder stones in complex patients with inaccessible urethras and challenging anatomy. Patients and methods: We present three cases which were managed in a tertiary centre. The procedure involved using a flexible cystoscope via the Mitrofanoff stoma and laser stone fragmentation without the need for an access sheath. Results: This technique was performed safely and demonstrated successful bladder stone clearance on follow-up, with no postoperative complications. Conclusion: Our case series illustrates a technique that can be performed in this select group of patients in specialist centres with the relevant surgical exposure and expertise. Level of evidence Level 4.

Objectives To investigate predictive pathological factors for local recurrence (LR) after glansectomy for penile squamous cell carcinoma (SCC) and to develop a risk score for prediction of LR after glansectomy. Patients and methods In this retrospective study, we analyzed 117 patients operated between February 2005 and January 2016 in a supraregional penile cancer center in the UK for LR after glansectomy and glans reconstruction. Univariate and multivariate Cox proportional hazards regression was used to identify 4 prognostic indicators for LR. The hazard ratio (HR) of LR was estimated in Kaplan-Meier analysis, and based on these data, we designed a postoperative model for prediction of LR based on 3 risk groups. Results Median follow-up period was 33.7 (95% CI: 26.8–40.3) months; 12.8% of the patients experienced LR. Univariate Cox proportional hazards regression revealed that the risk factors for recurrence were the presence of perineural invasion, carcinoma in situ, positive margin on definitive pathology, and high-grade disease. Based on Kaplan-Meier analysis stratified by number of factors present, we defined 3 risk groups for LR: low (0,1 risk factors) as reference, intermediate (2,3 risk factors) with HR of 13.9 (95% CI: 1.81–107.04, P = 0.0115), or high risk (all 4 risk factors present) with a HR of 34.2 (95% CI: 3.07–381.81, P = 0,0041). Limitations include the retrospective design and low number of events inherent to the rare nature of penile SCC. Conclusions Perineural invasion, carcinoma in situ, positive definitive margins, and the presence of high-grade SCC predict LR following glansectomy. These factors can be used to stratify patients into low-, intermediate-, and high-risk groups for recurrence which may be used to tailor follow-up.

Background Penile cancer is a rare malignancy that is confined to the glans in up to four out of five cases. Although descriptions of glansectomy exist, there are no contemporary video explanations or large published single centre series. Objective To show the efficacy and safety of glansectomy and split-thickness skin graft (STSG) reconstruction. Design, setting, and participants Data were collected retrospectively for patients identified from surgical theatre diaries between February 2005 and January 2016. 177 patients with histologically proven squamous-cell carcinoma on the glans underwent glansectomy and STSG at a tertiary referral centre in the UK. The median follow-up was 41.4 mo. Surgical procedure The skin is incised at the subcoronal level and deepened onto Buck's fascia. Dissection is performed over or under Buck's fascia, depending on suspicion of invasion or risk of disease. The glans is excised and a neoglans is created using a STSG. Measurements Local recurrence, cancer-specific survival, overall survival, and complications. Results and limitations Sixteen out of 172 patients (9.3%) experienced local recurrence during the follow-up period. Eighteen out of 174 (10.7%) patients died of penile cancer, while 29 patients in total died during the follow-up period. Of 145 patients, 9% required operative intervention for complications, including graft loss and meatal stenosis. Limitations include the retrospective data collection and the lack of functional and sexual outcomes. Conclusions Glansectomy and STSG comprise a safe procedure in terms of oncologic control and complications for patients with penile cancer confined to the glans penis. Further studies are required to assess functional and sexual outcomes in these patients. Patient summary We report on the management of penile cancers confined to the head of the penis using glansectomy and a split-thickness skin graft to recreate the appearance of a glans. This technique is safe and effective, with limited complications.

BACKGROUND: Penile cancer patients with advanced metastatic disease in the inguinal region present a therapeutic challenge. We compared the outcomes for patients with advanced inguinal node disease requiring myocutaneous flap reconstruction (MFR) against primary closure for N3 disease. METHODS: A retrospective comparative study of a consecutive cohort of advanced penile cancer patients with N3 disease was performed. Patient demographics, presenting symptoms, primary tumour site, stage and grade were recorded. The type of MFR used, patient outcomes and post-operative complications were recorded from an institutional database. Kaplan-Meier (KM) curves were calculated to analyse the cancer-specific survival (CSS) rates for the MFR group and compared with the no-MFR group. P values were calculated by log-rank and Chi square tests for CSS rates and complications respectively. RESULTS: Eighteen patients requiring MFR were identified; mean age 62 years. Ten (55.6%) patients had a first presentation with penile cancer and advanced nodal disease with the remaining 8 (44.4%) presenting with an inguinal recurrence having already undergone surgery. The majority (n=15) underwent a vertical rectus abdominis myocutaneous (VRAM) flap. The average length of stay was 23 days for the MFR group versus 8.5 days for the no-MFR group. The 5-year CSS was 20.9% for the MFR group and 39.8% for the no-MFR group (P

