Tangible effects of the COVID-19 pandemic: A fall in dexterity amongst surgical trainees?

BACKGROUND: The coronavirus pandemic has had an indisputable impact on surgical training. The qualitative effect on the perceived confidence and capability of trainees has been widely reported. In order to fully delineate the scope of the problem, quantitative data is also required. METHODS: This cross-sectional study collected compared data on the laparoscopic skills (pre- and post-pandemic) of first-year urology residents in the United Kingdom, who attended the annual Urology Simulation Boot Camp (USBC) in 2018 and 2019 (pre-pandemic), and 2021 (post-pandemic). RESULTS: Pre-pandemic group performance was significantly better in 2 out of 4 tasks (Task 3 p < 0.001) (Task 4 p = 0.003) during the practice session. During the assessment, pre-pandemic group performance was better (p = 0.017) for Task 2 and significantly faster (p = 003) for Task 4. CONCLUSIONS: Our results provide evidence to support the notion that the coronavirus pandemic has had a tangible and detrimental effect on the technical skills of surgical trainees.

A Low-Cost Synthetic Abdominal Wall Model ("Raj Model") for the Training of Laparoscopic Port Insertion.

OBJECTIVE: To assess the content validity of a low-cost bench-top model ("Raj Model") for the training of laparoscopic port insertion at the Urology Simulation Bootcamp course (USBC). MATERIALS AND METHODS: A low-cost abdominal wall model of 40 × 40 cm was created to simulate laparoscopic port placement. The model was made using different synthetic materials to represent layers (skin-vinyl sheet, subcutaneous fat-10 mm soft foam, anterior rectus sheath and muscle-floor mat, posterior rectus sheath-masking wall tape, peritoneum-sellotape). Each model was used by up to 3 trainees to practise laparoscopic port placement. The model was assessed for content validity by trainees and experts using a 5-point Likert scale. RESULT: In total, 88 trainees and 6 experts participated in the study. For all aspects of the synthetic abdominal wall, good (4) or very good (5) scores ranged from 52.7-69.2%, whereas very poor (1) rating ranged from 0 to 4.3%. There was no significant difference in responses for the content validity of the model between trainees and experts. There was a high intraclass correlation amongst responses from trainees (0.89) and experts (0.79). Approximately 76.3% of trainees and experts felt that the model is suitable for training. CONCLUSION: This is the first validation study of a low-cost abdominal wall model for teaching laparoscopic port placement for trainees. Our study demonstrates that this synthetic model has high content validity and is useful for surgical training.

"Clip-strasse": A novel complication following partial nephrectomy.

This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months after open partial nephrectomy for renal cell carcinoma. A computed tomography urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. Rigid ureteroscopy revealed three calcified objects in the pelvic ureter. These had the appearance of calcified Weck® clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which had been used for haemostasis during the partial nephrectomy. These were removed with graspers after balloon dilatation of the distal ureter. This phenomenon of multiple clips migrating with stone formation and obstruction of the ureter was named "clip-strasse".

Can the Leibovich score for clear cell renal cell carcinoma (ccRCC) be accurately reported by a general pathologist?

OBJECTIVES: To evaluate the accuracy of reporting of the Leibovich score (LS) by general pathologists at our centre by comparing the LS in their initial reports with the LS in subsequent review reports by our specialist urological pathologists. We also assessed whether a revision in the LS subsequently altered the risk group. PATIENTS AND METHODS: In all, 54 consecutive patients had had their initial histology after nephrectomy reported by a general pathologist between August 2008 and March 2012. The histological slides were subsequently re-reviewed by the two specialist urological pathologists and revised LS were given if appropriate. The cases were then discussed at the Uro-oncology Multi disciplinary meeting (MDT) and the reason for the revised LS was discussed with the participating panel and reviewed by the uropathologist. RESULTS: The general pathologists allocated the 54 patients into low- (13 patients), intermediate- (25) and high-risk (16) categories. After a review of the slides by the specialist urological pathologists and discussion at the MDT meeting the LS was revised in 23 patients (42.6%). The 23 patients who had their LS revised were divided into two groups for the purpose of the present study. On revision of the LS a total of eight patients (14.8%) changed their prognostic group. The change in the prognostic group in the eight patients was increased from intermediate- to high-risk in four patients. There was a reduction in the LS in four patients, which was from high- to intermediate-risk category in one patient and intermediate- to low-risk in three patients. CONCLUSION: In the present study, histopathology review by a specialist urological pathologist led to a change in LS in 42.6% of cases leading a change in risk grouping in 14.8% of cases. This level of discrepancy is not insignificant. However, the few cases evaluated in the present study does limit robust conclusions and further studies are needed to investigate this issue, so that recommendations can be made to enhance diagnostic accuracy and reproducibility.

Boari flap vesicocalycostomy: a salvage drainage procedure for complete ureteric stricture and pyelocalyceal fistula.

To increase the working knowledge on how to drain a transplanted kidney via the use of a Boari flap as a salvage procedure. A female with a transplant kidney had complete obstruction at the ureteropelvic junction and multiple strictures of the ureter causing deterioration of the graft function. Surgery was the only way to successfully drain the obstructed kidney, but conventional methods were not possible due to dense fibrosis around the kidney. A Boari flap to the lower pole calyx of the transplant kidney was therefore employed. A Boari flap vesicocalycostomy is a potential method available to the transplant surgeon to successfully restore graft function in a case where the transplant or native ureter is unsalvageable.

The continent, catheterizable abdominal conduit in adult urological practice.

OBJECTIVE: To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. PATIENTS AND METHODS: We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. RESULTS: The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. CONCLUSIONS: Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.