Five-Year results of a multi-specialty induction course for surgical training.

Background: The Essential Surgical Skills Course (ESSC) is a multi-specialty induction "boot camp" style course that has been run successfully for five years. The aim of the current paper is to create an accurate guide for the replication of the course by other teams and assess the course's fitness for purpose, through the survey feedback provided by trainees. Methods: The course's fitness for purpose was assessed through cumulative five-year survey feedback from trainees. This observational study describes the design and process of content adjustment according to feedback. Results: The course its five-year span offered twelve different procedural skills in four different specialties. Feedback for each session was persistently >8/10. Key themes identified as beneficial include teacher-to-trainee ratio (often 1:1), teaching style, course structure and responsiveness. Conclusions: The ESSC was found to be fit for purpose for the induction of trainees into surgical training. The key factors contributing to the success of the course include the structured method of curriculum design, outstanding teaching delivery methods, teacher-to-trainee ratio, the availability of appropriate faculty and infrastructure and the willingness to learn from trainee feedback and adjust the content of the course accordingly. It acts as a paradigm for courses aimed to prepare surgical trainees for a "step-up" in their careers.

An Update on Evaluation and Management in Cystinuria.

Cystinuria is the most common cause of inherited stone disease and is caused by the failure of absorption of filtered dibasic amino acids including cystine in the proximal tubules. It is associated with a very high recurrence rate in affected patients, with the potential for significant morbidity in such patients due to the need for repeated surgical interventions. A multimodal and multispecialty approach in a dedicated centre is the key to improving treatment outcomes and patient adherence to the treatment. This article reviews the latest knowledge on the clinical and diagnostic features and summarises key developments to aid clinicians in diagnosis and management options, together with future directions for the care of these patients.

Endoscopic surgical simulation using low-fidelity and virtual reality transurethral resection simulators in urology simulation boot camp course: trainees feedback assessment study.

OBJECTIVES: The objective of our study was to study trainees' feedback and rating of models for training transurethral resection of bladder lesions (TURBT) and prostate (TURP) during simulation. METHODS: The study was performed during the ''Transurethral resection (TUR) module" at the boot camp held in 2019. Prior to the course, all trainees were required to evaluate their experience in performing TURBT and TURP procedures. Trainees simulated resection on two different models; low-fidelity tissue model (Samed, GmBH, Dresden, Germany) and virtual reality simulator (TURPMentor, 3D Systems, Littleton, US). Following the completion of the module, trainees completed a questionnaire using a 5-point Likert scale to evaluate their assessment of the models for surgical training. RESULTS: In total, 174 simulation assessments were performed by 56 trainees (Samed Bladder-40, Prostate-45, TURPMentor Bladder-51, Prostate-37). All trainees reported that they had performed < 50 TUR procedures. The Samed model median scores were for appearance (4/5), texture (5/5), feel (5/5) and conductibility (5/5). The TURPMentor median score was for appearance (4/5), texture and feel (4/5) and conductibility (4/5). The most common criticism of the Samed model was that it failed to mimic bleeding. In contrast, trainees felt that the TURPMentor haptic feedback was inadequate to allow for close resection and did not calibrate movements accurately. CONCLUSIONS: Our results demonstrate that both forms of simulators (low-fidelity and virtual reality) were rated highly by urology trainees and improve their confidence in performing transurethral resection and in fact complement each other in providing lower tract endoscopic resection simulation.

Global Assessment of Urological Endoscopic Skills (GAUES): development and validation of a novel assessment tool to evaluate endourological skills.

OBJECTIVE: To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures. METHODS: We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task-specific and two global-rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter-rater reliability was also assessed. RESULTS: We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P = 0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC = 0.841 (95% confidence interval 0.767-0.893; P < 0.001, n = 88). CONCLUSIONS: We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment.

Impact of urology simulation boot camp in improving endoscopic instrument knowledge.