Objectives To review the management and clinical outcomes of uni- or bilateral non-visualization of inguinal lymph nodes following dynamic sentinel lymph node biopsy (DSNB) in patients diagnosed with penile cancer and clinically impalpable inguinal lymph nodes (cN0). An additional objective was to develop an algorithm for the management of patients in which non-visualisation occurs. Patients and Methods This is a retrospective observational study over a period of 4 years comprising 166 patients with penile squamous cell carcinoma undergoing DSNB and followed up for a minimum of 6 months. All cases diagnosed with uni- or bilateral non-visualisation of sentinel nodes in this cohort were identified from a penile cancer database. The management of the inguinal lymph nodes following non-visualisation and the oncological outcomes including local and regional recurrence rates were documented. Results Out of 166 consecutive patients undergoing DSNB, 20 (12%) patients had unilateral non-visualisation following injection of intradermal 99mTc. Of these 20 patients, 7 underwent repeat DSNB at a later date with 6 having successful visualisation. One patient had persistent non-visualisation and proceeded to a superficial modified inguinal lymphadenectomy (SML). None of these patients experienced recurrence at follow-up. A further seven patients underwent modified SML with on table frozen section analysis of the lymph node packet; none of these patients were found to have micrometastatic disease in the inguinal lymph nodes although one patient developed metastatic inguinal node disease at a later date. Six patients elected to undergo clinical surveillance and have remained disease free. Conclusion Patients with impalpable inguinal lymph nodes undergoing DSNB with ≥ T1G2 disease should ideally have bilateral visualisation of the sentinel lymph nodes reflecting the drainage pattern from the primary tumour. In this series, 12% of patients were found to have unilateral non-visualisation following DSNB. Patients offered a repeat DSNB at a later date, were successful in localising the sentinel node in 86% of cases. Patients with favourable histological parameters can be placed on clinical surveillance. Those with high-risk disease can be offered a repeat DSNB procedure on the proviso that a SML may be carried out if there is repeated non-visualisation. Larger cohorts are required in order to validate this proposed algorithm. This article is protected by copyright. All rights reserved.

Introduction and objectives Adult undescended testicles (UDTs) often present to fertility specialists with subfertility or azoospermia and with either an intra-abdominal or inguinal testicle(s). Performing an orchidopexy followed by a surgical sperm retrieval (SSR) is a potential option to retrieve spermatozoa. A microdissection TESE (mTESE) procedure is performed to retrieve mature spermatozoa for use in ICSI. This paper reviews the outcomes of mTESE in adults following an orchidopexy. Material and methods A cohort of azoospermic patients underwent adult orchidopexy over a 10-year period at a single specialist centre. Data were collected retrospectively from the patient records retrieved from an institutional database. All patients underwent pre-operative imaging to localize the testicles, serum testosterone levels and a semen analysis. Separate intraoperative testicular biopsies were performed to exclude intratubular germ cell neoplasia (ITGCN) and to analyse the Johnsen score. Results Twelve patients (age range 18-36 years) underwent orchidopexy procedures for either intra-abdominal or inguinal testicles. Mean follow-up was 34 months (range 13-58). Ninety per cent of patients had bilateral UDT with azoospermia. Pre-operative testosterone levels were within the normal range (mean 13.9 nmol/L; range 9.1-24.2). Five pelvic testicles (from four patients) were brought down and underwent a delayed mTESE. A total of nine inguinal orchidopexy procedures were carried out in eight men, and spermatozoa were found and preserved in three patients. None of the men with intra-abdominal testicles had mature spermatozoa present following a delayed mTESE. Overall, SSR was successful in 37.5% of the patients. Histological analysis showed no cases of ITGCN and the Johnsen scores ranged from 1 to 3.3. Conclusions Microdissection TESE following orchidopexy for inguinal testicles can result in a successful SSR in over 1/3rd of patients. Intra-abdominal testicles appear to lack spermatogonia although the testicles can still be preserved for endogenous hormone production. Adult orchidopexy allows preservation of endogenous testosterone, easier self-examination and an immediate or delayed mTESE in azoospermic patients.

