Comparison of healing after cystotomy and repair with fibrin glue and sutured closure in the porcine model.

PURPOSE: We compared healing after laparoscopic cystotomy using fibrin glue, sutures, or a combination to determine whether fibrin glue can obviate the need for sutures and whether there is any detriment when glue is used in the presence of sutures. MATERIALS AND METHODS: In 24 Yorkshire pigs, a 3.5 cm vertical cystotomy was created laparoscopically and repaired as follows: Group 1--no closure; group 2--fibrin glue closure; group 3--suture repair; group 4--combined fibrin glue and suture repair. All animals had a Foley catheter for 1 week. In each group, three animals were harvested at 1 week (acute) and three animals were harvested at 6 weeks (chronic). RESULTS: Acute: Group 1--all pigs had an unhealed defect that leaked when evaluated by cystography. Groups 2, 3, 4--mean leak pressures were 80, 97, and 60 cm H(2)O (P = 0.36), respectively. Mean bladder capacity was not significantly different between groups. Chronic: No leakage seen on a cystogram at 1 week; at 6 weeks, bladders were filled at > or =95 to 100 cm H(2)O without leakage. Histologically, there was more inflammation in the acute group v chronic group pigs. In the acute group pigs repaired with glue or suture + glue, there was more inflammation and less epithelial continuity than in the suture alone group. At 6 weeks, there was no difference between groups. CONCLUSION: Fibrin glue provoked an intense inflammatory response that might have delayed healing acutely, resulting in a lower burst pressure in both scenarios in which it was used (i.e., alone or in combination with sutures). However, by 6 weeks, there did not seem to be any difference between groups either clinically or histopathologically.

Immediate impact of an intensive one-week laparoscopy training program on laparoscopic skills among postgraduate urologists.

INTRODUCTION: Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience. METHODS: Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of P

In-vivo evaluation of flow characteristics of novel metal ureteral stent.

PURPOSE: To characterize the flow of a novel ureteral stent composed of a nickel-cobalt-chromium-molybde-num alloy and compare it with flow in a standard ureteral stent. MATERIALS AND METHODS: Six 6F Resonance stents and six 6F standard Black Beauty ureteral stents were placed in six Yucatan minipigs, with each pig serving as its own control. Flow assessment was performed on all stents via a nephrostomy tube delivering a standard rate of 0.9% saline at 35 cm H(2)O. Flow studies on the standard stents encompassed extraluminal (i.e., lumen of stent occluded with a guidewire), intraluminal (i.e., ureter secured to stent with a constricting suture), and combined (i.e., open lumen without constricting suture) flow. In the Resonance stent, only combined and intraluminal flow could be addressed, as there is no access to the lumen of this stent. RESULTS: With the Resonance stent, intraluminal flow was much greater than combined flow, with mean values of 5.15 mL/min and 2.50 mL/min, respectively (P = 0.057; SD = 7.73). Intraluminal flow was similar to combined flow in the 6F standard stent, with mean values of 7.34 mL/min and 7.30 mL/min, respectively (P = 0.88; SD = 1.76). The standard stent had significantly greater combined flow than the Resonance stent (P = 0.023) but not intraluminal flow (P = 0.247). Of note, whereas it was possible to occlude the 6F standard stent completely with a ureteral ligature (i.e., no guidewire placed in the lumen), it was not possible to occlude the Resonance stent regardless of how tightly the suture was tied. CONCLUSION: The Resonance metal alloy stent provides less overall flow than a standard stent. However, under circumstances of extrinsic ureteral compression sufficient to occlude a standard stent (e.g., extrinsic compression plus an internal guidewire), the metal stent continues to provide satisfactory drainage.

Rapid communication: effects of Steris 1 sterilization and Cidex ortho-phthalaldehyde high-level disinfection on durability of new-generation flexible ureteroscopes.

