International consensus panel for transurethral resection of bladder tumours metrics: assessment of face and content validity.

OBJECTIVE: To develop performance metrics that objectively define a reference approach to a transurethral resection of bladder tumours (TURBT) procedure, seek consensus on the performance metrics from a group of international experts. METHODS: The characterisation of a reference approach to a TURBT procedure was performed by identifying phases and explicitly defined procedure events (i.e., steps, errors, and critical errors). An international panel of experienced urologists (i.e., Delphi panel) was then assembled to scrutinise the metrics using a modified Delphi process. Based on the panel's feedback, the proposed metrics could be edited, supplemented, or deleted. A voting process was conducted to establish the consensus level on the metrics. Consensus was defined as the panel majority (i.e., >80%) agreeing that the metric definitions were accurate and acceptable. The number of metric units before and after the Delphi meeting were presented. RESULTS: A core metrics group (i.e., characterisation group) deconstructed the TURBT procedure. The reference case was identified as an elective TURBT on a male patient, diagnosed after full diagnostic evaluation with three or fewer bladder tumours of ≤3 cm. The characterisation group identified six procedure phases, 60 procedure steps, 43 errors, and 40 critical errors. The metrics were presented to the Delphi panel which included 15 experts from six countries. After the Delphi, six procedure phases, 63 procedure steps, 47 errors, and 41 critical errors were identified. The Delphi panel achieved a 100% consensus. CONCLUSION: Performance metrics to characterise a reference approach to TURBT were developed and an international panel of experts reached 100% consensus on them. This consensus supports their face and content validity. The metrics can now be used for a proficiency-based progression training curriculum for TURBT.

Development Methodology of the Novel Endoscopic Stone Treatment Step 2/A Training/Assessment Curriculum and a Roadmap on Developing Hands-on Training Curriculums in Future: An International Collaborative Work by European Association of Urology Sections.

Background: Basic simulation training in endourology was established with the endoscopic stone treatment step 1 (EST-s1), which is now recognized worldwide for training and examination. Following on from EST-s1, the endoscopic stone treatment step 2 (EST-s2) was started by the European Association of Urology (EAU) sections. Objective: We describe the methodology used in the development of EST-s2 assessment curriculum. Materials and Methods: The "full-life cycle curriculum development" template was followed for curriculum development, focusing on intermediate training of EST protocol with complex endourologic tasks. A cognitive task analysis (CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EAU Urolithiasis Section experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in European Urology Residents Education Programme 2019 and in phase five the protocol was finalized with full tutor instruction sheet. Results: The EST-s2/A curriculum development took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees, respectively. Although the experts agreed that EST-s2/A protocol was well structured (96%), covered the complex endourologic maneuvers (92%), and was useful to optimize and improve hands-on-training (HoT) sessions (92%), the overall evaluation was scored 4.25/5 by trainees. Conclusion: We describe the development methodology for intermediate EST curriculum, which also provides a roadmap on developing other HoT protocols in future. Patients Summary: In this report we described the development of the novel intermediate training curriculum for EST, called EST-s2, which took 3 years of collaborative work inside the EAU. This article is aimed to strengthen the standards in curriculum development and clearly describe the background of this new EAU official endourology protocol.

Validation of the endoscopic stone treatment step 1 (EST-s1): a novel EAU training and assessment tool for basic endoscopic stone treatment skills-a collaborative work by ESU, ESUT and EULIS.

INTRODUCTION: The endoscopic stone treatment step 1 (EST s1) protocol has been developed after 2 years of collaborative work between different European Association of Urology (EAU) sections. OBJECTIVES: In this study, we added construct validity evidence to the EST s1 curriculum. MATERIALS AND METHODS: The EST-s1 curriculum includes four standardized tasks: flexible cystoscopy, rigid cystoscopy, semi-rigid URS and flexible URS. Validation was performed during the annual 2016 EUREP meeting in Prague. 124 participants provided information on their endoscopic logbook and carried out these 4 tasks during a DVD recorded session. Recordings were anonymized and blindly assessed independently by five proctors. Inter-rater reliability was checked on a sample of five videos by the calculation of intra-class correlation coefficient. Task-specific clinical background of participants was correlated with their personal performance on the simulator. Breakpoint analysis was used to define the minimum number of performed cases, to be considered "proficient". "Proficient" and "Non-proficient" groups were compared for construct validity assessment. Likert scale-based questionnaires were used to test content and to comment on when the EST-s1 exams should be undertaken within the residency program. RESULTS: 124 participants (105 final-year residents and 19 faculty members) took part in this study. The breakpoint analysis showed a significant change in performance curve at 36, 41, 67 and 206 s, respectively, corresponding to 30, 60, 25 and 120 clinical cases for each of the 4 tasks. EST-s1 was scored as a valid training tool, correctly representing the procedures performed in each task. Experts felt that this curriculum is best used during the third year of residency training. CONCLUSION: Our validation study successfully demonstrated correlation between clinical expertise and EST-s1 tasks, adding construct validity evidence to it. Our work also demonstrates the successful collaboration established within various EAU sections.