Objective: Education and training of surgeons has traditionally focused on the development of individual knowledge, technical skills and decision making. Knowledge about endoscopic instruments is one of the core elements of urological training. We assessed the precourse knowledge of newly appointed urology trainees and the impact of boot camp in improving their knowledge. Methods: Newly appointed specialty trainees in urology took part in a pilot 5-day urology simulation boot camp (USBC). The aim of the USBC was to improve their confidence, procedural performance and non-technical skills, with one of the modules looking at the trainees' knowledge about common endoscopic instruments in urology. Delegates were first asked to identify and assemble the instruments, followed by one-to-one teaching about the instruments. An Objective Structured Assessment Tool was used to assess their knowledge in the identification and assembly of the cystoscope, resectoscope and optical urethrotome, before and at the end of the course. Results: Data of two successive boot camps were collected to assess knowledge of instruments of newly appointed urology trainees. Majority of the trainees had good precourse knowledge of the cystoscopy kit, with 84% able to correctly identify the parts. Seventy-six per cent of candidates were able to identify the resectoscope equipment, but only approximately a third of trainees were able to correctly identify the urethrotome kit. The assembly of cystoscope, resectoscope and urethrotome was performed correctly in 74%, 42% and 32% at baseline and 94%, 90% and 77% postcourse, respectively. Overall performance improved significantly in the postcourse assessment (<0.001). Conclusion: This urology boot camp has addressed gaps in trainees' core equipment knowledge and guided them to improve their knowledge with respect to identification and assembly of cystoscope, resectoscope and urethrotome.

The Validation of the Clinical Male Pelvic Trainer Mk 2-Advanced Models for Scrotal Examination Simulation.

OBJECTIVES: To validate the use of a novel physical model, the "Clinical Male Pelvic Trainer (CMPT) Mk 2-Advanced," for scrotal examination simulation and evaluate its use for surgical education. MATERIALS AND METHODS: A total of 7 CMPT Mk 2-Advanced scrotal models were used for teaching: normal, varicocele, testicular tumor, epididymal cyst, hydrocele, epididymo-orchitis, and indirect inguinoscrotal hernia. At 4 surgical courses in the West Yorkshire Foundation Deanery, UK, between 2015 and 2016, trainees were asked to assess their clinical experience, confidence levels in diagnosing scrotal pathology and simulation properties of the scrotal models on a 5-point Likert Scale. Expert responses were used to validate these findings. RESULTS: In total, 65 trainees and 12 experts (including 3 senior residents) participated in the study (n = 77). There was a positive-tailed distribution in responses from experts for realistic simulation of scrotal contents and pathology; only 1.5% and 14.4% of all responses by experts were scored as a "1" (strongly disagree) or "2" (disagree). The intraclass coefficient (κ) was 0.86 among experts. No significant differences between experts and trainees in assessment of simulation were observed. Following use of the models, there was a significant increase in confidence scores matched by trainee (p < 0.001). Approximately 92.9% and 100% of trainees and experts were in favor of using the models for assessment and future training respectively. CONCLUSIONS: Our study demonstrates that the CMPT MK 2-Advanced models have high "face validity" and may be a valuable tool for surgical education. The use of these models should be explored for use in the curriculum at medical school.

Adult multilocular cystic nephroma: Report of six cases with clinical, radio-pathologic correlation and review of literature.

BACKGROUND: Cystic renal neoplasms of the kidney can be benign or malignant. Multicystic nephroma (MCN) represents a rare benign cystic lesion of the kidney, which usually presents as a unilateral multicystic renal mass without solid elements. According to the World Health Organization (WHO) classification of the renal neoplasms, it is grouped along with mixed epithelial-stromal tumor of the kidney. MATERIALS AND METHODS: We report a retrospective review of six cases of MCN of kidney. Patient demographics, imaging findings, operative details and final histology were recorded. RESULTS: All patients had suspicious/malignant features on radiological examination, leading to a radical nephrectomy. However, microscopically these lesions were lined by cuboidal epithelium, and in a few places hobnail epithelium. No cells with clear cytoplasm, blastemal or immature elements were seen. In one case, foci of inflammatory cells and histiocytes were present. CONCLUSIONS: MCN is a benign cystic lesion and clinical presentations are nonspecific with symptoms such as abdominal pain, hematuria and urinary tract infection. These nonspecific clinical presentations and confusing radiological features create difficult preoperative differentiation from malignant cystic renal neoplasms.

Assessment of Clavien-Dindo classification in patients >75 years undergoing nephrectomy/nephroureterectomy.