BACKGROUND AND PURPOSE: The effects of commonly used reprocessing methods on flexible ureteroscope longevity have never been examined. We prospectively studied the effects of Steris 1 sterilization and Cidex ortho-phthalaldehyde (OPA) high-level disinfection (HLD) on the image quality, physical structure, and deflective properties of two new flexible ureteroscopes. MATERIALS AND METHODS: Two identical "out-of-the-box" Storz 11278AU1 flexible ureteroscopes (Karl Storz Endoscopy, Tuttlingen, Germany) were sterilized individually using the Steris 1 system (Steris Mentor, Ohio) or disinfected with Cidex OPA (Advanced Sterilization Products, J&J, Irvine, CA) for 100 trials followed by a crossover to the other method for another 100 trials over a period of 1 year. After every five trials, optical quality, angle of deflection, and fiber damage were analyzed in the laboratory. Throughout the study, neither of these ureteroscopes was used clinically. RESULTS: After 100 trials, ureteroscope 1, which was sterilized initially in the Steris system, had a 12-mm tear on its shaft (noted after the 17th trial), 297 damaged fibers, and a 37% drop in resolution (loss of 3.75 lines/mm). There was no change in deflection from baseline. In contrast, after 100 cycles, ureteroscope 2, which was subjected to HLD with Cidex OPA, had no visible external damage, a 0% change in resolution, 10 damaged fibers, and no change in deflection. After the crossover, ureteroscope 2 developed a semilunar defect that obscured the endoscopic view, whereas there was no further significant damage to ureteroscope 1. CONCLUSION: After 100 cycles, the Steris 1 system rendered the flexible ureteroscope unusable, whereas HLD with Cidex OPA had minimal adverse impact.

Short-term impact of a laparoscopic "mini-residency" experience on postgraduate urologists' practice patterns.

BACKGROUND: To assist practicing urologists incorporate laparoscopic urology into their practice, a 5-day mini-residency (M-R) program with a mentor, preceptor, and proctor experience was established at the University of California, Irvine, and we report the initial results. STUDY DESIGN: Thirty-two urologists underwent laparoscopic ablative (n=17) or laparoscopic reconstructive (n=15) training, including inanimate model skills training, animal laboratory, and operating room observation. A questionnaire was mailed 1 to 15 months (mean, 8 months) after their M-R program, and responses were reviewed. RESULTS: A 100% response rate was achieved. The mean M-R participant age was 49 years (range 31 to 70 years). The majority of the participants (72%) had laparoscopic experience during residency training and had performed between 5 and 15 laparoscopic cases before attending the M-R program. Within 8 months after M-R, 26 participants (81%) were practicing laparoscopic surgery. Participants were performing laparoscopic radical nephrectomy (p=0.008), nephroureterectomy (p<0.0005), and pyeloplasty (p=0.008) at substantially higher rates after training. At the same time, fewer of the M-R participants were performing hand-assisted laparoscopic surgery after training (p=0.008) compared with before the M-R. Ninety-two percent of the participants indicated that they would recommend this training program to a colleague. CONCLUSIONS: A 5-day intensive laparoscopic ablative and reconstructive surgery course seems to encourage postgraduate urologists, already familiar with laparoscopy, to successfully expand the scope of their procedures to include more complex laparoscopic techniques such as nephrectomy, nephroureterectomy, and pyeloplasty into their clinical practice.

Comparison of resolution, contrast, and color differentiation among fiberoptic and digital flexible cystoscopes.

BACKGROUND AND PURPOSE: Advances in electro-optics continue to improve the urologist's ability to perform minimally invasive procedures. While the development of flexible fiberoptic cystoscopes more than 20 years ago greatly impacted the practice of urology, distal-sensor digital technology may represent the next step in the evolution of endoscopy. We compared a new distal-sensor digital flexible cystoscope with two standard fiberoptic flexible cystoscopes. MATERIALS AND METHODS: We evaluated the resolution, contrast, and color discrimination of a new ACMIICN distal-sensor digital cystoscope with >165,000 effective pixels in its clear aperture (viewing area), a new ACMI-ACN II fiberoptic cystoscope with <15,000 pixels in its clear aperture, and a Storz 1127 office fiberoptic cystoscope. Five subjects compared each cystoscope across 13 test parameters. RESULTS: There was no difference in the performance of the two fiberoptic cystoscopes. The ICN cystoscope was statistically superior to one or both fiberoptic cystoscopes across 12 of the 13 tests, including color differentiation between shades of dark red (P < 0.05), contrast discrimination along a 15-step grayscale gradient (P < 0.001 compared with the 1127 fiberoptic cystoscope only), resolution at 10 mm (7.52 line pairs/mm [lp/mm] (ICN) nu 3.58 lp/mm for both fiberoptic cystoscopes; (P < 0.001), and clear resolution of a 1-mm target at a distance of 6.1 cm (ICN) nu 3.3 cm (1127) and 3.8 cm (ACN II) (P < 0.001). CONCLUSIONS: The ICM distal-sensor all-digital cystoscope was clearly superior to two representative fiberoptic cystoscopes in vitro in terms of resolution, contrast discrimination, and red color differentiation. In-vivo performance remains to be assessed.

