Expanding Global Surgery Education in Brazil: Perspectives after the 35th Brazilian Surgical Congress.

The 35th Brazilian Congress of Surgery marked a turning point for surgical education in the country. For the first time, the Brazilian College of Surgeons included Global Surgery on the main congressional agenda, providing a unique opportunity to rethink how surgical skills are taught from a public health perspective. This discussion prompts us to consider why and how Global Surgery education should be expanded in Brazil. Although Brazilian researchers and institutions have contributed to the fields expansion since 2015, Global Surgery education initiatives are still incipient in our country. Relying on successful strategies can be a starting point to promote the area among national surgical practitioners. In this editorial, we discuss potential strategies to expand Global Surgery education opportunities and propose a series of recommendations at the national level.

Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.

BACKGROUND: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH). METHODS: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4. RESULTS: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term. CONCLUSION: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.

Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function. METHODS: In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies. RESULTS: Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function. CONCLUSIONS: Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function.

Sacral neuromodulation in the golden years: Treatment outcomes in elderly 75 years and older.

INTRODUCTION: Despite high prevalence and increased severity and burden of overactive bladder (OAB) and fecal incontinence (FI) in the elderly, sacral neuromodulation (SNM) is often overlooked as a potential treatment option for this demographic. In this study, we report the outcomes of SNM in patients aged 75 years or older at the time of surgery. METHODS: We conducted a retrospective cohort study of patients who underwent SNM implantation between 2013 and 2022 performed by a single, high-volume urologist at a tertiary center. Success, complication, and adjunct therapy rates were analyzed by Fisher's or Wilcox rank-sum test as appropriate. We compared outcomes between patients aged 75-79 years and octogenarians. RESULTS: Of 632 patients, 50 were ≥75 years. Patients had a mean age of 78.4±2.6 years and were predominantly female (84%). The indications for SNM were 66% OAB, 16% FI, 16% non-obstructive urinary retention, and 4% pelvic pain. Within the first year, 94% of patients reported satisfaction and improvement in symptoms, while 76% continued to experience improvement beyond one year. SNM insertion led to reduced oral medication use from 68% to 24% (p<0.0001). The complication rate was 16% and mostly included device pain. No significant difference was observed in treatment success, complication, or adjunct therapy rate between age groups. CONCLUSIONS: SNM is a safe and effective option in well-selected patients over the age of 75 years. Treatment success rate is comparable to younger cohorts. Advanced age should not preclude third-line therapy options in this population.

Perceived Impact of Coronavirus Disease 2019 on Surgical Training: A Brazilian Survey.

INTRODUCTION: Recent studies revealed that coronavirus disease 2019 (COVID-19) negatively impacted residency programs worldwide, particularly procedure-based programs. However, most studies are from high-income countries, with scarce data from low- and middle-income countries. Pandemic effects on surgical training were likely worse in strictly apprenticeship models relying heavily on surgical volume as opposed to competency-based programs. Notably, training programs in Brazil and other low- and middle-income countries follow these strict apprenticeship style frameworks. In this study, we aimed to evaluate the trainees' perceptions of the impact of COVID-19 on their Brazilian surgical programs. METHODS: A cross-sectional study was performed using an anonymous survey in Portuguese, distributed via social media platforms to surgical residents enrolled in Brazilian surgery programs. Data collection took place from August 2021 to May 2022. The survey contained 30 questions on the perception of the impact of COVID-19 on surgical training. RESULTS: One-hundred sixty-two residents from 17 different surgical specialties and all five regions of Brazil responded to the survey. Of 162 residents, 145 (89%) believed the pandemic negatively impacted their surgical training. Furthermore, of 162 residents, 153 (94%) reported that elective surgical volume decreased during the pandemic and 91 (56%) were redeployed to assist with COVID-19 management. As a result, 102 of 162 (63%) residents believed their surgical skills were negatively impacted by COVID-19. Yet, 95 of 162 (59%) residents reported their residency programs did not offer resources to mitigate the pandemic's impact on training. Of 162 residents, 57 (35%) reported they did not feel on track for graduation, with no statistical difference between responses by year of residency (P = 0.083). Additionally, 124 of 162 (77%) residents reported that the pandemic negatively affected their mental health, most commonly related to stress at work, stress about transmitting COVID-19, and loss in surgical training. CONCLUSIONS: Most of the surveyed Brazilian surgical residents felt the COVID-19 pandemic negatively impacted their training. This leads to believe that the detrimental impacts of the pandemic exposed preexisting weaknesses in the Brazilian surgical training model's dependence on a strict apprenticeship model. Our findings suggest a crucial need to redesign surgical education programs to make residency programs more prepared for changes in surgical volume, evolve the apprenticeship model to competency-based approaches, and unify surgical training standards in low- and middle-income countries.

Expanding Global Surgery Education in Brazil: Perspectives after the 35th Brazilian Surgical Congress / Expandindo o Ensino de Cirurgia Global no Brasil: Perspectivas após o 35º Congresso Brasileiro de Cirurgia

ABSTRACT The 35th Brazilian Congress of Surgery marked a turning point for surgical education in the country. For the first time, the Brazilian College of Surgeons included Global Surgery on the main congressional agenda, providing a unique opportunity to rethink how surgical skills are taught from a public health perspective. This discussion prompts us to consider why and how Global Surgery education should be expanded in Brazil. Although Brazilian researchers and institutions have contributed to the fields expansion since 2015, Global Surgery education initiatives are still incipient in our country. Relying on successful strategies can be a starting point to promote the area among national surgical practitioners. In this editorial, we discuss potential strategies to expand Global Surgery education opportunities and propose a series of recommendations at the national level.