INTRODUCTION: There is a paucity of a standardized post-operative complications grading system in urology especially in the elderly population. Studies show satisfactory survival and oncological outcomes albeit with a slight increase in post-operative morbidity compared to younger patients. The Clavien-Dindo classification for post-operative complications is established as a valid system worldwide and applicable in many fields of surgery. PURPOSE: Retrospective assessment of post-operative complications in patients >75 years who underwent open/laparoscopic nephrectomy/nephroureterectomy for renal diseases and grading the post-operative complications according to the Clavien-Dindo classification. MATERIALS AND METHODS: Retrospective review of case notes was performed in patients >75 years who underwent a laparoscopic/open nephrectomy/nephroureterectomy between 2000 and 2008. Post-operative complications were graded according to the Clavien-Dindo classification. RESULTS: A total of 54 patients >75 years underwent nephrectomy/nephroureterectomy. 29 patients had laparoscopy and 25 had open surgery. Fifty one patients had a malignancy and 3 had benign diseases. Grade I, II, IIIa, IIIb and IVa were 25.6%, 41.1%, 7.7%, 7.7% and 17.9% respectively. No significant difference was noted in the 2 groups. CONCLUSIONS: We believe that in elderly patients, laparoscopic surgery can be offered safely without significantly increasing the surgical risks. The Clavien-Dindo classification is easy to use and effectively applied to categorize post-operative complications associated with nephrectomy/nephroureterectomy in elderly population. However, this system needs slight modification to incorporate intra-operative complications and large studies are needed to validate and standardize this classification for all urological procedures.

Laparoscopic heminephrectomy of a horseshoe kidney.

Minimally invasive surgery has revolutionized surgery for urologic disorders, and laparoscopic procedures have become widely available for several different ablative and reconstructive operations. Laparoscopic heminephrectomy in patients with horseshoe kidney can be a technically challenging procedure due to aberrant vessels, functional parenchyma in the isthmus, and abnormal location. We report the management of a case of symptomatic nonfunctioning left moiety of a horseshoe kidney with emphasis on its surgical technique combined with a review of the literature. Laparoscopic heminephrectomy is a feasible option in the surgical management of benign and malignant conditions of the horseshoe kidney and can be performed safely using a transperitoneal or a retroperitoneal approach.

An update on new oral PDE5 inhibitors for the treatment of erectile dysfunction.

The management of erectile dysfunction (ED) has been revolutionized by the discovery of phosphodiesterase 5 (PDE5) inhibitors, which have been commercially available for more than a decade and are the first-line therapeutic option for men with ED. Sildenafil, vardenafil and tadalafil were approved by the European Medicine Agency and the US FDA for the treatment of ED on the back of their high efficacy rates and favorable safety profiles. However, despite the fact that more than 50 million patients with ED worldwide have been successfully treated with one of these PDE5 inhibitors, some men--most notably those with severe neurologic damage, diabetes mellitus or severe vascular disease--are resistant to the currently available drugs and require more-invasive treatments, such as intracavernosal injection therapy. Partly as a consequence of this, research into alternative therapeutic approaches continues, including the development of new PDE5 inhibitors, centrally acting pharmaceutical agents, and application of molecular technologies such as gene therapy and stem cell therapy.

Endoscopic management of upper tract transitional cell carcinoma.

Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The "gold standard" management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.

Minimally invasive surgical options for ureteropelvic junction obstruction: A significant step in the right direction.

Open pyeloplasty is the gold standard treatment for adult ureteropelvic junction obstruction (UPJO) with published success rates consistently over 90%. In recent years, the management of UPJO has been revolutionized by the introduction of endoscopic procedures and laparoscopic techniques. We analyzed the long-term results of endoscopic and other minimal access approaches for the treatment of UPJO.Early results for endopyelotomy were promising but long-term results were not encouraging. Laparoscopic pyeloplasty technique is well defined and duplicates the surgical principles of conventional open pyeloplasty. With such a large variety of minimally invasive procedures for the treatment of UPJO available, the treatment choice for UPJO must be based on the success and morbidity of the procedures, the surgeon's experience, the cost of the treatment, and the patient's choice. We feel that with the technological advances in instrumentation coupled with a decrease in cost and improved training of urological surgeons, laparoscopic pyeloplasty may evolve to be the new "gold" standard for the treatment of UPJO.

Technical description and outcomes of a continuous anastomosis in open radical prostatectomy.

