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weeks. Teacher technique will be on vertical and mattress sutures. So I'll show you the, uh, video right now. Actually, yeah. Oops. On second place. Apology. Right. Mattress sutras are useful if you want to produce a version of the skin edges. If a wound is under tension, this can be more difficult to produce. They will also be used if a wound has overlapping edges. You may find this useful when closing difficult wounds in any or wounds that are under tension. For example, in the pilonidal area, vertical mattress vertical searches are indicated for a virginal skin edges. A large bite is used to bring the wound edges close together, followed by a small bite to approximate the edges of the skin. So, uh, Jenny graft the wound edge and enter the skin perpendicularly supinate your wrist so that they need to pass it through the nervous and comes out in the middle of the wound. Grasp the wound edge and bring out the needle on the other side of the wound. Enter and exit the skin approximately 5 to 8 millimeters from the wound edge. Yeah, reverse the needle and the needle holder and perform a backhand suture. Re enter the skin, taking a small, superficial bite approximately 2 to 3 millimeters from the wound edge in line with the previous suture. Come out in the distance side and perform a standard instrument time. Okay? Uh huh, Yeah. Horizontal mattress. The horizontal mattress suture is an advert suture technique that spreads tension along the wound edge. This technique is commonly used for putting wound edges together over a distance or as initial suture to anchor. To would edges so called holding suges. These sutures, like vertical mattress sutures, incorporate a large amount of tissue within the passage of suture thread. Gently left the skin with the salt forceps and into the skin at 90 degrees Supinate. The rest of the needle passes through the dummies and out in the middle of the wound. Gently lift the other skin, edge with your forceps and pass the needle through the derms from inside to outside. Equal bites of depth and distance from the wound should be taken to allow wounded just to oppose equally and neatly. Now reload the needle facing in the opposite direction away from you. The aim is to throw a not suture across the wound 8 to 10 millimeters distally and peril to your first feature. You need to bring your suture back to the side of original entry so that you can tie your not Yeah. All right. Uh huh. Yeah. Uh, so that's, uh, that's a short video on how to perform vertical and mattress sutures. Um, so without further ado do I'd like you to introduce you to Mr Rennie. May hasten who is a consultant, urologist or at Epsom and ST Helier Hospital. Uh huh. I think you're not. You're You're muted. Can you? I think. Yeah. Sorry. It said the host would not allow me to a mute, but I'm here now. Hi, everyone. My name's sorry. May hasten. I'm a urologist at Epsom and ST Helier. Um, I'm just about to share screen. Um, and we will get going. Can everyone see my screen? Yeah. Um, so I'm going to talk briefly about urology. I'm sure most of you are already fairly familiar with what it involves. We're going to talk about, uh, two cases that are things that I would expect the foundation doctor to be able to manage. Um, talk briefly about catheters as well, and then uh um for our case. Three. We were asked to talk about a operation that we enjoyed. Um, and I've chosen a strata expiration. And I'll tell you why. Um, finally and we'll talk about why I became a urologist. Um, and what the things that influenced my career have been. So what is urology about? So as you all know, it's managing the problems of the urine tract. We deal with both benign and malignant conditions. Most centers, especially in district general hospitals, will deal with Children and adults. Uh, it's basically elective operating with some emergency work. But the emergency work is done, um, as a nonresident on call, which means that you're at home in your own bed, but that if the they need you in the hospital, they'll call you and you have to go in. So most of us will do that as a 24 hour on call. So we'll do a normal working day, followed by a overnight on call from home. And then the standard practice would be to work again the next day from eight or two. So it's very variable, as any on call can be quite quiet, and it can mean that you get absolutely no sleep at all. So very varied. Um, so in terms of, uh, common operations. So we as you want to just manage the whole spectrum. So we do open operating Germany on things like genito in the scrotal surgery, thinking about things like hydrocele circumcisions, scrotal expirations, endoscopic surgery. So resection of bladder tumor's section of prostates. Um, also, stone surgery for the vast majority is also, uh, endoscopic. And urology has been one of the specialties that's taken up robotic surgery very early. And it's quite extensively used for things like Cystectomies prostatectomies, uh, and some nephrectomies, uh, and in tertiary sort of cancer centers also lymphadenectomy and things like that. So, you know, if you are urologist and as I do, you'll do a whole spectrum. Eventually, most of us will sub specialize into just one of those areas, but they're certainly escape to do more