Single-Center Experience with Three Metallic Ureteral Stents (Allium® URS, Memokath™-051, and Resonance®) for Chronic Ureteral Obstruction.

Purpose: Patients with chronic ureteral obstruction (CUO) are traditionally managed with polymer stents/nephrostomy. However, these are prone to failure and require regular exchange. This study evaluates the efficacy of Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents in managing patients with CUO. Methods: Following institutional approval (Imperial College Healthcare NHS Trust, UK, Registration Number SPS_045), operating theater records were reviewed to identify patients with CUO managed with Allium® URS, Memokath™-051, or Resonance® metallic ureteral stents (September 2015/July 2020). Baseline patient variables (age, gender, underlying etiology, and American Society of Anesthesiologists score) and stricture characteristics (length, level, and continuity) were extracted. Intraoperative and postoperative clinical and radiologic assessments at 6 weeks, 3 months, and then every 6 months, as well as any emergency attendances, were reviewed. The primary outcome was duration of functional stent survival. Secondary outcomes included intraoperative placement success and, as an estimate of renal function, mean serum creatinine over time. Results: One hundred twenty-nine stent insertion episodes (SIEs) (Allium® URS: 23; Memokath™-051: 48; Resonance®: 58) occurred in 76 patients (Allium® URS: 16; Memokath™-051: 31; Resonance®: 29). Kaplan-Meier estimates demonstrated that Resonance® provided superior functional stent survival. Overall median actual functional stent follow-up was 11.4 months for Allium® URS, 5.5 months for Memokath™-051, and 11.7 months for Resonance®. 47.8% of Allium® URS (11/23), 64.6% of Memokath™-051 (31/48), and 19% of Resonance® SIEs (11/58) failed. No Resonance® SIEs for benign indication ended in failure. Intraoperative placement success was high (Allium® URS: 95.7%; Memokath™-051 and Resonance®: both 100%). In the first year following SIE, creatinine ranged from +21.3% to +46.7% for Allium® URS, -7.8% to +8.9% for Memokath™-051, and -9.4% to +27.3% for Resonance®. Conclusions: Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents are all viable management options of CUO. In this cohort, Resonance® provided superior functional stent survival. Prospective large-scale comparisons with long-term follow-up are needed to help inform stent choice dependent on individual patient and stricture characteristics.

[Evolution and miniaturization of percutaneous nephrolithotomy]. / Évolution et miniaturisation de la néphrolithotomie percutanée.

Percutaneous nephrolithotomy (PCNL) was at first indicated for larger renal stones. Technological progress allowed a significant improvement of the available equipment, mostly to miniaturize the devices. However, this should not affect the stone clearance. Many different techniques arised aiming to reduce the complications of PCNL, in particular the risk of haemorrhage. As it becomes less invasive, the indications are greatly expanded, and a growing number of patients will benefit from it in the future. This explains the significance of knowing this procedure in continual development in greater detail.

La néphrolithotomie percutanée (NLPC) était initialement indiquée pour les calculs rénaux de grande taille. Les progrès technologiques ont permis une amélioration significative du matériel disponible, principalement dans le sens de la miniaturisation des instruments. Ceci ne doit cependant pas se faire au détriment de la plus grande clairance possible des calculs. Une multitude de techniques sont apparues sur le marché dans l'optique de diminuer les complications possibles des NLPC, en particulier le risque hémorragique. L'invasivité de cette intervention étant réduite, ses indications s'en trouvent considérablement élargies et un nombre croissant de patients vont en bénéficier à l'avenir. Ceci explique l'intérêt de connaître un peu mieux cette technique chirurgicale en constante évolution.

Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review.

The effectiveness of metallic stents in the management of malignant ureteric obstruction is unclear. This systematic review evaluates the use of 4 commercially available metallic stents (Resonance, Memokath 051, Uventa, and Allium URS). Twenty-one studies met eligibility criteria. Overall success rates ranged from 88% for the Allium stent to 65% for Memokath 051. Resonance demonstrated the lowest migration rate (1%). Uventa had the lowest obstruction rate (6%). Metallic ureteric stents offer a viable alternative in the management of malignant ureteric obstruction. Further high quality studies are required to assess cost effectiveness and refine specific indications based on etiology and level of the ureteric obstruction.