OBJECTIVE: To describe the surgical technique, objective and subjective medium-term outcomes of a novel continuous vesico-urethral anastomotic suture in open radical prostatectomy (ORP). PATIENTS AND METHODS: A continuous anastomosis comprising separate anterior and posterior monofilament 3-0 polydioxanone sutures, with the bladder neck 'parachuted' down on to the urethral stump, was used in 39 consecutive patients. A cystogram was taken after ORP in the first 23 patients. The catheter was removed as soon as patients were fully mobile. A validated postal questionnaire to determine continence and its effect on quality of life was sent to all patients ≥3 months after ORP. RESULTS: The mean follow-up was 18 months; there were no major complications. There was an insignificant or no leak in 91% of the patients who had a cystogram. Before discharge, 33 patients reported that they were continent, whilst five required a pad(s) for stress incontinence, and one was discharged with a catheter after failing the first catheter removal. Of the 95% who completed the questionnaire, 95% either did not leak urine, or only leaked a small amount; 84% of patients reported that leaking had a minimal effect on everyday life. No patients developed symptomatic urethral or bladder neck stricture/contracture. CONCLUSIONS: Our technique of continuous anastomotic suturing for ORP is safe, reliable and well tolerated. Further randomized studies are warranted to compare the outcome with the standard interrupted vesico-urethral anastomosis.

Complication of a dorsal penile block: needle breakage and migration.

We present a case where the hypodermic needle used to administer the local anaesthetic broke off from the plastic hub during the administration of a penile block in an adult and migrated 15 cm to the left groin. This prompted a review of the manufacturer's technical data and biomechanical studies. On the basis of these, we recommend that utmost care be taken to maintain control of the needle during injection, particularly to prevent buckling forces that might lead to breakage.

Updates in endourology.

Rapid urologic innovations in minimally invasive treatment are creating exciting new horizons in endourology. However, these new concepts are blurring the traditional boundary between endourology and oncology. Organ-sparing surgery, laparoscopy, robotics systems, and image-guided ablation techniques enable surgeons to develop specifically tailored treatments for patients. We examine recent developments and future prospects for how new technology will continue to advance the field of endourology.

Endopielotomía con acucise / Acucise endopyelotomy

La técnica de la endopielotomía con Acucise® se basa sobre el principio de la dilatación e incisión simultánea de una estrechez ureteral bajo control endoscópico sin necesidad de la ureteroscopia. Este procedimiento atrajo a muchos urólogos porque es fácil de aprender y puede realizarse como procedimiento ambulatorio con una experiencia endourológica mínima. La tasa de éxito para las distintas series es de 66% a 84% y la tasa de complicaciones graves en la mayoría de las series es baja (hemorragia,0 a 4%). El dispositivo Acucise de nueva generaciónes más pequeño y por lo tanto su inserción es más fácil en ambos sexos. Aunque la endopielotomía con el dispositivo Acucise no iguala la tasa de éxito de la pieloplastia a cielo abierto, sigue siendo preferida por los urólogos como opción terapéutica alternativa en la obstrucción de la unión pieloureteral por su menor tiempo quirúrgico, menor morbilidad, hospitalización más corta y menor costo hospitalário.

Acucise® endopyelotomy technique is based on theprinciple of simultaneous dilatation and incision of aureteral narrowing under fluoroscopic guidance withoutthe need for ureteroscopy. This procedure appealed tomany urologists, as it is easy to learn, can be performedas an outpatient procedure with minimal endourologicalexperience. The success rates for various series reportsfrom 66-84% and serious complication rates for mostseries is low (bleeding-0-4%). The new generation acucisedevice is smaller and is therefore easy to insert in bothsexes. Although acucise endopyelotomy does not matchthe success rate of open pyeloplasty, it is still preferredby urologists as an alternative treatment option in ureteropelvicjunction obstruction because of its reducedoperative time, less morbidity, shorter hospitalisation anddecreased cost to the hospital.

Sonographic Features of an Adult Granulosa Cell Tumor of the Testis.

A 25-year-old man presented with epididymoorchitis. Sonography revealed a 5 mm hypoechoic lesion with scattered foci of high level echoes and an area of calcification in the upper pole of the left testicle close to the hilum. Growth and pronounced neovascularity was demonstrated a subsequent scan. An orchidectomy was performed and histological studies revealed a granulosa cell tumour of the testicle. Testicular granulosa cell tumors are extremely rare. Comparing the previously published findings to our case, we suggest that common sonographic features of testicular granulosa cell tumors include a hypoechoegenic lesion with hyperechoic and calcified foci, sharply defined edge, and internal vascularity.