Surgical site complications in kidney transplant recipients: incidence, risk factors and outcomes in the modern era.

BACKGROUND: Surgical site complications (SSCs) are an important source of morbidity after kidney transplantation. We assessed the incidence, risk factors, outcomes and economic impact of SSCs in a large, diverse population of kidney transplant recipients. METHODS: We conducted a single-centre, observational cohort study of adult (age ≥ 18 yr) patients who underwent kidney transplantation between Jan. 1, 2005, and Dec. 31, 2015, with a minimum of 1 year of follow-up. Cases of SSC, including infections and wound dehiscence, were determined from patient records. Inpatient and outpatient hospital costs were determined 6 and 12 months after transplantation. We used the Kaplan-Meier product-limit method to determine the cumulative probability of SSCs and other outcomes. We evaluated risk factors and clinical outcomes using Cox proportional hazard ratios. Linear regression models were used to study the effect of SSCs on graft function. RESULTS: The incidence rate of SSCs within 30 days after transplantation was 4.19 per 100 person-months. The cumulative probability of developing an SSC within 30 days after transplantation was 4.13% (95% confidence interval [CI] 3.23%-5.28%). Increased recipient body mass index (BMI) (hazard ratio [HR] 1.07, 95% CI 1.02-1.11), longer cold ischemic time (HR 1.05, 95% CI 1.01-1.09) and transplantation in 2010-2012 versus 2005-2009 (HR 2.20, 95% CI 1.19-4.04) were risk factors for SSC development. In multivariable stepwise Cox proportional hazard models, SSC was a significant risk factor for death-censored graft failure (HR 3.08, 95% CI 1.60-5.90) and total graft failure (HR 2.09, 95% CI 1.32-3.32). Cumulative median hospital costs were $2238.46 greater for patients with an SSC than for those without. CONCLUSION: Increased BMI, longer cold ischemic time and the 2010-2012 transplantation period predisposed to SSCs. The development of SSCs was associated with a higher risk of graft failure. Strategies to minimize SSCs may improve outcomes after kidney transplantation and reduce costs.

Evaluation of Optimal Timing of Expert Feedback in a Simulated Flexible Ureteroscopy Course.

Introduction: Simulation-based training (SBT) has become an increasingly popular modality to train novice surgical residents in the face of rapidly increasing innovative surgical techniques across all surgical disciplines. Recent studies have already demonstrated SBT to be effective in helping overcome the learning curve associated with new surgical techniques, especially in junior residents and endoscopic procedures. In addition, it is known that trainees benefit significantly from expert feedback; however, there is a paucity of data looking into the optimal timing of this feedback during SBT. To address this knowledge deficit, an SBT curriculum was developed for junior urology residents to assess optimal timing of feedback during SBT for flexible ureteroscopy (fURS). Materials and Methods: The SBT course consisted of a pretraining assessment, three independent practice sessions, and a post-training assessment, with residents receiving expert feedback right after their pretraining assessment (early feedback [EF]) or after their final independent training session (late feedback [LF]). Results: Fifteen trainees with similar baseline fURS experience and precourse fURS task performance score participated in the study. There was a significant difference between the pre- and post-task completion times overall (15.2 minutes vs 9.1 minutes, p < 0.001), with no difference between the early or LF groups (p = 0.884). The mean performance scores improved for both groups (18.2 vs 24.2, p < 0.001) with the EF group having a more statistically significant improvement in performance scores than the LF group (p = 0.05), and most (73%) of residents preferred EF. Conclusions: This study demonstrates that an SBT curriculum for fURS is effective for technical skills development among junior trainees, and that EF resulted in marginally better overall scores and was preferred by residents.

Optimizing the Timing of Expert Feedback During Simulation-Based Spaced Practice of Endourologic Skills.

