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Coffee. So we're going to be starting on the next lot of the mornings talks. So first off, we're starting with Dr Rachel Hubbard. She's a uroradiology consultant and honorary senior clinical lecturer at Sheffield teaching hospitals. She's had a strong interest in urology ever since her early days as a court surgical trainee. Um and she's actively involved in the training of urology and trainees alike. She's a lecturer of the National F R C S urology course. She's also a keen academic radiologist, actively engaged in some very exciting sounding research um such as producing health inequalities in the outcomes of muscle, invasive bladder cancer. So, anybody in the room today who's a budding neuro radiologist, she's definitely the person to talk to. So without further a do, I'll let Dr Rachel Hubbard take over. Hi, everyone. Thank you so much for having me. I'm, they've given me a seat. So basically, if you ever go skiing and there's a really steep run called the wall and the snow is bad, don't, don't go down it. So I grabbed all the ligaments in my knee and people are taking photos and they've offered me a seat, but I've got some, you know, if you were a really quite amazing pink shoes on. So I'm just trying to stand whilst I can and then when the cameras stopped, I can sit, I hope you're enjoying the conference. I love the SRT conference. When I was a trainee, I always found the lectures were at a great level for, I needed to know. Um It's really good for prizes as well for boosting up your CV. If you're applying to radiology or C C T NG, um if you ever want to see a award winning SRT video on how to do CPR in a CT scanners with someone wearing a bright pink dress, you can find me on youtube also, if there's anyone training in London and you wear the rivalry. I made an educational video about Bosniak criteria featuring a kidney that had a graduation hat and an SRT, not an S R T had a Bosniak T shirt and it came second at SRT due to someone from Kings and I've never forgiven them. So we're gonna be thinking about your radiology. So I'm a Uro radiologist um and a clinic electorate Sheffield and I trained and did my sub spect at UCL down in London, which is essentially the birthplace of prostate M R. So every, every talk I shout out to Claire Allen, she's probably the best year radiologist that I know probably the best in the world. So when your trainee find a mentor that inspires you because honestly, it's life changing and it makes you such a better radiologist and in, in the future, you can be lucky and be able to do it to them and to others. So what we're gonna do, we're gonna understand why your radiology is the best specialty. And I was really excited reading the bio profiles of SRT to see how many of them wanted to do the same special as me because the reality is every time someone goes, what do you want to do? But what are you doing? And I'd be like Euro and then they all go in your oh, I love the bra and I'm like, you're oh, and then they keep going new, right? So, so many great your radiologists out there. But as I say to every neuroradiologist or any other radiologist, balls, not brains, people, balls, not brains. So we're going to be thinking about why uroradiology is the best one. We're going to think about how to you do acute urological ultrasound because often that's quite scary how the premise of what to do and an apology that you can find out how you can really help them. And then I really like the last one of the other talks I was talking about adding the extra factor. So as a trainee, one of the key things I learned was not just to be an average radiologist but to really add the extra factor. So be the radiologist that people come to because diagnostically or procedurally you're there, they know they can trust your reports, they know what you can see. So how to add the extract factor. So why uroradiology? Number one, it's got great memes. It's got great pictures, but it's the most fun. So, here are some of your uh radiologist know these are all urologists. So, urologists are the most fun surgical's people that you can find. This is the one conference when I left you cl the urologist, free Meal leaving party. Darren the garden. The right is probably one of the most eminent stone surgeons in the UK. I got him to sing a duet with me and karaoke at a karaoke leaving party and we did a duet to Sean Paul and I've never ever peaked as high as that. This is asset the F R C S examine ating course where we lectures. That's moving lots of different surgeons. Twitter is great for networking. Um You make really good friends, you get lots of great opportunities and you just get to keep each other going. The NHS as hard at times is really demoralizing. So kind of really nurture these friendships. And this is probably saying, so he's probably a lot more eminent that I care to think. And it was my birthday MDT. So naturally big regional you're on MDT. It goes on for hours. I wanna seeking dress and we got the drug rep to buy lunch. You've got this oncology professor who literally kicked the drug reps away. And we're like, yeah, we don't want your promotional material in the picture with Rachel. So all the flood like drug rep, pictures are gone and that's us with the lungs that we've got. So if you want the most fun specialty with