Bilateral Renal Anastomosing Hemangiomas: A Tale of Two Kidneys.

Background: Renal anastomosing hemangioma (RAH) is an extremely rare benign vascular tumor first described in 2009. Making this diagnosis is fraught with challenges. Radiologically they share features consistent with renal cell carcinomas (RCCs). Their vascular nature poses risks if considering preoperative biopsy and histologically they share characteristics akin to angiosarcomas. The few reports published in the literature suggest presentation with hematuria, flank pain, and polycythemia although the majority are diagnosed at postnephrectomy histologic examination. This case represents the first metachronous RAH in the literature, and is the first RAH presenting with severe hemorrhage. Case Presentation: A 62-year-old woman of Albanian heritage presented to urology with visible hematuria and positive urine cytology. Three years before this presentation, she had undergone an elective radical right-sided nephrectomy for a suspected RCC detected on magnetic resonance imaging, which proved to be an RAH after postoperative histologic examination of the specimen. The patient was investigated with cystoscopy and ureteroscopy for this new hematuria presentation, both of which were unremarkable. Fourteen hours post ureteroscopy, the patient became severely hypotensive and developed acute kidney injury. A CT scan indicated a large left-sided renal subcapsular and retroperitoneal hematoma that was actively bleeding. The patient was hemodynamically unstable and, therefore, required an emergency open left-sided nephrectomy, rendering her anephric and dialysis dependent. Postoperative histologic examination proved that the left kidney also contained an RAH. Conclusion: The anastomosing hemangioma is an important subtype to differentiate from angiosarcoma before and after a nephrectomy. Urologists should carefully consider invasive tests in patients with previously diagnosed vascular lesions as there may be an increased risk of bleeding. Patients with a previously diagnosed anastomosing hemangioma may require surveillance of the contralateral kidney.

Day case laparoscopic radical prostatectomy.

BACKGROUND: To evaluate the feasibility of performing laparoscopic radical prostatectomy (LRP) as a day case procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for day case LRP. METHODS: We performed a prospective study with 32 patients undergoing extraperitoneal LRP. These patients were counselled before the procedure that they would go home the same evening of the procedure. Pain scores and quality of life data were recorded day 1 postoperatively via a telephone consultation. The patients underwent routine blood tests on day 2 and an outpatient review on day 7 and regularly thereafter via an assigned key worker. Socio-demographic data, comorbidities, and outcomes were collected for analysis. RESULTS: All patients were successfully discharged the same day of surgery. Mean patient age was 62 years with a mean body mass index of 25. Mean operative time was 147 minutes, and estimated blood loss was 101 ml. Three patients were treated for post operative urinary tract infections; two patients developed infected lymphoceles which required percutaneous drainage and one patient required re-catheterisation due to a burst catheter balloon. Of these six complications four patients required re-admission. Post-operative pain, nausea and vomiting were low whilst patient satisfaction scores were unanimously high in all patients surveyed. CONCLUSIONS: The early experience with extraperitoneal LRP as a same day surgery is promising although patients who are at high risk of lymphocele should be excluded. Preoperative patient counselling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, a well-motivated patient, meticulous attention to detail through an integrated pathway, a multidisciplinary team and adequate postoperative assessment are essential.

Endourologic Management of an Iatrogenic Ureteral Avulsion Using a Thermoexpandable Nickel-Titanium Alloy Stent (Memokath 051).

Background: The use of ureteroscopy in the management of urolithiasis is well established. Ureteral avulsion is a rare but challenging complication of the procedure. Postureteral injury strictures are a common result of such injuries and are typically managed with reconstructive surgery or endoscopically with polymer stent. This case represents the first effective management of ureteral avulsion and subsequent ureteral stricture using a Memokath ureteral stent. Case Presentation: A 54-year-old gentleman presented to the Department of Urology with right loin pain as a result of right renal calculi, previously treated with extracorporeal shockwave lithotripsy. The patient was investigated with ultrasonography and noncontrast CT of his urinary tract, revealing mild right-sided hydroureteronephrosis and two right proximal ureteral stones, measuring 9 and 4 mm, respectively. He underwent a right semirigid ureteroscopy and laser stone fragmentation with complete stone clearance, but on withdrawal of the ureteroscope, a right ureteral injury occurred with ureteral mucosal avulsion extending from the L3/L4 vertebrae to the right vesicoureteral junction. Upon consideration of several options for management of this ureteral avulsion, the patient opted for endourologic stenting. After 10 months, the patient developed a ureteral stricture as a result of the avulsion. He was troubled with stent-related symptoms and wanted to avoid reconstructive surgery and, therefore, opted for a Memokath ureteral stent. The patient recovered well with excellent renal function and drainage on subsequent mercaptoacetyl-triglycyl renogram. Conclusion: Ureteral avulsion is a rare but important complication of ureteroscopy with numerous options available for management. Discussions should be had with the patient to weigh the various options, and metallic stents should be considered in the long-term management of such injuries and their sequel.

