Teaching hypospadias repair by utilising a novel 3D-printed silicon model: An initial assessment using structured trainee and trainer feedback.

INTRODUCTION: Simulated paediatric surgical training is inherently advantageous and flourishing. Moreover, several working conditions resulted in reduced training hours, index and subspecialty cases encountered, and the COVID-19 pandemic affected elective surgery backlogs, hence training opportunities. Hypospadias repair is technically-demanding and requires a spectrum of dissective and reconstructive skills. We therefore aimed to test a 3D-printed silicon model for hypospadias repair, in the context of hands-on surgical training. MATERIAL AND METHODS: Twenty-Seven trainees, under the supervision of 15 instructors, completed the activity. They were given a seminar to show the relevant anatomy, and 8 key steps of the exercise: (1)-degloving; (2)-urethral plate marking; (3)-incision; (4)-tubularisation; (5)-glansplasty/glanuloplasty; (6)-dartos layer preparation; (7)-preputioplasty and (8)-skin closure. Each trainee completed a structured feedback assessment. An on-site trainer supervised and evaluated each exercise. Trainees and trainers rated the model through the above steps from unsatisfactory-(1/5) to excellent-(5/5), presented herein via cross-sectional analysis. RESULTS: Eleven-(40.7 %) trainees were in years:1-3 of specialist training, 10-(37 %) were in years:4-6, and 6-(22.2 %) were beyond year-6. Two-(7.4 %) trainees had nil-hypospadias experience, 16-(59.2 %) previously assisted in procedures or performed steps, 5-(18.5 %) performed whole procedures supervised and 4-(14.8 %) independently. Twenty-(74 %) trainees and 15-(100 %) instructors judged the model to resemble the anomaly. Seventeen-(63 %) trainees and 13-(86.6 %) instructors rated the material needle-penetrability ≥3/5, compared to human tissue. Sixteen-(59 %) trainees and 13-(86.6 %) instructors rated the material suture holding ≥3/5. Eleven-(73.3 %) trainees and 13-(86.6 %) instructors rated sutures' evenness and edge coaptability ≥3/5. DISCUSSION: Hypospadias is an index operation, which requires precision skills. Simulated training in Paediatric Surgery and Urology is gaining importance. 3D-printed models are gaining a key role in simulated training. The study presents a novel 3D-printed high-fidelity silicon-based hypospadias model designed for hands-on training. A structured pathway to divide a standard hypospadias repair into key steps is displayed to ensure skill acquisition and stabilisation. CONCLUSION: This 3D-printed silicon-based hypospadias model is proven useful for hands-on training. The fidelity can still improve, especially regarding suture holding of the material. LEVEL OF EVIDENCE: LEVEL III.

Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION: Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors. METHODS: We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2). RESULTS: 270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair). DISCUSSION: Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement. CONCLUSION: Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Surgical simulation of hypospadias repair - High-fidelity, reproducible and affordable animal tissue model.

INTRODUCTION: Teaching methods in hypospadias repair are still traditional. Available simulators often lack authenticity in terms of haptic feedback and realistic tissue handling. OBJECTIVE: Our aim was to develop a high-fidelity, easily reproducible, and affordable animal tissue model for the advanced surgical simulation of hypospadias repair with realistic haptic feedback and tissue handling. MATERIAL AND METHODS: A regular-sized chicken leg and a lamb tenderloin are used to assess the feasibility of simulating hypospadias correction by using the example of a Snodgrass Tubularized Incised Plate-Repair. The model preparation is incorporated into the training process. RESULTS: A detailed description of the high-fidelity model is provided. All steps of a hypospadias repair can be trained while providing realistic anatomy, adequate size, and multilayer tissue properties. Haptic conditions highly resemble human tissue properties. Fine tissue handling corresponds to intraoperative conditions. Limitations to this surgical model apply as in other animal tissue models. CONCLUSION: We developed a high-fidelity, easily reproducible, and affordable hypospadias animal tissue model. Due to the multilayer animal tissue properties, this model provides realistic haptic feedback and thus an inexpensive and reproducible model for hypospadias simulation. External validation is mandatory prior to implementation into urological training.

