Objective• To determine the relationship of preoperatively measured cardiorespiratory function, to the development of postoperative complications and length of hospital stay (LOS) in a cohort of patients undergoing radical cystectomy (RC), as RC and conduit formation is curative but is associated with significant postoperative morbidity and mortality. Patients and Methods• Consecutive patients planned to have RC underwent cardiopulmonary exercise testing (CPET) to a standardised protocol.• The results of the CPET were 'blinded' from the clinicians involved in the care of the patients. • Patients were prospectively monitored for the primary outcome of postoperative complications, as defined by a validated classification (Clavien-Dindo).• Secondary outcome included LOS and mortality. Results• In all, 82 patients underwent CPET before RC. Eight patients did not subsequently undergo RC and a further five did not exercise sufficiently to allow for appropriate determination of the cardiopulmonary variables of interest.• There was a significant difference in LOS between those patients who had a major perioperative complication (Clavien score > 3) and those that did not (16 vs 30 days; P < 0.001; hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.1-6.3).• The anaerobic threshold (AT) remained as the only significant independent predictor variable for the presence or absence of major postoperative complications (odds ratio 0.74, 95% CI 0.57-0.97; P = 0.03).• When the optimal predictive value of AT of 12 mL/min/kg was used as a fitness marker, there was a significant relationship between fitness and LOS (median LOS: 'unfit' 22 days vs 'fit' 16 days; HR 0.47, 95% CI 0.28-0.80; P = 0.006) Conclusion• Impaired preoperative cardiopulmonary reserve was related to major morbidity, prolonged LOS and increased use of critical care resource after RC. • This has important health and economic implications for risk assessment, rationalisation of postoperative resource and the potential for therapeutic preoperative intervention with exercise therapy.

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SUMMARYWe present a case of a 21-year-old man with hip pain to the orthopaedic team. During the initial assessment he was found to be hypercalcaemic (adjusted calcium 3.55) due to the primary hyperparathoidism (PTH 1285), with all other screening for multiple endocrine neoplasia negative. During his time on the ward while being treated for the hypercalcaemia he had a fall resulting in bilateral femoral fractures, requiring surgical management. He underwent an emergency exploration of neck and excision of a large parathyroid adenoma, measuring 5.5 cm. He also developed renal failure as a result of nephrocalcinosis. This case highlights the importance of early detection and management of hyperparathyroidism with the aim of preventing longterm complications. This patient ultimately required a renal transplant and multiple orthopaedic procedures as a result of undiagnosed PTH and recently underwent excision of the remaining parathyroid glands. BACKGROUND

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