than one. So every day is different. And obviously, on the weeks that you're doing emergency work, that's a completely different ballgame. Uh, and you're never quite sure what's going to come in the door. So, in terms of subspecialties, I'm, uh, specialized in female and functional urology. Um, so that's, uh, things like incontinence work. We do prolapse as well, but work quite closely with the uro gynecologists. You can't do upper tract, which things like nephrectomies nephro ureterectomy pelvic oncology. So there's a largely the robotic surgeons, the Cystex myths, and across electric chemists andrology to people who want to do a penile cancer and erectile dysfunction work. Pediatrics. They're thinking about Children with undescended testes or patent processes. Vaginalis um, that would come under the pediatrics remit. If you work in a tertiary center, it can also include disorders of sexual differentiation. So some really interesting areas there, uh, superficial bladder cancer is a specialty, and so is prostate diagnostics. Increasingly. And the thing that I think people forget that you want to just do is that we also do a transgender surgery, largely male to female. So again, uh, you know, a very interesting area, and certainly something that we're seeing much more demand for. And therefore, more and more urologists are choosing to sub specialize into that. So the pathway of becoming a neurologist. So the fairly standard foundation years F one F two course surgical training. Um, so most people will do a themed CT one c T. Two job where you're doing at least sort of 6 to 12 months of urology. There there are run through specialty training. Those used to be academic, but now they're more widely available. And that means that you join urology as an s t one. The benefit. Of course, being that means you get to stay in one place for the duration of your training. And after that specialty training, so S t 3 to 7 and then fellowships in urology at least, are still fairly optional. There's a good market for urologist, so there's lots of jobs and not lots of us. So it's a good time to be thinking about urology because the chance of a job where you want it at the end of it is actually quite promising. So, um, as I said, the first thing I want to talk about was visible hematuria, um, so just briefly in terms of your clerking. So you're seeing the patient often they come in through a and E, so you're going to want to know how long it's been going for. Has it happened before? Are their clocks in their urine is the blood at the beginning or the end of the stream? Um, and are they actually, we ing normally. So one of the things you want to watch out for in this cohort of people is whether they're in clock retention. Are they already sort of struggling to we? Um and that's something that you want to ask thoroughly about. Most people also ask about lower urinary tract symptoms. You want to know if they have a history of malignancy? As you probably know, smoking is a risk factor for bladder cancer, as is, um, certain sort of profession. So historically give you still about rubber and paint die as a risk factor. So it's something to ask about something that comes up a lot in our skis. Um, and you obviously want to check the hemoglobin, and they're obs. So I think the main thing to remember is that a lot of you will do a GP job. You'll see people with visible hematuria. But not all of those people need to be admitted. So who would you admit? People who are in clot retention people who are anemic people who are hemodynamically unstable, but pretty much everyone else can be seen in clinic. And most of you will be familiar with the idea of a cancer pathway. So these patient's will come in. They'll be seen within two weeks, and they'll all have a flexible cystoscopy. And in most sense, is that have a CT urogram. Um, and that's because, as you well know, the bleeding could be coming from the bladder. It could be coming from the prostate. It could be coming from the Urata, and it could be coming from the kidney. So by doing those two investigations, it's a good step in terms of trying to make a diagnosis. But for these patient's in a any what would I recommend doing well? I'll make sure you have a group and save. It's very rare for a patient to have a bad enough hematuria that they're requiring a transfusion, But it's always worth having a group and say you want to know that they're going to be sort of properly monitored overnight. You want to put in a three way catheter, and as I said, I'll talk about catheters briefly. A little bit later, you're going to start irrigation for your catheter and you're going to do bladder wash out and again, I'll talk about that when I talk about catheters. So the second case I'm going to talk about is a painful testicle. So most of you will be aware that one of the few, uh, neurological emergencies is a painful testicle. Um, and most of us will get out of bed at two AM to come and see these people. So the main thing to say is that it is vastly the Children or at least boys up to the age of 30. In theory, it can be any age, but it's much more common, Um, in sort of the puberty ages and then up to 30. So the main question that you want to know in history is what time did the pain start? Most of the most of you will know that testicles. The