Impact of COVID-19 on surgical residency training programs in Mexico City: The third victim of the pandemic. A resident's perspective.

OBJECTIVE: The aim of this study is to assess the perceptions of the impact of health-care disruption due to COVID-19 on the academic training and skills of surgical trainees. MATERIAL AND METHODS: We developed a 32-question survey assessing the clinical and surgical impact of COVID-19 on surgical training programs and proposals to compensate for the decrease in surgical education. We got 453 responses of surgical trainees in Mexico City. RESULTS: Sixty-six percent of the respondents answered that their centers had converted to the exclusive attention of COVID-19 patients. Ninety-five percent reported a decrease in surgical skills learning and 91.8% reported a decrease to clinical exposure. On proposals, 75.6% reported that it is essential to take the necessary measures to recover the clinical and surgical milestones lost. In the binary logistic regression analysis, we found that the postgraduate year (≥ PG-Y3) was statistically significant factor (p ≤ 0.000) related to a favorable opinion to developing an academic contingency plan and postponing the end of the academic residency year. CONCLUSION: More than 90% of the survey respondents reported having been affected by COVID-19 mitigation strategies. Our data calls for urgent training adjustments by hospital and university program leaders to mitigate downstream educational repercussions.

OBJETIVO: Evaluar las percepciones del impacto de la interrupción de la atención médica por COVID-19 en la formación académica y las habilidades de los residentes quirúrgicos. MATERIAL Y MÉTODOS: Realizamos una encuesta de 32 preguntas, evaluando el impacto clínico y quirúrgico del COVID-19 en los programas de entrenamiento quirúrgico y propuestas para compensar la disminución de la educación quirúrgica. Obtuvimos 453 respuestas de residentes quirúrgicos en la Ciudad de México. RESULTADOS: El 66% respondió que sus centros se convirtieron en atención exclusiva de pacientes con COVID-19. El 95% presentó una disminución en el aprendizaje de habilidades quirúrgicas y el 91. 8% presentó una disminución de la exposición clínica. El 75.6% consideró fundamental tomar las medidas necesarias para recuperar las destrezas clínicas perdidas. En el análisis de regresión logística binaria, encontramos que el año de posgrado (> PG-Y3) fue un factor estadísticamente significativo (p <0,000) relacionado con una opinión favorable para desarrollar un plan de contingencia académica y posponer el final del año de residencia académica. CONCLUSIÓN: Más del 90% de los encuestados fueron afectados por las estrategias de mitigación de COVID-19. Nuestros datos exigen ajustes urgentes por parte de los líderes de programas de hospitales y universidades para mitigar las repercusiones educativas posteriores.

Current practices in percutaneous nephrolithotomy in Mexico: results of a nation-wide electronic survey.

Practice patterns and choice of technological instruments in PCNL are not always standardized. There are no previous reports on the PCNL practice tendencies and patterns in Latin America. The aim of the study is to describe the current practice patterns of PCNL among the members of the Mexican Society of Urology ("Sociedad Mexicana de Urologia"). Observational and descriptive study. A 9-item closed questionnaire on PCNL practice patterns was answered by members of the Mexican Society of Urology in a secure website hosted survey after e-mail invitation. A descriptive numerical and graphical analysis was performed. A total of 90 contestants were registered out of 492 potential participants. PCNL is performed by 80% of the participants, with an average of 16 procedures per year. Percutaneous tracts are commonly obtained by urologists on the same day of the procedure. Sequential and telescopic dilators are equally preferred over balloons. The pneumatic litotriptor is the most common choice and CT scan and X-ray are equally used as follow-up. The practice patterns of PCNL from Mexican urologists are different from other international reports. Influence of socio-economic circumstances is inferred.

Urinary expression of novel tissue markers of kidney injury after ureteroscopy, shockwave lithotripsy, and in normal healthy controls.

