Online versus in-person surgical near-peer teaching in undergraduate medical education during the COVID-19 pandemic: A mixed-methods study.

Background and Aims: The coronavirus disease 2019 (COVID-19) pandemic stimulated a paradigm shift in medical and surgical education from in-person teaching to online teaching. It is unclear whether an in-person or online approach to surgical teaching for medical students is superior. We aim to compare the outcomes of in-person versus online surgical teaching in generating interest in and improving knowledge of surgery in medical students. We also aim the quantify the impact of a peer-run surgical teaching course. Methods: A six-session course was developed by medical students and covered various introductory surgical topics. The first iteration was offered online to 70 UK medical students in March 2021, and the second iteration was in-person for 20 students in November 2021. Objective and subjective knowledge was assessed through questionnaires before and after each session, and also for the entire course. Data were analyzed from this mixed-methods study to compare the impact of online versus in-person teaching on surgical knowledge and engagement. Results: Students in both iterations showed significant improvement of 33%-282% across the six sessions in knowledge and confidence after completing the course (p < 0.001). There was no significant difference in the level of objective knowledge, enjoyment, or organization of the course between online and in-person groups, although the in-person course was rated as more engaging (mean Likert score 9.1 vs. 9.7, p = 0.033). Discussion: Similar objective and subjective surgical teaching outcomes were achieved in both iterations, including in "hands-on" topics such as suturing, gowning, and gloving. Students who completed the online course did not have any lower knowledge or confidence in their surgical skills; however, the in-person course was reported to be more engaging. Surgical teaching online and in-person may be similarly effective and can be delivered according to what is most convenient for the circumstances, such as in COVID-19.

Benefits and Harms of Benign Prostatic Obstruction Treatments in Renal Transplanted Patients.

CONTEXT: In an increasingly ageing transplant population, timely management of benign prostatic obstruction (BPO) is key to preventing complications that result in graft dysfunction or compromise survival. OBJECTIVE: To evaluate benefits/harms of BPO treatments in transplant patients by reviewing current literature. EVIDENCE ACQUISITION: A computerised bibliographic search of Medline, Embase, and Cochrane databases was performed for studies reporting outcomes on BPO treatments in transplanted patients. EVIDENCE SYNTHESIS: A total of 5021 renal transplants (RTs) performed between 1990 and 2016 were evaluated. BPO incidence was 1.61 per 1000 population per year. Overall, 264 men underwent intervention. The mean age was 58.4 yr (27-73 yr). In all, 169 patients underwent surgery (n = 114 transurethral resection of the prostate [TURP]/n = 55 transurethral incision of the prostate [TUIP]) and 95 were treated with an un-named alpha-blocker (n = 46) or doxazosin (n = 49). There was no correlation between prostate volume and treatment modality (mean prostate size = 26 cc in the surgical group where reported and 48 cc in the medical group). The mean follow-up was 31.2 mo (2-192 mo). The time from RT to BPO treatment was reported in six studies (mean: 15.4 mo, range: 0-156 mo). The time on dialysis before RT was recorded in only three studies (mean: 47.3 mo, range: 0-288 mo). There was a mean improvement in creatinine after intervention from 2.17 to 1.77 mg/dl. A total of 157 men showed an improvement in the International Prostate Symptom Score (from 18.26 to 6.89), and there was a significant reduction in postvoid residual volume in 199 (mean fall 90.6 ml). Flow improved by a mean of 10 ml/s following intervention in 199 patients. Complications included acute urinary retention (4.1%), urinary tract infections (8.4%), bladder neck contracture (2.2%), and urethral strictures (6.9%). The mean reoperation rate was 1.4%. CONCLUSIONS: Current literature is heterogeneous and of low-level evidence. Despite this, alpha-blockers, TUIP, and TURP showed a beneficial increase in the peak urinary flow and reduced symptoms in transplants patients with BPO. Improvement in the mean graft creatinine was noted after intervention. Complications were under-reported. A multicentre comparative cohort study is needed to draw firm conclusions about the ideal treatment for BPO in RT patients. PATIENT SUMMARY: In this report, we looked at the outcomes for transplant patients undergoing medical or surgical management of benign prostatic obstruction. Although the literature was very heterogeneous, we found that medical management and surgery with transurethral resection/incision of the prostate are beneficial for improving urinary flow and bothersome symptoms. We conclude that further prospective studies are required for better clarity about timing and modality of intervention in transplant patients.

Machine learning models in predicting graft survival in kidney transplantation: meta-analysis.