Assessment of the Educational Value of Distal Hypospadias Repair Videos on YouTube.

OBJECTIVE: To evaluate the quality of YouTube videos depicting distal hypospadias repair. METHODS: The search terms "distal hypospadias repair" were used to identify surgical videos on YouTube. Videos were sorted by view count and the top 34 videos were reviewed for baseline video characteristics, key surgical steps covered, and conformity to a modified LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) checklist. All videos were reviewed and discussed for conformity by 2 attending pediatric urologists and a urology resident. RESULTS: Of the 34 videos reviewed, 16 videos were excluded due to content. The median length of videos was 9.94 minutes (range, 2.57-99.12 minutes). Video quality was deemed of high quality in only 39% of videos. The most common type of hypospadias procedures described were tubularized incised plate urethroplasty (n = 13) and meatal advancement and glanuloplasty incorporated (n = 2). The median view count was 7828.5 (range, 1,133-58,619 views). Only 1 video met all modified LAP-VEGaS criteria (range of 33%-100%), and only 2 videos showed every surgical step of distal hypospadias repair (range 33%-100%). Modified LAP-VEGaS score, surgical step score, or quality of the video was not associated with a higher view count. CONCLUSION: Despite being a common procedure, there is a paucity of high-quality videos on YouTube describing distal hypospadias repair techniques. It is unclear how learners select videos for study purposes and the most utilized videos on YouTube are not the most educational videos.

Learning curve of various type of male urethroplasty.

PURPOSE: To determine the number of cases required to achieve a specified recurrence-free rate (>80%) among urethroplasty types. MATERIALS AND METHODS: A retrospective analysis of consecutive patients, who underwent urethroplasty performed by a single surgeon between April 2013 and January 2019, was conducted. Urethroplasty subtypes were divided according to stricture location: penile, bulbar, and posterior. If there was no recurrence for >6 months after surgery, the surgery was considered to be a success. The average success rates among quintile groups were compared to determine the learning curve for each type. RESULTS: Of 150 patients who underwent urethroplasty, 112 were included in this study. The overall success rate was 89.7% in penile, 97.8% in bulbar, and 74.1% in posterior urethroplasty. Bulbar urethroplasty reached the target success rate in the first quintile group (1-9 cases). Penile urethroplasty also achieved the target success rate in the first quintile group (1-8 cases), and the success rate gradually increased until the fifth quintile group (32-39 cases). In posterior urethroplasty, the target success rate was achieved in the fifth quintile group (20-27 cases). CONCLUSIONS: Bulbar urethroplasty had the fastest learning curve, and posterior urethroplasty the slowest.

Competency in Tubularized Incised Plate Repair for Distal Hypospadias: Cumulative Sum Learning Curve Analysis of a Single Surgeon Experience.

PURPOSE: We sought to determine the number of cases to achieve competency and proficiency in tubularized incised plate technique for distal hypospadias repair using cumulative sum analysis. MATERIALS AND METHODS: From 2001 to 2015 we reviewed all distal tubularized incised plate repairs performed by a single surgeon since independent practice. Data for 450 consecutive cases included age, meatal location, presence of curvature, operative time, occurrence of complications and followup duration. A cumulative sum analysis cohort chart was used to determine trends in complication rate and operative time during the evaluation period. In order to account for surgical experience with time, the highest peak, plateau, and down trends in operative time and complication rate were identified on the plot and set as the transition points between learning (phase 1), competence (phase 2) and proficiency (phase 3). RESULTS: Based on the cumulative sum analysis learning curve, the competence phase with plateau of operative time and complication rate commences beyond the 127th case, and the proficiency phase with notable decline in operative time and complication rate was noted beyond the 234th case. When comparing case characteristics and surgical outcomes between phases and learning curve, the proficiency phase involved younger patients and more severe degree of distal hypospadias being repaired using the tubularized incised plate approach with fewer complications related to meatal stenosis and fewer cosmetic complications. CONCLUSIONS: In our study competency in distal hypospadias tubularized incised plate repair was reached beyond the 127th case, while proficiency was attained beyond the 234th case.