BACKGROUND AND PURPOSE: Shockwave lithotripsy (SWL) and ureteroscopy (URS) are minimally invasive treatment alternatives for kidney stones. Although less invasive, SWL subjects the renal parenchyma to a high level of energy and the potential to cause renal injury. The ability to detect renal injury post-SWL in a reliable and noninvasive way would be clinically beneficial. Kidney injury molecule 1 (KIM-1) and N-acetyl-ß-D-glucosaminidase (NAG) are two proteins secreted by the kidney into the urine and have been found to be sensitive markers of acute kidney injury in transplant patients. The aim of this work was to measure urinary levels of KIM-1 and NAG in patients with kidney stone who were treated by SWL or URS and in nonstone volunteers. PATIENTS AND METHODS: Patients with kidney stones who were treated by SWL (n = 50) or URS (n = 10) were recruited. Voided urine samples were collected before and 2 to 3 hours after URS and SWL. In addition, further urinary specimens were collected 2 days and 2 weeks post-SWL treatment. Voided urine samples from healthy volunteers were also collected. RESULTS: Mean KIM-1 values were increased in patients with kidney stones when compared with volunteers. KIM-1 and NAG levels significantly increased post-SWL and returned to baseline within 2 weeks post-SWL. Poor kidney function was significantly associated with increased biomarker activity both in baseline and post-SWL measurements. There was no significant change in urinary KIM-1 and NAG concentrations before and after URS. CONCLUSIONS: Kim-1 and NAG levels significantly increased post-SWL treatment suggesting a potential role for these urinary markers in identifying patients at higher risk of tissue injury.

A multicentre single-blind randomized controlled trial comparing bipolar and monopolar transurethral resection of the prostate.

INTRODUCTION: Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia. Although generally considered safer, TURP experience is limited in Canada. METHODS: Forty-three patients from 5 Canadian centres were randomized to TURP with either bipolar or monopolar platforms. Patients underwent baseline determinations of American Urological Association (AUA) symptom score, peak urinary flow rate, post-void residual bladder volume and transrectal ultrasound prostate volume. Primary outcome measures were improvement in AUA symptom score, quality of life assessment and bother assessment. Secondary outcomes included procedural times, duration of catheterization, length of hospitalization, complications and the degree of thermal artifact in tissue specimens. Patients were followed for 6 months. RESULTS: Twenty-two patients were treated with bipolar and 21 with monopolar TURP. Preoperative demographics were not statistically different between groups. Postoperative data collection times were equivalent in AUA symptom, quality of life, bother and sexual function assessments. No differences were observed in the procedure time (60.7 min, bipolar vs. 47.4, monopolar) or the duration of urethral catheterization (1.5 days, bipolar vs. 1.1, monopolar). More patients in the bipolar group were discharged on the same day of surgery. There were no differences in the degree of tissue thermal artifact or complication rate. CONCLUSION: This trial suggests equivalent short-term outcomes for men undergoing monopolar or bipolar TURP.

Stray electrical currents in laparoscopic instruments used in da Vinci® robot-assisted surgery: an in vitro study.

BACKGROUND AND PURPOSE: The da Vinci(®) surgical system requires the use of electrosurgical instruments. The re-use of such instruments creates the potential for stray electrical currents from capacitive coupling and/or insulation failure. We used objective measures to report the prevalence and magnitude of such stray currents. MATERIALS AND METHODS: Thirty-seven robotic instruments were tested using an electrosurgical unit (ESU) at pure coagulation and cut waveforms at four different settings. Conductive gel-coated instruments were tested at 40W, 80W, and maximum ESU output (coagulation 120W, cut 300W). The magnitude of stray currents was measured by an electrosurgical analyzer. RESULTS: At coagulation waveform in open air, 86% of instruments leaked a mean of 0.4W. In the presence of gel-coated instruments, stray currents were detected in all instruments with means (and standard deviation) of 3.4W (± 2), 4.1W (± 2.3), and 4.1W (± 2.3) at 40W, 80W, and 120W, respectively. At cut waveform in open air, none of the instruments leaked current, while gel-coated instruments leaked a mean of 2.2W (± 1.3), 2.2W (± 1.9) and 3.2W (± 1.9) at 40W, 80W, and 300W, respectively. CONCLUSIONS: All tested instruments in our study demonstrated energy leakage. Stray currents were higher during coagulation (high voltage) waveforms, and the magnitude was not always proportionate to the ESU settings. Stray currents have the potential to cause electrical burns. We support the programmed end of life of da Vinci instruments on the basis of safety. Consideration should be given to alternate energy sources or the adoption of active electrode monitoring technology to all monopolar instruments.

