Role of radiomics as a predictor of disease recurrence in ovarian cancer: a systematic review.

Ovarian cancer is associated with high cancer-related mortality rate attributed to late-stage diagnosis, limited treatment options, and frequent disease recurrence. As a result, careful patient selection is important especially in setting of radical surgery. Radiomics is an emerging field in medical imaging, which may help provide vital prognostic evaluation and help patient selection for radical treatment strategies. This systematic review aims to assess the role of radiomics as a predictor of disease recurrence in ovarian cancer. A systematic search was conducted in Medline, EMBASE, and Web of Science databases. Studies meeting inclusion criteria investigating the use of radiomics to predict post-operative recurrence in ovarian cancer were included in our qualitative analysis. Study quality was assessed using the QUADAS-2 and Radiomics Quality Score tools. Six retrospective studies met the inclusion criteria, involving a total of 952 participants. Radiomic-based signatures demonstrated consistent performance in predicting disease recurrence, as evidenced by satisfactory area under the receiver operating characteristic curve values (AUC range 0.77-0.89). Radiomic-based signatures appear to good prognosticators of disease recurrence in ovarian cancer as estimated by AUC. The reviewed studies consistently reported the potential of radiomic features to enhance risk stratification and personalise treatment decisions in this complex cohort of patients. Further research is warranted to address limitations related to feature reliability, workflow heterogeneity, and the need for prospective validation studies.

Assessing circulating tumour DNA (ctDNA) as a prognostic biomarker in locally advanced rectal cancer: a systematic review and meta-analysis.

INTRODUCTION: Circulating tumour DNA (ctDNA) has emerged as a promising biomarker in various cancer types, including locally advanced rectal cancer (LARC), offering potential insights into disease progression, treatment response and recurrence. This review aims to comprehensively evaluate the utility of ctDNA as a prognostic biomarker in LARC. METHODS: PubMed, EMBASE and Web of Science were searched as part of our review. Studies investigating the utility of ctDNA in locally advanced rectal cancer (LARC) were assessed for eligibility. Quality assessment of included studies was performed using the Newcastle Ottawa Scale (NOS) risk of bias tool. Outcomes extracted included basic participant characteristics, ctDNA details and survival data. A meta-analysis was performed on eligible studies to determine pooled recurrence-free survival (RFS). RESULTS: Twenty-two studies involving 1676 participants were included in our analysis. Methodological quality categorised by the Newcastle Ottawa Scale was generally satisfactory across included studies. ctDNA detected at various time intervals was generally associated with poor outcomes across included studies. Meta-analysis demonstrated a pooled hazard ratio of 8.87 (95% CI 4.91-16.03) and 15.15 (95% CI 8.21-27.95), indicating an increased risk of recurrence with ctDNA positivity in the post-neoadjuvant and post-operative periods respectively. CONCLUSION: Our systematic review provides evidence supporting the prognostic utility of ctDNA in patients with LARC, particularly in identifying patients at higher risk of disease recurrence in the post-neoadjuvant and post-operative periods.

Robotic transanal minimally invasive surgery (R-TAMIS): current evidence in the treatment of early rectal neoplasia.

INTRODUCTION: Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic improvements over traditional laparoscopic TAMIS (L-TAMIS) include increased dexterity within a small operative field, with possibility of better surgical precision. We aim to collate the existing data surrounding the use of R-TAMIS to treat rectal neoplasms from cohort studies and larger case series, providing a foundation for future, large-scale, comparative studies. METHODS: Medline, EMBASE and Web of Science were searched as part of our review. Randomised controlled trials (RCTs), cohort studies or large case series (≥ 5 patients) investigating the use of R-TAMIS to resect rectal neoplasia (benign or malignant) were eligible for inclusion in our analysis. Quality assessment of included studies was performed via the Newcastle Ottawa Scale (NOS) risk of bias tool. Outcomes extracted included basic participant characteristics, operative details and histopathological/oncological outcomes. RESULTS: Eighteen studies on 317 participants were included in our analysis. The quality of studies was generally satisfactory. Overall complication rate from R-TAMIS was 9.7%. Clear margins (R0) were reported in 96.2% of patients. Local recurrence (benign or malignant) occurred in 2.2% of patients during the specified follow-up periods. CONCLUSION: Our review highlights the current evidence for R-TAMIS in the local excision of rectal lesions. While R-TAMIS appears to have complication, margin negativity and recurrence rates superior to those of published L-TAMIS series, comparative studies are needed.