Comparison of basic elements of human performance scores between urologists with various extents of experience.

BACKGROUND AND PURPOSE: An objective evaluation of innate ability and its ability to predict potential success as a surgical trainee is an appealing concept for the selection process of residency applications. The objective of this study was to evaluate whether basic elements of performance (BEP) could discriminate among resident applicants and urologists with various extents of surgical experience. SUBJECTS AND METHODS: One hundred forty-five participants were divided into four study groups: group A, 57 urology residency applicants to the 2002 and 2003 interview process; group B, 8 post-internship urology residents; group C, 19 urologists tested with BEP within 10 years of graduation from their residency training program; and group D, 61 urologists who had graduated from their residency training program more than 10 years prior to testing. The BEP measures consisted of 13 basic performance resources (BPR) including visual-information processing speed, visual-spatial immediate-recall capacity, and neuromotor channel capacity. RESULTS: The four study groups differed significantly in their mean age: group A=27.6 years, group B=29.1 years, group C=37.1 years, and group D=48.9 years (P<0.0005). There was essentially no significant difference between the groups with regard to immediate-recall memory, reaction time simple, or reaction time complicated. The younger participants (groups A and B) were faster than the older surgeons (groups C and D) (P<0.02). However, the older surgeons (groups C and D) were significantly more accurate than the younger groups (A and B) (P<0.0005). The only sex differences noted were in hand-grip strength and shoulder-strength scores, which were all higher in the men. CONCLUSIONS: There generally appears to be a lack of direct correlation between innate abilities and surgical experience. Urology resident applicants with no surgical experience and urology residents with limited surgical experience are faster but less accurate in innate skills testing than experienced practicing urologists.

Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns.

BACKGROUND AND PURPOSE: Laparoscopic surgical techniques are difficult to master, especially for surgeons who did not receive this type of training during their residencies. We have established a 5-day mentor-preceptor- proctor-guided postgraduate "mini-residency" (M-R) experience in minimally invasive surgery. The initial results from the first 16 participants in the laparoscopic M-R modules are presented. PARTICIPANTS AND METHODS: On the first and the last day of the M-R, all participants underwent surgical skills testing using an open-surgery, standard laparoscopic, and robot-assisted laparoscopic format. A written examination was also administered on the last day. The influence of M-R on the participants' practice pattern was then assessed by a follow-up questionnaire survey 1 to 7 months after their attendance. RESULTS: Data from the first 16 participants were analyzed. Of note, the score was significantly improved for only one of the four tested laparoscopic skills (i.e., threading a suture through loops). Nonetheless, on the follow-up survey, of the 15 respondents, two laparoscopically naïve participants had performed laparoscopic nephrectomy, and of the eight participants who had prior renal-ablative laparoscopic experience, four had performed advanced reconstructive laparoscopic cases. CONCLUSIONS: A 5-day dedicated postgraduate M-R in laparoscopy appears to be helpful for urologists wishing to incorporate this surgical approach into their practices. The "take rate" among participants is initially at the 40% level, similar to what has been previously reported after a 1 to 2-day hands-on didactic laparoscopy course.

Current trends in urologic laparoscopic surgery.

PURPOSE: We examined the status of laparoscopy in urology and the impact of residency and fellowship training on the performance of laparoscopy as primary surgeon. We also examined whether performing nonsurgical tasks requiring two-handed dexterity had any link to the adoption of laparoscopic techniques by urologists. MATERIALS AND METHODS: A total of 8760 laparoscopy questionnaires containing 135 queries were mailed to urologists listed on the American Urological Association practicing urologists mailing list. The questions sought information on area of practice, time in practice, fellowship training, ambidexterity, laparoscopic experience, and experience with robotics. The response rate was 1.8% (155 of 8760). RESULTS: There appeared to be no significant correlation between the performance of laparoscopic surgery and participation in activities requiring bimanual dexterity. However, a correlation of strong statistical significance did exist between laparoscopic residency training and performance of laparoscopy after residency (p=0.003. There also was a correlation between fellowship training in laparoscopy/endourology and doing laparoscopy as primary surgeon. CONCLUSIONS: Participation in laparoscopic surgery during residency training is a major determining factor in performance of laparoscopy as a primary surgeon in practice. Younger surgeons trained in laparoscopy during residency are performing more laparoscopy post residency than those without laparoscopic training during residency. At present, there is a need to train more urologists in laparoscopy at the postgraduate level.

High-fidelity simulation-based team training in urology: evaluation of technical and nontechnical skills of urology residents during laparoscopic partial nephrectomy.

