Identifying candidates for one-night stay robot assisted simple prostatectomy: Single center analysis

Introduction & Objectives: Since COVID-19 global pandemic started, increasing importance was given to same-day discharge (SDD) protocols to minimize viral exposure, reducing healthcare costs without compromising patients' safety. While SDD protocols have been applied for robotic radical prostatectomy, literature is still lacking studies evaluating the feasibility of meeting SSD criteria for patients who underwent RASP. Our aim was to evaluate the feasibility and safety of hospital discharge 24h after surgery. Our secondary endpoint was to assess predictors of successful discharge on 1st postoperative day (POD). Material(s) and Method(s): Patients with allergy to local anesthetics, those scheduled for concomitant surgical procedures and those with severe comorbidities (ASA score 3-4) were excluded from the analysis. Outcomes of this study were: Postoperative Hb drop, 30-day post-surgical readmission, any post-discharge complication, postoperative, time to flatus and consequent regular diet restoration, PSA, flowmetry parameters and validated questionnaires. The SDD criteria included: stable postoperative hemoglobin and vital signs, tolerance of clear liquids, pain control with oral medications and no perioperative complications requiring a prolonged hospitalization (Clavien >1). Result(s): Demographics and baseline values of 63 consecutive patients were reported in Table 1. Perioperative outcomes were shown in table 2. No perioperative complications were reported, median DELTAHb was 2.2 mg/dl, vital signs were stable for every patient. Overall, 55 (87%) patients passed flatus within 24 hours from surgery, and regular diet was restored;7 patients (11%) needed opioids for pain control. Two thirds of patients (n=42, 67%) met the criteria for SDD. At logistic regression analysis, patient's age was the only independent predictor of one night stay (OR 0.89;95% CI 0.80 - 0.98 p=0.02;Table 3). Patients younger than 60 met 24 hours discharge criteria in 90%, while those older than 70 in 50% of cases. Conclusion(s): In a selected cohort of patients with negligible comorbidities profile, discharge within 24h from RASP seems a safe and feasible option in 67% of cases. Patient' age was the only predictor of successful 1 night stay after RASP in our series. [Table presented]Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Polyethylenglycol and polysorbate evaluation for COVID vaccines in two patients with multiple drug allergies

Background: Covid 19 is a global epidemic. One of the most important steps in the fight against this epidemic is vaccination. mRNA vaccines are used in vaccination in our country. Among the additives in the vaccine, the substance with the highest allergenic risk is polyethylene glucose (PEG). There are different molecular weights of PEG. Another additive that has a high risk of cross-reaction with PEG as an additive is POLISORBAT 80. Skin tests with drugs containing PEG and POLISORBAT 80 and, if available, tests with vaccines are instructive. Among the drugs containing PEG: Moxifloxacin tablet, ciprofloxacin tablet, Amoxicillin clavulanic acid tablet;Medicines containing polysorbate include: Omalizumab vaccine, Mepolizumab vaccine. The results of the skin test with PEG-containing methylprednisolone (DEPO-MEDROL) and POLYSORBAT-containing triamcinolone (KENACORT-A) in order to be evaluated in terms of vaccine in our 2 patients who had multiple drug sensitivities before were shared. Method(s): Case 1: 33 y, F *There are diagnoses of urticaria and angioedema. Urticaria 30 minutes after taking aspirin, levofloxacin, cefdinir tablet;5 minutes after taking ciprofloxacin tablets, he has anaphylaxis. *Applies before Biontec vaccine. *The patient had a history of anaphylaxis with PEG-containing ciprofloxacin. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *The patient for whom Biontec vaccine was not recommended received Synovac vaccine without any problems. Case 2: 52 years, F * He has a diagnosis of urticaria. 5 minutes after general anesthesia and local anesthesia;The patient who had cardiac arrest 3 times was evaluated. The patient, who had Synovac for 2 times without any problems, wanted to have the 3rd dose of Biontec vaccine. *Tested with general -local anesthetic agents. *Ciprofloxacin skin tests are negative;Urticaria plaques developed after 30 minutes of 1/4 tb in oral provocation. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *Biontec vaccine is not recommended. Result(s): A safer vaccination is ensured by testing with additives in Covid 19 vaccines. Conclusion(s): Drug additives should also be kept in mind in patients with multiple drug allergies.

