National Implementation of Simulator Training Improves Transurethral Resection of Bladder Tumours in Patients.

Background: Transurethral resection of bladder tumours (TURBT) is the initial diagnostic treatment for patients with bladder cancer. TURBT is not an easy procedure to master and simulator training may play a role in improving the learning curve. Objective: To implement a national training programme for simulation-based mastery learning in TURBT and explore operating theatre performance after training. Design setting and participants: From June 2019 to March 2021, 31 doctors at urology departments in Denmark performed two pretraining TURBT procedures on patients, followed by proficiency-based mastery learning on a virtual reality simulator and then two post-training TURBTs on patients. Outcome measurements and statistical analyses: Operating theatre performances were video-recorded and assessed by two independent, blinded raters using the Objective Structured Assessment for Transurethral Resection of Bladder Tumours Skills (OSATURBS) assessment tool. Paired-sample t tests were used to compare pretraining and post-training analyses and independent t tests for between-group comparisons. This trial is registered at ClinicalTrials.gov as NCT03864302. Results and limitations: Before training, novices had significantly lower performance scores in comparison to those with intermediate experience (p = 0.017) and experienced doctors (p < 0.001). After training, novices significantly improved their clinical performance score (from 11.4 to 17.1; p = 0.049, n = 10). Those with intermediate experience and experienced doctors did not benefit significantly from simulator training (p = 0.9 and p = 0.8, respectively). Conclusions: Novices improved their TURBT performance in the operating theatre after completing a proficiency-based training programme on a virtual reality simulator. Patient summary: We trained surgeons in an operation to remove bladder tumours using a virtual reality simulator. Novice doctors improved their performance significantly after the training, but the training effects for more experienced doctors were minimal. Therefore, we suggest the introduction of mandatory simulator training in the residency programme for urologists.

Validation of a Novel Assessment Tool Identifying Proficiency in Transurethral Bladder Tumor Resection: The OSATURBS Assessment Tool.

Background: Competence in transurethral resection of bladder tumors (TURB) is critical in bladder cancer management and should be ensured before independent practice. Objective: To develop an assessment tool for TURB and explore validity evidence in a clinical context. Design, Setting, and Participants: From July 2019 to March 2021, a total of 33 volunteer doctors from three hospitals were included after exemption from the regional ethics committee (REG-008-2018). Participants performed two TURB procedures on patients with bladder tumors. A newly developed assessment tool (Objective Structured Assessment for Transurethral Resection of Bladder Tumors Skills, OSATURBS) was used for direct observation assessment (DOA), self-assessment (SA), and blinded video assessment (VA). Outcome Measurements and Statistical Analysis: Cronbach's alpha and Pearson's r were calculated for across items internal consistency reliability, inter-rater reliability, and test-retest reliability. Correlation between OSATURBS scores and the operative experience was calculated with Pearson's r and a pass/fail score was established. Differences in assessment scores were explored with paired t-test and independent samples t-test. Results and Limitations: The internal consistency reliability across items Cronbach's alpha was 0.94 (n = 260, p < 0.001). Inter-rater reliability was 0.80 (n = 64, p < 0.001). Test-retest correlation was high, r = 0.71 (n = 32, p < 0.001). Relationship with TURB experience was high, r = 0.71 (n = 32, p < 0.001). Pass/fail score was 19 points. DOAs were strongly correlated with video ratings (r = 0.85, p < 0.001) but with a significant social bias with lower scores for inexperienced and higher scores for experienced participants. Participants tended to overestimate their own performances. Conclusions: OSATURBS tool for TURB can be used for assessment of surgical proficiency in the clinical setting. DOA and SA are biased, and blinded VA of TURB performances is advised. Clinical Trials NCT03864302.

Undergraduate Education for Urology in Europe. Where Do We Stand?