Whole-Body MRI Screening for Carriers of Germline TP53 Mutations-A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review evaluated whole-body MRI (WB-MRI) as a cancer screening tool for individuals carrying germline TP53 mutations, a population known to be at a significantly elevated risk of malignancy. The primary objective is to assess the diagnostic performance of WB-MRI in detecting cancer in this cohort. METHODS: PubMed, MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials were searched until 18 August 2023. Eligible studies were selected based on predefined inclusion criteria. The data extracted included information on study characteristics, patient demographics, and the WB-MRI diagnostic performance. RESULTS: This systematic review identified eight eligible studies, comprising 506 TP53 mutation carriers. The mean age was 34.6 ± 16.3 (range 1-74) years. In total, 321/506 (63.4%) of the patients were female and 185/506 (36.6%) were male. In addition, 267/506 (52.8%) had a previous oncological diagnosis. Thirty-six new cancers were diagnosed with WB-MRI (36/506 (7.1%)). The overall pooled proportion of cancer detected on MRI was 7% (95% confidence interval 5-10). In total, 44 new lesions were picked up, as multiple lesions were found in some patients. CONCLUSION: WB-MRI is an effective cancer screening tool for TP53 mutation carriers. While these findings suggest the potential for WB-MRI to contribute to early cancer detection in this high-risk population, further research and the standardisation of protocols internationally are warranted to optimise its clinical utility.

Assessing Circulating Tumour DNA (ctDNA) as a Biomarker for Anal Cancer Management: A Systematic Review.

This systematic review investigates the potential of circulating tumour DNA (ctDNA) as a predictive biomarker in the management and prognosis of squamous cell carcinoma of the anal canal (SCCA). PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials were searched until 7 January 2024. Selection criteria included research articles exploring ctDNA in the context of anal cancer treatment response, recurrence risk assessment, and consideration of salvage surgery. A total of eight studies were therefore included in the final review, examining a total of 628 patients. These studies focused on three main themes: SCCA diagnosis and staging, treatment response, and patient outcomes. Significant heterogeneity was observed in terms of patient cohort, study methodology, and ctDNA biomarkers. Four studies provided information on the sensitivity of ctDNA biomarkers in SCCA, with a range of 82-100%. Seven studies noted a correlation between pre-treatment ctDNA levels and SCCA disease burden, suggesting that ctDNA could play a role as a biomarker for the staging of SCCA. Across all seven studies with paired pre- and post-treatment ctDNA samples, a trend was seen towards decreasing ctDNA levels post-treatment, with specific identification of a 'fast elimination' group who achieve undetectable ctDNA levels prior to the end of treatment and may be less likely to experience treatment failure. Residual ctDNA detection post-treatment was associated with poorer patient prognosis. This systematic review identifies the broad potential of ctDNA as a useful and decisive tool in the management of SCCA. Further analysis of ctDNA biomarkers that include larger patient cohorts is required in order to clearly evaluate their potential role in clinical decision-making processes.

Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis.

PURPOSE/AIM: Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. METHODS: PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality. RESULTS: Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49;

Current applications and future potential of ChatGPT in radiology: A systematic review.