the best parties and the best Christmas parties join Euro, it's a great mix of both practical and diagnostic options. So if you want to do nonvascular I R I have fun but have a better work life balance on call. Uh Do your oh, you can do next changes. You can do acute Neff insertions. You can save lives because septic obstructive kidneys kill and you can also do what I did once which was drain a prostatic abscess on I T U. You can do renal frequency ablation. So Blake renal tumor's which is up and common. There's lots and lots of fun procedural stuff that you can do or you can do a bit less glamorous. So like fluoroscopy where you're injecting capitals to lots of different penises and finding out of their strictures. And so you can make a real difference to the patient's lives and there's a great mix of diagnostic options as well. So you can have a bit more of a chilled lifestyle and be at the cutting edge. Research wise, there's absolutely loads. So we've helped. Not many people ask me, but prostate MRI has completely transformed. The prostate cancer diagnostic pathway. You are picking up anterior tumor's that were missed before. And it's really at the cutting edge of cancer research, things that we're doing at Uni Sheffield at the moment, uh showing that new adjuvant chemo is improving the outcomes in muscle invasive bladder cancer way more than you could think or imagine. We're looking at reducing the health inequalities. So there's big inequalities based on where you live in the UK. So you're more likely to die if you don't live in London or in the south. So thinking how can we reduce the north south divide? And even you in Yorkshire, statistically, we've proven you're more likely to get a worse outcome with bladder cancer. Um If you live in certain poorer cities and we're also looking at with the urologist, the rescue style. So point of care, ultrasound in testicular torsion, which we'll talk about later on. So there's just a bit for everyone if you like fun procedures, diagnostic or research. Um Come do your, oh, that's your oh, not neuro. Um And it's also great for networking. So you've got the British Society of your Radiology and European Society of your Radiology. Um So really join the sub spect specialties because you'll learn about jobs outside. I moved from London to Sheffield, which I wouldn't have done about BS. You are and I'm absolutely loving life. So I was really proud of this pan and I taught my trainees that on Tuesday and no one laughed until I pointed it out and no one's laughing now, which is sad. So, penis greater emergencies, we're going to think about how you can handle it on call. Yeah, there's one I like you. Thank you. So, what we're gonna think about is understand the basics of penis. Great ultrasound. We're going to understand the indications for providing on call cover and helping a urologist in the management of the acute setting. And we're gonna recognize the variety of penoscrotal pathologies and, and how to accurately characterize them on call. Can anyone guess the first one? I'm just waiting for the men to like grimace penile fracture. Also, I'm sad you weren't here for the intrigue because I was going to say, I hope after 10 years of on call, I will look older because I'm always asked if I'm a medical student. So it's good to know that we can aid. Yes. So penile fracture. So we're gonna think about penile fracture and the ultrasound features. We have a disclaimer that unless you're at a tertiary or quarter, Neri Euro center of a dedicated your radiologist, you probably won't have to do them, but it's important to think about the premise and how to do it. So if you get asked, you might be able to help out. So this is when we watched the men in the room grimace and cross their legs were gonna be talking about the mechanism of the injury a second year when I gave this lecture, literally put his head in his hands and nearly vomited on Tuesday. So, so penile fracture is a result of a rupture of the penal corpora. So the skin thing that goes around the penis, it's relatively uncommon, but it's associated with sexual intercourse, specifically trauma to erect penis. So what I love about your radiology is honestly the conversations you have a patient and colleagues, you have no barriers at all which spills out to the dinner table and dates, which is not a good idea. So normally it's very clear based on the history and the examination of the patient's that often most places don't do imaging for it. And it very much depends on the designated Euro Center as to the opinions about the benefit of it. But actually, you're on ultrasound and MRI can be helpful to help confirm the diagnosis and to exclude the presence of a corporal injury. When it will affect the patient, they might not have to go to theater. So let's think about the specifics. How does it happen? So what happens is an actual force on an erect penis. And this typically occurs during very vigorous sexual intercourse where the erect penises misdirected um against the pubic bone or the perineum. So I say often the penis like a man doesn't ask for directions, it hits the wrong part of the body and then it fractures. Um and most common especially in the Western population is to you to vaginal sexual intercourse and the position of the women on the man in the Middle East. So it's by Taekwondo. So does