BACKGROUND: The variations in outcome and frequent occurrence of kidney allograft failure continue to pose important clinical and research challenges despite recent advances in kidney transplantation. The aim of this systematic review was to examine the current application of machine learning models in kidney transplantation and perform a meta-analysis of these models in the prediction of graft survival. METHODS: This review was registered with the PROSPERO database (CRD42021247469) and all peer-reviewed original articles that reported machine learning model-based prediction of graft survival were included. Quality assessment was performed by the criteria defined by Qiao and risk-of-bias assessment was performed using the PROBAST tool. The diagnostic performance of the meta-analysis was assessed by a meta-analysis of the area under the receiver operating characteristic curve and a hierarchical summary receiver operating characteristic plot. RESULTS: A total of 31 studies met the inclusion criteria for the review and 27 studies were included in the meta-analysis. Twenty-nine different machine learning models were used to predict graft survival in the included studies. Nine studies compared the predictive performance of machine learning models with traditional regression methods. Five studies had a high risk of bias and three studies had an unclear risk of bias. The area under the hierarchical summary receiver operating characteristic curve was 0.82 and the summary sensitivity and specificity of machine learning-based models were 0.81 (95 per cent c.i. 0.76 to 0.86) and 0.81 (95 per cent c.i. 0.74 to 0.86) respectively for the overall model. The diagnostic odds ratio for the overall model was 18.24 (95 per cent c.i. 11.00 to 30.16) and 29.27 (95 per cent c.i. 13.22 to 44.46) based on the sensitivity analyses. CONCLUSION: Prediction models using machine learning methods may improve the prediction of outcomes after kidney transplantation by the integration of the vast amounts of non-linear data.

Evaluation of the Effectiveness of Interventions on Nephrolithiasis in Transplanted Kidney.

CONTEXT: De Novo nephrolithiasis in renal transplant can have severe consequences since renal transplantation involves a single functioning kidney with medical and anatomical specificities (heterotopic transplantation on iliac vessels, immunosuppressive treatments, and comorbidities). OBJECTIVE: To systematically review all available evidence on the prevalence of de novo nephrolithiasis in renal transplant, presentation, and stone characteristics, and to report in a meta-analysis the efficacy of stone treatments (extracorporeal shock wave lithotripsy [ESWL], medical treatment, percutaneous nephrolithotomy [PCNL], open surgery, and ureteroscopy). EVIDENCE ACQUISITION: Medline, Embase, and the Cochrane Library were searched up to November 2021 for all relevant publications reporting the management of de novo nephrolithiasis in renal allografts. The primary outcome was stone-free rate (SFR) at 3 mo. Secondary outcomes included prevalence, stone characteristics (size, density, and composition), symptoms on presentation, need for drainage, complications, and recurrence. Data were narratively synthesized in light of methodological and clinical heterogeneity, and a meta-analysis was performed for SFR. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: We included 37 retrospective studies with 553 patients and 612 procedures; of the 612 procedures 20 were antegrade ureteroscopy, 154 retrograde ureteroscopy, 118 PCNL, 25 open surgery, 155 ESWL, and 140 surveillance/medical treatment. The prevalence of nephrolithiasis in renal transplant was 1.0%. The mean stone size on diagnosis was 11 mm (2-50). The overall SFR at 3 mo was 82%: 96% with open surgery, 95% with antegrade ureteroscopy, 86% with PCNL, 81% with retrograde ureteroscopy, and 75% with ESWL. CONCLUSIONS: De novo nephrolithiasis in renal transplant is an infrequent condition. A high SFR were obtained with an antegrade approach (ureteroscopy, PCNL, and open approach) that should be considered in renal transplant patients owing to the heterotopic position of the renal graft. The choice of technique was correlated with stone size: generally ureteroscopy and ESWL for stones 11-12 mm (mean stone size) versus PCNL and open surgery for 17-25 mm stones. PATIENT SUMMARY: De novo nephrolithiasis in renal transplants is an infrequent situation that can have severe consequences on the function of the renal graft. We evaluated the efficacy of each treatment and noted that antegrade approaches (open surgery, percutaneous nephrolithotomy, and antegrade ureteroscopy) were associated with the highest stone-free rate. As opposed to the management of nephrolithiasis in native kidney, an antegrade approach should be considered more in renal transplant patients.

Medium and Long-Term Clinical Outcomes of Kidney Transplantation in Patients With Prune Belly Syndrome: A Single-Centre Experience.

