Miniaturized PCNL techniques can deliver high SFRs with a small risk of Clavien I/II complications. The size of tract seems to influence the nature of complications, with higher hematuria and renal extravasation with increasing tract size.

Day-case percutaneous nephrolithotomy procedure seems to be a safe procedure with good outcomes, and low risk of complications and readmissions. Detailed preoperative protocol and planning are paramount, with indications for inpatient admission as well as a thorough follow-up plan.

More dental practitioners should utilize diagnostic testing in order to arrive at accurate diagnoses. The availability of diagnostic tests did not completely translate to usage and none of the scenarios presented warranted pulp sensibility testing from all respondents.

Empowering patients through improving clarity of sun protection ratings on sunscreenSir, A recent survey by the Royal Pharmaceutical Society [1] has suggested that the majority of people cannot correctly recognize and fully understand the labelling on sun protection cream and lotion bottles with regard to the protection afforded by the contents. The survey found that only 8% of 2057 British adults understood that 'sun protection factor' (SPF) pertained to UVB protection, with 31% stating that they did not check the UVA 'star rating'.The difficulty appears to lie in the confusion between UVA and UVB protection, with many people believing that the SPF rating is the absolute measure of the quality of protection afforded by the contents of the bottle. This, however, only pertains to UVB radiation and not UVA radiation, and this lack of knowledge could result in people purchasing a product that does not fulfil their requirements.Patients being unable to understand the rating systems of sunscreen can increase the impact of sun exposure. This can potentially leave users at risk of skin damage, raising the risk of sunburn, benign sun-related lesions, or skin malignancies, which are potentially fatal. It is estimated that melanoma will become the fourth most common cancer in males and the sixth most common in females in the year 2030, affecting a predicted 5% of each gender [2].Knowledge of the quality of the sun protection provided is crucial in allowing people to make informed decisions on how to best protect themselves from harm resulting from excessive sun exposure.To this end, it is important to empower the public in their decision-making. This could easily be done through providing a clear white space on the front of all bottles, of a minimum size, that only contains the two rating scales -the SPF and the UVA protection.This is similar to the rectangle on cigarette packaging with health warnings. It would allow for the information to be readily available for the purchaser, allowing direct comparison between different products in the shop at the same time, enabling the consumer to choose the product that they feel they need and want.Increasing clarity and thus empowering people to make informed decisions is something at the very core of primary disease prevention. It is through simple yet effective measures such as improving the clarity of the labelling on sun protection products that can improve this. We as a profession should be doing our utmost to prevent disease and it is through campaigning for simple changes such as these with a coherent and unified voice that we could make big strides forward against skin cancer and other sun-related pathologies.

Objective: To deliver a case report showing that robotic pyeloplasty in a patient with a horseshoe kidney is not only successful but also potentially superior to laparoscopic surgery. To the best of our knowledge, this is the first case report of its kind in the United Kingdom. Method: PubMed was used to do a literature search. We have excluded papers that were written in foreign languages, or were paediatric case studies. Results: Horseshoe kidneys are the commonest congenital abnormality of the renal and are often associated with pelvic-ureteric junction obstruction (PUJO) – in the order of 30%. Minimally invasive surgery is the gold standard for management of PUJO. With the advancement of the Da Vinci robot, this case report presents a patient undergoing pyeloplasty in a horseshoe kidney with PUJO on the left side, using a robotic technique. We performed a robotic pyeloplasty on a 32-year-old woman, with a horseshoe kidney. We felt this is a case worth discussion, giving the alteration in the surgical technique in conjunction with the anatomical abnormalities, and the lack of similar reported cases in the literature. We propose that in some cases, the robotic operative technique is superior to standard laparoscopic technique. Although there is an increased cost when using the Da Vinci robot, this may be offset by the 3D visualisation, enhanced dexterity, tremor filtering and movement scaling, increased range of motion, as well as the reduction of operative time, hospital stay, blood loss, complications, and indeed patient satisfaction. In addition to the benefits of robotic surgery itself, we demonstrate that robotic surgery in this particular case was preferable to other techniques, given the anatomical exclusivity of a horseshoe kidney. Conclusion: We propose that in some cases, the robotic operative technique is superior to other minimal access techniques in urological surgery. Level of Evidence: 4

Objective: The literature predicting difficulties during Laparoscopic Cholecystectomy (LC) for Acute Gallstone Pancreatitis (AGP) is mainly focused on the timing of operation. In our experience, LC for AGP is rarely difficult irrespective of the timing of operation. The aim of this study was to assess intra- operative difficulties in mild AGP patients to verify this observation. Material and Methods: A retrospective analysis of all consecutive patients who underwent LC for mild AGP between 2014 and 2018 in a single centre was performed. Patients with known alcohol abuse, post-endoscopic retrograde cholangiopancreaticography (ERCP) induced pancreatitis, and those with chronic pancreatitis were excluded. Univariate weighted analysis was performed with 11 factors, with a linear threshold boundary defined as the mean distance between the four degrees of difficulty (DoD 1-4). Results: Ninety-six patients (Male= 33, median age= 56; Female= 63, median age= 52) were analysed. Majority of the patients were an ASA of two (n= 50; 52%) with a median BMI of 28 (range 18-50). Five procedures were technically difficult (DoD≥ 3) and only one procedure was converted to open operation. Univariate analysis showed that duration of pancreatitis >6 days (p= 0.002) and evidence of acute cholecystitis (p< 0.05) are associated with a difficult LC (DoD≥ 3). The rest of the factors did not influence DoD. Conclusion: Based on this result, we suggest that LC for mild AGP is rarely difficult, and this finding can be used in practice for selecting these patients for training lists.

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This Comment considers a previously unexamined, and particularly vile, consequence of the movement towards consumer arbitration clauses: their impact on incarcerated people and their families. Incarceration is physically, emotionally, and financially ruinous for both the incarcerated and for families who are routinely forced to subsidize their loved one's incarceration through paying for things like phone calls and basic needs that prisons fail to meet. The burden on families has only increased as governments have contracted various aspects of correctional systems out to private companies that charge exorbitant prices for basic services, knowing full well that consumers have no choice but to comply if they want to provide for and stay connected to incarcerated loved ones. This system would be inhumane enough without the added element of forced arbitration. This Comment hopes to shine a light on how mandatory arbitration clauses make an already exploitative situation all the worse. Not only are families of the incarcerated charged outrageous and illegal prices to communicate with and protect their loved ones, but mandatory arbitration ensures that they have no real ability to hold responsible companies accountable. * Grace Bennett is a third-year law student at Harvard Law School. She serves as an Executive Managing Editor for the Harvard Law Civil Rights Civil Liberties Law Review and is president of the Harvard Law ACLU. While in school, she has worked for Common Cause Massachusetts, the ACLU's Voting Project, the NAACP Legal Defense and Educational Fund, and Dovel & Luner, a plaintiff side law firm. She would like to thank Deepak Gupta, whose class on forced arbitration and its pernicious impact inspired this Comment.