Assessment of the safety and feasibility of local anaesthetic cystodiathermy for indeterminate bladder lesions in the COVID-19 era

Introduction: Patients presenting with bladder lesions identified during cystoscopy require histological diagnosis, routinely obtained by biopsy under general anaesthetic (GA). GA biopsies are resource intensive as they require the use of an operating theatre and surgical staff. Local anaesthetic cystodiathermy (LAC) is an alternative method for obtaining biopsies, suitable for bladder lesions <5mm in size. LAC can be performed in the outpatient setting thus reducing the need for theatre resources. The aim of our audit was to assess the safety and feasibility LAC bladder biopsies for indeterminate bladder lesions. Method(s): LAC were carried out at our peripheral London outpatient clinic. The main inclusion criteria was the presence of sub 5mm indeterminate lesions identified during routine and surveillance flexible cystoscopy. Patients notes were reviewed for follow up 2 months after their procedure. Result(s): 10 patients underwent LAC between July and September 2021, with an age range of 36-83 years old and ASA grade between 1 and 3. 6 patients were invited following positive findings at routine surveillance cystoscopy, 3 following cystoscopy for new haematuria, and 1 was investigated for routine UTIs. Only one patient had a malignant histology, with 90% reporting a benign biopsy. No patient required admission or subsequent GA biopsy, and no complications were reported. Conclusion(s): LAC is a resource-effective procedure eliminates the exposure of patient to GA. It avoids the need for preassessment and inpatient admission, thus freeing up theatre resources for other patients. This project supports the use of LAC for small indeterminate bladder lesions.

Day case thoracoscopy in a UK district general hospital

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19. Copyright © 2022 Elsevier Ltd

Oral paracetamol premedication: a proposal for increasing its use

Peri-operative intravenous paracetamol use has not been shown to be superior to oral administration in a randomised controlled trial looking at postoperative pain [1]. The use of intravenous paracetamol carries a wellrecognised increased financial and environmental cost compared to oral paracetamol. We audited the use of paracetamol in patients attending theatre at a district general hospital and propose a method to increase premedication with oral paracetamol. Methods We retrospectively audited the notes of all patients who underwent an elective surgical procedure in theatres, across a 5-day period at a district general hospital. Data regarding the use of paracetamol were collected. Patients who were already an inpatient and those having surgery under local anaesthetic alone were excluded. Results Forty-seven patients were included, five of whom had a spinal and 42 a general anaesthetic with representation from six different surgical specialities. Five of the patients included were under 18 years. Thirty-seven patients received paracetamol peri-operatively. Thirty-four patients received only intravenous paracetamol, two patients received oral paracetamol and one patient received both due to length of time between preoperative oral dose and surgery. Ten patients did not receive any paracetamol. No patients included had a documented allergy or contraindication to paracetamol. Discussion Our department recognised the financial and environmental benefits associated with oral pre-medication. Although many of these anaesthetists would prefer to prescribe pre-operative analgesia, the data indicate that there are barriers that prevent prescription and/or administration. As a result of the COVID-19 pandemic, elective orthopaedic surgery with an enhanced recovery protocol including the use of oral paracetamol premedication, was underrepresented in our data. Previous encouragement to prescribe oral premedication has produced good, short-term results but does not appear to provide long-lasting change. We propose a Patient Group Directive for the administration of pre-operative oral paracetamol by the admitting nurse on arrival to the pre-operative ward. We anticipate that this will both standardise and embed oral paracetamol premedication into the department and will therefore provide long-term change.

Development of a Novel Near-peer Surgical Simulation-based Teaching Programme for Intern Doctors

Background: Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Method(s): Interns pursuing a career in Surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Result(s): Of The 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a Simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. on completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusion(s): Near-peer delivery of surgical training has enhanced The basic surgical skills of interns. Similar programmes in other sites would ensure that interns have The skills required to safely care for surgical patients.