reason we worry about torsion is because the blood supply is mixed up in the twist, and that means that the blood supply has been cut off. So most testicles will have a life expectancy of roughly. And I do really mean roughly six hours from the time that testicle has twisted, and if you're talking about someone who's presenting it three days, the chance of finding a viable testicle are very low. So if someone presented at three days, chances are you're not going to take them to theater. You're going to get an ultrasound. But that's why it's so important to know when it started. You also want to know what they were doing when it started. So have they been kicked? Have they, you know, knocked it against something? I've had two recent cases of boys playing rugby who've come in with testicular pain, and they actually had a testicular rupture, which the management is similar, but not the same. And you obviously want to be clear about what diagnosis you're looking at. Um, you want to know if it's happened before. You can get something called intermittent tuition, but it's not very common, but it's something to watch out for. And even if they say the pain settles each time, I'd have a low threshold for taking them to theater. The other thing you want to know is what they've been doing since so often we get these five year olds that come in, and they told their mom after they got home from school that they're testicle hurt. But then they have a proper dinner, and then they played football with their friends, and then they came in and, you know, then your threshold, your suspicion is going to be low because actually, this is a well child who's doing normal things. Um, and I think the key thing was always to watch the patient walk. Often, these boys won't be able to walk completely normally. Um, they'll be waddling a little, so it's something to watch out for. It's not just taking the history. It's also looking at the patient and thinking about how they're behaving, especially when you've got a young child who may not be a consistent historian. Um, so the only other thing to watch out for is previous testicular surgery. Um, there are people obviously had undescended testes who will already have their testicle fix. And in these cohort, it's often unnecessary to go on to re explore. Um, so what to do next? Obviously you want to examine. You won't think about the size. The shape of the test is you want to look at the temperature. You want to look at any skin changes. You want to look for any penile discharge? Is this actually an S T I? You also want to ask for a urine depth, so, um epididymo-orchitis can can be a cause of testicular pain. Not all of those boys will also have an associated positive urine dip. But it's something to think about. So, um, in terms of your differential, so you've got a twisted testicle. You've got a twisted appendage, which is a cyst of more Ghani. It's unnecessary fetal remnant, um, that most boys, um, will actually not have. But it does present very similarly to a torsion. So it's something to watch out for. And I said epididymo-orchitis So what would I expect you as the foundation doctor should do next? Well, I think if the history is good or even if you're not sure and the two child in the right age range I'm expecting you to pick up the phone. So, you know, we're all paid as per our level of responsibility, and this is definitely something that I'm paying. I'm being paid to take responsibility for. So, you know, if in doubt, pick up the phone because there is nothing worse than someone coming to you a few days later and saying, Did you remember this child that you saw? Um, so make sure you pick up the phone. Um, you know, discuss it with your registrar or your consultant or whoever is on call. And then And if that's what they decide, obviously you're going to go on to consent. Mark them. Um, this is an urgent operation, so it's one of those times when you can cut into an elective list. So if there's an elective list that's finishing and the emergency theater is full, we're allowed to sort of cut into someone else's theater list. It's quite controversial, and nobody likes it, But generally, most surgeons degree that a testicle is probably worth saving. And so most of us will give way. Um, but it is urgent, and we proceed to a scrotal expiration. Um, I think the main thing to say about these cohorts is that you want to make sure that you've properly consented them and the parents for the idea that they may lose their testicle and that that's something that you may be doing inter optionally. So it isn't just that you're gonna have a look, there's a chance that they may lose their testicle, and they may need to have the other side fixed to present prevent this from happening to the other side. So, sadly, I don't think you can talk about urology without talking about catheters. I think we have reputation for doing the catheters. I guess it's a bit like a nieces have their cannulas and we have our catheters. Um, in a way. Actually, you know, being proficient in captors, I think, is a useful skill. Um, it's, um, often by the time we turn up, at least three people have tried, if not more, and the patient is begging you to do something. So actually, the patient's often delighted to see and I'd say about 60% probably