Development and content validation of the Urethroplasty Training and Assessment Tool (UTAT) for dorsal onlay buccal mucosa graft urethroplasty.

OBJECTIVES: To develop and validate the Urethroplasty Training and Assessment Tool (UTAT) using Healthcare Failure Mode and Effect Analysis (HFMEA) for training and assessment of urology trainees learning this urethral reconstruction technique, as urethroplasty is the 'gold standard' treatment for long and recurrent urethral strictures and with a variety of techniques and a lack of standardised reconstructive curricula, there is a need for procedure-specific training tools to improve surgeon training and patient safety. MATERIALS AND METHODS: This international observational study was performed over an 11-month period. The HFMEA was used to identify and evaluate hazardous stages of urethroplasty to develop the UTAT. Hazard scores were calculated for the included steps of urethroplasty. Content validation was performed by 12 expert surgeons and multidisciplinary teams from international tertiary centres. RESULTS: The HFMEA process resulted in an internationally validated UTAT. Hazard scores ≥4 and single point weaknesses were included to implement actions and outcome measures. Content validation was achieved by circulating the process map, hazard analysis table, and developed tools. Changes were implemented based on the feedback received from expert surgeons. The content validated dorsal onlay buccal mucosa graft bulbar UTAT contained five phases, 10 processes and 23 sub-processes. CONCLUSIONS: The modular UTAT offers a comprehensive validated training tool developed via a detailed HFMEA protocol. This may be utilised to standardise the training and assessment of urology trainees.

Improving surgical training by identifying the most common feedback trainees receive for index cases.

BACKGROUND: To make surgical training more effective, a proven method is needed to provide feedback to residents on their surgeries. Residency programs may make up for limited training time in the operating room by improving feedback that trainees receive about cases. OBJECTIVE: The goals of this study were (1) to determine if an online tool to communicate feedback for attendings and trainees shows face validity and (2) to use an online tool to identify the most common feedback trainees receive after performing orchiopexy and hypospadias repair by survey. METHODS: In 2016, determining whether an online tool to provide pediatric urology trainees feedback after surgery shows face validity begun. The tool was launched at the authors' institutions. Then, attendings, fellows, and postgraduate year 4-5 trainees of 65 resident training programs were surveyed for their observations on preparing for and performing orchiopexy and hypospadias repair using the study tool to identify common feedback. RESULTS: The results of using the tool to provide feedback shows face validity are as follows: feedback was exchanged between attendings and trainees on orchiopexy (n = 28) and hypospadias (n = 22). Anecdotally, the tool was easy to use. The results of using the tool to identify the most common feedback trainees receive by survey are as follows: from a pool of 65 institutions, 37 attendings and 28 trainees were enrolled who made 219 observations. Most trainees prepare using undocumented online resources (17/28, 67%) instead of speaking with their attendings or cotrainees (11/28, 33%). For orchiopexy, most respondents reported that trainees need to improve skills for hernia ligation (observations: attending = 28/45, 62%; and trainee = 17/26, 65%) and strategies for hernia exposure (observations: attending = 17/27, 62%; and trainee = 7/12, 58%). For hypospadias, most respondents reported that trainees need to improve skills for neourethroplasty (observations: attending = 31/53, 58%; and trainee = 10/16, 62%) and strategies for repair choice (observations: attending = 15/22, 68%; and trainee = 12/18, 67%) (chi-squared, all P = NS). DISCUSSION: It was shown that both trainees and attendings agree on the areas of surgical strategy and execution which require improvement. With this study, it is also shown that the online feedback tool developed shows face validity in allowing attendings and trainees to communicate before and after surgery. CONCLUSIONS: The most common feedback pediatric urology trainees receive for routine pediatric urology surgery is identified. Online tools that emphasize remediations to address a trainee's specific feedback needs are to be built, so that they will be able to improve their skills at their next case.