Background Primary squamous cell carcinoma (SCC) of the male proximal urethra is an aggressive and rare urogenital malignancy. Objective To review the surgical management and outcomes for male proximal urethral SCCs within a single centre and to suggest an algorithm for the surgical management of these rare tumours. Design, setting, and participants This was a retrospective study of patients undergoing surgery for male proximal urethral SCC within a single tertiary academic centre managing rare genital tumours. Ten patients with a histological diagnosis of proximal urethral SCC were identified from an institutional database over a period of 10 yr with a median follow-up of 22.5 mo (standard deviation ± 25.77 mo). Outcome measurements and statistical analysis Pathological staging, surgical treatment, and neoadjuvant and adjuvant treatment were recorded. Complications according to the Clavien-Dindo classification and overall survival rates were recorded. Kaplan-Meier curves were used for overall survival. Results and limitations A total of 10 patients were identified of whom eight underwent panurethrectomy and radical prostatectomy. Radical inguinal lymphadenectomy was performed in five patients, which confirmed bilateral metastatic disease. Perioperative complications were reported in six patients (Clavien I and II). Within 6 mo of surgery, 90% of patients developed distant metastatic disease. Nine patients died of urethra cancer during the follow-up. One patient is still on follow-up. The median overall follow-up was 13.92 mo (range: 5–91 mo). At 5 yr, cancer-specific/overall survival was 10%. A limitation of this study is the retrospective design, which is unavoidable for such a rare disease. Conclusions Radical surgery allows local disease control, but despite neo/adjuvant treatment, proximal urethral SCC is associated with poor survival outcomes and progression to distant metastatic disease within 6 mo. Patient summary Proximal urethral squamous cell carcinoma is a rare cancer in men which is often detected late. Patients often present with problems such as voiding, urethral bleeding, or a palpable mass. Aggressive surgery allows local control, but despite this the overall survival is poor. Adjuvant and neoadjuvant radiochemotherapy can improve survival. Multicentric randomised trials are needed to identify the correct treatment modality.

Introduction We reviewed the medical and surgical management and long-term outcomes for patients diagnosed with penoscrotal extramammary Pagets disease (EMPD) within an eUROGEN centre. Patients and Methods Retrospective review of cases from an institutional database with biopsy proven penoscrotal EMPD. Results A total of 10 patients were identified with penoscrotal EMPD over a 10-year period. Two patients had a previous history of gastrointestinal and urogenital cancers (20%) and no synchronous or metachronous cancers were identified. Eight patients with non-invasive EMPD (80%) underwent wide local excision of the affected skin, with at least a 5mm macroscopic resection margin and in selected cases simultaneous multiple mapping biopsies around the lesion were performed. Residual disease was present at the margins in seven patients (87.5%), of which three required further surgical excision or adjuvant topical immunotherapy (42.8%). Recurrence after complete excision was 12.5% and was successfully treated with topical imiquimod immunotherapy and CO2 laser therapy. Two patients (20%) had invasive carcinoma and metastatic disease at diagnosis. Conclusion Reported recurrence rates of non-invasive penoscrotal EMPD are high and residual disease is present in most cases requiring either close clinical surveillance or adjuvant treatment. We propose an algorithm in the management of this rare disease.

Penile cancer is a rare disease that constitutes 0.2 % of all male malignancies in Western countries but can account for over 10 % of malignant disease in men in some parts of Africa, Asia and South-America. This variation is mostly explained by socio-economic conditions and religious practices. Circumcision is found to be a protective factor (OR 0.33), mainly by prevention of phimosis. Penile cancer is also directly associated with areas of poverty.

We describe the case of a man aged 43 years who presented with a 2-week history of a palpable lump in the right proximal penile shaft. This was preceded by a 6-month history of perineal pain, accompanied by erectile dysfunction. An urgent MRI scan of his penis identified a thrombus within the right crus and corpus of the penis. His thrombophilia screen was normal. The patient was started on oral anticoagulation and a phosphodiesterase inhibitor (PDE-5i) to prevent thrombus progression and maintain erectile function. At 5 months, the patients9 symptoms had resolved and an MRI showed a reduction in the thrombus size. MRI is a useful imaging modality to diagnose a thrombus within the corpus cavernosum in patients presenting with a history of penile and perineal pain together with a palpable lump. The non-enhancement of the lesion helps to differentiate this from alternative rare lesions within the penis and perineum.

426 Background: Sarcopenia is a decrease in skeletal muscle mass and is a quantifiable marker of frailty associated with poor oncological outcomes. Currently there are no studies using sarcopenia as a prognostic indicator for patients with penile cancer. This study investigated the association of sarcopenia with mortality and morbidity outcomes in penile cancer patients in a specialist centre. Methods: A retrospective case-controlled study was performed. Patient cohort comprised 50 patients with metastatic penile cancer ( > pN2 disease) and 50 patients with non-metastatic disease (N0) ; minimum follow-up period of 2 years. Sarcopenia was classified as a skeletal muscle index < 55cm2/m2 and was measured using software and CT imaging. Results: Sarcopenia was present in 31% of our cohort (n = 100). A univariate analysis showed a statistically significant association between the following parameters and patient mortality; sarcopenia (p = 0.005), metastatic disease (p = 0.001), tumour stage (p = 0.001), sarcomatoid squamous cell carcinoma (p = 0.009), CIS (p = 0.034), lymphovascular invasion (LVI) (p = 0.001) and perineural invasion (p = 0.002). Logistic regression analysis found an association between mortality and sarcopenia (p = 0.035) and metastatic disease (p = 0.000) and approached statistical significance with LVI (p = 0.061). Subdividing our cohort into metastatic and non-metastatic groups, showed that sarcopenia was associated with mortality in patients with metastatic disease but was not associated with post-operative complications or chemo-radiotherapy toxicity. Interestingly, sarcopenia was associated with post-operative infection in patients undergoing surgery for non-metastatic disease (p = 0.027). Additionally, for every day remaining in hospital after the 4th post-operative day, there was a 1.275 increase in the risk of death in patients with sarcopenia. Conclusions: Sarcopenia has a potential role as a novel prognostic indicator and could be used as a risk stratification tool in patients with metastatic penile cancer when deciding treatment options. By identifying this subgroup, additional nutritional support and a supervised exercise program can be implemented to improve the morbidity rate.