OBJECTIVE: To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT). METHODS: Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analyzed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of nonurological causes. RESULTS: The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pretransplant urological operations in preparation for kidney transplantation, while 4 patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10, and 15 years were 90.9%, 57.7%, and 38.5%, respectively. Graft survival for control cohort at 5, 10, and 15 years were 89.9%, 80%, and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (P = .449, P = .134, respectively). CONCLUSION: This single-center study showed that the medium-term graft survival rates in patients with PBS are encouraging and comparable to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multicenter international collaboration will be needed.

Effectiveness and Harms of Using Kidneys with Small Renal Tumors from Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review.

CONTEXT: Kidney transplantation is the best treatment for patients with end-stage renal disease. Incidence of small renal masses (SRMs), which most frequently are renal cell carcinomas (RCCs), is highest in patients aged >60 yr. The increasing age of donors can lead to the diagnosis of a higher number of SRMs when assessing the patient for transplantation, and so can theoretically decrease the number of kidneys suitable for transplantation. Aiming to increase the pool of kidneys suitable for transplantation, a number of studies have reported their experience using kidneys with SRMs for transplantation. OBJECTIVE: To systematically review all available evidence on the effectiveness and harm of using kidneys with SRMs as a source of transplantation. EVIDENCE ACQUISITION: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting outcomes of adult renal transplantation using kidneys with SRMs. EVIDENCE SYNTHESIS: Nineteen studies enrolling 109 patients were included and synthesized narratively. The mean recipient age was 44.2 yr, and kidneys used were retrieved from living donors in 86% (94/109) of cases. Tumor excision was performed ex vivo in all cases except for two. The vast majority of excised tumors were RCCs (88/109 patients), and clear-cell subtype was most common. The mean tumor size was 2cm (range 0.5-6.0cm) and tumor grade was G1-G2 in 93% (75/81) of patients. With a mean follow-up of 39.9 mo, overall survival rates at 1, 3, and 5 yr were 97.7%, 95.4%, and 92%, respectively, and the mean graft survival rates 99.2%, 95%, and 95.6%, respectively. Only one local relapse occurred 9 yr after transplantation, which was managed conservatively. Functional outcomes, although infrequently reported, appear to be similar to those of conventional transplants, with 1.6% of these patients needing reoperation. CONCLUSIONS: The current literature, although with low-level evidence, suggests that kidneys with excised SRMs are an acceptable source of transplantation without compromising oncological outcomes and with similar functional outcomes to other donor kidneys. PATIENT SUMMARY: Renal transplantation using a kidney with a small renal mass does not appear to increase the risk of cancer recurrence and can be a good option for selected patients after appropriate counseling and allocation.

Nonantibiotic prevention and management of recurrent urinary tract infection.

Urinary tract infections (UTIs) are highly prevalent, lead to considerable patient morbidity, incur large financial costs to health-care systems and are one of the most common reasons for antibiotic use worldwide. The growing problem of antimicrobial resistance means that the search for nonantibiotic alternatives for the treatment and prevention of UTI is of critical importance. Potential nonantibiotic measures and treatments for UTIs include behavioural changes, dietary supplementation (such as Chinese herbal medicines and cranberry products), NSAIDs, probiotics, D-mannose, methenamine hippurate, estrogens, intravesical glycosaminoglycans, immunostimulants, vaccines and inoculation with less-pathogenic bacteria. Some of the results of trials of these approaches are promising; however, high-level evidence is required before firm recommendations for their use can be made. A combination of these agents might provide the optimal treatment to reduce recurrent UTI, and trials in specific population groups are required.

European Association of Urology Guidelines on Renal Transplantation: Update 2018.

CONTEXT: The European Association of Urology (EAU) panel on renal transplantation (RT) has released an updated version of the RT guidelines. OBJECTIVE: To present the 2018 EAU guidelines on RT. EVIDENCE ACQUISITION: A broad and comprehensive scoping exercise was performed, encompassing all areas of RT guidelines published between January 1, 2007, and May 31, 2016. Databases covered by the search included Medline, Embase, and the Cochrane Libraries. Previous guidelines were updated, and levels of evidence and grades of recommendation were assigned. EVIDENCE SYNTHESIS: It is strongly recommended to offer pure or hand-assisted laparoscopic/retroperitoneoscopic surgery as the preferential technique for living donor nephrectomy. Decisions on the acceptance of a donor organ should not be based on histological findings alone since this might lead to an unnecessarily high rate of discarded grafts. For ureterovesical anastomosis, a Lich-Gregoir-like extravesical technique protected by a ureteral stent is the preferred technique for minimisation of urinary tract complications. It is also strongly recommended to perform initial rejection prophylaxis with a combination therapy comprising a calcineurin inhibitor (preferably tacrolimus), mycophenolate, steroids, and an induction agent (either basiliximab or anti-thymocyte globulin). The long version of the guidelines is available at the EAU website (http://uroweb.org/guidelines). CONCLUSIONS: These abridged EAU guidelines present updated information on the clinical and surgical management of RT for incorporation into clinical practice. PATIENT SUMMARY: The European Association of Urology has released the renal transplantation guidelines. The implementation of minimally invasive surgery for organ retrieval and the latest evidence on transplant surgery as well as on immunosuppressive regimens are key factors for minimisation of rejection and achievement of long-term graft survival.