don't need. They just need a pair of experienced hands and the right choice of catheter. But I think one of the nice things about you being the urologist is that you will actually meet a lot of the other specialties in this capacity of putting in catheters, and I think it's quite nice. I think being a specialty doctor can occasionally be a little bit isolating everybody else. You meet is a surgeon. We all do the same thing. So it's quite nice actually to go out to meet other people's foundation doctors to meet. You know, the other registrars, like the Med Reg, will call us just as we call them. And that's quite nice. Um, I think it's a nice way of building a relationship, having some report. Um, the cons, obviously is that the vast majority of them seem to happen out of hours, which is very frustrating. So it's probably the worst thing about the on call, even though we get to see it on home from home is when you have to go in for a catheter. Um, so in terms of tips for catheters, I mean, I'm not going to tell you I suspect anything that you don't already know. But for a male, make sure you're using a 16 French catheter. Make sure you're holding it as vertically as possible. So lifting it up as if to the sky, um, really stretching it out because if you can imagine, there's a you bend, um, as it goes past, just before it enters the prostate. So you want to, um, sort of unthinking that as best as possible. Um, there are curved tip casters in the hospital. They are more helpful for slipping past the prostate. Um, and actually, you know, there is no reason why you shouldn't be using them. We'd encourage you to try a normal castor first, but there's nothing different about the curve tip casters. They're not dangerous in anyway. So, actually, if you have one around and somebody's asking you to use it, there's actually no real and not too so female characters. Actually, I think for most doctors make them more nervous because so many are done by the nurses. So again use a 12 French 12 or 14. And the other thing I'd say is get the patient to sit on their hands so to put their hands underneath their bottom. And it tilts the pelvis, and that makes the urethra more visible. So for the vast majority of women, the reason we get called is because perhaps people are having trouble identifying their urethra. And actually, once you've got them tilted in the correct position with their pelvis tilted upwards, you'll be able to find that urethra. The other thing that you can do is to put them head down. And that can help, especially if they have a sort of a larger BMI. It can just shift things towards the head in the same way that you might put a patient head down intraoperatively to shift things towards the head to give you easier access. So my favorite operations, So I choose a scrotal expiration. I'm sure that most of you were expecting me to choose something much more exciting. Uh, like a cystectomy. But, um, why is it my favorite? Well, to be honest, when you meet these sort of young Children or you know, um, 18 to 30 year old men, it's sometimes you're just not sure. Sometimes there isn't a bond or answer, and sometimes it's just a gut feeling that you have that you think this is a torsion or you can't convincingly say it isn't. And so I think so. Much of what we do now as surgeons is based on a CT scan. So you know a patient comes in with abdominal pain, you'll get a CT scan, whereas with this there is no scan. That's going to tell you the answer. This is you and your gut instinct about what you think and obviously based on what your what your findings are. But actually, I think it's a nice chance to test my clinical acumen and see how often I get it right. It's a nice opportunity to work with people my own age or even Children. So actually, most of my patient's urologist the between 80 and 100 and sometimes more than that. So it's quite nice to work with young people. There is no waiting around, so the emergency list is obviously fantastic. We all have to share. So there's Ask the general surgeons of Zing Gainey. If you're unlucky, there's also orthopedics as well, and everyone's squabbling about who gets to go first. And the nice thing about a torsion is that actually, nobody argues 99% of the time you are going next. It isn't even a discussion, maybe just a courtesy call to the other specialty, But it's quite nice not to have to wait around for everyone else. So that's nice. And the other thing is, I actually think it's a great teaching case. It was probably the first operation I was ever involved in. Um, so you know, I think the first time I just did sutures or something, you know, relatively simple. But it was really nice just to get to do something. And it is a nice training case, so it's definitely the first operation I ever did. Skin to skin. Um, so yeah, so I guess it holds a place in my heart. And the other thing is, expect the unexpected. So as I said, we had the two boys with the testicular rupture. I had another man who turned out to have a testicular cancer. So these things do happen. Um, and it's just about expecting the unexpected. So conclusions, So why choose urology? So I choose urology because I liked the varied demographic. Um, now I work predominantly with women, But sometimes, you know, I do a general urology clinic. So you still see