Evaluation of Optimal Timing of Expert Feedback in a Simulated Flexible Ureteroscopy Course.

Introduction: Simulation-based training (SBT) has become an increasingly popular modality to train novice surgical residents in the face of rapidly increasing innovative surgical techniques across all surgical disciplines. Recent studies have already demonstrated SBT to be effective in helping overcome the learning curve associated with new surgical techniques, especially in junior residents and endoscopic procedures. In addition, it is known that trainees benefit significantly from expert feedback; however, there is a paucity of data looking into the optimal timing of this feedback during SBT. To address this knowledge deficit, an SBT curriculum was developed for junior urology residents to assess optimal timing of feedback during SBT for flexible ureteroscopy (fURS). Materials and Methods: The SBT course consisted of a pretraining assessment, three independent practice sessions, and a post-training assessment, with residents receiving expert feedback right after their pretraining assessment (early feedback [EF]) or after their final independent training session (late feedback [LF]). Results: Fifteen trainees with similar baseline fURS experience and precourse fURS task performance score participated in the study. There was a significant difference between the pre- and post-task completion times overall (15.2 minutes vs 9.1 minutes, p < 0.001), with no difference between the early or LF groups (p = 0.884). The mean performance scores improved for both groups (18.2 vs 24.2, p < 0.001) with the EF group having a more statistically significant improvement in performance scores than the LF group (p = 0.05), and most (73%) of residents preferred EF. Conclusions: This study demonstrates that an SBT curriculum for fURS is effective for technical skills development among junior trainees, and that EF resulted in marginally better overall scores and was preferred by residents.

Intraoperative Radiographic Determination of Ureteral Length as a Method of Determining Ideal Stent Length.

INTRODUCTION: Accurate determination of ureteral length (UL) and appropriate stent length remains a challenge. The objective of this study was to describe an intraoperative technique to measure UL and determine appropriate stent length, and to compare this technique with other methods of determining appropriate stent length. METHODS: Patients undergoing ureteroscopy requiring postoperative stenting and who had a preoperative CT were prospectively identified. Gender, age, height, body mass index, L1 to L5 lumbar height on CT, and surgeon's estimate of UL were recorded. UL was measured using four methods: direct measurement with a ureteral catheter, ureteropelvic junction (UPJ) to ureterovesical junction distance on axial and coronal CT, and using a novel intraoperative radiographic technique. Radiographic measurement was performed using a radiographic nipple marker affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals. UL was the distance from the UPJ to the marker at the UO measured using the catheter markers. Correlation between direct measurement and the recorded variables and methods of ureteral measurement were calculated. Stent length was chosen based on radiographic measurement. Stents were deemed of appropriate length if they showed a proximal coil in the renal pelvis and a distal coil in the bladder without crossing midline. RESULTS: Twenty-five ureters from 23 patients were included. Radiographically measured UL was strongly correlated with direct measurement. (r = 0.873, p < 0.01). Coronal and axial CT ULs were significantly associated with direct measurement (p < 0.05). Height, lumbar height, and surgeon's estimate of UL were not. Stents were deemed of appropriate length in 23/25 cases (92%). CONCLUSIONS: This new method for radiographic UL measurement is strongly correlated with directly measured UL. A length of stent chosen based on radiographic UL resulted in an appropriate stent length.

The laparoscopic experience of recently trained Canadian urologists.

OBJECTIVE: While laparoscopy represents an increasingly important aspect of operative urology, the experience of Canadian urology trainees is poorly defined. The purpose of this study was to determine the level of laparoscopic training of Canadian urology trainees during residency as well as their comfort level with various laparoscopic techniques. METHODS: An e-mail-and web-based questionnaire was administered to the two most recent cohorts of Canadian-trained urologists (residencies completed in 2003 or 2004). A total of 50 questionnaires were sent. Overall laparoscopic experience and experience with specific laparoscopic tasks (e.g. colonic mobilization) were assessed. Subjects also reported on their relative comfort level (Likert scale of 1 to 5) with various laparoscopic procedures and tasks. Finally, attitudes towards the future role of laparoscopy in the practice of urology were determined. RESULTS: Thirty-six individuals (72%) responded to the questionnaire. Of the respondents, 28 (78%) were performing fellowships; of those pursuing fellowship training, 13 (36%) involved laparoscopy. Thirty-five respondents (97%) had received some laparoscopic exposure during residency; 29 (81%) had mobilized the colon, spleen or liver and 27 (75%) had dissected the renal vessels. Only 7 out of 33 respondents (21%) felt that their residency adequately prepared them to perform laparoscopy independently. There were no significant differences between the responses of the two cohorts. CONCLUSION: Most Canadian urology trainees are being exposed to laparoscopy, but more exposure is required in order to perform laparoscopy in practice. Many residents still require fellowship training to become facile in laparoscopy.