RESUMO O 35º Congresso Brasileiro de Cirurgia foi marcado por discussões inovadoras para a educação cirúrgica no país. Pela primeira vez, o Colégio Brasileiro de Cirurgiões incluiu a Cirurgia Global na pauta principal do congresso, proporcionando uma oportunidade única de repensar como as habilidades cirúrgicas são ensinadas a partir de uma perspectiva de saúde pública. Essa discussão nos leva a considerar por que e como o ensino da Cirurgia Global deve ser expandido no Brasil. Embora pesquisadores e instituições brasileiras tenham contribuído para a expansão do campo desde 2015, as iniciativas de educação em Cirurgia Global ainda são incipientes em nosso país. Basear-se em estratégias bem-sucedidas pode ser um ponto de partida para promover a área entre os profissionais de cirurgia nacionais. Neste editorial, discutimos potenciais estratégias para expandir as oportunidades de educação em Cirurgia Global e propomos uma série de recomendações a nível nacional.

How I Do It: Transcutaneous tibial nerve stimulation TENSI+ system.

Overactive bladder (OAB) is a common condition that significantly impacts the quality of life (QoL), well-being and daily functioning for both men and women. Among various treatments, peripheral tibial nerve stimulation (PTNS) emerges as an effective third-line treatment for OAB symptoms, with options for either a percutaneous approach (P-PTNS) or by transcutaneous delivery (T-PTNS). Recent studies have shown negligible differences between P-PTNS and T-PTNS efficacy in alleviating urinary urgency and frequency and QoL improvement and, overall no difference in efficacy over antimuscarinic regimens. The TENSI+ system offers a cutting-edge transcutaneous approach, allowing patients to self-administer treatment conveniently at home with electrical stimulation delivery through surface electrodes. It stands out for its ease of preparation, tolerability, and high levels of patient satisfaction. Prospective multicentric data highlights TENSI+ to be an effective and safe treatment for lower urinary tract symptoms with high treatment adherence at 3 months. This paper aims to familiarize readers with the TENSI+ system, current studies, device assembly, operation, and treatment recommendations.

A scoping review of office-based prostatic stents: past, present, and future of true minimally invasive treatment of benign prostatic hyperplasia.

PURPOSE: To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH). METHODS: A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively. RESULTS: Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed. CONCLUSION: Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits.

How I Do It: Penthrox in Urology.

Penthrox is a portable handheld inhaler that delivers a low dose of methoxyflurane - an anesthetic with analgesic effects, rapid onset of action, and a favorable side-effect profile. It has been widely used for acute pain management in Australia for the past 40 years. Currently, it is approved for use in over 55 countries, including Canada. Prospective randomized studies highlight Penthrox analgesic effectiveness and safety profile for emergency, prehospital and outpatient settings. In addition, the use of multimodal analgesia, specifically Penthrox, can play an important role in the analgesic management of urological procedures, such as prostatic biopsies and office-based minimally invasive surgical therapies. Herein readers will familiarize themselves with Penthrox, significant studies, and technique used for outpatient urological procedures.

Women Representation on Editorial Boards in Latin America Journals: Promoting Gender Equity in Academic Surgery, Anesthesia, and Obstetrics.

BACKGROUND: Inequitable representation in journal editorial boards may impact women's career progression across surgical, anesthesia, and obstetric (SAO) specialties. However, data from Latin America are lacking. We evaluated women's representation on editorial boards of Latin America SAO journals in 2021. METHODS: We conducted a cross-sectional analysis, retrieving journals through Scimago Journal and Country Rank 2020. Journals were included if active, focused on SAO topics, and publicly provided information on editorial board staff. Editorial board member names and positions were extracted from journals' websites. Members were classified into senior (e.g., editor-in-chief), academic (e.g., reviewer), and non-academic roles (e.g., administrative office). Women's representation was predicted from first names using Genderize.io. The number of women SAO physicians per country was obtained from articles and governmental reports. RESULTS: We included 19 of 25 identified journals and analyzed 1,318 names. Three anesthesiology, seven obstetric, and nine surgical journals represented five Latin American countries. Women held 17% (224/1,318) of board positions [p < 0.0001; 95% CI(0.14, 0.19)]. Women held fewer academic roles (14.3%, 155/1,084) compared to senior [28.9%, 64/221 (p < 0.001)] and non-academic roles [38.4%, 5/13 (p = 0.042)]. Surgical journals had fewer women (7.7%, 58/752) compared to anesthesia [25.5%, 52/204 (p = 0.006)] and obstetrics [31.5%, 114/362 (p < 0.001)]. Women's proportion on editorial boards increased according to the number of women SAO physicians per country (p < 0.001). CONCLUSIONS: Our study assessed the composition of editorial boards from Latin America SAO journals and demonstrated that women remain underrepresented. Our findings highlight the need for regional strategies to advance women's careers across SAO specialties.