INTRODUCTION: The use of low-risk simulation training for resident education is rapidly expanding as teaching centers integrate simulation-based team training (SBTT) sessions into their education curriculum. SBTT is a valuable tool in technical and communication skills training and assessment for residents. We created a unique SBTT scenario for urology residents involving a laparoscopic partial nephrectomy procedure. MATERIALS AND METHODS: Urology residents were randomly paired with a certified registered nurse anesthetists or an anesthesia resident. The scenario incorporated a laparoscopic right partial nephrectomy utilizing a unique polyvinyl alcohol kidney model with an embedded 3cm lower pole exophytic tumor and the high-fidelity SimMan3G mannequin. The Urology residents were instructed to pay particular attention to the patient's identifying information provided at the beginning of the case. Two scripted events occurred, the patient had an anaphylactic reaction to a drug and, after tumor specimen was sent for a frozen section, the confederate pathologist called into the operating room (OR) twice, first with the wrong patient name and subsequently with the wrong specimen. After the scenario was complete, technical performance and nontechnical performance were evaluated and assessed. A debriefing session followed the scenario to discuss and assess technical performance and interdisciplinary nontechnical communication between the team. RESULTS: All Urology residents (n = 9) rated the SBTT scenario as a useful tool in developing communication skills among the OR team and 88% rated the model as useful for technical skills training. Despite cuing to note patient identification, only 3 of 9 (33%) participants identified that the wrong patient information was presented when the confederate "pathologist" called in to report pathology results. CONCLUSION: All urology residents rated SBTT sessions as useful for the development of communication skills between different team members and making residents aware of unlikely but potential critical errors in the OR. We will continue to use SBTT as a useful method to develop resident technical and nontechnical skills outside of the high-risk operating environment.

Genitourinary exam skills training curriculum for medical students: a follow-up study of comfort and skill utilization.

PURPOSE: We developed a genitourinary skills training (GUST) curriculum for incoming third year medical students (MS3) and performed a follow-up study of comfort with and utilization of these skills. MATERIALS AND METHODS: GUST consisted of a didactic lecture followed by skills sessions including standardized patient testicular examination (TE) and digital rectal examination (DRE), male and female Foley catheter (MFC and FFC) placement training, suture-knot tying, and a faculty-directed small group learning session. Precourse and postcourse, and 6 and 18 months after the course, MS3 rated comfort with each skill (Likert scale 0-5), and quantified skill usage. Results were compared with 4th year students (MS4) who had not undergone GUST. RESULTS: Participants were 281 MS3 GUST students and 44 MS4. Post-GUST, mean comfort on a Likert scale (0=uncomfortable) increased for all four skills (88.2%-96.9% vs 8.3%-18.5%, P<0.0001). This was maintained at the 6-month and 18-month follow up time points (P<0.0001). At 18 months, MS3 trended toward higher comfort with TE compared with MS4 (74 vs 54%, P=0.068), while with the other skills, both groups showed equal comfort. MS4 learned exam skills from faculty and MFC and FFC from nurses on the wards. Eleven percent of MS4 were never formally taught TE or DRE. MS3 and MS4 performed TE and/or DRE on <8% of newly admitted patients. CONCLUSIONS: MS3 described improved comfort with the GU skills at all time points during follow-up. This was particularly important because both MS3 and MS4 reported using their skills infrequently during their clinical training years.

LapED 4-In-1 silicone training aid for practicing laparoscopic skills and tasks: a preliminary evaluation.

OBJECTIVE: We developed a simple, inexpensive model to simulate four reconstructive laparoscopic procedures: pyeloplasty, vesicourethral anastomosis, bladder injury repair, and partial nephrectomy. MATERIALS AND METHODS: Liquid silicone was applied in layers to a mold to create the 4-in-1 model. A questionnaire evaluating its face and content validity was distributed to postgraduate urologists participating in a mini-residency program at the University of California-Irvine (UCI), and in the 2006 American Urological Association Hands-On course on reconstructive laparoscopic pyeloplasty. RESULTS: A total of 56 postgraduate urologists used the model and completed an evaluation questionnaire. Ninety-four percent (51/54) and 96% (48/50) agreed that the model was helpful for practicing laparoscopic pyeloplasty and urethrovesical anastomosis, respectively. Urologists who were experienced in either performing laparoscopic pyeloplasty (n = 6) or robot-assisted and/or laparoscopic prostatectomy (n = 11) would recommend this model to surgeons in training. Overall, 94% (48/51) and 96% (50/52) of the respondents would recommend this model for postgraduate surgeons and residents, respectively. CONCLUSION: We present a versatile model for practicing laparoscopic and robotic suturing and knot-tying skills in four reconstructive urologic procedures. Our results support the face and content validity of this model for performing pyeloplasty and vesicourethral anastomoses.