Time to recurrence after nephrectomy as a predictor of cancer-specific survival in localized clear-cell renal cell carcinoma.

OBJECTIVE: To evaluate the prognostic impact of early recurrence (within 12 months) after surgery on cancer-specific survival (CSS) of patients with localized clear-cell renal cell carcinoma (ccRCC). METHODS: Patients with surgically treated localized ccRCC were studied. Using the Kaplan-Meier method, we calculated CSS; by univariate and multivariate models we analyzed the association of early recurrence with cancer-related mortality. RESULTS: We identified 259 patients with pT1-4/NX/0M0 ccRCC treated between February 1981 and September 2009; of 66 (25.5%) with disease recurrence, 29 (43.9%) had early relapse. Overall, 43 patients (16.6%) died from ccRCC. The 5- and 10-year CSS for those without, late and early recurrence was 98.5 and 96.5%, 53 and 39.8%, and 23 and 23%, respectively (p < 0.0001). In the multivariate Cox model, pT stage (p = 0.01) and early recurrence (p < 0.0001) independently predicted CSS. CONCLUSIONS: Recurrent disease after localized ccRCC confers a poor prognosis, especially if detected within 12 months after surgery. Thus, this criterion should be included as an independent risk factor for cancer-related mortality.

Impact of lymph node invasion and sarcomatoid differentiation on the survival of patients with locally advanced renal cell carcinoma.

INTRODUCTION: The application of current prognosticators in locally advanced nonmetastatic renal cell carcinoma (RCC) is controversial. We analyzed the impact of clinical and pathological variables on the survival of this subset of patients. PATIENTS AND METHODS: We studied patients with RCC in stages III and IV without metastases, treated surgically between 1980 and 2009. We calculated disease-free (DFS) and cancer-specific survival (CSS), and the relation of clinical and pathological variables with these end-points. RESULTS: We identified 126 patients with locally advanced RCC; 8.7% had sarcomatoid differentiation. Tumor stage was pT3a in 48% and pT3b in 42%; 11.9% had lymph node invasion (N+). Patients with N- and N+ had a 10-year DFS of 49.0 and 23.4%, respectively (p = 0.0001). In multivariate analysis N+ (p = 0.0002) was the strongest predictor of DFS. The 10-year CSS of patients without sarcomatoid differentiation was 53.1% while those with sarcomatoid differentiation did not reach the median time to death (p < 0.0001). In multivariate analysis, sarcomatoid differentiation (p = 0.01) was the strongest predictor of CSS. CONCLUSIONS: Locally advanced RCC portends poor prognosis. Preoperatively, weight loss and Eastern Cooperative Oncology Group performance status are predictors of recurrence and mortality, respectively. However, the most powerful predictors of DFS and CSS in our cohort were lymph node status and sarcomatoid differentiation.

Fusion of the seminal vesicles discovered at the time of robot-assisted laparoscopic radical prostatectomy.

The reported incidence of seminal vesicle anomalies is low, and it usually occurs in association with other genitourinary anomalies, thus frequently diagnosed by a cluster of fertility, pain or obstructive symptoms. We present a case of a clinically silent seminal vesicle fusion encountered during a robotic assisted radical prostatectomy. Awareness of potential congenital anomalies is crucial for surgeons, to prevent surgical complications or adverse outcomes as a result of the altered anatomy.