Spontaneous rupture of the bladder during vomiting.

A 46-year-old woman with no urological history or comorbidities presented with an acute abdomen with haematuria after a spell of protracted vomiting. The initial cystogram was negative; however, CT imaging highly suggested an intraperitoneal bladder perforation, which was confirmed during laparotomy and subsequently repaired. Cystoscopic evaluation prior to laparotomy revealed no concurrent bladder pathology, and the ureteric orifices were intact. A cystogram 2 weeks after repair demonstrated no leaks, and her catheters were removed. She recovered well, with expectant postoperative pain and lower urinary tract symptoms settling on 3-month review. Spontaneous bladder rupture is a rare entity, with very few reports in the literature.

Intraurethral bulking agents for the management of female stress urinary incontinence: a systematic review.

INTRODUCTION AND HYPOTHESIS: The object of this review was to assess the efficacy and safety of urethral bulking agents (UBA), principally Macroplastique and Bulkamid, in the treatment of female stress urinary incontinence (SUI). METHODS: MEDLINE® and EMBASE® databases were systematically searched up to June 2016. Year of publication, study type, outcome measures, urodynamics before and after the procedure, number of participants, procedure complications, proportion requiring repeat injections or surgical procedures, frequency of follow-up, and results were analysed. RESULTS: The use of Bulkamid and Macroplastique for the treatment of female SUI was described in 26 studies. Studies used modalities including the visual analogue scale, Likert scale, International Consultation on Incontinence Modular Questionnaire (ICIQ), Patient Global Improvement Questionnaire (PGIQ) and Incontinence Impact Questionnaire (IIQ) and showed success rates ranging from 66% to 89.7% at 12 months follow-up. Objective improvements in patient symptoms were measured using urodynamics, 24-h pad tests, cough tests and voiding diaries. Studies showed variable objective success rates ranging from 25.4% to 73.3%. Objective findings for UBAs remain less well documented than those for the midurethral sling procedure. CONCLUSIONS: There are a range of complications associated with UBAs, the most common being urinary tract infection. However, it remains a very well tolerated procedure in the majority of patients. UBAs should be considered as an alternative in patients unsuitable for more invasive procedures and those willing to accept the need for repeat injections. The majority of the literature focuses on subjective improvement measures rather than objective improvement measures. Further randomized controlled trials directly comparing UBAs are required to indicate the most effective agent.

Improving Compliance With a Single Post-Operative Dose of Intravesical Chemotherapy After Transurethral Resection of Bladder Tumour.

BACKGROUND: Post-operative single dose intravesical chemotherapy (PSDIVC) in patients with non-muscle invasive bladder cancer has been shown to reduce recurrence rates by up to 39%. However, some studies have suggested poor compliance with PSDIVC stating logistical issues and reluctance to give chemotherapy prior to histological confirmation as some of the reasons. OBJECTIVES: This study aims to analyse appropriate administration of PSDIVC practice in St. Mary's Hospital against European Association of Urology guidelines and implement an intervention bundle to improve practice. PATIENTS AND METHODS: All patients that underwent transurethral resection of bladder tumour (TURBT) between March 2012 and February 2013 were analysed retrospectively to review indication for post-operative chemotherapy, instillation rates and limiting factors preventing appropriate instillation. An intervention bundle including pre-operative delivery of mitomycin C (MMC) to the theatre suite, proforma placed in the operative notes and designated roles for PSDIVC induction was introduced to improve instillation and documentation rates. Prospective re-audit data was collected over six months between July 2013 and December 2013 following intervention. RESULTS: Sixty-four patients in group A underwent TURBT prior to introduction of the intervention bundle. Fifty-four patients had non-muscle invasive bladder cancer (NMIBC), which would have been eligible for PSDIVC. Fifteen (28% of NMIBC) were administered PSDIVC. Twenty-three (36% of all patients) were either given PSDIVC or had a documented contraindication. Thirty-one patients in group B underwent TURBT following induction of intervention bundle. Twelve (50% of NMIBC) patients were given PSDIVC. Twenty-eight (90% of all patients) were either given PSDIVC or had a documented contraindication. CONCLUSIONS: The intervention bundle prompted increased administration of PSDIVC and documentation. Similar centres may benefit from an intervention to improve compliance.

