Genitourinary toxicity in patients receiving TURP prior to hypofractionated radiotherapy for clinically localized prostate cancer: A scoping review.

BACKGROUND: When compared with conventional external beam radiotherapy, hypofractionated radiotherapy has led to less treatment sessions and improved quality of life without compromising oncological outcomes for men with prostate cancer. Evidence has shown transurethral prostatic resection prior to brachytherapy and external beam radiotherapy is associated with worsening genitourinary toxicity. However, there is no review of genitourinary toxicity when TURP occurs prior to definitive hypofractionated radiotherapy. In this review, we seek to illustrate the genitourinary outcomes for men with localized prostate cancer who underwent transurethral resection of the prostate prior to receiving definitive hypofractionated radiotherapy. Genitourinary outcomes are explored, and any predictive risk factors for increased genitourinary toxicity are described. METHODS: PubMed, Medline (Ovid), EMBASE and Cochrane Library were all searched for relevant articles published in English within the last 25 years. This scoping review identified a total of 579 articles. Following screening by authors, 11 articles were included for analysis. RESULTS: Five studies reported on acute and late toxicity. One article reported only acute toxicity while 5 documented late toxicity only. While most articles found no increased risk of acute toxicity, the risk of late toxicity, particularly hematuria was noted to be significant. Risk factors including poor baseline urinary function, prostate volume, number of prior transurethral prostatic resections, timing of radiotherapy following transurethral prostatic resection, volume of the intraprostatic resection cavity and mean dose delivered to the cavity were all found to influence genitourinary outcomes. CONCLUSION: For those who have undergone prior TURP hypofractionated radiotherapy may increase the risk of late urinary toxicity, particularly hematuria. Those with persisting bladder dysfunction following TURP are at greatest risk and careful management of these men is required. Close collaboration between urologists and radiation oncologists is recommended to discuss the management of patients with residual baseline bladder dysfunction prior to commencing hypofractionated radiotherapy.

"I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation.

BACKGROUND: There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation. METHODS: This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis. RESULTS: In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics. CONCLUSIONS: These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.

Treatment of the infected sacral nerve stimulator: A scoping review.

BACKGROUND: Sacral nerve stimulators (SNSs) are a widely accepted, efficacious surgical option to treat patients who have failed conservative management for overactive bladder, nonobstructive urinary retention, fecal incontinence, or pelvic pain. As with all implanted devices, there are associated risks for surgical site and implant infections. There are currently no clear published data or guidelines regarding treating such infections. AIMS: We present a scoping review aiming to examine the existing literature on the treatment approaches of infected SNSs. METHODS: A scoping review was conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis. The search strategy focused on "sacral modulation," and "infection," and "explantation," and conservative management methods such as "antibiotics." A search was conducted on medical databases, and a grey literature search was performed. RESULTS: Thirty articles were included for data extraction. Articles were published between 2006 and 2022. Outcomes were reported for 7446 patients. Two hundred and seventy-four infection events were reported, giving an overall 3.7% infection rate. Most infection events were treated with explantation, although there is some discussion on the role of conservative management using oral and intravenous antibiotics in the literature. Articles also discussed considerations for future reimplantation after explantation of SNS. CONCLUSIONS: There are currently no treatment protocols in the literature to help guide whether a patient is suited to conservative or surgical management. There is future scope for developing treatment algorithms to guide clinicians for optimal treatment of infected sacral neuromodulation devices.

Anatomical location and number of injection sites of intravesical OnabotulinumtoxinA for females with refractory idiopathic overactive bladder: A scoping review.

AIMS: The negative impact on quality of life and the economic-related burden to the patient and the health care system associated with idiopathic overactive bladder (iOAB) is well-documented. Intradetrusor OnabotulinumtoxinA (BTN/A) injections are a well-used treatment modality for the management of overactive detrusor refractory to medical management, with well-documented efficacy and safety profiles. There is currently no best practice guideline for the administration of BTN/A for this procedure and historically the trigone of the bladder has been excluded from the injection paradigm given the risk of vesicoureteral reflux (VUR). METHODS: A scoping review methodology was employed to assess available literature to evaluate current techniques used. There is emerging literature that the inclusion of the trigone may increase the efficacy of the procedure, while maintaining a similar adverse effect profile. Similar results could also be obtained by decreasing the number of injection sites. A scoping review was completed with systematic methodology using the Preferred Systematic Reviews and Meta Analyses extension for Scoping Review checklist. The search strategy looked to evaluate BTN/A and number of injection sites and the inclusion of the trigone in female patients with iOAB. Studies with male or neurogenic bladder only were excluded. Mixed studies were included. A specialist research librarian was engaged, with supervision from a functional urologist using a combination of MeSH and natural language terms. Two investigators independently reviewed the titles and abstracts. RESULTS: Twelve articles were included and were published between 2005 and 2021. There was no evidence of VUR in any of the results. All but one study reported similar if not improved efficacy of trigone-inclusion. Lower number of injection sites had similar efficacy profiles to higher numbers of intradetrusor injections. CONCLUSIONS: Further high-quality randomized control trials of trigone inclusion and reduction of injection sites are required. It is hoped that with further exploration of intraoperative methods for BTN/A injections, the development of universally accepted guidelines may optimize management and experiences for patients with iOAB.

Defining the good surgical resident: a resident and registrar perspective.