the people The young boy's coming in because they want a circumcision or the old man who The old men who wants his t u R P. So you see the whole spectrum. Um, they're interesting cases, So we've obviously talked about testicular pain in visible hematuria. But actually, you know, there's all the weird and the wonderful the foreign bodies. That shouldn't be where you found them. The the people with penile fractures. Um, yeah. So you see some You see some interesting stuff? Um, so that's a big appeal. I think it's got a really good quality of life. So all of you, presumably here because you want to consider a career in surgery. Um, and so much of surgery now, I think is increasingly consultant led. The general surgeons will obviously be in the hospital all night. Um, even if they're not always operating. And I think one of the nice things about urology is the nonresident on call. So yes, you know, sometimes the nights can be really busy. I'm not disputing that, but actually, there is something to be said for sleeping in your own bed. So, um, I think it's got a good quality of life, and there's lots of different operations, so I've obviously chosen to choosing continents and prolapse work. But I chose that because I prefer open surgery, and that's predominantly at the moment open. Although actually, we, too, may embrace robotics. Um, but other people choose robotic stones are so so many options, so much variety. And so what kind of person should be a urologist. Well, to be honest, anyone who wants to be a surgeon with a good quality of life, I don't think there is any specific characteristic you need. Neurology is becoming a, uh, one of the surgical specialties with the most number of women. So I was actually a kss trainee to trained in all. Did all my training in Kent. Sorry, Sussex. And over 50% of registrars there are female, so things are changing. We're definitely embracing it the most. I currently work in a department with four female urology consultants. Um, so, you know, it's it's really a specialty that embraces everyone. Um, it's got a reputation for being happy, so most of us are pretty relaxed. Um, we're generally chilled out, and I think that's because we have a good quality of life and we know it. Um, so you want to just congenital inlay be anyone, and I would encourage all of you. I'm really happy with the choice I made. Um, And I hope I persuaded you that you should be thinking about it. Thank you. Thank you dot Only for your amazing presentation. Um, guys, it's a question and answer time. If you've got any questions that you'd like to ask, miss my pain, Ms May hasten, Uh, please do put on the chat box, and we can just quickly just run through the questions. Uh, in the meantime, I'll also put down the link for the feedback links, which are which are really helpful for us, especially the guest speakers, because it's very useful for them. But you also get the certificates as well. So I put that up. But any burning questions that you have, please put it on the chat so that we can ask Ms Medicine one time. Um so someone mentioned, How is urology focused on the female different to gynecology? So the honest answer is there's a lot of overlap. The main difference is that a lot of the prolapse surgeries, where perhaps they have a uterine prolapse or something, will require hysterectomy, and that seems to be a red line for most urologists. So if the patient there's a hysterectomy, then they will have to see the urogynecologist. So but actually, other than that, there is a lot of crossover. So I'm currently working with the Uro gynecologists. Um, probably almost as much as they work with the other urologists, we have a regional pelvic floor meeting. We often will have meetings about patient's, uh, in order to be sure that we're offering the right operation. And actually, some of us will do the investigation to the video. Urodynamics, for example, can be done by either specialty and end up on whichever operating list was the initial team that saw them. So, actually, not that much difference is the honest answer. The only benefit is that occasionally you want a break from women and prolapse and incontinence. Actually, sometimes it's nice to have that variety where you know you're seeing them with other problems. Um, someone's mentioned a CT urology themed job. Main tips for getting into ST three for an interview. Okay, so, um, I I did a core training themed urology job. I think my main tips would be make sure that you're getting your publications and your presentation is done. So, um, asset. Actually, their conference is really good for presentations. It counts as a national, um, presentation. Um, so it's a good it's a good thing to aim for other things to say is when you're planning your core training job. Make sure you're doing your urology earlier on in the year. So nowadays, I think you apply in, like, November of your CT, too. So if all the urology you're doing is as a CT to your only two months into that job, that's not enough time to be doing the 100 flexible cystoscopy's And, you know, 10 2 versions or whatever it is that they ask for these days, um, you need to make sure that you're doing the urology earlier on in the core training so that you've actually got all your numbers ready to apply, if that makes any sense. Yeah. Any