Renal cell carcinoma in kidney transplant recipients: incidence, trends, clinical management & outcomes.

OBJECTIVE: To describe the incidence, characteristics, clinical management, and outcomes of renal cell carcinoma (RCC) among a large, single-centre cohort of kidney transplant recipients (KTR). METHODS: We conducted an observational cohort study looking at KTR transplanted between January 2000-December 2017 (n = 2443) with ≥ 1 year of follow-up. Simultaneous kidney/pancreas transplants were excluded. The Kaplan-Meier product-limit method was used to determine the incidence of RCC. Characteristics and management of RCC were examined using descriptive statistics. Risk factors and clinical outcomes were analyzed using Cox regression models. RESULTS: The incidence of RCC among our cohort was 0.32 per 100 person-years, 2.1% of all KTRs. Almost half (47.1%) of cases occurred within 4 years post-transplant. The majority of cases were T1a (86.3%), clear-cell (45.1%), and in the native kidney (80.4%). KTR diagnosed with RCC had a twofold higher incidence of other malignancies versus KTR without RCC. Overall mortality, but not cancer-specific mortality, at 2- and 5-years post-transplant was threefold higher among KTR with RCC than those without. CONCLUSIONS: Incidence of RCC among our KTR was slightly higher than the general population; majority of cases occur in the native kidneys and are low stage, low grade. Indolent histologic variants were more common than the general population. KTR with RCC had a higher incidence of other malignancies. Overall, but not cancer-specific, mortality was higher among KTRs diagnosed with RCC.

Standardized Reporting on the Preoperative CT Assessment of Potential Living Renal Transplant Donors: Can We Create a Universal Report Standard to Meet the Needs of Transplant Urologists?

Purpose: Determine whether standardized template reporting for the preoperative assessment of potential living renal transplant donors improves the comprehensiveness of radiology reports to meet the needs of urologists performing renal transplants. Methods: Urologist and radiologist stakeholders from renal transplant centres in our province ratified a standardized reporting template for evaluation of potential renal donors. Three centres (A, B, and C) were designated "intervention" groups. Centre D was the control group, given employment of a site-specific standardized template prior to study commencement. Up to 100 consecutive CT scan reports per centre, pre- and post-implementation of standardized reporting, were evaluated for reporting specific outcome measures. Results: At baseline, all intervention groups demonstrated poor reporting of urologist-desired outcome measures. Centre A discussed 5/13 variables (38%), Centre B discussed 6/13 variables (46%), and Centre C only discussed 1/13 variables (8%) with ≥90% reliability. The control group exhibited consistent reporting, with 11/13 variables (85%) reported at ≥90% reliability. All institutions in the intervention group exhibited excellent compliance to structured reporting post-template implementation (Centres A = 95%, B = 100%, and C = 77%, respectively). Additionally, all intervention centres demonstrated a significant improvement in the comprehensiveness of reports post-template implementation, with statistically significant increases in the reporting of all variables under-reported at baseline (P > .01). Conclusion: Standardized templates across our province for CT scans of potential renal donors promote completeness of reports. Radiologists can reliably provide our surgical colleagues with needed preoperative anatomy and incidental findings, helping to determine suitable transplant donors and reduce potential complications associated with organ retrieval.

Quantifying the "Assistant Effect" in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance.

PURPOSE: Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP). METHODS: Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors. RESULTS: 92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P = 0.011), and prior laparoscopic experience (P < 0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho = 0.248, P = 0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P = 0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing. CONCLUSIONS: This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.

Are Routine Laboratory Investigations Necessary Following Percutaneous Nephrolithotomy?

OBJECTIVE: To determine how effective routine postoperative blood work is in identifying complications after percutaneous nephrolithotomy (PCNL), the gold standard treatment for large volume stone disease. Although major complication rates are low, hemorrhagic and sepsis-related complications are serious and can occur. Routine post-PCNL complete blood count is routinely performed by most endourologists but may be a low-value practice. METHODS: A retrospective review was performed of all PCNL procedures at our center over a 3-year period. Patient demographic, stone characteristics and postoperative data were collected and analyzed. RESULTS: Three hundred and eighty-five patients (196 female and 189 males) underwent PCNL for the treatment of urolithiasis. Mean age was 55.8 years and mean length of stay in hospital was 1.74 days. Most patients (82.9%) had neither ureteric stent nor percutaneous tube prior to PCNL. Postoperatively, 4 patients (1.0%) required a blood transfusion and 14 patients (3.6%) developed urosepsis. Patients who required either a transfusion or developed urosepsis demonstrated abnormal vital signs (tachycardia, hypotension, or fever) postoperatively. Sixteen patients (4.2%) had normal vital signs but had an extended hospital stay only to monitor abnormal blood work results. None these patients required a transfusion nor developed urosepsis but had a length of stay that was a mean of 1.5 days longer patients with normal postoperative vital signs and blood work. CONCLUSION: Abnormal vital signs alone identified all patients that required transfusion or treatment for urosepsis after PCNL. Routine complete blood count testing postoperatively may not improve detection of infectious or bleeding complications and may prolong hospital admission unnecessarily.