The Impact of 'Golden Local Anaesthetic (GLA)' Principal on Emergency Theatre Efficiency - Analysing 232 Hand and Plastic Trauma Operations

Aim: 'Golden local anaesthetic' (GLA) principals are known to improve theatre efficiency. This first GLA case should be suitable to be completed unsupervised by a registrar and confirmed 12 hours prior to the start of the list with a negative COVID PCR test. This allows for list to be started, whilst the consultant is able to see and consent the remainder of the patients for that list, maximising theatre efficiency. Method: Operative timings was gathered in real time in our electronic database (TIMS). Initially, retrospective analysis was performed for cases in November 2020, comparing lists whereby a potential GLA first case was present, versus lists that did not. After remodelling this process, lists in October 2021 were analysed. Statistical analysis was carried out using Mann Whitney U Test. Results: Initially (PDSA-1), 110 trauma cases (58% GA and 42% LA) were performed [3.67/day] whilst post refinement (PDSA-2) 122 cases (52% GA and 48% LA) were performed [3.94 /day]. In PDSA-2, there was a 29% (9/ 31) uptake of GLA list principals. The average GLA list start time was 09:27hrs in PDSA-1 and 09:08hrs in PDSA-2 [Δ 19 mins, p<0.05] whilst the average non-GLA list start time was worse (09:53hrs and 10:12hrs). By refining the GLA principal, £470.63 was 'saved' with a further £445.86 potentially able to be saved when starting at the earliest recorded start time (1) Conclusions: The GLA model is a simple and sustainable method to improve theatre efficiency which could be adopted by other units.

SASA 2022 Virtual Conference Abstracts

The proceedings contain 23 papers. The topics discussed include: petroleum jelly as an alternative coupling medium in focus assessed transthoracic echocardiography;perspectives on desflurane;use of high-flow nasal oxygenation outside COVID-19: a rural hospital experience;fitness for purpose of South African anesthesiologists;the effect of caregiver's recorded voice on emergence delirium in children undergoing dental surgery;perioperative outcomes of mitral valve surgery at Charlotte Maxeke Johannesburg Academic Hospital;comparison of a novel low-cost hyperangulated optic intubation stylet with the Bonfils fiberscope: a simulated difficult airway manikin study;the awareness of local anaesthetic systemic toxicity amongst registrars from surgical disciplines in a tertiary hospital, South Africa;and SARS-CoV-2 infection prevalence in healthcare workers, administrative and support staff: the first wave experience at three academic hospitals in the Tshwane District of Gauteng.

Post-operative caesarean section pain and analgesia following neuraxial anaesthesia

Introduction: Pain following caesarean section (CS) may hinder recovery and ability to care for the newborn. NICE [1] and PROSPECT [2] suggest analgesia be individualised. Regular paracetamol and NSAID should be co-prescribed. NICE advise adding regular dihydrocodeine where required. PROSPECT advise opioids for breakthrough where other techniques (e.g. regional) are contraindicated. Our protocol is PR diclofenac 100 mg in theatre, regular oral paracetamol 1 g + ibuprofen 400 mg, breakthrough dihydrocodeine 30 mg and oramorph 5 mg. The NHSL pain scale is a 0–4 numeric patientreported score, with >2 and <3 representing high and low scores. A CS audit in 2019–20 demonstrated 95% of patients being satisfied/very satisfied with pain relief, but 42% and 31% reported high pain scores on movement and rest, respectively. Only 28% received PR diclofenac, 85% paracetamol + ibuprofen, and 86% breakthrough dihydrocodeine. This re-audit assessed dynamic pain scores following introduction of regular dihydrocodeine 30 mg. Methods: After hospital clinical audit team approval, a prospective reaudit of postoperative CS pain and analgesia following neuraxial anaesthesiawas performed using a standardised patient questionnaire conducted on postoperative day 1 or 2 in Sep–Oct 2021. Participation was voluntary, occurring contemporaneously with routine postneuraxial anaesthesia follow-up. The NHSL pain scale was used. Elective and emergency patients were included. Cases under general anaesthetic were excluded. Results: The main outcomes are reported in the Table. (Table Presented) Discussion: Following introduction of regular dihydrocodeine, pain scores on movement did not improve. Use of breakthrough analgesia reduced. Time taken to receive breakthrough analgesia increased. The COVID-19 pandemic impacted staff absence rates. Telephone reviews post-discharge were not evaluated for the re-audit, which may skew results, with confounding factors contributing to pain. Future work will include midwife education, review opioid protocol prescribing and introduction of routine regional anaesthetic techniques (e.g. TAP block), followed by re-audit.