other questions, Guys? Mm. Just wait for a few minutes. Hmm. And how did you find just one question? How did you find KSS as a region to train in urology, And so I actually think it's a great place to train. I think everyone's different. Some people prefer tertiary hospitals, other people, like district generals. I think the nice thing about district generals is you're doing the common things are common. So most people think of neurology and they think of what we think of as court urology, which are things like stones, bladder, tumor's prostates. And actually, all of these district generals are doing lots and lots of those. So from a training perspective, that's exactly what you want. As a trainee, you want to be doing lots of the same operation. Um and you know, you're not competing with lots of fellows, um, in these districts and the hospitals, often it's you and maybe another trainee. So I think from a training perspective, it's fantastic. We're obviously quite a small group. There's only 16 urology registrars and kss. So you get to know everyone really quickly. We have teaching once a month. Um and yeah, I mean, I think I've really enjoyed training that Yes, you have to move a little bit. So I moved halfway through. So I've worked in Worthing as an S T three and then moved up to Surrey for my S t 4 to 7. Um uh, So, yes, it is a large geographical Dina re, but I think very worth it. If anyone's looking for a degenerated training, someone's mentioned any must do recommended courses for urology themed court trainees. Yeah, So I think there's loads, of course, is out there. Some of them are quite expensive, and that's often the limiting factor. So, um, just be aware that some of the companies like Boston Scientific will do a course. Um, I think it's on ureteroscopy of memory serves, and it's free. You just need one of your consultants to get you with the rep from there. So you know when you run out of your study budget, which everyone does eventually, um, then it's worth thinking about. The other thing is the Royal College obviously have their course. There's, um, the catheter course, which I think is also quite affordable. Someone's already mentioned the emergency urology course on the chat. I did that. I would really recommend it. I think I did it as a senior trainee, but you'll get paired with a sort of course training, and that's quite that's quite good in that you get training from someone who's literally 1 to 1 with you, and they'll do sort of the more complex surgeries. And you do the sort of the scrotal expiration. Part of it may be a penile fracture repair, so actually, I think it's a really good course. The Cambridge Emergency urology course. Um, as a cataract Rick Course. It's excellent practice just to know the catheter courses actually free. So I've done it myself. Actually, it's pretty useful. Um, and do you know the competition ratio? Someone messaged me personally. I I actually don't at the moment is the honest answer. I know it's been dropping, but that's consistent with all surgical specialties. Over the last few years. I couldn't tell you one of my head. What it was 221 at the moment the previous year was 321. So it's a bit. It fluctuates every year. Guys take, for example, general surgery two years ago was, I think, like 1 to 1 pretty much or a bit above 1 to 1. But this year was 4 to 1, so it changes every single year. Guys, um, but I think you're Roger is slightly competitive. Still, that I think last year's probably not a true representative, but a good specialty, because I've done urology job myself, actually, um, so, yeah, any other questions? Guys, I think the only other thing that would be worth doing if you haven't already, is to print off the, uh, like the specification. Um, like the s C three specification, um, and just go through it with your portfolio and think about what you can evidence. Because I know it's very easy to do lots of stuff, but on the day they'll ask you for evidence. So if you don't have evidence, it's almost like it didn't count to. Just make sure you've got the evidence that you need and that your identifying things that you haven't yet done. So you know where you can pick up the rest of your marks? Uh uh. Yeah. I'd like to thank you, Donny. Miss my hasten problem giving us amazing presentation on urology. I think it's a great specialty. Uh, you know, I think I have I have a bit more of a passion for general surgery, but definitely. I thought urology was a fantastic job. I learned so much. A lot of practical skills. You get very good on catheters. Uh, so if anyone, you know, choose, if you guys get a chance to choose, uh, urology as a job for your foundation, your programs I would definitely recommend recommend you to do so. It's a good specialty. Good quality of life and good private practice. Uh, so Uh, yeah. Thank you. Uh, Miss may hasten for giving a wonderful presentation. Uh, guys, if you can fill up the feedback forms, it's very useful for us, especially the guest speakers. But you also get a certificate out of it at the end as well. Uh, and yeah, I would like to thank you all for joining us today. And thank you, Ms Medicine, for giving us this wonderful presentation until next time. Guys look after yourself and hopefully the weather is a bit better. Thanks dot C C c Uh, thank you.