anyone know what to Qanda is? Because I will be impressed if not a little bit traumatized if you know of this practice. So this is apparently some people do this in the Middle East, you bend the top part of the erect penis whilst holding the lower part of the shaft until you hear and feel a click. Mass spacing can also cause it. And also non sexual trauma. For example, if you have an erect penis and then you roll over your bed, you can damage it and animal bites. So we'll move on. Why is it important? Well, it may come as a surprise to you or that the penis is important to a lot of people. And for the urologist, they need to know whether the tunica. So the layer surrounding the penis, the tunica al Virginia is ruptured. And if the rupture extends to the urethra, if you've got your refill damage, no one wants urine floating around such a precious organ and no one wants strictures or problems peeing in the future. And so that determines whether you need to do an emergency surgical exploration. So it has key impacts and makes a key difference to both the patient and the surgical management. So how does the penis look like on august and often people get scared. Most people refuse to scan them. It's very easy, just a bit socially awkward. Um I like to think of my Friday afternoon penal ultrasound list is essentially a counseling session with 23 minutes scanning and 15 minutes providing reassurance to variety of men. So you normally get the patient lying down. So essentially stripped down pants and trousers off and I get them to move the penis in different positions. And essentially you just want to do dorsal and ventral scanning. So uh eventually get the penis to point towards the hair. So it lays on the tummy and if not get them to point the penis down and get them to hold it and move it. Um And that's all, all you need to do. And it's a very easy scan. It takes 20 seconds, use a high frequency pro because obviously very superficial structures and obtain transfers and longitude views of the penis and the structures. And what you've got is you've got the penis consisting of free cylindrical bodies called the penal corpora. So um there are two dorsal corpora cavernosa and one ventral corpus spongiosum, which is a bit that surrounds the urethra. And then just to remember when trying to work out what is dorsal and ventral in anatomy, the penis has to be erect. I don't know who decides that. So you have to flip it up um to corporate cavernosa uh enclosed by the fiber sheath called the tunica engineer and then this is surrounded by the Bucks fascia. So this is what it looks. Um And you can see here you've got a long needle view. So the tunica at the top and the tunica is that thin layer. So that little white bit below it. And then below, you've got a transverse few Corpus Ponsi. Awesome and the corpus cavernosa. Uh So anyone who knows me, knows, I like to bake. So if you want to know exactly what it looks like, this is what it looks like in a cake form. Corpora, corpora spongiosa. And then you can see at the top, the deep dorsal veins and the vasculature. And then when we talk about what site rupture is more common, it'll become clear if you've got hematoma at the top, what happens is basically the deep dorsal vein will rupture and that's what's causing the blood. You don't necessarily need an operation. So why is it helpful? Well, all the sound can identify tear the tunica and it's seen as a defect in the line with overlying hematoma. Most tears are central and that's because the tunica at that level at the ventral aspect is finished. So it's most likely to rupture and hematoma and untreated tears can lead to erectile dysfunction and fibrosis and most people don't like that. So it's important to prevent that for the future. So here are some examples. Um U C L I was doing my sub spect during COVID, there was nothing else to do. So, I'd ride in at the weekend and they scanned every penile fracture. And what we did there was you located the defect marked it with an X and they instead of the typical way to fix the penile fractures, do a circle is brutal, do a circumcision, completely degloved the penis. You take all the skin to the bottom and repair it. And so what they would do there is a very unique situation. You would locate the defect precisely and they would just do a limited operation. So it made a big difference. And what you're looking for is a defect here. So you can see here the white tunica and then it stops and then you can see the hematoma coming up around it. Here's one like hematoma, it looks the same as like everywhere else, but it's on the penis. And then sometimes you do MRI and you can see here the massive longitudinal defect here. So there's like this really obnoxious urology trainee who has an Instagram page and he's like wrote an article about how he was the first person to discover a longitudinal defect because they're really rare and it wasn't, it was me. So I'm annoyed and this is what it looks like. So we've done the penis. What's another really important organ that you might have to deal with on call the testicles? So we're now gonna think about testicular torsion. So testicular torsion occurs when the test is taught. So it twists on itself and on the spermatic cord and that cuts off the blood supply to the testicle itself. And the most common cause is a key testicular