Splanchnic Nerve Block as a Bridge Therapy in Painful Chronic Pancreatitis During COVID 19 Pandemic: A Case Report

Agonizing and debilitating pain is what most patients with chronic pancreatitis endure. Chronic pain often leads to depression and poor quality of life. Surgical decompression can result in permanent pain relief by reducing intraductal hypertension. Elective surgical procedures had to be postponed during the Covid-19 pandemic as the resources, including oxygen supplies, workforce, and ventilators, were dedicated to the service of Covid-19 patients. We present a case of 20 year-old-male suffering from severe abdominal pain due to chronic pancreatitis refractory to analgesic medications. Given the refractory pain and inability to proceed with surgery due to the pandemic, we subjected him to undergo splanchnic nerve block (SNB) with local anesthetic and steroid. SNB provided adequate analgesia and enabled the patient to tide over the crisis. To our knowledge, no case has been reported using a combination of local anesthetic and steroid in SNB for a patient with chronic pancreatitis.

Establishing outpatient ureteric stent changes under local aesthetic in the Northeast region;a safety and feasibility study

Introduction: The COVID19 pandemic has led to unprecedented pressures on theatre waiting lists. The numbers of patients requiring regular ureteric stent changes under general anesthetic (GA) can be significant. We performed a regional study of these patients to assess;i) suitability for procedures under local anaesthetic (LA) and ii) outcomes for those then having LA rather than GA procedures. Patients and Methods: A retrospective cohort study from 3 urology centres was performed. Feasibility criteria for transition to LA stent change was determined on;comorbidities, indication for stent placement and operative factors. 2 centres subsequently initiated regular out-of-theatre LA stent change lists and outcomes were reviewed. Results: 216 cases were included. Median age was 68 and sex ratio 1:1 (M:F). Commonest indications for indwelling stents included benign strictures (37%), non-urological malignancy (24.1%) and urological malignancy (22.2%). 34 patients were suitable for/awaiting definitive procedures. Average number of changes was 2.4/year with 49% of patients being ASA3 or higher. LA stent changes were deemed feasible in 70 patients. 63 procedures were performed under LA with a 98% success rate. Complications (30d) included stent migration (2), haematuria (2) and infection (1). Conclusion: Innovation is required to deal with significant COVID-19 related problems. LA ureteric stent changes are safe and tolerable in appropriately selected patients. Performing these outside of the theatre environment increases capacity on surgical waiting lists. Patient benefits include reduced risks of multiple GA procedures in elderly and co-morbid patients. This data encourages expansion of this initiative.

Hydrocele aspiration and injection sclerotherapy under local anaesthetic: a viable alternative to open surgical repair

Introduction: Hydroceles could cause discomfort, scrotal heaviness, cosmetic problems or adversely impact quality of life. Conventional treatment involves open surgical repair under general anaesthetic. Aspiration and injection sclerotherapy is however an attractive alternative since literature suggests it has comparable outcomes, lower complication rates and can be performed under local anaesthetic (LA) in timely manner. Patients and Methods: Consenting patients were prospectively recruited following necessary approvals. The procedure was carried out under LA and ultrasound guidance at our urology clinic. The hydrocele was drained and sclerosant (3% sodium tetradecyl sulphate) immediately injected into the tunica vaginalis. Post-procedure followup ranged from 3-12months. Results: Thirty-two patients with 35 procedures (2 re-do, 1 bilateral) were studied. Average volume drained was 283ml (18-1000ml). Overall success rate was 77.1% (complete resolution- 21 [60.0%], mild re-accumulation without need for re-intervention- 4 [11.4%], moderate re-accumulation successfully treated with re-do sclerotherapy- 2 [5.7%]). Large/significant recurrence was noted in 8 (22.9%) patients- they all had large (>200ml) hydroceles ab-initio and went on to have straightforward open surgical repair. One procedure was abandoned due to traumatic aspiration and was excluded. Conclusions: Hydrocele aspiration and injection sclerotherapy under LA is safe, easy to set-up and effective, with trend towards better outcomes for smaller hydroceles. This treatment could ease waiting-list pressures occasioned by the COVID-19 pandemic and should be considered as part of informed consent process for all men with hydroceles. Further data is required to define most suitable patients and also to fully assess ease of hydrocele repair after failed sclerotherapy.