Third place: Flank position is associated with higher skin-to-surface interface pressures in men versus women: implications for laparoscopic renal surgery and the risk of rhabdomyolysis.

BACKGROUND AND PURPOSE: There have been several reports of rhabdomyolysis occurring after prolonged laparoscopic procedures in the flank position. Accordingly, we evaluated interface pressures between the skin and three commonly used operating room table surfaces. The aim of our study was to determine if pressure changes could be related to body mass index (BMI), sex, position, and/or the table surface material. PATIENTS AND METHODS: Ten men and 10 women were grouped according to BMI <25 or >or=25, with five participants in each group. Subjects were placed in the left lateral decubitus position with the operating table flat, half flexed, fully flexed, half flexed with the kidney rest elevated, and fully flexed with the kidney rest elevated. Interface pressures were recorded, using an X-Sensor pressure sensing mat, for 5-minute periods in each of the described positions on each surface. RESULTS: Sex and BMI were statistically significant predictors of increased pressures (P= 0.0042 and 0.0402, respectively). The parameter estimate for the difference between men and women was 4.63 mm Hg (P= 0.0002), and the difference for BMI >or= 25 compared with <25 was also significant (P < 0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P= 0.0001) and the half-flexed (25-degree) position (P < 0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P < 0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P= 0.0117). CONCLUSION: Women have significantly lower interface pressures when compared with men. BMI >or= 25 also increases interface pressures. The use of the kidney rest is associated with markedly increased pressure; use of a half-flexed position is preferable to a full-flexed position. These data have implications for patient positioning and identification of persons at risk for rhabdomyolysis during laparoscopic renal surgery.

Short-term impact of a robot-assisted laparoscopic prostatectomy 'mini-residency' experience on postgraduate urologists' practice patterns.

INTRODUCTION: To assist practising urologists acquire and incorporate robot-assisted laparoscopic prostatectomy (RALP) into their practice, a 5 day mini-residency (M-R) programme with a mentor, preceptor and potential proctor experience was established at the University of California, Irvine, Yamanouchi Center for Urological Education. The follow-up results from the initial 21 RALP M-R participants are presented. METHODS: Between September 2003 and September 2004, 21 urologists from six states and four countries underwent a RALP M-R. Each participant underwent 1:2 teacher:attendee instruction over a 5 day period, which included inanimate model skills training, animal/cadaver laboratory skills training and operating room observation experience. Participants were also offered a proctoring experience at their hospital if they so desired. A questionnaire survey was mailed 1-14 months (mean 7.2 months) following completion of the mini-residency and these results were tabulated and reviewed. RESULTS: A 100% response rate was achieved from the mailed questionnaires. The mean M-R participant age was 43 years (range 33-55 years). One-third of the M-R participants were practising in an academic environment. Most of the participants (55%) had no fellowship training. Of those with fellowship training (45%), three (15%) were in laparoscopy and three (15%) were in oncology; 25% of the participants were in large (>6 physicians), 25% in small (2-6 physicians) and 15% in solo practices; 70% of the participants were located in an urban setting. The majority of the participants (80%) had laparoscopic experience during residency training and had performed 20-60 laparoscopic cases prior to attending the M-R programme. Within 7.2 months after M-R (range 1-14 months), 95% of the participants were practising robot-assisted laparoscopic prostatectomy and 25% of the RALP M-R participants had also performed robotic-assisted laparoscopic pyeloplasty. Of the M-R participants, 38% availed themselves of the preceptor/proctor component of the programme; among these, 100% reported that they were performing RALP vs. only 92% of the MR participants who did not have a proctor experience. The 5 day length of the M-R was considered to be of satisfactory duration by 90% of the participants, while 1 participant considered it too brief and 1 considered it too long. All but one of the participants rated the M-R as a very or extremely valuable experience. All the M-R participants indicated that they would recommend this training programme to a colleague. CONCLUSIONS: A 5 day intensive RALP M-R course seems to encourage postgraduate urologists, already familiar with laparoscopy, to successfully incorporate robotic surgery into their practice. The take rate, or the percentage of participants performing robotic-assisted surgery within 14 months after M-R, was 95%. Continued follow-up will ultimately determine the long-term effectiveness of this 1 week intensive training programme for postgraduate urologists.