Results of distal hypospadias repair after pediatric urology fellowship training: A comparison of junior surgeons with their mentor.

BACKGROUND: Teaching and learning hypospadias repair is a major component of pediatric urology fellowship training. Educators must transfer skills to fellows, without increasing patient complications. Nevertheless, few studies report results of surgeons during their first years of independent practice. PURPOSE: To review outcomes of distal hypospadias repairs performed during the same 2-year period by consecutive, recently matriculated, surgeons in independent practice, and to compare them to results by their mentor (with >20 years of experience). MATERIALS: Exposure to hypospadias surgery during fellowship was determined from case logs of five consecutive fellows completing training from 2007-2011. TIP was the only technique used to repair distal hypospadias. No fellow operated independently or performed complete repairs under supervision. Instead, the first 3 months were spent assisting their mentor, observing surgical methodology and decision-making. Then, each performed selected portions under direct supervision, including: degloving, penile straightening, developing glans wings, incising and tubularizing the urethral plate, creating a barrier layer, sewing the glansplasty, and skin closure. Overall fellow participation in each case was <50%. In 2011-2012, urethroplasty complications (fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum) were recorded for consecutive patients undergoing primary distal repair by these recent graduates in their independent practices. The fellow graduating in 2011 provided 1 year of data. All patients undergoing repair during the study period were included in the analysis, except those lost to follow-up after catheter removal. Composite urethroplasty complications were compared between junior surgeons, and between junior surgeons and their mentor, with Fisher's exact contingency test. RESULTS: Training logs indicated fellow participation ranged from 76-134 hypospadias repairs, including distal, proximal and reoperative surgeries. Post-graduation case volumes ranged from 25-68 by junior surgeons versus 136 by the mentor. With similar mean follow-up, urethroplasty complication rates were statistically the same between the former fellows, and between them versus the mentor, ranging from 5-13%. Nearly all were fistulas or glans dehiscence. Junior surgeons reported they performed TIP as learned during fellowship, with one exception who used 7-0 polydioxanone rather than polyglactin for urethroplasty. DISCUSSION: This is the first study directly comparing hypospadias surgical outcomes by recently graduated fellows in independent practice with those of their mentor. We found junior surgeons achieved similar results for distal TIP hypospadias repair. Although their participation during training largely comprised observation and surgical assistance, with discrete performance of key steps, skills sufficient to duplicate the mentor's results were transferred. These data suggest there should be no learning curve for distal hypospadias after training. This report raises several considerations for surgical educators. First, mentors should review their own results, to be certain that they are correctly performing and teaching procedures. Second, programs need to determine key steps for procedures they teach, and then emphasize their optimal performance. Finally, mentors should expect former fellows to report back their initial results of hypospadias repair to be certain lessons taught were learned. Otherwise, preventable complications resulting from technical errors will be multiplied in the children operated by their trainees as they enter independent practice.

Assessment of the Male Urethral Reconstruction Learning Curve.

OBJECTIVE: To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. MATERIALS AND METHODS: We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. RESULTS: A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P = .0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P = .0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P = .0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P = .0014). Complications decreased with time (P = .0053). CONCLUSION: This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.

Augmented reality assisted surgery: a urologic training tool.