Safety and efficacy of REZUM for the treatment of BPH in an Australian cohort

Introduction & Objectives: Minimally invasive transurethral therapies for benign prostatic hypertension are becoming increasingly common in Europe and America. They may be performed under local anaesthetic and provide a good alternative to invasive procedures in a COVID era. REZUM, a minimally invasive transurethral water-vapor therapy, has been shown to be a safe and effective treatment for BPH, especially where preserved sexual function is a priority. Although short-term clinical outcomes are promising, long-term data from robust studies is lacking. In Australia, there are few providers of REZUM, which utilises steam injections to reduce prostatic tissue. This study aims to investigate the safety and efficacy of REZUM in an Australian cohort. Methods: A clinical audit was conducted of 50 patients who underwent REZUM to treat symptoms of BPH over a 12-month period. Procedures were performed under general anaesthetic. Demographics, comorbidities, sexual function, prostate volume, PSA, voiding flow rate, post-void residual volume and International Prostate Symptom Score were extracted from medical records, in addition to patient's reasons for seeking minimally invasive treatment. Corresponding post-operative data was collected. Descriptive statistics of the cohort were obtained using Stata 16.0. Paired t-test was used to identify if there was a significant difference between IPSS scores pre- and postprocedure Results: Patients accessing treatment ranged from 48 to 84 years (mean 64.6). Median prostate volume was 55mL (inter-quartile range 45-78mls) and mean International Prostate Symptom Score (IPSS) was 20.3. 28% of the cohort cited concern for ejaculatory function, either from medication side effects or TURP, as their primary reason for seeking minimally invasive treatment. A further 25% of the cohort was additionally concerned about other side effects from medications and/or TURP or had experienced medication failure. The mean follow up period was 6 months (range 6-weeks-26 months). 69% of men were satisfied with their symptom improvement at the time of review, with the expectation of ongoing improvement in men who had attended a 6-week post-operative review only. Postprocedure mean IPSS was 7.9 (range 2-33). Mean reduction in IPSS score post-procedure was 12.7 points (p<0.001). 3 men experienced complications (retention, infection, bulbar stricture). Conclusions: REZUM provides a safe alternative to traditional invasive prostatic treatments. It may be performed under local anaesthetic, providing an effective alternative in a COVID era. Men concerned about medications, more invasive treatments and ejaculatory dysfunction are increasingly seeking relief from this minimally invasive option and experiencing good outcomes including significant symptom improvement sustained over medium-term follow up.

An Interactive Curriculum Increases Confidence in Identification and Management of Gynecologic Office Emergencies

INTRODUCTION: Emergencies during gynecologic office procedures are uncommon. However, knowledge in management of these complications is essential as more gynecologic procedures move from the operating room to the office. Our goal was to develop an interactive curriculum to address a gap in residency training in the management of office-based procedural emergencies. METHODS: A curriculum including management of unanticipated bleeding, anaphylaxis, vasovagal response, and local anesthetic systemic toxicity (LAST) was developed and implemented using a combination of simulated patient sessions, a “choose-your-own-adventure” PowerPoint, and a mock oral board session. Pre and post intervention surveys queried participants' confidence in recognition and management. The curriculum was delivered as in-person simulation sessions or virtual sessions due to COVID restrictions. Institutional review board (IRB) approval was obtained. Mean pre and post intervention scores were compared using paired t-test. RESULTS: Four accredited obstetrics and gynecology residency programs participated. Twenty-nine trainees completed the curriculum, and 24 submitted pre and post surveys (82.8% response rate). There was significant improvement in confidence scores for management of unanticipated bleeding (mean difference 0.96, P<.001), anaphylaxis (mean difference 1.7, P<.001), vasovagal response (mean difference 1.0, P<.001), and LAST (mean difference 2.5, P<.001). Additionally, significant improvement in confidence scores for identification of risk factors and signs/symptoms of vasovagal response (mean difference 0.96, P<.001, and 0.46, P=.005) and LAST (mean difference 2.3, P<.001, and 2.2, P<.001) was noted. CONCLUSION: Implementation of an office emergencies curriculum significantly increased confidence in identification and management of unanticipated bleeding, anaphylaxis, vasovagal response, and LAST. Future studies evaluating knowledge-based assessments of learners are needed.