Metastatic lesions in the penis are uncommon in patients with prostate or bladder cancer but penile metastatic lesions from rectal tumours are rare with only 65 cases reported in the literature. We describe the case of a 70-year-old man who developed metastatic lesions within his corpus cavernosum 2 years after being diagnosed and treated for a mucinous adenocarcinoma of the rectum and a year after a wedge resection of an isolated lung metastasis. He proceeded with total penectomy and intraoperatively two skip lesions were also found within the wall of his urethra; histological analysis proved that these were also metastatic lesions. A perineal urethrostomy was formed with the remaining macroscopically healthy urethra. He made a good recovery from his operation and continued his treatment under the oncology team.

We present the case of a 60-year-old man who was referred with a 1-year history of a slow-growing right scrotal lump. Following surgical excision together with a radical orchidectomy, the histological diagnosis was of a paratesticular dedifferentiated liposarcoma. Radiological staging showed no metastatic disease. Six months later the patient presented with a new left scrotal lump, which was felt to be separate from the testis. Owing to the previous history of a liposarcoma and indeterminate ultrasound findings, this was surgically excised without orchidectomy. Histological analysis showed this to be an angiolipoma. The patient remained on clinical and radiological surveillance. Paratesticular tumours are rare neoplasms and liposarcomas of the spermatic cord only represent 7% of these lesions. Any link between lipomatous tumours and liposarcomas remains controversial and is still under investigation. This is the first case to report a paratesticular liposarcoma and a contralateral angiolipoma in the same patient.

A 77-year-old man presented with a chronic lesion located in the left penoscrotal area. Apart from pruritus, bleeding and an occasional discharge from this area, he also reported reduced appetite and weight loss. Examination revealed an ulcerated skin lesion attached to a firm subcutaneous mass. Wide local excision of the lesion revealed invasive adenocarcinoma on a background of extramammary Paget's disease. Staging studies showed disseminated metastatic disease within the lymph nodes, and liver and bone metastases. He was treated with carboplatin and paclitaxel chemotherapy initially, but then continued only on Carboplatin chemotherapy due to side effects from Paclitaxel. Eleven weeks after the start of his chemotherapy, his restaging imaging showed reduced lymphadenopathy, unchanged liver metastasis and sclerosis of bone metastasis. With completion of chemotherapy, repeat imaging showed stable disease. The patient is currently on follow-up.

Controversy still exists in some centers on whether diabetes mellitus is a risk factor for penile prosthesis infection. The aim of this review is to examine the evidence correlating penile implant infections to the presence of diabetes mellitus in patients with organic erectile dysfunction.We performed a systematic review searching through Medline database from 1960 to 2014, using keywords; penile prosthesis(es), penile implant(s), and diabetes mellitus. We used the Prisma 2009 Flow diagram for systematic reviews. Thirty-eight publications were selected for inclusion in this qualitative analysis.Most case series reporting a greater infection rate in patients with diabetes mellitus date from the 1970s to 1990s. These series reported an infection rate of 5.5 to 20% and contained small cohort of patients. In the 1990s larger case series reported a lower infection rate in patients with diabetes mellitus compared with patients with paraplegia, pelvic trauma, and patients on steroids, but still reported an infection rate as high as 10.6%. With the implementation of antibiotic coated implants in 2001, infection rates reduced further with reported rates becoming less than 2% in patients with diabetes mellitus. The latest and largest case series by Eid et al. (2012) reported an infection rate of 0.46% with antibiotic coated implants and "no touch" technique in a cohort of 1511 cases, out of which 41% were patients with diabetes mellitus.Strong evidence exists that the risk of penile prosthesis infection has reduced over the decades with device improvement and surgical expertise. In larger case series infection rates in patients with diabetes mellitus is not statistically significant from that experiences in the population at large.