Objective Assessment and Standard Setting for Basic Flexible Ureterorenoscopy Skills Among Urology Trainees Using Simulation-Based Methods.

Objective: To objectively assess the performance of graduating urology residents performing flexible ureterorenoscopy (fURS) using a simulation-based model and to set an entrustability standard or benchmark for use across the educational spectrum. Methods: Chief urology residents and attending endourologists performed a standardized fURS task (ureterorenoscopy and repositioning of stones) using a Boston Scientific© Lithovue ureteroscope on a Cook Medical© URS model. All performances were video-recorded and blindly scored by both endourology experts and crowd-workers (C-SATS) using the Ureteroscopic Global Rating Scale, plus an overall entrustability score. Validity evidence supporting the scores was collected and categorized. The Borderline Group (BG) method was used to set absolute performance standards for the expert and crowdsourced ratings. Results: A total of 44 participants (40 chief residents, 4 faculties) completed testing. Eighty-three percent of participants had performed >50 fURS cases at the time of the study. Only 47.7% (mean score 12.6/20) and 61.4% (mean score 12.4/20) of participants were deemed "entrustable" by experts and crowd-workers, respectively. The BG method produced entrustability benchmarks of 11.8/20 for experts and 11.4/20 for crowd-worker ratings, resulting in pass rates of 56.9% and 61.4%. Conclusion: Using absolute standard setting methods, benchmark scores were set to identify trainees who could safely carry out fURS in the simulated setting. Only 60% of residents in our cohort were rated as entrustable. These findings support the use of benchmarks to earlier identify trainees requiring remediation.

Metabolic evaluation guidelines in patients with nephrolithiasis: Are they being followed? Results of a national, multi-institutional, quality-assessment study.

INTRODUCTION: The significant cost burden of kidney stones underscores the importance of best clinical practice in kidney stone management. We evaluated adherence to kidney stone metabolic evaluation guidelines in a Canadian population and the interest of patients with regard to prevention. METHODS: A questionnaire based on Canadian Urological Association (CUA) best practice guidelines was designed. Patients presenting for extracorporeal shockwave lithotripsy treatment (ESWL) were administered this questionnaire to evaluate risk factors of stone disease and assess the use of metabolic evaluations. Patients were asked if they received explanations about their results and if they were interested in kidney stone prevention. RESULTS: We identified 530 patients at five academic institutions; 79.4% had at least one indication to receive a metabolic evaluation (high-risk stone formers), which increased to 96.6% if first-time stone formers whom reported an interest in metabolic evaluation were included. However, only 41.1 % of these patients had a metabolic evaluation. Endourologists ordered metabolic evaluation more often than other referring urologists (63.6% vs. 36.5%; p<0.001). Furthermore, urologists ordered metabolic evaluations more often than other prescribing physicians (68.9% vs. 31.1%; p<0.001). Sixty-two percent of patients received explanations about their metabolic evaluation results and 77.5% understood them. Regarding prevention, 84.1% and 83.8% were interested in more explanations and in following a diet or taking a medication, respectively. CONCLUSIONS: Adherence to CUA metabolic evaluation guidelines is suboptimal and could be improved by urologists referring patients for ESWL. Communication between physician and patient may not be adequate. The majority of stone formers are interested in kidney stone prevention.

Basic Laparoscopic Skills Assessment Study: Validation and Standard Setting among Canadian Urology Trainees.

PURPOSE: As urology training programs move to a competency based medical education model, iterative assessments with objective standards will be required. To develop a valid set of technical skills standards we initiated a national skills assessment study focusing initially on laparoscopic skills. MATERIALS AND METHODS: Between February 2014 and March 2016 the basic laparoscopic skill of Canadian urology trainees and attending urologists was assessed using 4 standardized tasks from the AUA (American Urological Association) BLUS (Basic Laparoscopic Urological Surgery) curriculum, including peg transfer, pattern cutting, suturing and knot tying, and vascular clip applying. All performances were video recorded and assessed using 3 methods, including time and error based scoring, expert global rating scores and C-SATS (Crowd-Sourced Assessments of Technical Skill Global Rating Scale), a novel, crowd sourced assessment platform. Different methods of standard setting were used to develop pass-fail cut points. RESULTS: Six attending urologists and 99 trainees completed testing. Reported laparoscopic experience and training level correlated with performance (p <0.01). Attending urologists were significantly better than trainees (p <0.05), demonstrating construct validity evidence for the 4 AUA BLUS tasks. The C-SATS method of assessment correlated well with the traditional methods of time and error based scoring, and the global rating scale. We were able to use relative and absolute standard setting methods to define pass-fail cut points for all 4 AUA BLUS tasks. CONCLUSIONS: The 4 AUA BLUS tasks demonstrated good construct validity evidence for use in assessing basic laparoscopic skill. Performance scores using the novel C-SATS platform correlated well with traditional time-consuming methods of assessment. Various standard setting methods were used to develop pass-fail cut points for educators to use when making formative and summative assessments of basic laparoscopic skill.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