INTRODUCTION: Provision of expert feedback is widely acknowledged to be an essential component of simulation-based training. However, little is known about the most effective and efficient ways to provide feedback to novices. Optimizing the timing of expert feedback may improve outcomes while reducing resource requirements. The main objective of this study was to determine the impact of providing early versus late expert feedback to novice learners engaged in a flexible ureteroscopy (fURS) training curriculum. METHODS: Senior medical students were recruited to participate in this study. Each student participated in a comprehensive fURS training curriculum that included 3 deliberate, independent practice sessions. Baseline and postcourse fURS skill was assessed for each student using a standardized fURS test task. Each student was randomized to either an early feedback group (EFG) or late feedback group (LFG). The EFG participants were provided expert feedback immediately after the baseline skill test, whereas LFG participants were given feedback before their final deliberate, independent practice session. RESULTS: Eighteen senior medical students completed the study (9 EFG and 9 LFG participants). There were no discernible demographic differences between the groups at baseline. When controlling for pretest performance, early rather than late feedback was associated with both shorter postcourse time to completion of the task (19.2 vs. 21.5 minutes, P < 0.01) and higher performance scores (13.1 vs. 10.5, P < 0.01). CONCLUSIONS: This study offers preliminary evidence that novice learners may benefit more from early feedback when learning a novel skill. Further study is required.

Simulation-based flexible ureteroscopy training using a novel ureteroscopy part-task trainer.

INTRODUCTION: Simulation-based training (SBT) is being increasingly used for novice trainees as a means of overcoming the early learning curve associated with new surgical skills. We designed a SBT flexible ureteroscopy (fURS) course using a novel inanimate training model (Cook Medical, Bloomington, IN; URS model). We evaluated the course and validated this Cook URS model. METHODS: A 2-week SBT fURS course was designed for junior level urology trainees at 2 Canadian universities. The curriculum included didactic lectures, hands-on training, independent training sessions with expert feedback, and use of the Cook URS part-task model. Baseline and post-course assessments of trainee fURS skills were conducted using a standardized test task (fURS with basket manipulation of a calyceal stone). Performances were video-recorded and reviewed by 2 blinded experts using a validated assessment device. RESULTS: Fifteen residents (postgraduate years [PGY] 0-3) participated in the course. Of the participants, 80% rated the Cook URS model as realistic (mean = 4.2/5) and 5 endourology experts rated it as useful as a training device (mean = 4.9/5), providing both face and content validity. The mean overall performance scores, task completion times, and passing ratings correlated with trainee clinical fURS experience - demonstrating construct validity for the Cook URS model. The mean post-course task completion times (15.76 vs. 9.37 minutes, p = 0.001) and overall performance scores (19.20 vs. 25.25, p = 0.007) were significantly better than at baseline. Post-course performance was better in all domains assessed by the validated assessment device. CONCLUSIONS: This study demonstrates that a SBT curriculum for fURS can lead to improved short-term technical skills among junior level urology residents. The Cook URS model demonstrated good face, content and construct validity.

Surgeon-specific factors affecting treatment decisions among Canadian urologists in the management of pT1a renal tumours.

INTRODUCTION: The ubiquitous use of diagnostic imaging has resulted in an increased incidental detection of small renal masses (SRM). Patient- and tumour-related factors affect treatment decisions greatly; however, with multiple treatment options available, surgeon-specific characteristics and biases may also influence treatment recommendations. We determine the impact of surgeon-specific factors on treatment decisions in the management of SRM in Canada. METHODS: An online survey study was conducted among Canadian urologists currently registered with the Canadian Urological Association. The questionnaire collected demographic information and recommended treatments for 6 SRM index cases involving theoretical patients of various ages (51-80 years) and comorbidities. RESULTS: A total of 110 urologists responded (17% response rate) to the survey. Of these, 18% were over 65 years old and 45% were from academic centres. With increasing patient age and comorbidity, active surveillance and thermal ablative therapies were more the recommended treatment. Laparoscopic/robotic surgery was more commonly recommended by academic urologists and those under 65. Recommending surgery (radical nephrectomy or partial nephrectomy) for both elderly (about 80 years old) index patients correlated with surgeon age (surgeons over 65, p < 0.001), surgeons with no oncologic fellowship training (p = 0.021), surgeons with a non-academic practice (p = 0.003), surgeons with a personal history of cancer (p = 0.038) and surgeons with a family history of cancer death in the last 10 years (p = 0.022). CONCLUSIONS: There are various factors that influence the management options offered to patients with SRMs. Our results suggest that surgeon age, personal history of cancer, practice-type and other surgeon-specific variables may affect treatments offered among urologists across Canada.