Where are the paediatric patients with testicular torsion during the COVID-19 pandemic?

Introduction The Irish people were put on lockdown in mid-March 2020 due to concern of the spread of coronavirus. With these societal changes came a notable reduction in emergency department attendance. Our aim was to analyse emergency urological procedures performed during the COVID-19 era versus the previous year. Methods A retrospective review of theatre logbooks was undertaken comparing numbers of emergency urological procedures performed between 1 March 2020 and 31 May 2020 (i.e. the COVID-19 era) with the corresponding 3-month period in 2019. Results A total of 173 cases were analysed between the two time periods. Similar overall numbers of cases were performed in 2019 (n = 90) and 2020 (n = 83). In particular, similar patient case numbers are also noted in both scrotal explorations (13 vs 9) and ureteric stone surgeries (69 vs 70). However, orchidectomies for testicular cancers were reduced by 63% (3/8). On further analysis of the scrotal exploration group, only 3 were performed in the period after lockdown regulations were instated. Conclusion Whilst patients with ureteric colic continue to present, those with acute testis pain requiring exploration attended less frequently, raising the possibility of undiagnosed testicular torsion in the community.

219 Have New National Guidelines Changed Practice in Referrals with Suspected Ureteric Colic?

Aim To assess how many patients had a non-contrast CT as first-line investigation for suspected renal colic, and how this was affected by the release of the 2019 NICE guidelines. A secondary aim was to assess the proportion of patients who had CT KUBs that demonstrated a ureteric calculus. Method CT KUB scans performed over two separate 3 month periods were identified. These reflected periods of time before and after the new NICE guidelines. Electronic records were used to assess if the patients had an ultrasound performed as the initial diagnostic investigation, instead of a CT scan. The results of the scans were reviewed to identify if a ureteric or renal calculus had been positively identified. Results In the period before the new guidelines, 61 patients were scanned. 4 had an ultrasound to assess for a stone prior to a CT. All of these patients were medical inpatients. None of the ultrasounds diagnosed a stone. 22/61 patients had CT-proven stones (36%) In the period after the new guidelines, 79 patients were scanned. 12 had an ultrasound to assess for a stone prior to a CT. 8 were medical patients, 3 were surgical and 1 was gynaecological. 1 ultrasound diagnosed a stone. 28/79 patients had CT-proven stones (35.4%) Conclusions The release of new guidelines did not improved compliance with suggested imaging pathways. This clearly demonstrates an area for improvement. It is also worth noting that only 1/3 of referrals with suspected renal colic did actually have a stone, which has implications for specialty referral pathways.

543 Improving the Management of Acute Ureteric Colic in A Multi-Centre District General Hospital: A Closed-Loop Audit

Introduction The British Association of Urological Surgeons (BAUS) released guidance in 2018 regarding the optimum management of acute ureteric colic: a condition which can present as a surgical emergency. Our aim was to review the current practice at our hospital in diagnosing and managing acute ureteric colic and ultimately, implement sustainable change to address any areas of limitations. Method The following data was retrospectively collected for of all patients admitted with acute ureteric colic: investigations performed, medications administered, details of surgical intervention and follow-up. 1st Cycle: March 2017 to February 2018. Intervention: Teaching sessions delivered to staff (including doctors and nurses) in the A&E and urology department. 2nd Cycle: January 2019 to December 2019. Results 268 patients presented to A&E with ureteric colic – 18% increase from previous year. On admission: 60.4% of patients had serum calcium checked, 97.7% had a CT KUB performed within 24 hours and 67.2% were given NSAIDs; this is a 20.4%, 0.4% and 5.2% increase from the previous year, respectively. Only 31.3% of patients had an acute surgical intervention. The average wait time for clinic follow-up was reduced to 41 days following departmental education, but only 26.4% of patients were seen within the BAUS advised 4-week timeframe. Conclusions Re-audit showed distinct improvement in the management of acute ureteric colic. Thus, departmental education strategies have had a positive impact. It is recommended that the reservation of one daily elective theatre slot for an emergency operation and a computerised clinic booking system will further optimise our management in line with BAUS guidance.