INTRODUCTION: We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). METHODS: A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. RESULTS: Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. CONCLUSIONS: We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Surgical skills acquisition among left-handed trainees-true inferiority or unfair assessment: a preliminary study.

INTRODUCTION: Studies involving the formal assessment of surgical skills have often reported inferior abilities among left-handed surgical trainees (LHT). Most surgical training curricula and assessment methods, however, are inherently geared toward right-handed trainees (RHT); potentially placing LHT at both a training and assessment disadvantage. We evaluated the effect of a hand dominance-based curriculum for acquisition of basic suturing and knot tying skills among medical students. METHODS: After Institutional Review Board approval, first- and second-year medical students from the University of California, Irvine School of Medicine were recruited to participate in a basic suturing and knot tying skills course. Consenting students were randomized to either a left-handed curriculum or a right-handed curriculum consisting of (1) a 30-minute introductory video and (2) a 2-hour instructor-led, hands-on training session on basic suturing and knot tying. All instructional methods, instruments, and instructors were exclusively right-handed or left-handed for the right-handed curriculum or left-handed curriculum, respectively. Students were assessed on the performance of 2 suturing tasks, continuous running suturing and instrument knot tying, and performance assessments were conducted both immediately and 2 weeks posttraining. RESULTS: A total of 19 students completed the training course and both assessments (8 LHT, 11 RHT). Students randomized to a curriculum "concordant" with their hand dominance performed significantly better than those randomized to a "discordant" curriculum on both tasks (p < 0.01). This difference was found at both immediate and 2 weeks posttraining assessments. Within concordant and discordant groups, there were no significant differences between LHT and RHT. CONCLUSIONS: This preliminary study demonstrates that medical students, both LHT and RHT, immersed in a training environment that is discordant with their hand dominance might have inferior acquisition of basic suturing and knot tying skills.

Multidisciplinary validation study of the da Vinci Skills Simulator: educational tool and assessment device.