VARIATIONS IN CLINICAL PRACTICE IN PAEDIATRIC RHEUMATOLOGY UNITS AS A RESULT OF THE COVID-19 PANDEMIC: INITIAL FINDINGS OF A UK WIDE MULTI-CENTRE SURVEY

Background/Aims To understand the impact of COVID-19 on UK paediatric rheumatology services, to determine the learning points that could change future practice and provide information for trainees to plan further quality improvement projects. Methods Survey details with a Microsoft forms link were emailed to consultants in each UK paediatric rheumatology centre. Consultants were asked to forward the survey onto any regional units linked. The survey was also sent to the paediatric rheumatology trainee's network. The questionnaires covered blood monitoring, joint injections, oral corticosteroid use, modes of consultations, positive and negative impacts and what changes should be carried forward. Results 20 staff responded to the survey;17 consultants and three trainees (registrar level). 85% (17) reported changes had occurred to the frequency of blood monitoring to rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDs) and/or biologics during the pandemic. 60% (12) reported this was due to patient/family reluctance to attend or due to unavailability of appointments. 75% (15) recorded no complications following changes of blood frequency on disease activity or flare. Of those that did have a flare, a number of factors were described including: parents not contacting their service, patient/family discontinuation of treatment, lack of clinic attendance, running out of treatment and safety concerns re prescribing from primary care or local department. One patient on methotrexate experienced significantly deranged liver function tests.75% (15) reported changes with provision of joint injections due to theatre unavailability. As a consequence, 60% (12) reported an increase in the use of oral corticosteroids with 20% (4) performing more ward-based injections with local anaesthetic or Entonox on younger children. 100% (20) changed their mode of consultation. Between 5 and 40% of all appointments are now virtual (telephone or video) and 60-95% are face-face. 60% (12) report that frequency of review appointments has now returned to normal. Major disruption has occurred in seeing new patients due to a backlog of patients created by the pandemic. Some patients have been referred to units with possible arthritis that haven't been examined or seen face-face in primary care prior to referral. Conclusion COVID-19 caused significant changes to UK paediatric rheumatology services. The results highlighted the use of virtual consultations where appropriate, consideration of joint injections without general anaesthetic as much as possible, enabling virtual teaching/conferences and also raising the need to review blood monitoring frequency for patients on DMARDs/biologics. Longer waiting lists, increased anxiety amongst children and young people, increase in disease activity and the impact on learning opportunities for trainees were concerning negative aspects of the pandemic. It is likely the impact of these negative consequences will continue to be experienced for some time. Future planning and consideration is required to minimise the negative impact of these aspects on our patients and colleagues.

TCTAP C-141 An Interesting Case of Bilateral Renal Artery Stenting in a Patient of Takayasu Arteritis With Uncontrolled Hypertension

Clinical Information Patient Initials or Identifier Number: SP Relevant Clinical History and Physical Exam: A 30-year-old female was referred to our centre with chief complaint of orthopnea. The patient had received medical attention elsewhere and was treated empirically for asthma, COVID pneumonia and antitubercular treatment. On examination the patient had a bounding pulse on right upper limb and an impalpable pulse on left upper limb, weak pulses in bilateral carotid and lower limbs. Further examination revealed a right upper limb blood pressure of 230/120 mm of Hg. [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: The chest roentgenogram of the patient revealed bat-wing pulmonary edema with cardiomegaly. ECG revealed left ventricular hypertrophy with strain pattern and echocardiography revealed left ventricular dysfunction with ejection fraction of 35%. CT aortogram revealed wall thickening with fusiform dilatation of distal thoracic, proximal abdominal aorta, and stenosis of left subclavian, celiac artery at ostium and bilateral renal arteries at ostium. The patient also had a raised ESR (40 mm/hr). Interventional Management Procedural Step: The procedure was done under local anesthetic from a right femoral artery access with 7 French sheath. A coronary angiogram was done first which revealed normal epicardial coronaries. Pull back gradient was then taken across thoracic and abdominal aorta which revealed a gradient of 20 mmHg. Next, renal angiogram was taken in individual renal arteries which revealed significant ostial stenosis of bilateral renal arteries. The lesions were serially dilated with 1.5 mm, 2.5 mm and 4 mm diameter coronary balloons. After dilatation Invatec Hippocampus 5x15 mm stent was placed in right renal artery and a 6x14 mm Boston scientific vascular SD stent placed in left renal artery. Post stenting angiography showed a good flow with relief of stenosis. [Formula presented] [Formula presented] [Formula presented] Conclusions: Although, there is controversy regarding role of angioplasty in treatment of hypertension in atheromatous renal artery stenosis, no consensus exists in Takayasu arteritis with renal artery stenosis due to a lack of randomised controlled trials. Our case represents an interesting case where the patient had a dramatic relief of hypertension and heart failure after bilateral renal angioplasty in Takayasu arteritis.