This study aimed to comprehensively evaluate the current utilization and future potential of ChatGPT, an AI-based chat model, in the field of radiology. The primary focus is on its role in enhancing decision-making processes, optimizing workflow efficiency, and fostering interdisciplinary collaboration and teaching within healthcare. A systematic search was conducted in PubMed, EMBASE and Web of Science databases. Key aspects, such as its impact on complex decision-making, workflow enhancement and collaboration, were assessed. Limitations and challenges associated with ChatGPT implementation were also examined. Overall, six studies met the inclusion criteria and were included in our analysis. All studies were prospective in nature. A total of 551 chatGPT (version 3.0 to 4.0) assessment events were included in our analysis. Considering the generation of academic papers, ChatGPT was found to output data inaccuracies 80% of the time. When ChatGPT was asked questions regarding common interventional radiology procedures, it contained entirely incorrect information 45% of the time. ChatGPT was seen to better answer US board-style questions when lower order thinking was required (P = 0.002). Improvements were seen between chatGPT 3.5 and 4.0 in regard to imaging questions with accuracy rates of 61 versus 85%(P = 0.009). ChatGPT was observed to have an average translational ability score of 4.27/5 on the Likert scale regarding CT and MRI findings. ChatGPT demonstrates substantial potential to augment decision-making and optimizing workflow. While ChatGPT's promise is evident, thorough evaluation and validation are imperative before widespread adoption in the field of radiology.

Radiomics; Contemporary Applications in the Management of Anal Cancer; A Systematic Review.

INTRODUCTION: The management of anal cancer relies on clinical and histopathological features for treatment decisions. In recent years, the field of radiomics, which involves the extraction and analysis of quantitative imaging features, has shown promise in improving management of pelvic cancers. The aim of this study was to evaluate the current application of radiomics in the management of anal cancer. METHODS: A systematic search was conducted in Medline, EMBASE, and Web of Science databases. Inclusion criteria encompassed randomized and non-randomized trials investigating the use of radiomics to predict post-operative recurrence in anal cancer. Study quality was assessed using the QUADAS-2 and Radiomics Quality Score tools. RESULTS: The systematic review identified a total of nine studies, with 589 patients examined. There were three main outcomes assessed in included studies: recurrence (6 studies), progression-free survival (2 studies), and prediction of human papillomavirus (HPV) status (1 study). Radiomics-based risk stratification models were found to provide valuable insights into treatment response and patient outcomes, with all developed signatures demonstrating at least modest accuracy (range: .68-1.0) in predicting their primary outcome. CONCLUSION: Radiomics has emerged as a promising tool in the management of anal cancer. It offers the potential for improved risk stratification, treatment planning, and response assessment, thereby guiding personalized therapeutic approaches.

Radiogenomics: Contemporary Applications in the Management of Rectal Cancer.

Radiogenomics, a sub-domain of radiomics, refers to the prediction of underlying tumour biology using non-invasive imaging markers. This novel technology intends to reduce the high costs, workload and invasiveness associated with traditional genetic testing via the development of 'imaging biomarkers' that have the potential to serve as an alternative 'liquid-biopsy' in the determination of tumour biological characteristics. Radiogenomics also harnesses the potential to unlock aspects of tumour biology which are not possible to assess by conventional biopsy-based methods, such as full tumour burden, intra-/inter-lesion heterogeneity and the possibility of providing the information of tumour biology longitudinally. Several studies have shown the feasibility of developing a radiogenomic-based signature to predict treatment outcomes and tumour characteristics; however, many lack prospective, external validation. We performed a systematic review of the current literature surrounding the use of radiogenomics in rectal cancer to predict underlying tumour biology.

Prognostic value of pre-operative mean corpuscular volume (MCV) in colorectal cancer.