Management of Localised Prostate Cancer in Kidney Transplant Patients: A Systematic Review from the EAU Guidelines on Renal Transplantation Panel.

CONTEXT: Cancer development after kidney transplant (KT) has become a major problem, and currently, it is one of the primary causes of death in this population. Urological cancers after KT such as prostate cancer (PCa) have also increased, partly due to the increasing age of recipients and prolonged survival. PCa is the second most commonly diagnosed cancer in men, accounting for 15% of all cancers. Managing localised PCa after KT remains challenging because of treating an immunosuppressed patient with a kidney graft in the pelvic cavity. Several papers reporting PCa treatment after KT have been published. Merging all the available data and summarising most important evidence could be useful for scientific community involved in this issue. OBJECTIVE: To systematically review all the available evidence in literature regarding the management of localised PCa after KT. EVIDENCE ACQUISITION: Computerised bibliographic search of Medline, Embase, and Cochrane databases was performed for all studies reporting outcomes of localised PCa diagnosed in KT patients undergoing curative treatments, including surgery, external beam radiotherapy (EBR) and brachytherapy. EVIDENCE SYNTHESIS: In total, 41 studies included 319 patients with localised PCa after KT. Their mean age was 61.8 (range, 47-79) yr and mean time from KT to PCa was 122 (range, 2-336) mo. Mean prostate-specific antigen was 8.5 (range, 0.3-82), most frequent biopsy Gleason score was 3+3 (50.5%), 62.1% were cT1-cT2, and 56.1% belonged to low-intermediate D'Amico-risk groups. Surgery was performed in 82.1%. After mean follow-up of 33 (range, 1-240) mo, cancer-specific survival at 5 yr was 97.5%, 87.5%, and 94.4% after surgery, EBR, and brachytherapy, respectively. CONCLUSIONS: Radical prostatectomy is the preferred treatment of localised PCa after KT. Overall oncological outcomes do not seem to be worse than general population when performed in referral centres. Other curative treatments such as EBR or brachytherapy were less frequently used; however, brachytherapy showed promising results in a small number of patients. Further better-quality studies should help to clarify the optimal method of managing localised PCa after KT. PATIENT SUMMARY: Localised PCa after KT seems to have similar oncological outcomes after curative treatments than in general population, with surgery being the most common option for treatment.

The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review.

CONTEXT: Renal transplantation is the gold standard renal replacement therapy in end-stage renal disease owing to its superior survival and quality of life compared with dialysis. When the potential recipient has a history of cancer, the waiting period before renal transplantation is usually based on the Cincinnati Registry. OBJECTIVE: To systematically review all available evidence on the risk of cancer recurrence in end-stage renal disease patients with a history of urological cancer. EVIDENCE ACQUISITION: Medline, Embase, and the Cochrane Library were searched up to March 2017 for all relevant publications reporting oncologic outcomes of urological cancer in patients who subsequently received a transplantation or remained on dialysis. The primary outcome was time to tumour recurrence. Secondary outcomes included cancer-specific and overall survival. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: Thirty-two retrospective studies enrolling 2519 patients (1733 dialysed, 786 renal transplantation) were included. For renal cell carcinomas, the risks of recurrence, cancer-specific, and overall survival were similar between transplantation and dialysis. For prostate cancer, most of the tumours had favourable prognoses consistent with nomograms. Studies dealing with urothelial carcinomas (UCs) mainly included upper urinary tract UC in the context of aristolochic acid nephropathy, for which the risks of synchronous bilateral tumour and recurrence were high. Data on testicular cancer were scarce. CONCLUSIONS: Immunosuppression after renal transplantation does not affect the outcomes and natural history of low-risk renal cell carcinomas and prostate cancer. Therefore, the waiting time from successful treatment for these cancers to transplantation could be reduced. Except in the particular situation of aristolochic acid nephropathy, more studies are needed to standardise the waiting period after UC owing to the paucity of data. PATIENT SUMMARY: Renal transplantation does not appear to increase the risk of recurrence of renal carcinoma or the recurrence of low-risk prostate cancer compared with dialysis. More reliable evidence is required to recommend a standard waiting period especially for urothelial and testicular carcinomas.

