We retrospectively reviewed all primary external dacryocystorhinostomies (DCRs) and endonasal KTP laser DCRs performed for epiphora as a result of nasolacrimal duct obstruction in our unit between 1993 and 2000. Forty-nine patients underwent an external approach and 76 endonasal laser procedures were performed. The success rate of the external group was 94% with a mean follow-up of 9 months. In contrast, the endonasal group's success rate was 64% with a mean follow-up of 12 months. This difference reached statistical significance (P = 0.0002). However, when including revision procedures, the success rate in the endonasal group increased from 64% to 82%. The success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases (P = 0.0084), thereby demonstrating a learning curve. Our study confirms external DCR as the 'gold standard' for a successful outcome. However, the endonasal technique has significant advantages, including being a quicker procedure with less morbidity, no cutaneous scar, and being more amenable to a bilateral procedure, daycase surgery and local anaesthetic. We are persisting with the endonasal technique because of its advantages but have moved towards more 'cold steel' techniques in an effort to improve results and emulate other series. In conclusion, for nasolacrimal duct obstruction, the endonasal technique is our approach of choice, with revision surgery if necessary, and the external technique is held in reserve.

Anterior ethmoidal artery ligation is a well-established surgical procedure in the management of epistaxis. We describe a procedure of anterior ethmoidal artery ligation via minimal access external surgery with the use of a rigid endoscope. This is, as far as we are aware, the first description of an external approach endoscopic anterior ethmoidal artery ligation.

Background: Bone is the most common site of metastatic disease in advanced prostate cancer. Radium-223 (223 Ra) is a calcium-mimetic alpha-particle emitter, which has been shown to have activity in prostate cancer with clinical benefit in patients with symptomatic bone metastasis. The recommended schedule is six cycles of 223 Ra, 5 kBq/kg, at 4-weekly intervals. Although previous studies have assessed clinical outcomes in patients who received six cycles of Ra 223 , there is very little information about outcomes of patients receiving fewer courses of treatment. Patients and Methods: Patients with hormone-refractory metastatic prostate cancer treated from May 2014 to August 2016 were included in this retrospective study. A total of 113 patients were identified with a median age of 76 (range=52-92) years. The median number of cycles administered was 5 (range=1-6) with 54 (48%) completing six cycles of treatment. Eighty-five patients (75%) received 223 Ra prior to docetaxel chemotherapy and 28 (25%) received it after receiving docetaxel. Results: Eleven patients developed grade 2/3 thrombocytopenia, and none of these received further 223 Ra. Only 25% of patients who had a haemoglobin level of 10 g/dl or below at the start of the treatment were able to complete six courses of 223 Ra. Of the patients who completed fewer than six cycles of 223 Ra (1-5 cycles), the survival was 121 days, compared to 398 days in men who received six cycles (odds ratio(OR)=4.767, 95% confidence internal(CI)=1.07-21.25; p=0.0005). Conclusion: Careful selection of patients is essential to obtain good clinical outcomes from 223 Ra therapy. When fewer than six cycles were delivered then a beneficial survival effect was not seen. Prostate cancer is the second most common cancer in men, with a worldwide incidence of 1.1 million new cases/year (1, 2). The treatment of metastatic prostate cancer has evolved with the use of docetaxel chemotherapy and third-generation endocrine agents such as abiraterone and enzalutamide (3-7). Since the first trials with mitoxantrone plus prednisolone, numerous agents have been found to improve outcomes for patients with this disease. Bone is the most common site of metastasis in prostate cancer and leads to an increased risk of skeletal-related events which include pathological fractures, spinal cord/nerve root compression, limited mobility, increased morbidity, hypercalcaemia, increased pain and dependence on opioids. These can have a serious impact on quality of life and in turn affect survival in patients with advanced disease (8, 9). Newer bone-targeted therapies with different mechanisms of action, such as zolendronate and denosumab, are significant additions to the management of prostate cancer (10). Radium-223 (223 Ra) is a first in its class calcium-mimetic alpha-particle emitter which has been shown to have activity in prostate cancer, with clinical benefit in patients with symptomatic bone metastasis. It has a half-life of 11.43 days and is taken up preferentially in areas of high bone turnover, partic...