687 Timings of CT Scans in Suspected Renal Colic

Aim Renal/ureteric colic is common; it has an annual incidence of 1-2 cases per 1000 people and has high recurrence rates. National Institute for Health and Care Excellence (NICE) guidelines recommend imaging within 24 hours of presentation for all patients with suspected renal or ureteric stones and, for most adults, a low-dose non-contrast computed tomography (CT) scan should be offered. We set out to assess adherence to this guidance within our centre. Method We reviewed the records of patients presenting with suspected renal colic from December 2019, up to and including March 2020, in a single centre. We assessed the proportion of adult patients who underwent a CT within 24 hours. Results The data from 95 patients aged 19-82 years was analysed. We found that 37(38.9%) patients did not receive a CT scan within 24 hours. 16(17%) patients waited over 1 week for a CT KUB. Conclusions Our findings show a considerable proportion of patients who did not receive a CT within the first 24 hours of presenting with suspected renal/ureteric colic. This has led to plans for a formal clinical pathway to be established within out trust.

Erdheim-Chester Disease - Multisystemic Radiological Manifestations

Erdheim-Chester disease (ECD) is a rare, multisystem disorder with a constellation of clinical and radiological findings. We present a case of ECD who came with acute obstructive uropathy and chronic bone pain. Radiological work up in this patient led to a host of findings in various systems, the correlation of which led to narrowing of the differential diagnoses. A 44-year-old male presented with right loin pain and nausea for 1-day duration. A provisional diagnosis of right ureteric colic was made. Routine lab investigations revealed normal total counts and urine analysis. Additional laboratory investigations revealed a raised erythrocyte sedimentation rate (ESR) and Creactive protein (CRP). Radiological Investigations 1. Patient was referred for ultrasound of abdomen which revealed mild to moderate right hydronephrosis with a suspicious hypoechoic area (~ 0.7 x 1.2 cm) in the renal pelvis region raising possibility of a lesion. 2. Contrast computed tomography (CT) study of abdomen was performed which revealed enhancing soft tissue infiltration (+30 to +45 HU) around bilateral kidneys (giving ‘hairy kidney appearance’) (Figures 1, 2 & 3) and adrenal glands with infiltration to renal sinus and constriction of bilateral renal pelves resulting in moderate right and mild left hydronephrosis. Thin streak of excreted contrast was traversing the narrowed segment of renal pelves (Figures 4 & 5). 3. Soft tissue infiltration covering the visualized thoracic and abdominal aorta (giving ‘coated aorta appearance’) (Figures 6 & 7), extending below renal arteries to aortic bifurcation and proximal bilateral common iliac arteries. 4. The adrenal glands were not separately visualized from the above mentioned perinephric soft tissue. 5. Both ureters were normal in course and caliber. No evidence of ureteric calculus. 6. No significant retroperitoneal lymphadenopathy. 7. Few tiny centriacinar nodules with patchy ground glass opacities in postero basal segment of both lungs (left > right) (Figure 8).

401 Three Birds with One Stone: Ureteric Calculus Precipitates Diagnosis and Resection of Three Primary Neoplasms

A 67 year-old female presented to our centre with a 2 day history of right flank pain, clinically suggestive of ureteric colic. Computed tomography (CT) confirmed a 6mm right ureteric calculus. However, CT also revealed a large 13cm ipsilateral renal mass, concerning for renal cell carcinoma (RCC). At ureteroscopy for management of the obstructing calculus, a small papillary lesion was noted in the bladder, and excised. Histology confirmed pTa low-grade transitional cell carcinoma. Following discussion at the Urology multidisciplinary tumour board, MRI venogram (MRV) was recommended to delineate the extension of tumour into the renal vein, and to characterise a pelvic mass seen on original CT. MRV showed enhancing material extending into the IVC, consistent with tumour thrombus. However, it also identified a concerning 6cm solid ovarian mass. The patient proceeded to open right radical nephrectomy and IVC thrombectomy, hysterectomy, bilateral salpingo-oopherectomy, and omental biopsy, with combined input from Urological, Gynaecological and Vascular surgical teams. Post-operative course was uneventful. Histology showed an 11cm pT3a G2 clear cell RCC, and 7.5cm ovarian fibroma, both fully excised. This case demonstrated the serendipity of a simple ureteric calculus precipitating a cascade of investigations, that ultimately led to complete resection of three primary neoplasms.

Medical Expulsive Therapy (MET) in Adults With Ureteric Colic

This chapter summarizes the results of the SUSPEND trial, a methodologically rigorous three-armed randomized controlled trial of medical expulsive therapy in the form of the alpha-blocker tamsulosin or the calcium channel blocker nifedipine versus placebo. The mean stone size in all three groups was comparable and three-quarters of the stones were 5 mm or less. It was a “negative trial” that failed to demonstrate a substantial benefit from the widely established practice of treating patients with small ureteral stones with medical expulsive therapy. Serious adverse events were very infrequent.