Risk Stratification Tools and Prognostic Models in Non-muscle-invasive Bladder Cancer: A Critical Assessment from the European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel.

CONTEXT: This review focuses on the most widely used risk stratification and prediction tools for non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE: To assess the clinical use and relevance of risk stratification and prediction tools to enhance clinical decision making and counselling of patients with NMIBC. EVIDENCE ACQUISITION: The most frequent, currently used risk stratification tools and prognostic models for NMIBC patients were identified by the members of the European Association of Urology (EAU) Guidelines Panel on NMIBC. EVIDENCE SYNTHESIS: The 2006 European Organization for Research and Treatment of Cancer (EORTC) risk tables are the most widely used and validated tools for risk stratification and prognosis prediction in NMIBC patients. The EAU risk categories constitute a simple alternative to the EORTC risk tables and can be used for comparable risk stratification. In the subgroup of NMIBC patients treated with a short maintenance schedule of bacillus Calmette-Guerin (BCG), the Club Urológico Español de Tratamiento Oncológico (CUETO) scoring model is more accurate than the EORTC risk tables. Both the EORTC risk tables and the CUETO scoring model overestimate the recurrence and progression risks in patients treated according to current guidelines. The new concept of conditional recurrence and progression estimates is very promising during follow-up but should be validated. CONCLUSIONS: Risk stratification and prognostic models enable outcome comparisons and standardisation of treatment and follow-up. At present, none of the available risk stratification and prognostic models reflects current standards of treatment. The EORTC risk tables and CUETO scoring model should be updated with previously unavailable data and recalculated. PATIENT SUMMARY: Non-muscle-invasive bladder cancer is a heterogeneous disease. A risk-based therapeutic approach is recommended. We present available risk stratification and prediction tools and the degree of their validation with the aim to increase their use in everyday clinical practice.

Development Methodology of the Novel Endoscopic Stone Treatment Step 1 Training/Assessment Curriculum: An International Collaborative Work by European Association of Urology Sections.

Background: Simulation-based technical skill assessment is a core topic of debate, especially in high-risk environments. After the introduction of the E-BLUS (European Basic Laparoscopic Urological Skills) exam for basic laparoscopy, no more technical training/assessment urological protocols have been developed in Europe. Objective: We describe the methodology used in the development of the novel Endoscopic Stone Treatment step 1 (EST s1) assessment curriculum. Materials and Methods: The "full life cycle curriculum development" template was followed for curriculum development. A cognitive task analysis was run to define the most important steps and details of retrograde intrarenal surgery, in accordance with European Association of Urology (EAU) Urolithiasis guidelines. Training tasks were created between April 2015 and September 2015. Tasks and metrics were further analyzed by a consensus meeting with the European Section of Urolithiasis (EULIS) board in February 2016. A review, aimed to study available simulators and their accordance with task requirements, was subsequently run in London in March 2016. After initial feedback and further tests, content validity of this protocol was achieved during European Urology Residents Education Programme (EUREP) 2016. Results: The EST s1 curriculum development, took 23 months. Seventy-two participants tested the five preliminary tasks during EUREP 2015, with sessions of 45 minutes each. Likert-scale questionnaires were filled out to score the quality of training. The protocol was modified accordingly and 25 participants tested the four tasks during the hands-on training sessions of the European Section of Uro-Technology (ESUT) 2016 congress. One hundred thirty-four participants finally participated in the validation study in EUREP 2016. During the same event, 10 experts confirmed content validity by filling out a Likert-scale questionnaire. Conclusion: We described a reliable and replicable methodology that can be followed to develop training/assessment protocols for surgical procedures. The expert consensus meetings, strict adherence to guidelines, and updated literature search toward an Endourology curriculum allowed correct training and assessment protocol development. It is the first step toward standardized simulation training in Endourology with a potential for worldwide adoption.