A urinoma is a collection of urine outside the urinary tract as a result of disruption of the collecting system. Obstructive causes of urine extravasation secondary to stones are not unseen but display a delayed diagnosis due to the gradual onset of symptoms, which can mimic pyelonephritis. We present the case of a 70-year-old female patient who was admitted to hospital with symptoms of right loin pain and sepsis. We describe her case from the initial clinical diagnosis of pyelonephritis to the final diagnosis of an infected urinoma after a calyceal rupture from an obstructive partial staghorn calculus. This case highlights the importance of early computerized tomography imaging in patients with renal stones and suspected pyelonephritis as ultrasound scans can sometimes be misleading. Misdiagnosis of infected urinomas delays definitive treatment and leads to increased morbidity.

425 Background: Squamous cell carcinoma (SCC) of the posterior urethra is rare and is associated with sexually transmitted infections, urethritis, chronic strictures or urethral surgery. Unlike anterior urethral SCC, the presentation of posterior urethral SCC is often late and there are currently no standardised treatment protocols. We present our series of posterior urethral SCC treated by radical surgery and bladder preservation by performing a pan-urethrectomy, radical prostatectomy with a bladder neck closure and chemoradiotherapy. Methods: We retrospectively collected data from patients diagnosed with posterior urethral SCC from a penile cancer database. Data including patient age, histological subtypes, surgical management, post-operative complications, chemo-radiotherapy and survival rates were recorded. Results: A total of 10 cases with histologically proven posterior urethral SCC were treated in a single centre. Median follow-up was 19 months (SD±10 months). Mean age at presentation was 49 years (SD±6.44) and usual type SCC (80%) was the most prevalent histological subtype followed by NOS and condylomatous SCC. The majority of cases were poorly differentiated SCC (70%), stage ≥ T3 and required radical surgery with total urethrectomy and radical prostatectomy. Complications included post-operative ileus (30%), wound infection (20%), sepsis (10%), perioperative transfusion was required in one patient. Lymphovascular invasion was present in 90% of cases and local recurrence occurred in 60% of patients. Only one patient was suitable for neo-adjuvant chemo-radiotherapy (cisplatin/5-FU) and a further 5 required adjuvant chemoradiotherapy following surgery. 60% of patients developed metastatic disease and 60% died with a median survival of 9.6 months (SD±5.3) from diagnosis to death. Conclusions: Posterior urethral SCC is rare and the late presentation means that neoadjuvant chemoradiotherapy is often not possible. Radical surgery requires a pan-urethrectomy and urinary diversion. Despite adjuvant chemoradiotherapy, posterior urethral SCC is associated with significant mortality with a median survivial of less than one year.

419 Background: Patients presenting with advanced penile cancer with significant inguinal disease requiring extensive resection. Reconstruction is required to cover the defect and protect underlying vascular structures when undergoingl adjuvant treatment. Often the performance status or the extent of the disease makes neoadjuvant chemo/radiotherapy difficult. Although this group of patients undoubtedly have a poor prognosis, palliative resection reduces the tumour burden and allows improved wound management and quality of life. The aim of this study was to present the techniques and report the outcomes for patients with N3 disease undergoing flap reconstruction. Methods: Medical records were reviewed for penile cancer patients with fixed inguinal nodal disease either at presentation or recurrence. Resection was performed by a team comprising urological and plastic surgeons. Cancer specific survival and the impact of adjuvant chemo/radiotherapy was recorded. Results: Seventeen patients were included; mean age 62 (range 37–85) years. Nine (53%) patients had a first presentation with penile cancer and advanced nodal disease, with 8 (47%) presenting with inguinal disease recurrence. The majority (n = 13) underwent a vertical rectus abdominis musculocutaneous (VRAM) flap. Of these, 3 required femoral vein reconstruction. Where defects were smaller, a tensor fascia latae (n = 2) or a scrotal advancement flap was used (n = 1). The average length of stay was 23 days (10-45 days) regardless of type of flap. Ten patients had adjuvant radiotherapy, 5 underwent neoadjuvant chemotherapy with a 4 undergoing adjuvant chemotherapy. The disease specific survival was 595 days (range 24-3881). Complications were related to wound healing and managed conservatively. Post operative lower limb lymphoedema occurred in the majority of patients. There were no flap failures and all but one patient was discharged home. Conclusions: Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible. This aids wound management and improves the quality of life for patients. Survival rates can extend to over 12 months following adjuvant treatment.