Teamwork Assessment Tools in Modern Surgical Practice: A Systematic Review.

Introduction. Deficiencies in teamwork skills have been shown to contribute to the occurrence of adverse events during surgery. Consequently, several teamwork assessment tools have been developed to evaluate trainee nontechnical performance. This paper aims to provide an overview of these instruments and review the validity of each tool. Furthermore, the present paper aims to review the deficiencies surrounding training and propose several recommendations to address these issues. Methods. A systematic literature search was conducted to identify teamwork assessment tools using MEDLINE (1946 to August 2015), EMBASE (1974 to August 2015), and PsycINFO (1806 to August 2015) databases. Results. Eight assessment tools which encompass aspects of teamwork were identified. The Nontechnical Skills for Surgeons (NOTSS) assessment was found to possess the highest level of validity from a variety of sources; reliability and acceptability have also been established for this tool. Conclusions. Deficits in current surgical training pathways have prompted several recommendations to meet the evolving requirements of surgeons. Recommendations from the current paper include integration of teamwork training and assessment into medical school curricula, standardised formal training of assessors to ensure accurate evaluation of nontechnical skill acquisition, and integration of concurrent technical and nontechnical skills training throughout training.

Should surgical outcomes be published?

Despite publishing surgical outcomes being a positive step forwards in the progression of England's healthcare system, it has no doubt been faced with criticism and reservations. This review article aims to discuss the pros and cons of publishing individual surgical outcomes, as well as the challenges faced. Publishing outcomes requires data from a number of sources such as national clinical audits, hospital episode statistics, patient-reported outcomes, registers and information from revalidation. As yet, eight surgical specialties have begun publishing their data, including cardiac (coronary artery bypass graft, valve and aortic surgery), endocrine (thyroidectomy, lobectomy, isthmusectomy), orthopaedic (hip and knee replacement), urological (full and partial nephrectomies, nephroureterectomy), colorectal (bowel tumour removal), upper gastrointestinal (stomach cancer and oesophageal cancer removal, bariatric surgery), ear, nose and throat surgery (larynx, oral cavity, oropharynx, hypopharynx and salivary gland cancer removal), as well as vascular surgery (abdominal aortic aneurysm, carotid endarterectomy). However, not all procedures have been addressed. Despite the controversy surrounding the topic of publishing surgical outcomes, the advantages of reporting outcomes outweigh the disadvantages, and these challenges can be overcome, to create a more reliable, trustworthy and transparent NHS. Perhaps one of the main challenges has been the difficulty in collecting large amounts of clinically significant data able to quantify the performance of surgeons.

Management of erectile dysfunction post-radical prostatectomy.

Radical prostatectomy is a commonly performed procedure for the treatment of localized prostate cancer. One of the long-term complications is erectile dysfunction. There is little consensus on the optimal management; however, it is agreed that treatment must be prompt to prevent fibrosis and increase oxygenation of penile tissue. It is vital that patient expectations are discussed, a realistic time frame of treatment provided, and treatment started as close to the prostatectomy as possible. Current treatment regimens rely on phosphodiesterase 5 inhibitors as a first-line therapy, with vacuum erection devices and intraurethral suppositories of alprostadil as possible treatment combination options. With nonresponders to these therapies, intracavernosal injections are resorted to. As a final measure, patients undergo the highly invasive penile prosthesis implantation. There is no uniform, objective treatment program for erectile dysfunction post-radical prostatectomy. Management plans are based on poorly conducted and often underpowered studies in combination with physician and patient preferences. They involve the aforementioned drugs and treatment methods in different sequences and doses. Prospective treatments include dietary supplements and gene therapy, which have shown promise with there proposed mechanisms of improving erectile function but are yet to be applied successfully in human patients.