pain. And the most underlying common pathology causing this is the bell capital for mitty, which just means it's a bit more mobile than normal. So, diagnosis is clinical. Um but if in doubt, ultrasound can be helpful in confirming the diagnosis. Last alternative diagnosis is or pathology is causing it. So you might have different practices where you work. A lot of places will be like no towards in is a political emergency. You need to take them to theater. Now. Um as a heads up times and urology are changing and they're not happy with the amount of people that they're taking two theater. So they want to know with more greater sensitivity if there's torsion on ultrasound or not. And so I would be prepared. Obviously, it might not hit your generation. But for the next generations of radiology trainees, it's going to be something that we are having to do more and more. Um urologists are doing were involved with a rescue style to see if there's any correlation between ultrasound findings and what they find in theater because they want to take less and less patience to theater because there's a high negativity rate on scrotal expiration. And we don't quite know the long term implications of A G A scrotal expiration and impact on fertility and the patient. So we are going to be asked to do more and more of them E S U R. So European, your radiologists are very much like you can do the peak flow. And you can tell I'm a bit more cautious because you can have high flow, low flow or no flow talk shin. But I think we can have pointers and actually, I'll explain for you in the cases how it can be helpful. So, prompt surgical management is key. Um So what do you do? So, ultrasound is the best imaging modality of choices to look at the structure of the testes and the vascularity and it doesn't involve radiation. And the most important thing is to compare like for like so most people have two testicles. So to compare the normal testicle and it's vascularity with the abnormal one. Sometimes you can see twisting of the spermatic cord and ultrasound. How I scan is I scan from the inguinal canal down. So I measure the vast I can tell if it's obstructed or not, if there might be fertility problems and it helps you because testicles move a lot and it's really hard to work out what is right and left sometimes because they're dancing around. So by going down the spermatic cord, I know confidently what is the right and the left testicle. But I can also tell if there's increased vascularity or some pathology of the spermatic cord as well. You can have the world flu sign, you can get altered blood flow. And you see that primarily by comparing both testicles together, you can have absent belfour, which is a bad sign and you can have an increase in size of the testes. And the epididymal itself, you need early stages. It can look homogeneous in the late stages. It can look heterogeneous. So why does it matter? Well, like the penis, the testicles are important and people like them and they're really important for fertility. So it has long term implications on on the patient and their partners. And the key thing for torsion is prompt surgical treatment and rapid diagnosis, which can lead to surgical intervention. And if diagnosed early enough, you can salvage the testicle and the tort it with minimal to no damage. If you leave it late, you might require an orchidectomy if the testicle is dead and if you leave it there, testicles release anti testicular antibodies which then attacked the normal contralateral testicle. And that's a bad sign and the likelihood of salvage is directly related to the time and onset of symptoms. So less than six hours, you can get up to 100% salvage 6 to 12 hours. It drops down to 50% and after 12 to 24 hours down to 20%. But don't be put off by the timing's if you're on call at the weekend because you can still make a difference even if it's over 24 hours. So if we look at some examples now. So, um whenever someone comes to my Friday afternoon list of fun, my first picture, I always make them do is what I call the Scrotal view. What I like to think the Rachel Hubbard view, but that doesn't really go well, likes to, it's great. Um So this is the first brutal view and I guarantee I maintain that you can diagnose the pathology on just one picture and you can so right is on the right and left, which testicle is abnormal, the left one. And we know that straightaway how because it's bigger and on color flow, there's no none. And so straight away, I know that this is really and this is, this is what's happening. And this was one where he had, they just described testicular pain, turns out he had technology of fallow, which was not treated and lost to follow up. So the anesthetist didn't want to take into fierce unless we could prove historian. Luckily, it was so clear um that they did. But unfortunately, by that point, as you can tell by the absence of flow, it was dead. And another one, what I also teach my trainees is um I always always ask questions myself and the top of any testicular report, I write the onset of symptoms. Uh because as much as I love urologists, they lie and often the patient doesn't tell them. So as soon as I get a testicular pain, I'm like, when did it start? Was it unilateral? Do you have any urine symptoms? And I put it at the top, this one, they said I've just