s / International Journal of Surgery 12 (2014) S13eS117 S98 Conclusions: Negative laparotomies rates are reducing but slowly. It is important for institutions such as those in rural South Africa to invest in surgical expertise to be able to select appropriate cases for exploratory laparotomy and therefore reduce patient morbidity and reduce hospital costs. Upper-gastrointestinal surgery 0018: CHRONIC NEUROPATHIC PAIN POST THORACOTOMY FOR IVOR LEWIS OESPHAGECTOMY Mohamed Elsharif *, Laura Lewis, Bruno Sgromo. Oxford Radcliffe Teaching Hospitals, Oxford, UK. Introduction: Chronic pain post thoracotomy is a well-recognised problem following oesophagectomy due to various aspects related to the incisions location and may theoretically involve a neuropathic component due to compression of intercostal nerves under the rib spreader. Reported incidence has varied [11%-80%] with various surgical and anaesthetic techniques being used over the years, as a tertiary referral centre which performs 100 oesophagectomies a year we conducted this study to establish incidence in contemporary practice and assess whether or not a neuropathic component was involved. Methods: Detailed phone questionnaires using PAINDETECT assessment tool were conducted with 43 oesophagectomy patients a year following their surgery. Results: Incidence of chronic pain was reported at 56%, the majority of patients had at least 1 neuropathic feature in their pain descriptors, but only 4% fulfilled all criteria for neuropathic pain. Only 50% of sufferers were receiving pain treatment of any sort. Conclusions: Current day practice is still associated with a high incidence of chronic pain, however only a minority of patients fulfil the criteria for neuropathic pain bringing into question our assumptions about the nature of this pain. Long-term pain management should be reviewed and audited as a service quality indicator. 0023: OUTCOMES OF LAPAROSCOPIC FUNDOPLICATION WITH THE USE OF BIO-MESH IN PATIENTS WITH GORD OR LARGE SYMPTOMATIC HIATAL HERNIAS Michelle Christodoulidou , Sarah Hassan, Paul Sutton, Joseph Varghese. Royal Bolton Hospital NHS Foundation Trust, Bolton, UK. Introduction: Since 2011 in cases where we have identified a large hiatus hernia during Laparoscopic fundoplication, the hiatal repair was augmented with biosynthetic mesh (Gore Bio-A®). With this audit we aimed to establish the impact of the addition of mesh on symptomatic outcomes. Methods: All Laparoscopic fundoplication's performed between October 2011 and January 2013 by a single surgeon were included. The data were collected retrospectively and patient outcomes (GORD-HRQL quality of life questionnaire) were obtained both pre and post-operatively. Results: 23 patients with a median age of 63 years underwent the procedure, 14 of which received mesh augmentation. Comparable symptomatic improvement (GORD-HRQL) was seen in both groups. Three patients (13%) complained of mild dysphagia (2 in the mesh group), one patient from the mesh group had a minor surgical site infection and one patient from each group had a post-operative pneumonia. No patient required a re-operation for recurrence of symptoms. Conclusions: Augmentation of the hiatal repair with biosynthetic mesh may be necessary to achieve comparable postoperative outcomes in selected cases with a large hiatus hernia. We suggest a randomised control trial with long-term follow-up for definitive evaluation. 0187: AN AUDIT OF MANAGEMENT OF ACUTE PANCREATITIS IN A NETWORKED DISTRICT GENERAL HOSPITAL Mohammed Elsayed , James Pine, John Wayman, John Robinson. Cumberland Infirmary, Carlisle, UK. Introduction: To re-audit the management of acute pancreatitis against the UK Working Party on Acute Pancreatitis guidelines in a DGH after introduction of tertiary centre networking. Methods: A northern regional audit was performed in 2007. Following the introduction of networking with the tertiary centre a re-audit was undertaken on consecutive patients admitted with acute pancreatitis, between May 2012 and March 2013. Results: 33 patients were identified. Aetiology was determined in 75.8% (Target 80%, previously 88.0%). Diagnosis was achieved within 48 hours in all patients and severity stratification in 66.7% (Target 100%, previously 17.6%). Imaging within 24 hours was performed in 75.8% (Target is 100%, previously 26.9%). Overall survival rate was 96.5% (Target 90%, previously 94.4%). In severe cases 42.9% were admitted to high dependency unit (Target 100%, previously 24.3%). 75.0% had computer tomography after seven or more days of admission (Target 100%, previously 81.8%). 60.0% of patients with severe gallstone pancreatitis had an urgent endoscopic retrograde cholangiopancreatography (Target 100%, previously 20.0%). Survival in severe cases was 85.7% (Target 70%, previously 83.3%). Conclusions: There is an improvement in adherence to national guidelines and patient outcome since the initial regional audit and greater collaborative working between secondary and tertiary units. 0191: VENOUS THROMBOEMBOLISM RISK IN GASTRIC CANCER PATIENTS Ruth Graham , Joy Singh. Glangwili General Hospital, Carmarthen, UK. Introduction: To show patients with Gastric cancer have an increased risk of VTE and that this risk increases further with chemotherapy. Methods: CANISCC database was used to identify patients diagnosed with Gastric Cancer from 2008-2012. Clinical portal allowed identification of patients who had follow-up CT scans and those who were diagnosed with Pulmonary Embolism (PE) or Deep vein thrombosis (DVT). The Health Board chemotherapy database was used to identify treatment regimes. Results: Of the 157 patients identified, 103 went on to have treatment and 62 had follow-up CT scans. 53 patients had chemotherapy,15 in association with surgery and 3 with endoscopic treatment. 31 patients had surgery and 19 endoscopic treatment only. A total of 5 PEs and 8 DVTs were identified. PEs were noted in patients who had surgery and chemotherapy (3,20%) and chemotherapy alone (2, 7.7%). DVTs were identified in patients who had no treatment (2, 3.7%), chemotherapy alone (2, 5.7%) and surgery alone (4, 12.9%). Conclusions: Patients with Gastric Cancer have a higher risk of PE/DVT than the general population. Our results suggest around 1/5 patients who have surgery and chemotherapy will have a PE. We recommend VTE prophylaxis during treatment. 0194: BARIATRIC SURGERY PRODUCES SIGNIFICANT AND SUSTAINED REDUCTION IN POLYPHARMACY DEPENDENCY IN OBESE PATIENTS e A RETROSPECTIVE REVIEW OF POST-OPERATIVE OUTCOMES IN NHS LOTHIAN Stefanie Chua , Laura Arthur , Andrew de Beaux , Bruce Tulloh , Peter Lamb . University of Edinburgh, UK; Department of General and Upper GI surgery, Royal Infirmary of Edinburgh, UK. Introduction: To evaluate medication dependency, prescription costs, weight and BMI for patients preand post-bariatric surgery in NHS Lothian. Methods: 140 patients who underwent 162 procedures from November 2003 March 2012 were identified from a prospectively maintained departmental database. Data was collated from case notes and electronic records review. Weight, height and prescription drugs preand postoperatively at yearly intervals were recorded where available up to 4 years post-surgery. Drug pricing was sourced fromwww.bnf.org. Follow-up data was complete for 54 patients who were included in this analysis. Paired ttests were calculated in SPSS v.19 with significance set at p