Learning curves for cardiothoracic and vascular surgical procedures--a systematic review.

OBJECTIVES: The aim of this systematic review is to evaluate the learning curve (LC) literature and identify the LC of cardiothoracic and vascular surgical procedures. SUMMARY AND BACKGROUND: The LC describes an observation that a learner's performance improves over time during acquisition of new motor skills. Measuring the LC of surgical procedures has important implications for surgical innovation, education, and patient safety. Numerous studies have investigated LCs of isolated operations in cardiothoracic and vascular surgeries, but a lack of uniformity in the methods and variables used to measure LCs has led to a lack of systematic reviews. METHODS: The MEDLINE®, EMBASE™, and PsycINFO® databases were systematically searched until July 2013. Articles describing LCs for cardiothoracic and vascular procedures were included. The type of procedure, statistical analysis, number of participants, procedure setting, level of participants, outcomes, and LCs were reviewed. RESULTS: A total of 48 studies investigated LCs in cardiothoracic and vascular surgeries. Based on operating time, the LC for coronary artery bypass surgery ranged between 15 and 100 cases; for endoscopic vessel harvesting and other cardiac vessel surgery between 7 and 35 cases; for valvular surgery, which included repair and replacement, between 20 and 135 cases; for video-assisted thoracoscopic surgery, between 15 and 35 cases; for vascular neurosurgical procedures between 100 and 500 cases, based on complications; for endovascular vessel repairs between 5 and 40 cases; and for ablation procedures between 25 and 60 cases. However there was a distinct lack of standardization in the variables/outcome measures used, case selection, prior experience, and supervision of participating surgeons and a range of statistical analyses to compute LCs was noted. CONCLUSION: LCs in cardiothoracic and vascular procedures are hugely variable depending on the procedure type, outcome measures, level of prior experience, and methods/statistics used. Uniformity in methods, variables, and statistical analysis is needed to derive meaningful comparisons of LCs. Acknowledgment and application of learning processes other than those reliant on volume-outcomes relationship will benefit LC research and training of surgeons.

Simulation-based ureteroscopy training: a systematic review.

OBJECTIVE: Simulation is a common adjunct to operative training and various modalities exist for ureteroscopy. This systematic review aims the following: (1) to identify available ureteroscopy simulators, (2) to explore evidence for their effectiveness using characteristic criterion, and (3) to provide recommendations for simulation-based ureteroscopy training. DESIGN: The preferred reporting items for systematic reviews and meta-analysis statement guidelines were used. A literature search was performed using the PubMed, EMBASE, and Cochrane Library databases. RESULTS: In total, 20 articles concerning ureteroscopy simulators were included. Overall, 3 high-fidelity bench models are available. The Uro-Scopic Trainer has demonstrated face, construct, and concurrent validity, whereas the Scope Trainer has undergone content, construct, and predictive validation. The adult ureteroscopy trainer has demonstrated face, content, and construct validity. The URO Mentor is the only available ureteroscopy virtual-reality system; 10 studies were identified demonstrating its face, content, construct, concurrent, and predictive validity. The Uro-Scopic Trainer, the Scope Trainer, and the URO Mentor have demonstrated high educational impact. A noncommercially available, low-fidelity model has demonstrated effectiveness comparable to its high-fidelity counterpart at 185 times lesser than the price of the Uro-Scopic Trainer. The use of porcine models has also been described in 3 studies but require further study. CONCLUSIONS: Valid models are available for simulation-based ureteroscopy training. However, there is a lack of many high-level studies conducted, and further investigation is required in this area. Furthermore, current research focuses on the technical skills acquisition with little research conducted on nontechnical skills acquisition within ureteroscopy. The next step for ureteroscopy training is a formalized and validated curriculum, incorporating simulation, training models, development of nontechnical skills, and real-life practice.

'A reservoir within a reservoir' - An unusual complication associated with a defunctioned inflatable penile prosthesis reservoir.