Regardless of career intentions, junior doctors will meet patients with urological problems. There are no studies on the status of undergraduate education for urology in Europe. We designed an 18-item online survey using the platform www.surveymonkey.com to assess the current status of undergraduate education in urology. A total of 347 medical students, trainees, and urologists responded to the survey. Medical students' exposure to urology during their undergraduate career was heterogeneous. Although the quality of urology education was valued from moderate to high, urology as a speciality did not influence their future training decision making. Decision making in relation to residency training correlated with the number of hours spent on practical training, duration of urology rotation, and year of medical school in which urological exposure was introduced. The current European exposure to urology at undergraduate level is heterogeneous, with various factors influencing future decisions regarding training and specialisation. A uniform undergraduate curriculum would eliminate such heterogeneous exposure and facilitate a workforce fit for the future urological needs. PATIENT SUMMARY: Junior doctors will meet patients with urological problems in the wards, emergency departments, and primary care. Institutions should work together for a urological curriculum that fits the future clinical requirements.

Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study.

PURPOSE: To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures. METHODS: A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed. RESULTS: A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤  50 h per week, laparoscopic training and having laparoscopic training boxes. CONCLUSIONS: Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.

Bladder recurrence of primary upper tract urinary carcinoma following nephroureterectomy, and risk of upper urinary tract recurrence after ureteral stent positioning in patients with primary bladder cancer.

Upper tract urinary carcinoma (UTUC) and bladder cancer (BCa) share similar biological, histological and pathological characteristics. These resemblances could explain the high rate of synchronous and metachronous tumors affecting both upper urinary tract and bladder. In patients affected by primary UTUC bladder recurrence is quite common and it represents one of the major concerns during the follow-up of patients who underwent radical nephroureterectomy. Conversely, UTUC recurrence after primary non-muscular invasive BCa is a relatively rare event. Moreover, there is no clear evidence on whether the use of Double-J stenting as drainage in patients affected by BCa increases the risk of UTUC recurrence. The aim of the current study was to summarize the most recent evidence regarding the bladder recurrence after UTUC surgical treatment, and the UTUC recurrence after stent positioning in patients affected by primary BCa.

Current status of urological training in Europe.

Modern urological training has changed drastically in the past years, due to the global surgical training trends, advances in technology, subspecialization of the field and, working hour regulations for doctors. The lack of a standardized curriculum across Europe, puts in evidence the great difference in the requirements in every country, from the start of the residency, to obtaining the accreditation. We sought to identify problems related to medical, scientific and surgical activity during urological training, and summarize data obtained from surveys realized during the European Urology Residents Education Programme (EUREP) in 2013, and from countries such as Germany, Italy and Spain. Data from surveys reveals an evident lack of surgical confidence across all participants for major procedures, a general non-compliance with the working hour regulations, and a worrisome risk for burnout and negative consequences in resident's personal lives. Possible solutions are discussed, involving an early preference for a particular practice, and a standardized simulation-based training. The European Association of Urology (EAU) and the European School of Urology (ESU) offer a wide range of working groups, educational and scientific activities for improving the acquisition of competencies (surgical and scientific) of residents and urologists at any point of their career. We describe a brief description of the most important EAU and ESU opportunities.

Electroporation enhances mitomycin C cytotoxicity on T24 bladder cancer cell line: a potential improvement of intravesical chemotherapy in bladder cancer.

Intravesical mitomycin instillation combined with electric pulses is being used experimentally for the treatment of T1 bladder tumors, in patients unfit for surgery. Electroporation may enhance the uptake of chemotherapeutics by permeabilization of cell membranes. We investigated if electroporation improves the cytotoxicity of mitomycin. In two cell lines, T24 (bladder cancer cell line) and DC3F (Chinese hamster fibroblast), exposure to different concentrations of mitomycin (0.01-2000µM) was tested with and without electroporation (6 pulses of 1kV/cm, duration: 99µs, frequency: 1Hz). Cell viability was assessed by colorimetric assay (MTT). For both cell lines, mitomycin's IC_50 was approximately 1000µM in both pulsed and unpulsed cells. On T24 cells, electroporation and mitomycin caused (relative reduction) RR of survival of: 25%, 31% and 29%, by concentrations 0µM, 500µM and 1000µM respectively. For DC3F cells, the RRs of survival were: 28%, 29%, and 33%, by concentrations 0µM, 500µM and 1000µM respectively. In conclusion, electroporation and mitomycin together are about 30% more effective than mitomycin alone. The results help to elucidate the additive effect of mitomycin and electric pulses and support the use of this combination in the treatment of bladder cancer.