Mantle cell lymphoma presenting as a pelvi-ureteric junction obstruction: a case report.

INTRODUCTION: Mantle cell lymphoma is one of the several subtypes of non-Hodgkin's lymphoma. Mantle cell lymphoma is the rarest of the subtypes, accounting for about 6% of all non-Hodgkin's lymphoma cases in the United States and Europe. Lymphoid neoplasms of the urinary tract and male genital organs are relatively rare, accounting for less than 5% of extranodal lymphomas. We present a rare case of mantle cell lymphoma infiltrating the ureter causing pelvi-ureteric junction obstruction on tissue diagnosis. CASE PRESENTATION: A 78-year-old Caucasian woman was referred to our department with right flank pain, pyrexia and features of a urinary tract infection. A nephrostogram revealed a grossly distended right pelvicalyceal system in a pelvi-ureteric junction obstruction pattern. She underwent an elective pyeloplasty after her acute management and the results of histological examination revealed mantle cell lymphoma. CONCLUSION: We describe a rare presentation of mantle cell lymphoma as a pelvi-ureteric junction obstruction. To the best of our knowledge, there has not been any previously published report of the above finding. Our patient had a history of a previous lymphoma but the aim of this manuscript is to highlight a possible presentation rather than determining whether the mantle cell lymphoma was de novo or a transformation from her previous splenic lymphoma with villous lymphocytes.

Intravesical tension-free vaginal tape removal: is there a single solution?

Stress urinary incontinence (SUI) affects 10-20% of women in the general population. Surgery for stress incontinence has been performed on women for over a century, but with the advent of new urogynaecological sling procedures for its management, urological surgeons are having to deal with an increasing number of patients presenting with associated complications. With no clarity on the full range of possible complications or certain consensus on their optimal management, the ideal treatment remains a decision for the individual surgeon. In view of this, we felt it of common interest to review the literature for the history of sling procedures, present commonly arising complications, and seek to answer the question in the title.

What is the current status of revalidation in urology?

The aim of revalidation (or maintenance of certification) is to reassure patients, the general public, employers and other healthcare professionals that an individual is fit to practice. It may lead to a reduction in near misses or adverse events. The process of revalidation entails a commitment to the provision of lifelong learning and assessment of clinical practice that ultimately ensure patient safety. Lifelong learning addresses knowledge and skills, whereas assessment of clinical practice ensures quality of care. Various learning and assessment tools are available in clinical practice; however, the tools for revalidation are not validated at specialist level. Further research is needed to develop and implement evidence-based structured programmes of revalidation that consider the holistic needs of modern urologists.

High-intensity focused ultrasound for localized prostate cancer: initial experience with a 2-year follow-up.

OBJECTIVE: To report on the short-term functional and oncological results, from one institution, of high-intensity focused ultrasound (HIFU) for treating localized prostate cancer. PATIENTS AND METHODS: Over a 3-year period, 43 patients with localized prostate cancer were scheduled for HIFU in the primary (31) and salvage (12) settings using a second-generation Ablatherm device (EDAP, Lyon, France). Oncological failure was defined by several criteria, including biochemical failure (assessed using both the Phoenix definition of the nadir + 2 ng/mL) and the current Food and Drug Administration (FDA) trial endpoint of a prostate-specific antigen (PSA) level of > or = 0.5 ng/mL, or starting salvage therapy, or the presence of cancer on biopsy after treatment. RESULTS: Three patients had their procedures abandoned due to technical limitations/rectal wall thickness. The mean PSA levels in the primary and salvage groups were 9.2 and 5.1 ng/mL, respectively. The mean HIFU treatment time in the primary and salvage groups was 71.1 and 63.3 min, respectively. Using the Phoenix definition of biochemical failure, HIFU treatment failed in 13 patients in the primary group (46%) and five in the salvage group. Using the FDA trial endpoint, HIFU failed in 21 patients in the primary group (75%) and eight in the salvage group. One man died from metastatic prostate cancer 18 months after salvage HIFU. There were two urethral strictures in the primary (7%) and one in the salvage treatment group. There were two prostato-rectal fistulae in the salvage HIFU group. CONCLUSIONS: HIFU is proposed to be a minimally invasive low-morbidity ablative treatment for localized prostate cancer, and with good efficacy. The present limited series is unable to support these claims. There were significant rates of complications and oncological failure in both the primary and salvage setting. As a result we have suspended our programme pending further evidence of its safety and efficacy.