We presented a case of a 13-year-old girl who attended the emergency department with acute urinary retention and 1400 mL residual urine after catheterisation. She had no significant medical history, neurological examination was normal and she had not reached menarche. She was found to have a haematocolpos on ultrasound scan which was compressing the urinary bladder. Examination under anaesthesia confirmed an imperforate hymen and therefore an incision was performed and the haematocolpos drained. She managed to pass urine normally the day following her procedure. In this article, we emphasise on the differential diagnosis in this case and the learning points derived from it.

We describe a very rare complication of migration of Artificial Urinary Sphincter pump device, following an elective implantation in a male patient with significant stress incontinence secondary to cauda equina syndrome. Looking through existing literature there has not been a similar complication reported. Usual complications reported include erosion, infection and mechanical failure.

A 23-year-old man with poorly controlled insulin-dependent diabetes mellitus presented to casualty with community-acquired pneumonia and diabetic ketoacidosis. Shortly after admission he deteriorated and developed cardiac failure, pulmonary oedema and further decreased level of consciousness. He was sedated and ventilated for 3 weeks in the intensive care unit. On waking from sedation he was found to be tetraplegic. MRI scan showed gross oedema of the cervical spinal cord with area suspicious of infarction. We describe a rare cause of spinal cord injury and discuss the proposed hypotheses.

A 66-year-old female patient was referred to drology department when a bladder mass was incidentally found on a transvaginal ultrasound scan. Cystoscopy revealed a small, smooth mass just above the trigone which appeared to be covered with normal urothelium. The histology from this growth after transurethral resection revealed a paraganglioma of the bladder. We will discuss the management of this case and literature review of this finding in this study.