Augmented reality is widely used in aeronautics and is a developing concept within surgery. In this pilot study, we developed an application for use on Google Glass ® optical head-mounted display to train urology residents in how to place an inflatable penile prosthesis. We use the phrase Augmented Reality Assisted Surgery to describe this novel application of augmented reality in the setting of surgery. The application demonstrates the steps of the surgical procedure of inflatable penile prosthesis placement. It also contains software that allows for detection of interest points using a camera feed from the optical head-mounted display to enable faculty to interact with residents during placement of the penile prosthesis. Urology trainees and faculty who volunteered to take part in the study were given time to experience the technology in the operative or perioperative setting and asked to complete a feedback survey. From 30 total participants using a 10-point scale, educational usefulness was rated 8.6, ease of navigation was rated 7.6, likelihood to use was rated 7.4, and distraction in operating room was rated 4.9. When stratified between trainees and faculty, trainees found the technology more educationally useful, and less distracting. Overall, 81% of the participants want this technology in their residency program, and 93% see this technology in the operating room in the future. Further development of this technology is warranted before full release, and further studies are necessary to better characterize the effectiveness of Augmented Reality Assisted Surgery in urologic surgical training.

Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?

OBJECTIVE: To evaluate trends in male urethral and penis/incontinence case volumes among urology residents and assess these for adequate surgical training/competency. METHODS: Accreditation Council for Graduate Medical Education (ACGME) case logs of urology residents graduating from U.S. programs from 2009 to 2013 were reviewed to determine the surgical volume of select index categories. Male urethral cases encompass urethrectomy and urethroplasty, whereas male penis/incontinence cases include urethral slings and sphincters. Case volumes as "surgeon," "assistant," and "teaching assistant" were reviewed and compared to ACGME minimum requirements. RESULTS: A total of 1032 graduating residents reported case logs. For male urethral surgery, residents reported weighted averages (standard deviation [SD]) of 12.7 (9.0) cases as "surgeon," 1.5 (3.5) cases as "assistant," and 0.2 (1.0) as "teaching assistant." The minimum requirement for these cases is 5. The annual 10th percentiles as "surgeon" ranged from 4 to 5 cases throughout the study period. For male penis/incontinence cases, residents reported weighted averages (SD) of 45.5 (22.7) cases as "surgeon," 3.6 (5.5) cases as "assistant," and 1.5 (3.0) cases as "teaching assistant." The minimum requirement is 10 cases. The 10th percentiles as "surgeon" ranged from 19 to 23 cases. CONCLUSION: Although the majority of residents met the minimum standard for these cases, about 10% of residents did not meet the requirement for male urethral surgery. In addition, a review of learning curves for these procedures suggests that the ACGME minimum requirements may be insufficient to confer actual competency in skill. Increasing this number in training or specialized postgraduate training programs is needed to provide actual competency.

Laparoscopic varicocelectomy: virtual reality training and learning curve.

OBJECTIVES: To explore the role that virtual reality training might play in the learning curve of laparoscopic varicocelectomy. METHODS: A total of 1326 laparoscopic varicocelectomy cases performed by 16 participants from July 2005 to June 2012 were retrospectively analyzed. The participants were divided into 2 groups: group A was trained by laparoscopic trainer boxes; group B was trained by a virtual reality training course preoperatively. The operation time curves were drafted, and the learning, improving, and platform stages were divided and statistically confirmed. The operation time and number of cases in the learning and improving stages of both groups were compared. Testicular artery sparing failure and postoperative hydroceles rate were statistically analyzed for the confirmation of the learning curve. RESULTS: The learning curve of laparoscopic varicocelectomy was 15 cases, and with 14 cases more, it came into the platform stage. The number of cases for the learning stages of both groups showed no statistical difference (P=.49), but the operation time of group B for the learning stage was less than that of group A (P<.00001). The number of cases of group B for the improving stage was significantly less than that of group A (P=.005), but the operation time of both groups in the improving stage showed no difference (P=.30). The difference of testicular artery sparing failure rates among these 3 stages was proved significant (P<.0001), the postoperative hydroceles rate showed no statistical difference (P=.60). CONCLUSIONS: The virtual reality training shortened the operation time in the learning stage and hastened the trainees' steps in the improving stage, but did not shorten the learning curve as expected to.