been headbutted by a dog. So the personal called, scanned them and said it was a epididymal hematoma which I personally have never seen in my extensive career of scanning screw Tums. And this was a pit that they saved. The patient then came back and had a repeat scan because the pain and got worse and this was what happened. So the testicle I think was dead on the first scam. They've taken a picture and show no vascularity but they've gone. And that's, that's what happens on call. You get distracted by the key fact to the key fact with the dog had head buttered the patient. And so it was all about trauma and it wasn't, the patient had acute testicular pain two hours before the head, but injury and they hadn't focused on that. And the testicle was necrotic um on operation and I think he was only 20. So that's really sad. Now, we're gonna think about acute testicular trauma. So again, you might be asked to scan these. So what about trauma is the third most common cause of acute scrotal pain and it can result in varying degrees of damage to the testicles and can be blood or in some cases for the most unfortunate penetrating. So what do you get? Well, you can often get an associated hematocele. You need to assess the tunica disruption of the tunica. So just like scanning the penis, um you've got to look at the tunica and the layer around the testicle and how I do that is, I'm a big fan of Sydney loops. It's really hard for me to review pictures about Sydney leep because I'm not there. So it's very easy if there's a so for me to look at and then I can be confident that the tunica is intact or not. It's a lot easier to get a review from a designated sub specialist with Sydney leaps. You want to assess for ischemic insult. So often rhetorician and testicular trauma cases, I will take a Sydney loop of the testicle that's affected and a Sydney loop with vascularity. So I can say if there's an impact on that. So here's what an inter testicle a hematoma looks like. So you can see the hypoechoic hematoma in the body of the testicle. And this is where history is key because in an absence of trauma, you'll be worried about Touma and this will resolve and they might not necessarily need an operation. But if it's a tumor, you don't want to leave it in. And here again, you can see with just one picture here, the rupture of the tunica. So you've got a nice bright tunica and then disruption and here's a complete extra ization of the testicular contents out, but the testicle itself would still be salvageable. They would just take the hematoma and then so up the rest of it, what about testicular infection abscess? So that's a complication of severe epididymo-orchitis but needs to distinguish from other pathology which may mimic it. So the most people that develop testicular abscesses are a result of untreated or severe infection and the demographics are the same which are young, sexually active males that are most likely to get a testicular abscess. So you get focal areas of altered ecogenicity, mixed cystic or solid parts. You can get increased vascularity of the affected area and evidence of coexisting in infection in the tubing. The epididymal leaving, you often can get a reactive hydroseal. In some cases, it can be loculated may also contain parts and those are the ones that need to go to theater. This is what testicular abscess can look like. So, again, focal area within it often they resolve with antibiotics. And what I always say is I schedule repeat scanning and then reassure them that we can scan sooner because sometimes the infection can be so severe that the spermatic cord just in gorges and cuts off flow. And then I've had cases where patients have needed orchidectomy when it hasn't been treated properly. This is again a large abscess, essentially replacing the testicle and you can see the massive vascularity. So we saw earlier in the talks. It's quite interesting when you become sub specialist. I did my breast book in ST too and I was at friendly and they literally kicked me out. They said we could tell you really like prostate. So there's no point coming to the breast MDT. But it's nice to hear other people do talks. But then I've learned, I just know you listen to the bit. So I really like the Forney's bit in your lecture this morning. And it is really important because actually they don't always examine people in A and e especially they're really busy and Fournier gangrene kills. And it's necrotizing fasciitis of the perineum. And it's a true neurological emergency due to the high mortality rate and primarily is essentially a clinical diagnosis. Imaging can help and define the extent of damage, but it must not delay treatment. And especially if you're doing whole body scans and they haven't examined the perineum. Actually, by pointing out you can save a life or a penis because in some extreme cases, they might debride all of it. So it's older member of diabetes. So typically 50 to 70 years old, end stage renal or liver failure, hypertension, immunosuppression, obesity, alcoholism, and smoking, how they present they are really, really unwell to get penoscrotal pain, swelling, redness. I would never ever recommend going to see a patient with Fournier is because it's the worst smile that you'll ever have. You can get practice from the soft tissue gas up to 65% of pace and systemically, the