BACKGROUND: Mean corpuscular volume (MCV) has been shown to have some correlation to oncological outcomes in oesophageal cancer, with high pre-operative MCV associated with disease recurrence. A similar association has previously been reported in colorectal cancer. AIMS: This study is aimed at investigating whether high MCV bears similar relation to post-operative outcome and disease recurrence in colorectal cancer (CRC). METHODS: Patients undergoing elective CRC resection with curative intent between January 2008 and December 2019 were identified from our prospective database. Review of patient demographic details, American Society of Anaesthesiologists (ASA) grade, smoking and alcohol intake were performed. In addition, tumour location and staging, operation performed, pre-operative laboratory data and oncological management of each patient were noted. Post-operative morbidity (Clavien-Dindo (CD) score > 2), 30-day mortality, in-hospital mortality and cancer recurrence were examined and multivariable regression analysis was performed to predict these outcomes. RESULTS: A total of 1,293 CRCs were resected, with 1,159 patients (89.7%) experiencing a hospital course without major morbidity (CD < 3). 30-day mortality rate was less than 1% (12/1293). There were 176 patients (13.6%) with recurrence at follow-up. When multivariable regression analysis was performed, high pre-operative MCV did not predict negative post-operative or oncological outcomes. CONCLUSION: MCV does not appear to be an independent prognostic factor for outcomes following elective CRC resection.

Tracheoesophageal fistula development following radiotherapy and tyrosine kinase inhibitors in a patient with advanced follicular thyroid carcinoma: a case-based review.

INTRODUCTION: Tracheoesophageal fistulas (TEF) are a rare complication that can occur in patients with radioactive iodine refractory metastatic follicular thyroid carcinoma (FTC) following treatment with radiotherapy (RT) and tyrosine kinase inhibitors (TKI). METHODS: We describe the case of a TEF development in a 69-year-old male who underwent targeted therapy TKIs and adjuvant RT for radioactive iodine refractory FTC. RESULTS: In the case, staging investigations revealed a metastatic, poorly differentiated FTC refractory to radioactive iodine. After 2 years of disease control on Lenvatinib, the patient's condition progressed, necessitating a switch to Cabozantinib. Soon after, they presented with haemoptysis secondary to invasion of the primary thyroid tumour into the trachea. Radical radiotherapy (45 Gy/30 fractions) was also administered to the thyroid gland, ultimately complicated by radiation necrosis. Four months post-completion of RT and recommencing TKI, the patient presented with haemoptysis and hoarseness secondary to recurrent laryngeal nerve compression and tracheal invasion, as well as dysphagia secondary to oesophageal compression. Following an acute presentation with intractable throat pain, investigations revealed a TEF. Surgical and endoscopic management was deemed inappropriate given the patient's rapid deterioration and anatomical position of the TEF, and therefore a palliative approach was taken. CONCLUSION: This case report highlights a rare cause of TEF development in a patient having TKI therapy post-RT for advanced FTC. It highlights the importance of monitoring TEF development in this cohort of patients. It demonstrates the importance of patient counselling and education regarding treatment options and the rare side effects of treatments.

Redo Pelvic Surgery and Combined Metastectomy for Locally Recurrent Rectal Cancer with Known Oligometastatic Disease: A Multicentre Review.

INTRODUCTION: Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. 'Selective' patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates. METHODS: A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes. RESULTS: Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/- 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/- 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5-17.5 months) and 25.9 months (IQR 6.2-39.7 months), respectively. CONCLUSIONS: Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.

Pelviureteric junction obstruction in adults: A systematic review of the literature.

Background: Pelviureteric junction obstruction (PUJO) is a common urological disorder that can present at any stage of life. The underlying etiology in children has been well studied; however, a gap exists in the literature for the adult population. Herein, we performed a systematic review of the literature to evaluate the current evidence on the underlying etiologies of adult patients presenting with PUJO. Materials and methods: Four electronic databases were searched for relevant studies assessing the underlying etiologies of pelviureteric junction obstruction in adults. Studies were assessed for eligibility based on predefined inclusion and exclusion criteria, and a critical appraisal of methodological quality and risk of bias was performed. Finally, qualitative and quantitative data analyses were performed. Results: Twelve studies comprising a total of 513 patients with radiologically confirmed PUJO met the inclusion criteria and were included in our analysis. The most common finding was crossing vessels, which were observed in 50.5% of patients, followed by intrinsic ureteral stenosis (27.1%), adhesions (15.3%), and high insertion of the ureter (10.1%). Conclusions: The underlying etiologies of PUJO in adults remain unclear. This study indicated that obstruction secondary to crossing vessels is the most common cause of obstruction in adults and occurs more frequently than in the pediatric population.

Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials.

BACKGROUND AND OBJECTIVES: Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer. METHODS: A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny. RESULTS: Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection. CONCLUSIONS: LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows.

Radiomics and Radiogenomics in Pelvic Oncology: Current Applications and Future Directions.

Radiomics refers to the conversion of medical imaging into high-throughput, quantifiable data in order to analyse disease patterns, guide prognosis and aid decision making. Radiogenomics is an extension of radiomics that combines conventional radiomics techniques with molecular analysis in the form of genomic and transcriptomic data, serving as an alternative to costly, labour-intensive genetic testing. Data on radiomics and radiogenomics in the field of pelvic oncology remain novel concepts in the literature. We aim to perform an up-to-date analysis of current applications of radiomics and radiogenomics in the field of pelvic oncology, particularly focusing on the prediction of survival, recurrence and treatment response. Several studies have applied these concepts to colorectal, urological, gynaecological and sarcomatous diseases, with individual efficacy yet poor reproducibility. This article highlights the current applications of radiomics and radiogenomics in pelvic oncology, as well as the current limitations and future directions. Despite a rapid increase in publications investigating the use of radiomics and radiogenomics in pelvic oncology, the current evidence is limited by poor reproducibility and small datasets. In the era of personalised medicine, this novel field of research has significant potential, particularly for predicting prognosis and guiding therapeutic decisions. Future research may provide fundamental data on how we treat this cohort of patients, with the aim of reducing the exposure of high-risk patients to highly morbid procedures.

Robotic-assisted versus laparoscopic nephroureterectomy; a systematic review and meta-analysis.

Background: Upper tract urothelial carcinoma (UTUC) is the malignant transformation of urothelial cells, from the renal calyces to the ureteral orifices. While the benefits of minimally invasive nephroureterectomy over their open counterpart have been established, the optimal technique remains a debate. We aimed to assess current evidence in the literature and compare outcomes between robotic-assisted (RANU) and laparoscopic nephroureterectomy (LNU). Methods: A systematic review of the literature was performed for studies comparing RANU and LNU for bladder cancer. Outcome measurements were recurrence rates (local and distal), positive margins, positive lymph node yield and perioperative outcomes. Meta-analysis was performed using Review Manager 5. Results: Our results demonstrate a significantly higher mortality rate in patients undergoing laparoscopic nephroureterectomy when compared with the robotic-assisted approach for the treatment of UTUC (1.8% vs. 1.1%, p = 0.008); however, these results were inconsistent on sensitivity analysis and should therefore be interpreted with caution. No significant difference was observed for other outcomes. Conclusion: The ideal approach to minimally invasive radical nephroureterectomy remains undetermined. Future research, ideally prospective randomised studies, should focus on long-term outcomes, in particular recurrence, recurrence-free survival, overall survival and the correlation between surgical technique and survival.

Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy?

INTRODUCTION: Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy. METHODS: A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against. RESULTS: From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC. CONCLUSIONS: In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.

Introduction of an advanced nurse practitioner (ANP)-led male lower urinary tract symptom (LUTS) clinic and development of integrated referral pathway.