Initial validation of a virtual-reality learning environment for prostate biopsies: realism matters!

BACKGROUND AND PURPOSE: A virtual-reality learning environment dedicated to prostate biopsies was designed to overcome the limitations of current classical teaching methods. The aim of this study was to validate reliability, face, content, and construct of the simulator. MATERIALS AND METHODS: The simulator is composed of (a) a laptop computer, (b) a haptic device with a stylus that mimics the ultrasound probe, (c) a clinical case database including three-dimensional (3D) ultrasound volumes and patient data, and (d) a learning environment with a set of progressive exercises including a randomized 12-core biopsy procedure. Both visual (3D biopsy mapping) and numerical (score) feedback are given to the user. The simulator evaluation was conducted in an academic urology department on 7 experts and 14 novices who each performed a virtual biopsy procedure and completed a face and content validity questionnaire. RESULTS: The overall realism of the biopsy procedure was rated at a median of 9/10 by nonexperts (7.1-9.8). Experts rated the usefulness of the simulator for the initial training of urologists at 8.2/10 (7.9-8.3), but reported the range of motion and force feedback as significantly less realistic than novices (P=0.01 and 0.03, respectively). Pearson r correlation coefficient between correctly placed biopsies on the right and left side of the prostate for each user was 0.79 (P<0.001). The 7 experts had a median score of 64% (59%-73%), and the 14 novices a median score of 52% (43%-67%), without reaching statistical significance (P=0.19). CONCLUSION: The newly designed virtual-reality learning environment proved its versatility and its reliability, face, and content were validated. Demonstrating the construct validity will necessitate improvements to the realism and scoring system used.

Anatomical and histological equivalence of the human, canine, and bull vas deferens.

INTRODUCTION: Several animal models have been utilized for in-vitro experimentation and surgical training exercises of the vas deferens. The canine model is currently the standard for both in-vivo and ex-vivo study. Due to increasing costs associated with experimentation on canines, and in keeping with the principles of refine, reduce, and replace, a novel model that is cost-effective and easily obtained is desired. We compared morphology of the bull vas deferens to that of the human and the canine. MATERIALS AND METHODS: Bilateral vas deferens tissue from the human (n = 6), canine (n = 6), and bull (n = 5) were compared. Outer diameter (OD), inner diameter (ID), and microscopic measurements of the luminal mucosa and muscularis were then determined from each of these tissues. Histological comparisons were performed by a single pathologist. Data was analyzed using Two One-sided Tests (TOST) Analysis of Equivalence. RESULTS: According to the TOST statistical analysis, the vassal ID was equivalent for all three species. Similarly, equivalent microscopic measurements were noted for both vassal mucosal (human-canine and human-bull) and muscularis thicknesses (canine-bull). Lastly, all three species had similar histological characteristics. CONCLUSIONS: The vas deferens' of the human, canine, and bull are equivalent in many ways, including histological similarities. It is reasonable to conclude that the bull vas could be substituted for the human vas for both in-vitro testing and microscopic vasovasostomy simulation exercises. Specimens are cost-effective, provide ample tissue length, and are easy to obtain.

Suspected testicular torsion - urological or general surgical emergency?