INTRODUCTION: Inflatable penile prostheses (IPP) have been a successful method of treating men with erectile dysfunction since the early 1970s. IPP are comprised of two intracorporal cylinders, a scrotal pump and a fluid reservoir. PRESENTATION OF CASE: We present a case of a retained reservoir in a sixty eight year old gentlemen presenting with a cystic abdominal mass and bothersome LUTS, 15 years after the removal of the penile components of a three-piece penile prosthesis. Percutaneous drainage of the cyst was performed, with four litres of purulent fluid evacuated. A midline laparotomy was required to remove the reservoir and drain the collection completely. DISCUSSION: Inflammatory reaction and subsequent erosion of an IPP reservoir is an infrequent but severe complication of IPP insertion, replacement or infection. Infection remains the primary indication for penile prosthesis removal and in this setting removal of the reservoir is routine. A thorough literature search has identified that in the non-infective setting, the routine removal of the original reservoir is not standard practice during three-component IPP replacement. In patients with a history of IPP presenting with new LUTS, reservoir erosion should be considered in the differential diagnosis and investigation with cystoscopy and computed tomography included early in the investigatory armament of the urologist. CONCLUSION: It is our belief that a defunctionalized reservoir serves no purpose; rather it can only cause trouble in the future. Consequently, at our institution we do not leave defunctionalized reservoirs in situ.

Performance of technology-driven simulators for medical students--a systematic review.

BACKGROUND: Simulation-based education has evolved as a key training tool in high-risk industries such as aviation and the military. In parallel with these industries, the benefits of incorporating specialty-oriented simulation training within medical schools are vast. Adoption of simulators into medical school education programs has shown great promise and has the potential to revolutionize modern undergraduate education. MATERIALS AND METHODS: An English literature search was carried out using MEDLINE, EMBASE, and psychINFO databases to identify all randomized controlled studies pertaining to "technology-driven" simulators used in undergraduate medical education. A validity framework incorporating the "framework for technology enhanced learning" report by the Department of Health, United Kingdom, was used to evaluate the capabilities of each technology-driven simulator. Information was collected regarding the simulator type, characteristics, and brand name. Where possible, we extracted information from the studies on the simulators' performance with respect to validity status, reliability, feasibility, education impact, acceptability, and cost effectiveness. RESULTS: We identified 19 studies, analyzing simulators for medical students across a variety of procedure-based specialities including; cardiovascular (n = 2), endoscopy (n = 3), laparoscopic surgery (n = 8), vascular access (n = 2), ophthalmology (n = 1), obstetrics and gynecology (n = 1), anesthesia (n = 1), and pediatrics (n = 1). Incorporation of simulators has so far been on an institutional level; no national or international trends have yet emerged. CONCLUSIONS: Simulators are capable of providing a highly educational and realistic experience for the medical students within a variety of speciality-oriented teaching sessions. Further research is needed to establish how best to incorporate simulators into a more primary stage of medical education; preclinical and clinical undergraduate medicine.

A review of the available urology skills training curricula and their validation.

BACKGROUND: The transforming field of urological surgery continues to demand development of novel training devices and curricula for its trainees. Contemporary trainees have to balance workplace demands while overcoming the cognitive barriers of acquiring skills in rapidly multiplying and advancing surgical techniques. This article provides a brief review of the process involved in developing a surgical curriculum and the current status of real and simulation-based curricula in the 4 subgroups of urological surgical practice: open, laparoscopic, endoscopic, and robotic. METHODS: An informal literature review was conducted to provide a snapshot into the variety of simulation training tools available for technical and nontechnical urological surgical skills within all subgroups of urological surgery using the following keywords: "urology, surgery, training, curriculum, validation, non-technical skills, technical skills, LESS, robotic, laparoscopy, animal models." Validated training tools explored in research were tabulated and summarized. RESULTS AND CONCLUSIONS: A total of 20 studies exploring validated training tools were identified. Huge variation was noticed in the types of validity sought by researchers and suboptimal incorporation of these tools into curricula was noted across the subgroups of urological surgery. The following key recommendations emerge from the review: adoption of simulation-based curricula in training; better integration of dedicated training time in simulated environments within a trainee's working hours; better incentivization for educators and assessors to improvise, research, and deliver teaching using the technologies available; and continued emphasis on developing nontechnical skills in tandem with technical operative skills.