s / International Journal of Surgery 10 (2012) S53–S109 S97 ABSTRACTS year survival estimates, but follow up limits comparison of actual survival. However, a recent study has suggested that 2 year follow up data correlates well with 5-year survival. 0486: "SATURATION PROSTATE BIOPSY IN PATIENTS WITH RAISED AGERELATED PSA AND NON-MALIGNANT PREVIOUS TRUS BIOPSIES" Michelle Christodoulidou, Mohsen El-Gammal. Southport and Ormskirk Hospital NHS Trust, Southport,Merseyside, UK Aim: To review the demographic data of patients that underwent Saturation Prostate Biopsies over an 18 month period with emphasis on the indications, antibiotic cover, complications and histological outcome. Method: Patients were traced by the Theatres Register and GALAXY system. Data were collected from case notes. Results: 28 Saturation Biopsies were performed between July 2010 and December 2011. Median age was 67, 54% of patients had LUTS and 7% had family history of prostate cancer. 14% had abnormal DRE. Median value of 2 TRUS biopsies were taken prior to the Saturation Biopsy. All patients were given 160mg Gentamicin IV and a 3 day course of Ciprofloxacin orally. Only one case presentedwith Urosepsis requiring IV antibiotics. Saturation biopsy diagnosedmalignancy in36%ofpatients.1patientwhohadbenign saturation biopsy subsequently underwent a Template biopsy that showedmalignancy. Conclusions: Saturation Biopsy is useful in diagnosing prostate cancer in about 36% of cases after 2 inconclusive TRUS Biopsies. The pick up rate of cancer is higher than a 3rd TRUS biopsy. The currently adopted antibiotic prophylaxis appears appropriate with 3.6% risk of urosepsis. When Saturation Biopsy is non malignant and PSA is still rising, template biopsy maybe considered. 0524: USE OF THE SWOP CALCULATOR TO REDUCE UNNECESSARY PROSTATE BIOPSIES IN MEN WITH ELEVATED PSA Andrew Birch , John Withington , Janette Kinsella , Peter Acher , Ben Challacombe . 1 East Sussex Healthcare NHS Trust, East Sussex, UK; Guy's and St. Thomas' NHS Foundation Trust, London, UK Background: The SWOP calculator is a nomogram derived from the European Randomised Study of Screening for Prostate Cancer which predicts the percentage probability ofmalignant prostate biopsy by using the variables of age, DRE finding, PSA, ultrasound appearance and prostate volume. Aim: To investigate whether using a 10% or 15% risk threshold could avert unnecessary biopsies. Method: Data from 207 eligible patients (median age 60) biopsied from 2004-2010 were entered retrospectively into the risk calculator. The clinical outcomes for patients with 15% SWOP risk were investigated. Results: Of the 42 patients with 15% SWOP risk 13 patients (31%) had malignant histology at biopsy (9 Gleason 3+3, 4 Gleason 3+4), 7 received radical treatment (5 radical prostatectomies, 2 brachytherapy) and 5 entered active surveillance. Of the 17 patients with a SWOP risk 10% 4 (24%) had positive biopsies (Gleason 3+3); none required treatment, 3 entered active surveillance (one patient has no follow-up data). Conclusions: These data show that were a 15% risk threshold applied, then significant prostate cancers requiring treatment would have been missed but a 10% risk-threshold may have avoided unnecessary biopsies. The SWOP calculator may be useful for avoiding unnecessary biopsies in low-risk patients; this has significant implications for reducing biopsy and treatment morbidity and cost. 0551: TRANSPERINEAL TEMPLATE-GUIDED SATURATION BIOPSIES OF THE PROSTATE – EARLY EXPERIENCES IN A DISTRICT GENERAL HOSPITAL OF A NOVEL TECHNIQUE OF SATURATION BIOPSY Jaspal Phull, Alison Townsend, Megan Whitaker, Llinos Davies, Andy Thomas. Princess of Wales Hospital, Bridgend, UK Aims: Transrectal ultrasound-guided (TRUS) biopsy may miss 30% of significant prostate cancer, likely to be in the anterior zone. Transperineal template-guided saturation biopsies (TTB) is a NICE approved means of saturation-biopsy. We assessed detection rates with TTB. Methods: A prospective, non-randomized, cohort study of TTBs between July 2010 and August 2011. All cases were peer-reviewed at MDT, and would seek radical treatment if positive. The primary outcome was detection of malignancy. Results: 22 TTBs were performed. 81.8% (n1⁄418) had >1 negative TRUS, 9.1% (n1⁄42) were on active surveillance, 4.5% (n1⁄41) was post-radiotherapy PSArelapse, and 4.5% (n1⁄41) chose to have TTB as the primary biopsy method. 12 of the 22 cases (54.5%) had new-diagnosis carcinoma only detected at TTB. 7 were benign (31.8%). Of the malignant histology (n1⁄415) 13.3% were Gleason 6 (n1⁄42), 73.3% were Gleason 7 (n1⁄411), and 13.3% were Gleason 8 carcinomas (n1⁄42). Conclusion: TTB should be considered for men with rising PSAs and negative TRUS biopsy. We advocate TTB as the preferred technique for saturation biopsy for detection of significant prostate cancer in men who would benefit from further treatment. 0572: OUT-PATIENT FLEXIBLE CYSTOSCOPY CAUSES PSYCHOLOGICAL DISTRESS TO A SIGNIFICANT NUMBER OF PATIENTS BEING INVESTIGATED FOR BLADDER CANCER Gidon Ellis , Jamie Fairweather , Ninaad Awsare , Sam Osaghae , Sam Smith , Thomas McNicholas , James Green . Whipps Cross University Hosptial, London, UK; Morriston Hospital, Swansea, UK; 3 Pilgrim Hospital, Lincolnshire, UK; University College London, London, UK; 5 Lister Hospital

We present an unusual and complicated case of a 39-year-old woman who was admitted three times in hospital over a period of 4emsp14;weeks, with abdominal pain initially and then right loin pain, fever and feeling generally unwell. She was investigated on each admission with different diagnoses set each time, but only on her last admission due to persisting symptoms, an MRI scan revealed a tubo-ovarian abscess associated with pelvic inflammatory disease (PID). We believe that the PID had developed secondary to the intrauterine device and a few weeks after the removal of the Mirena coil she was diagnosed with a tubo-ovarian abscess. As the case unfolds, we will introduce the possible diagnoses and causes that were likely to have led to the development of the abscess.