INTRODUCTION: Ireland's population is living longer, and the prevalence of any LUTS is estimated to be 63-83% in adult men, increasing with age. Ireland has one of the lowest urologists per population ratio in Europe, at approximately 1:127,027. The patients waiting the longest are those with routine benign conditions such as men with LUTS. The impact on quality of life for men experiencing LUTS can be profound. METHODS: Sláintecare funded an ANP post in TUH to develop an integrated referral pathway for male LUTS and develop a secondary care nurse-led clinic for LUTS and tackle the ever increasing new and return waiting lists. The initial focus of this role was on reducing pre-existing outpatient (OP) waiting lists. This is a review of the first 12-month outcomes of this ANP post. RESULTS: A total of 410 new patients were assessed over the 12-month period. The mean waiting time from referral to review was 24 months; however, some referrals dated back to 2014. Four hundred forty-two return patients were reviewed in the 12-month period. All these patients were waiting longer than 18 months for a return appointment. In absence of the ANP-led clinic, there was no capacity for any of these patients to be reviewed in the general urology clinics. Overall outcomes were as follows: 38% were given advice and education and discharged. Treatment was initiated in 42% and follow-up arranged. Physical review was deemed necessary for 11% of patients. Only 6% of patients reviewed required referral back to consultants' clinic. CONCLUSION: This study demonstrates the safety, efficacy and financial advantage of an ANP-led clinic for adult men presenting with lower urinary tract symptoms previously triaged by a consultant urologist.

What works best in hiatus hernia repair, sutures alone, absorbable mesh or non-absorbable mesh? A systematic review and network meta-analysis of randomized clinical trials.

Laparoscopic hiatal hernia repair (HHR) and fundoplication is a common low risk procedure providing excellent control of gastro-oesophageal reflux disease and restoring of normal anatomy at the hiatus. HHR may fail, however, resulting in hiatus hernia (HH) recurrence, and the use of tension-free mesh-augmented hernioplasty has been proposed to reduce recurrence. Previous research on this topic has been heterogeneous, including study methods, mesh type used and technique performed. A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out using 'PUBMED', 'EMBASE', 'Medline (OVID)' and 'Web of Science', of articles identifying HHR with suture cruroplasty, non-absorbable mesh (NAM) and absorbable mesh (AM) reinforcement. Eight RCTs with 766 patients were evaluated. NAM had significantly (P < 0.05) lower early recurrence rates (OR: 0.225, 95% CI 0.0342, 0.871) compared with suture repair alone; however, no differences in late recurrences were evident. For AM, no difference in early (0.508, 95% CI 0.0605, 4.81) or late (1.07. 95% CI 0.116, 11.4) recurrence rates were evident compared with the suture only group. Major complication rates were similar in all groups. NAM reinforcement significantly reduced early HH recurrence when compared with sutured cruroplasty alone; however, late recurrence rates were similar with all techniques. Given the limited data in comparing AM with NAM, this study was unable to conclude which composition was significant. We emphasize caution when interpreting small sample size RCTs, and recommend more research with larger randomized studies.

Assessing medical students' perception and educational experience during COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has significantly impacted the traditional delivery of medical education. Medical education programmes have had to cope with limitations on face-to-face learning, and accelerate the adoption of digital learning. In addition, the pandemic has potential serious implications on the psychological well-being of medical students. We aim to assess the changes in perceptions and experiences of medical students as a consequence of this pandemic. METHODS: Cross-sectional survey of medical students at Trinity College Dublin (TCD) between March and April 2022 was performed. The survey explored student satisfaction with the current education program, teaching delivery and the impact of COVID-19 on education and student well-being. RESULTS: 175 medical students participated in the survey. Overall, the majority of students were happy/neutral with their medical education. 93 (53.1%) felt tutorials and problem-based learning (PBL) to be the most effective method of teaching, followed by laboratory and clinical placements in 78 participants (44.6%) and hybrid-learning in 85 participants (48.6%). There was a mixed reaction to the changes in the delivery of education brought about by the pandemic. 67 participants (40.6%) felt happy with the changes, another 64 participants (38.8%) felt neutral, whilst only 34 participants (20.6%) were unhappy. However, most participants felt the pandemic negatively impacted their mental health, with 96 participants (55.8%) reporting negative responses. 58% of participants (n = 102/175) reported utilising the student support services at university campus and 49% (n = 50) were satisfied with their services. CONCLUSION: Digital content and delivery confer the benefit of greater flexibility in learning, the ability to learn at one's own pace and in a preferred environment, however lacks the advantage of bedside teaching and hands-on training. Our findings reinforce the potential advantages of online learning.