very unwell and septic, here's the plain film radiograph and you can see it on the extremities, you can see all the gas of in the scrotal tissues. Again, a cross sectional aspect of a CT. So if they're pointing you towards it, it can really help but often on your review areas or I always like to think is there gas and is it where it should be? It should not be in the scrotum? So pointed out when it's there and flag it up, we're going to spend some time just thinking about the premise of renal trauma because this will often come up, especially if you do trauma on calls or if you're in a trauma center. Um, kidneys are also important and, and renal injuries account for approximately 10% of abdominal traumas. Um The incident exists in preexisting congenital or acquired pathology such as the horseshoe kidney. And there's a very famous person with a horseshoe kidney. Does anyone know it? Mel Gibson? Yeah, Mel Gibson has a horseshoe kidney. So if he comes in with his SUV and there's a car crash, he's more likely to have a renal aspiration. So how does it present? So you typically get microscopic or microscopic hematuria plus or minus some flank pain. And in more severe cases, the hypertension and shock may be present the vast majority. So 95 to 98% is minor. So you get protected packed of the retro peritoneum. So the retroperitoneal protects them. So you don't get as much damage and 85% over 85% is from blood trauma. So, motor vehicle collisions and falls and that's because you've got a deceleration force and the kidney collides with either the vertical column or the thoracic aid and collision is bad. Um You can also get iatrogenic injuries. That's a surgery renal biopsy, nephrostomy or ESWL. So it's very easy to accept a scan person across to me for bleed or post renal biopsy. But lithotripsy. So ESWL is lithotripsies to be sent shockwaves to break down the stone, you can actually damage the renal capsule and then cause a big hematoma and bleed. So don't think, oh, they just had lithotripsy, there's nothing gonna be wrong with them actually, if they're coming with pain and there's flank pain and hematuria, that's a bad sign. So how do you image? So CT is key, you want to triple face. So the non contrast first arterial to evaluate vascular injury. And in an effort, genic one to evaluate the renal parenchymal Asians and delay to look for evaluating bleeding and collecting system. And here's a really nice picture which shows the different class faces of grading. So you can see here at grade one, you're gonna have a subcapsular hematoma plus or minus a renal confusion. So that's really, really mild grade two will involve lacerations gonna be less than one centimeters in depth, but you won't have any urine extra ization, grade free the lacerations giving more than one centimeters. But again, no urine league and grade four parent primal aspiration um extend into the urine collecting system and you can get urine leak at that point. And then grade four and five, you've got the extension into the renal vein and the chateau kidney will probably most likely need a nephrectomy. The higher grades speak to I R or the urologist. But one of the key home points that I always tell to my trainees in trauma or POSTOP imaging is always, always, always, always do a urogram. Um You've already given them contrast, you've already radiated them. It's just another quick scan down and you get so much more information. How do I know there's a urine leak? Do a urogram? How do I know they haven't much with the anastomosis post prostatectomy? Um do a urogram. So you will never get into trouble doing urogram but you, they annoy a lot of people by not doing it. And and also you think, oh, let's say radiation, actually what patients' need in the acute setting and in the post operative period is accurate imaging and the answers and the urogram is, takes another 20 seconds, but it's safe to bringing the patient down and it saves the complications. So, in summary, from this ultrasound is a great imaging tool in the acute setting and can make a key difference to the patient and their outcomes. If in doubt, take a Sydney leap and I say get your friendly year around to review but not all your labs are friendly, but we should be, but it's very easy to review stuff with a Sydney loop. So take a city leap, always, always, always check vascularity. And compared to the contractual side, testicular torsion scares people, it doesn't do you just work through the premise of scanning a testicle, but there's a big medical legal litigation risk. And if you miss it, so prove this vascularity, take a city league with vascularity and you can put a disclaimer that we can't rule out torsion or ultrasound. But we can prove our alternative pathology and supportive factor which helps them then make a clinical decision. An uncle always do a urogram because it will help save you and also maybe a kidney or bladder. So Lewis Carroll, great, a famous poem about Walrus and he says the time has come. They're always said to talk of many things of shoes and ships and sealing wax and cabbages and kings. And I'd like to say to Lewis Carroll, I wish I had time to talk to you about the nodal spread of prostate cancer, bladder cancer, the hypervascular renal mets that you don't want to miss in the pancreas adrenal or the liver. But I can't. And it's so sad