Despite the increased dexterity and precision of robotic surgery, like any new surgical technology it is still associated with a learning curve that can impact patient outcomes. The use of surgical simulators outside of the operating room, in a low-stakes environment, has been shown to shorten such learning curves. We present a multidisciplinary validation study of a robotic surgery simulator, the da Vinci(®) Skills Simulator (dVSS). Trainees and attending faculty from the University of Toronto, Departments of Surgery and Obstetrics and Gynecology (ObGyn), were recruited to participate in this validation study. All participants completed seven different exercises on the dVSS (Camera Targeting 1, Peg Board 1, Peg Board 2, Ring Walk 2, Match Board 1, Thread the Rings, Suture Sponge 1) and, using the da Vinci S Robot (dVR), completed two standardized skill tasks (Ring Transfer, Needle Passing). Participants were categorized as novice robotic surgeon (NRS) and experienced robotic surgeon (ERS) based on the number of robotic cases performed. Statistical analysis was conducted using independent T test and non-parametric Spearman's correlation. A total of 53 participants were included in the study: 27 urology, 13 ObGyn, and 13 thoracic surgery (Table 1). Most participants (89 %) either had no prior console experience or had performed <10 robotic cases, while one (2 %) had performed 10-20 cases and five (9 %) had performed ≥20 robotic surgeries. The dVSS demonstrated excellent face and content validity and 97 and 86 % of participants agreed that it was useful for residency training and post-graduate training, respectively. The dVSS also demonstrated construct validity, with NRS performing significantly worse than ERS on most exercises with respect to overall score, time to completion, economy of motion, and errors (Table 2). Excellent concurrent validity was also demonstrated as dVSS scores for most exercises correlated with performance of the two standardized skill tasks using the dVR (Table 3). This multidisciplinary validation study of the dVSS provides excellent face, content, construct, and concurrent validity evidence, which supports its integrated use in a comprehensive robotic surgery training program, both as an educational tool and potentially as an assessment device. Table 1 dVSS validation study participant demographic information Survey question Response Number (%) Gender Male 36 (67.9) Female 17 (32.1) Handedness Right-hand dominant 45 (84.9) Left-hand dominant 4 (7.5) Ambidextrous 3 (5.7) Level of training Junior Resident (R1-R3) 17 (32.1) Senior Resident (R4-R5) 12 (22.6) Fellow 16 (30.2) Staff Surgeon 8 (15.1) Specialty Urology 27 (50.9) ObGyn 13 (24.5) Thoracics 13 (24.5) Previous MIS experience (laparoscopic or thoracoscopic) None/minimal 17 (32.1) Moderate 11 (20.8) Significant 18 (34.0) Fellowship-trained in MIS 4 (7.5) Previous robotic surgery experience None 32 (60.4) Yes 21 (39.6) If yes, number of operative cases as surgical assistant 0 cases 33 (62.3) <10 cases 9 (17.0) 10-20 cases 3 (5.7) >20 cases 8 (9.4) If yes, number of operative cases at robotic console for at least 30 min 0 cases 41 (77.4) <10 cases 6 (11.3) 10-20 cases 1 (1.9) >20 cases 5 (9.4) MIS minimally invasive surgery Table 2 dVSS construct validity evidence dVSS exercise All subjects' overall score (%, mean ± SD) Novice robotic surgeon overall score (%, mean ± SD) Expert robotic surgeon overall score (%, mean ± SD) p value Camera Targeting 1 69.943 ± 21.7489 67.170 ± 21.5258 91.667 ± 4.2269 0.008 Peg Board 1 78.596 ± 11.9824 76.913 ± 11.6616 91.500 ± 3.8341 0.004 Match Board 1 69.880 ± 17.7691 67.864 ± 17.9075 84.667 ± 6.1860 0.028 Thread the Rings 74.152 ± 16.4289 71.825 ± 16.2605 89.667 ± 5.8878 0.011 Suture Sponge 1 74.787 ± 14.3086 73.171 ± 14.5067 85.833 ± 5.6716 0.042 Ring Walk 2 75.098 ± 20.0861 73.333 ± 20.1099 88.333 ± 15.4100 0.086 Peg Board 2 84.308 ± 11.7633 83.283 ± 12.0861 92.167 ± 3.6009 0.082 Table 3 dVSS concurrent validity evidence NP time NP errors RT time RT errors Camera Targeting 1 overall score 0.471 (0.001) 0.083 (0.575) 0.291 (0.045) 0.061 (0.685) Peg Board 1 overall score 0.486 (0.001) 0.141 (0.344) 0.325 (0.026) 0.088 (0.555) Match Board 1 overall score 0.543 (<0.001) 0.096 (0.530) 0.295 (0.050) 0.215 (0.162) Thread the Rings overall score 0.432 (0.005) 0.231 (0.147) 0.533 (<0.001) 0.163 (0.310) Suture Sponge 1 overall score 0.592 (<0.001) 0.105 (0.509) 0.437 (0.004) 0.015 (0.925) Ring Walk 2 overall score 0.454 (0.002) 0.179 (0.234) 0.399 (0.006) 0.022 (0.884) Peg Board 2 overall score 0.675 (<0.001) 0.058 (0.696) 0.073 (0.626) 0.045 (0.762) Subjects' overall score for each dVSS exercise is correlated with the time to complete (time) and number of errors (errors) for the Needle Passing (NP) and Ring Transfer (RT) tasks performed using the dVR. Data is expressed as Pearson correlation coefficient (p value).

Validation study of a virtual reality robotic simulator--role as an assessment tool?

PURPOSE: Virtual reality simulators are often used for surgical skill training since they facilitate deliberate practice in a controlled, low stakes environment. However, to be considered for assessment purposes rigorous construct and criterion validity must be demonstrated. We performed face, content, construct and concurrent validity testing of the dV-Trainer™ robotic surgical simulator. MATERIALS AND METHODS: Urology residents, fellows and attending surgeons were enrolled in this institutional review board approved study. After a brief introduction to the dV-Trainer each subject completed 3 repetitions each of 4 virtual reality tasks on it, including pegboard ring transfer, matchboard object transfer, needle threading of rings, and the ring and rail task. One week later subjects completed 4 similar tasks using the da Vinci® robot. Subjects were assessed on total task time and total errors using the built-in scoring algorithm and manual scoring for the dV-Trainer and the da Vinci robot, respectively. RESULTS: Seven experienced and 13 novice robotic surgeons were included in the study. Experienced surgeons were defined by greater than 50 hours of clinical robotic console time. Of novice robotic surgeons 77% ranked the dV-Trainer as a realistic training platform and 71% of experienced robotic surgeons ranked it as useful for resident training. Experienced robotic surgeons outperformed novices in many dV-Trainer and da Vinci robot exercises, particularly in the number of errors. On pooled data analysis dV-Trainer total task time and total errors correlated with da Vinci robot total task time and total errors (p = 0.026 and 0.011, respectively). CONCLUSIONS: This study confirms the face, content, construct and concurrent validity of the dV-Trainer, which may have a potential role as an assessment tool.