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.

Citrate salts for preventing and treating calcium containing kidney stones in adults.

BACKGROUND: Kidney stones affect people worldwide and have a high rate of recurrence even with treatment. Recurrences are particularly prevalent in people with low urinary citrate levels. These people have a higher incidence of calcium phosphate and calcium oxalate stones. Oral citrate therapy increases the urinary citrate levels, which in turn binds with calcium and inhibits the crystallisation thus reduces stone formation. Despite the widespread use of oral citrate therapy for prevention and treatment of calcium oxalate stones, the evidence to support its clinical efficacy remains uncertain. OBJECTIVES: The objective of this review was to determine the efficacy and adverse events associated with citrate salts for the treatment and prevention of calcium containing kidney stones. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register to 29 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that assessed the efficacy and adverse events associated with citrate salts for the treatment and prevention of calcium containing kidney stones in adults treated for a minimum of six months. DATA COLLECTION AND ANALYSIS: Two authors assessed studies for inclusion in this review. Data were extracted according to predetermined criteria. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS: We included seven studies that included a total of 477 participants, most of whom had oxalate stones. Of these, three studies (247 participants) compared potassium citrate with placebo or no intervention; three (166 participants) compared potassium-sodium citrate with no intervention; and one (64 participants) compared potassium-magnesium citrate with placebo. Overall, quality of the reporting of the included studies was considered moderate to poor, and there was a high risk of attrition bias in two studies.Compared with placebo or no intervention, citrate therapy significantly reduced the stone size (4 studies, 160 participants: RR 2.35, 95% CI 1.36 to 4.05). New stone formation was significantly lower with citrate therapy compared to control (7 studies, 324 participants: RR 0.26, 95% CI 0.10 to 0.68). The beneficial effect on stone size stability was also evident (4 studies, 160 participants: RR 1.97, 95% CI 1.19 to 3.26). Adverse events were reported in four studies, with the main side effects being upper gastrointestinal disturbance and one patient reported a rash. There were more gastrointestinal adverse events in the citrate group; however this was not significant (4 studies, 271 participants: RR 2.55, 95% CI 0.71 to 9.16). There were significantly more dropouts due to adverse events with citrate therapy compared to control (4 studies, 271 participants: RR 4.45, 95% CI 1.28 to 15.50). The need for retreatment was significantly less with citrate therapy compared to control (2 studies, 157 participants: RR 0.22, 95% CI 0.06 to 0.89). AUTHORS' CONCLUSIONS: Citrate salts prevent new stone formation and reduce further stone growth in patients with residual stones that predominantly contain oxalate. The quality of reported literature remains moderate to poor; hence a well-designed statistically powered multi-centre RCT is needed in order to answer relevant questions concerning the efficacy of citrate salts.

A Method to Evaluate Trainee Progression During Simulation Training at the Urology Simulation Boot Camp (USBC) Course.

OBJECTIVES: To evaluate skills progression at the Urology Simulation Boot Camp (USBC), a course intended to provide urology trainees with 32 hours of 1:1 training on low and high-fidelity simulators. DESIGN: In this single-group cohort study, trainees rotated through modules based on aspects of the United Kingdom urology residency curriculum and undertook a pre and postcourse MCQ. Specific procedural skill was evaluated by an expert and graded as either: "A"-Good (≥4 on a 5-point Likert Scale) or "B"-Poor (Likert scale of 1-3). Competence progression was calculated as the change in score between baseline and final assessments. SETTING: The USBC was held at St James' University Hospital, Leeds, U.K. PARTICIPANTS: Of the 34 trainees attended the second USBC, 33 trainees participated in all the pre and postcourse assessments. The mean duration of urology training prior to undertaking the USBC was 15 months. RESULTS: Competence progression was assessed in 33 urology trainees. Mean MCQ scores improved by 16.7% (p < 0.001) between pre and postcourse assessment. At final assessment, 87.9% of trainees scored "A" in instrument knowledge and assembly compared to 44.4% at baseline (p < 0.001). There was a mean improvement of 439s (p < 0.001) in the time taken to complete the European-Basic Laparoscopic skills assessment. CONCLUSIONS: The USBC has shown to aid trainees in competence progression during the simulation on a variety of urological skills; however, retention of skill in the long-term was undetermined. The use of our grading system is simple to understand and may be used in other simulation courses to guide participants with their future training needs.

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.

Tips and tricks of ureteroscopy: consensus statement. Part II. Advanced ureteroscopy.

Our "tips and tricks" focuses on all aspects of upper tract endourology and we hope these will be of use to all trainees and consultants who perform ureteroscopy. We report an "expert consensus view" from experienced endourological surgeons, on all aspects of advanced ureteroscopic techniques, with a particular focus on avoiding and getting out of trouble while performing ureteroscopy. In this paper we provide a summary of placing ureteric access sheath, flexible ureteroscopy, intra renal stone fragmentation and retrieval, maintaining visual clarity and biopsy of ureteric and pelvicalyceal tumours.

Tips and tricks of ureteroscopy: consensus statement Part I. Basic ureteroscopy.

Ureteroscopy is fast becoming the first line treatment option for the majority of urinary tract stones. Ureteroscopy training can be performed in a variety of ways including simulation, hands on ureteroscopy courses and supervised operative experience. We report an "expert consensus view" from experienced endourological surgeons, on all aspects of basic ureteroscopic techniques, with a particular focus on avoiding and getting out of trouble while performing ureteroscopy. In this paper we provide a summary of treatment planning, positioning, cannulation of ureteric orifice, guidewire placement, rigid ureteroscopy and stone fragmentation.

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.

Visualisation of the lymph node pathway in real time by laparoscopic radioisotope- and fluorescence-guided sentinel lymph node dissection in prostate cancer staging.

OBJECTIVE: To investigate the feasibility of visualizing lymphatic drainage of the prostate using indocyanine green. The results were compared with standard radio-guided sentinel lymph node dissection and validated by extended pelvic lymph node dissection. METHODS: From March 2010 to October 2011, (99m)Tc-labelled colloid (18 hours before surgery) and indocyanine green (immediately before surgery) were injected transrectally into the prostate of 26 consecutive patients. A dedicated laparoscopic fluorescence imaging system and a commercially available laparoscopic γ-probe were used. Lymphatic vessels were visualized in real time and followed to identify the sentinel lymph node. All detected hot spots (fluorescent signals and/or radioactivity) were considered as sentinel lymph nodes, dissected, and removed. Each specimen of excised tissue was labeled according to its anatomic position and whether it was positive for radioactivity or fluorescence. Every patient underwent laparoscopic extended pelvic lymph node dissection and radical prostatectomy. RESULTS: Five-hundred eighty-two lymph nodes (median 22, range 11-36) were removed. Two characteristic drainage patterns were identified: one was associated with the medial umbilical ligament and the other with the internal iliac region. A direct connection with para-aortic lymph nodes was found in 3 patients. A single solitary micrometastasis was visualized by fluorescence navigation alone. A strong correlation was established between radioactive and fluorescent lymph nodes. Compared with radio-guided sentinel lymph node dissection alone, additional fluorescence-guided sentinel lymph node dissection demonstrated a further 120 lymph nodes. CONCLUSION: Using the described technique of fluorescence navigation, not only lymph nodes but also lymphatic vessels are visualized in real time. The technique appears to be as effective as sentinel lymph node dissection but easier to apply.