because this starts the depth of uroradiology, which I think makes it the most exciting specialty. So I thought identified my famous favorite case, the award winning. Yes, you are case that most people will know me for and which may or may not freak you out. Why is it sound great? Here's a guy with a lump next to his venous. You can see corpora, corpus Fangio's um in this hypoechoic area with what looks like some hyper echoic aspects in it, which on closer definition look like this. Does anyone know what it is? So we were scanning, this guy had gone to another hospital and they sent him back to ask because like no one could work out what this peanut lump was. And I was scanning him and boss, my boss shouted out Rachel Weisz it moving. So something is moving. Yeah, in the venous. Um and we will get through to some videos. Yeah, of it in a minute. But the pathology that we have, I often say is like buses, you never see any. And then they all come at once. Here was another man. Um He presented with a testicular lump that he felt moved 3 to 4 times a day. And that is the picture that he had and you can see here on the original scan, what had happened. So with the first scan, he was a young guy, he was from Italy and we took him to theater. At which point my boss, this is the best relation with urologist, you hang out with them all the time. So we went up as your ads to theater. My boss pointed out to everyone in the room. I've got a new iphone 13. So why would I not be the official photographer for this? Obviously, get concerned with the patient's, everything's anonymized. And then suddenly now my phone has a penal were memory. This is what happened. So unfortunately, don't have sounds you don't hear the screams. So the academic material was this essentially like a Pasfield cavity with what looks like what we described as rice noodle, which was the error because then you are always, always put off eating rice needles and they've spoken to microbiology and idea and they were like, we want the worm alive, what would you do? And obviously, the video is hilarious because they're all going like I googled it on youtube and this is how you take it out and then it moves and then literally they scream. So you had an excision and drainage is you put a catheter in and it was separate to the urethra. And you can see here the live one, it was Dirofilaria reckons and actually interest uh they normally only surviving dogs in human factors. They don't go to fruition. If you do get a parasite infection, it will go to your eyes and your liver or your lungs fast. But unfortunately, uh it went to the penis scrotal region. Um So if you go to Italy or Sri Lanka, maybe don't do an HP. So from this, this is what I did um E S U R the infamous penoscrotal. Of course, my conclusion to that was that is a rare infection but prompt, an accurate assessment of ultrasound can guide the urologist in patient management, which again is a key key conclusion. Sydney leaves provide an invaluable tool for both M E T discussion review and actually prompt and close relationships with for me, for urologist, really a swift patient management. And it's like what we heard earlier. It's about how you can offer the X factor. You are such a key part of the patient pathway. What I love about my job is that essentially I'm part of the urology team, they come to me, I help them out. It may be behind the scenes, but it makes a big difference to the patient. Whether or not the patient realizes that when your uncle doing trauma scan by and being present, you're helping the patient by identifying the trauma, pointing out bits that they need to do, doing extra view areas. And for this, it makes a key difference by doing good ultrasound thinking about what's the pathology, where is it going? Is this rare wealth we can do? And it makes a big difference in the big key impact on the patient. And actually, it's really satisfying because at the end of the day, these are people as mom's dad, brothers, loved ones and you can make such a difference for them. Um You're in one of the best test is in the world with lots of opportunities for procedures for research, for ground cutting stuff. Some of the stuff we're doing is, is going to make a massive difference in the future, but it is hard. So you need to like look after yourself and be part of a good team and really encourage it. A T keep going. And part of that for me is being part of the urology team and knowing that I am making a difference and it is really satisfying. And for those are applying to radiology, like keep going. They've really made it hard. I feel for you guys with the new extra point system that they're doing. So you will never ever meet a radiologist that doesn't want other people to do radiology. So find a mentor, get alongside them be like how Claire Allen was to me and you can make a difference and really keep going because it is, it is really hard. But at the moment, morale is low, but you guys can make a key difference. So um everyone who knows me knows, I love the prostate and I love taking pictures of the prostate shape as a heart, a big shower to you. Also cancer research that are funding a lot of our research, which will hopefully make a key difference in reducing inequalities. So that everyone has equal access to the best care. Are there any questions? Thank you. Thank you.