Developing & centralising a nurse-led local anaesthetic (LA) transperineal (TP) biopsy service during COVID: A success story

Introduction: During the first COVID-19 wave, the BAUS Section of Oncology issued guidance to minimise risks of sepsis and general anaesthesia at prostate biopsy. Consequently, and as a result of diminished diagnostics capacity on Trust acute sites, we implemented a centralised network-wide nurse-led LA TP biopsy service on a COVID-secure 'green' site and abandoned trans-rectal biopsies. We evaluated the impact of this service improvement on patient waiting times before and after national lockdown in March 2020. Method: Classic Quality Improvement (QI) methodology was used with continuous data collection and waiting list management by clinical staff with standard admin support. Balancing measurements were collected. Run charts were used to confirm whether a change led to a real and sustainable improvement. Results: The number of days waiting, from time of request to date of biopsy, is presented in the following run chart. The mean waiting time for those pre lockdown was 145 days (SD 57) whereas post lockdown was 23 days (SD 20). This identified that there was a significant difference between the average waiting time pre and post lockdown (U=55.5, p= ,0.001) There were also reductions in waiting time when subcategorised into planned Active Surveillance cases, target cases and delayed cases. Conclusions: Centralising the TP biopsy service and converting to a nurse led LA service has led to reductions in waiting lists and was safely expedited and resilient even in the COVID-19 pandemic. Allowing a second advanced TP practitioner to be fully trained, during COVID. The service was highly valued by patients and staff.

Preference and perception of treatment choices between radiologists and urologists for treatment for urgent urinary obstruction – nephrostomy versus retrograde ureteric stent: European survey from YAU and ESUT Endourology groups

Introduction & Objectives: Urological emergencies related to urinary obstruction need Percutaneous Nephrostomy (PCN) or Retrograde Ureteric Stent (RUS). The choice of treatment is often debated between radiologists and urologists due to differences in perception for given scenarios and the skill set needed for these. We wanted to conduct a European survey to determine the preference of treatment in different clinical situations. Materials & Methods: A European survey was conducted via the EAU sections (YAU and ESUT) for preference and treatment choices between radiologists and urologists for using PCN or RUS or primary ureteroscopy (URS) in various clinical scenarios. Responders were asked to select urinary drainage for 3 clinical scenarios before and after reading evidence from literature on use of PCN or RUS. The scenarios were ureteric stone related – infected obstructed kidney (scenario 1), obese patient with pain and hydronephrosis (scenario 2) and solitary kidney with deranged renal function (scenario 3). Results: Of the responses (n=367), there were 15.4% (n=57) radiologists and 310 (84.5%) urologists. The choice of drainage for scenario 1,2 and 3 between urologists and radiologists pre- and post-evidence perusal are shown in Table 1. Regarding QoL, cost and radiation dose (Table 2), the perception was that Radiologists appear to consider JJ stents to provide a better QoL (p=0.0004) and more radiation exposure (p<0.0001) than Urologists. The perception in both groups was that stent was more expensive (p=0.652507). With COVID-19 pandemic, there was also a rise in the usage of local anaesthetic stent and URS procedures. (Table Presented) Conclusions: Choice of urinary drainage for urological emergencies is dependent on multiple factors, but prompt management is paramount. This survey has shown how urologists and radiologists both put patient safety at the forefront and their choice of treatment reflects their expertise in the given technique.