INTRODUCTION: Suspected testicular torsion (TT) is a surgical emergency, usually requiring urgent scrotal exploration. Provision of urology on-call cover varies widely between hospitals and often falls under the remit of the general surgical team. The purpose of this study was to investigate whether the management of suspected TT differed between urology (UT) and surgical (ST) trainees in the Severn and South West Peninsula Deaneries. SUBJECTS AND METHODS: An on-line questionnaire (SurveyMonkey. com) was sent to all UT and ST within the Deaneries. Questions covered training, on-call cover, intra-operative management and knowledge of complications following testicular fixation. Responses were analysed using an Excel spreadsheet and GraphPad statistical package. RESULTS: Responses were received from 26/31 UT and 43/52 ST throughout 17 hospitals. Only three hospitals had separate middle-grade specialist urology cover. Scrotal exploration was taught by urologists to 72% of UT compared with 40% of ST (P = 0.012, Fisher's exact test). Variability in the number of operations performed, supervision and management of true TT was insignificant. However, ST were more likely to fix a normal testicle either in the absence of other pathology (53% vs 28%) or with a twisted appendix testis (42% vs 15%) than UT (P = 0.045 and P = 0.032, respectively). UT were more aware of evidence regarding chronic pain (47% vs 14%) and infertility (53% vs 18%) following testicular fixation than ST (P = 0.005 and P = 0.003, respectively). Medicolegally, 76% of UT would inform the on-call consultant prior to operation compared with 45% of ST (P = 0.012). DISCUSSION: ST are significantly more likely to fix a normal testicle than UT (and then usually only on the affected side), contrary to best-practice. This variation may be due to the different sources of training received by the two groups. Knowledge of possible chronic pain and infertility following testicular fixation may also affect management. CONCLUSIONS: Due to the variation, we suggest urology departments should draw up guidelines for management; trainees should be encouraged to discuss the case pre-operatively with the consultant; core surgical training should include a urology placement.

Computer enhanced visual learning method to train urology residents in pediatric orchiopexy provided a consistent learning experience in a multi-institutional trial.

PURPOSE: Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial. MATERIALS AND METHODS: We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution. RESULTS: The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant). CONCLUSIONS: The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

A new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation.

PURPOSE: Residency programs must continue to restructure teaching and assessment of surgical skills to improve the documentation of Accreditation Council for Graduate Medical Education competencies. To improve teaching and documenting resident performance we developed a computer enhanced visual learning method that includes a curriculum and administrative reports. The curriculum consists of 1) study of a step-by-step surgical tutorial of computer enhanced visuals that show specific surgical skills, 2) a checklist tool to objectively assess resident performance and 3) a log of postoperative feedback that is used to structure deliberate practice. All elements of the method are repeated with each case performed. We used the Accreditation Council for Graduate Medical Education index case of orchiopexy to pilot this project. MATERIALS AND METHODS: All urology residents who trained at our institution from January 2006 to October 2007 performed orchiopexy using the computer enhanced visual learning method. The computer enhanced visual learning tutorial for orchiopexy consisted of customized computer visuals that demonstrate 11 steps or skills involved in routine inguinal orchiopexy, eg ligate hernia. The attending urologist rated resident competence with each skill using a 5-point Likert scale and provided specific feedback to the resident suggesting ways to improve performance. These ratings were weighted by case difficulty. The computer enhanced visual learning weighted score at entry into the clinical rotation was compared to the best performance during the rotation in each resident. RESULTS: Seven attending surgeons and 24 urology residents (resident training postgraduate years 1 to 8) performed a total of 166 orchiopexies. Overall the residents at each postgraduate year performed an average of 7 cases each with complexity ratings that were not significantly different among postgraduate year groups (average 2.4, 1-way ANOVA p not significant). The 7 attending surgeons did not differ significantly in assessment of skill performance or case difficulty (1-way ANOVA p not significant). Of the 24 residents 23 (96%) showed improvement in computer enhanced visual learning score/skill performance. In the entire group the average computer enhanced visual learning weighted score increased more than 50% from entry to best performance (137 to 234 orchiopexy units, paired t test p <0.0001). CONCLUSIONS: Computer enhanced visual learning is a novel method that enhances resident learning by breaking a core procedure into discrete steps and providing a platform for constructive feedback. Computer enhanced visual learning, which is a checklist tool, complies with Accreditation Council for Graduate Medical Education documentation requirements. Computer enhanced visual learning has wide applicability among surgical specialties.