BACKGROUND: Surgical residency provides insight into the essential skills required to become a successful surgical registrar. However, the role of the surgical resident remains largely undefined. While the Royal Australasian College of Surgeon (RACS) JDocs framework provides a useful guide, no published research explores what defines a highly performing surgical resident. We investigate what constitutes a 'good' surgical resident from the surgical resident and accredited surgical registrar perspectives. We hope this knowledge will improve patient care and assist surgical residents towards becoming valuable team members and successful accredited surgical training candidates. METHODS: A qualitative research approach was utilized employing reflexive thematic analysis. Using semi-structured interviews, 10 surgical residents and 10 accredited surgical registrars across eight surgical specialties were interviewed. RESULTS: Amongst surgical residents five themes were identified: efficiency: mastering the mundane, 'stepping up' to more responsibility, enthusiasm to learn, first do no harm: a safe practitioner, and lastly no resident is an island: a team player. Four themes described by accredited registrars included: somebody you can trust, finding a safe 'balance', a perfect fit: teamwork and communication and finally eagerness to improve. CONCLUSION: Themes correlated well with eight of 10 RACS competencies and the JDocs Framework. Our results reaffirmed the importance of developing early career non-technical skills. Explicit knowledge and understanding of these attributes used in conjunction with the core competency and JDocs frameworks may help those contemplating a career in surgery throughout their early surgical years.

Are we underestimating urinary retention following intravesical onabotulinumtoxinA in women with overactive bladder and a history of prior pelvic surgery?

AIMS: This study's purpose is to review the rates of urinary retention requiring intermittent catheterization (IC) post intravesical OnabotulinumtoxinA (BTN/A) injection for idiopathic overactive bladder from a single practicing specialist urological surgeon. METHODS: We performed a retrospective review of a single Australian urologist to identify the rate of intermittent catheterization in our clinical setting. Logistic regression was used to assess associations between requirement of IC and risk factors for urinary retention. RESULTS: Ninety-four patients were included after inclusion and exclusion criteria were applied and the average age was 69.7 years (SD 17.2) and all participants were female. Thirty-six percent (n = 34) of patients required IC. Of patients requiring IC, 32% had a prior urethral sling, 35% had prior vaginal prolapse surgery, and 29% had a preoperative urinary tract infection (UTI). There was strong evidence of univariate associations between IC and prior sling (odds ratio [OR]: 5.26, 95% confidence interval [CI]: 1.64-16.55, p = 0.005), preoperative UTI (OR: 4.25, 95% CI: 1.31-13.08, p = 0.016) and prior vaginal prolapse surgery (OR: 4.91, 95% CI: 1.64-14.72, p = 0.005). Evidence that prior sling patients were more likely to require IC remained strong in a multivariable model (OR: 7.35, 95% CI: 1.59-34.11, p = 0.011). CONCLUSION: Prior urethral sling surgery, prior vaginal prolapse surgery, and positive preoperative UTI, despite treatment, were found to be associated with a higher rate of initiation of intermittent catheterization. The rate of IC initiation of 36% was higher than reported in prior clinical trials.

Optimizing surgical training in the time of COVID-19-Victorian regional teaching hospital experience.

BACKGROUND: Reductions in elective surgery due to the COVID-19 pandemic led to a paralleled reduction in patient based surgical training opportunities. METHODS: To quantify the impact of COVID-19 on surgical training, we completed a retrospective audit of the Urology Department activity during Victorian pandemic waves in 2020 at our large regional teaching hospital. Corresponding weeks in the year prior were used as the control. Interviews with department members illustrated the adaptive approach to surgical training used at our institution. RESULTS: A State of Disaster Surgical Triage Team was assembled and surgical operations were split between one public and two private hospitals. A pandemic triaging protocol was established and 335 Category-2 patients were re-triaged. The first wave saw a 13.8% reduction in clinic reviews, with the second wave having an overall increase of 8.8% with 56% being telehealth. The second wave saw an 11.0% reduction in overall operating, with reduced emergency operating in both the first and second wave of 17.4% and 45.5%, respectively. Reductions impacted surgical technical skill training, resulting in surgical education provided through technology platforms including webinars, podcasts and pre-recorded operative videos. The unique challenges trainees were faced with due to the pandemic encouraged development of non-technical RACS competencies. CONCLUSION: The COVID-19 pandemic presented significant challenges for service delivery and training. Reduced direct patient contact and procedures, but opportunities to develop the non-technical skills required to respond to the pandemic. The use of variable educational opportunities and tools ensured our trainees continued to progress through their training.

Using Videos to Teach Medical Learners How to Address Common Breastfeeding Problems.

Introduction: Though breast milk is the recommended first food, only 84% of mothers try breastfeeding, and 19% of those babies are supplemented with formula by the second day of life. Mothers often fall short of their breastfeeding goals, which has been traced in part to primary care physicians' discomfort and lack of confidence in assisting breastfeeding mothers. A video-based educational intervention was developed to enhance learner comfort and confidence in supporting breastfeeding. Methods: Prior to watching the videos, two separate groups of learners (25 primary care residents and 40 medical students) were given two assessments to assess their baseline knowledge and self-perceived comfort and confidence with breastfeeding based on the American Academy of Pediatrics residency breastfeeding curriculum. We gave the learners a checklist to guide their observations while watching the videos. The learners repeated the assessments after watching the videos. Results: Students who participated showed a statistically significant increase in breastfeeding knowledge and self-perceived comfort and confidence in assisting mothers with common breastfeeding problems. Additionally, residents increased their knowledge and confidence, but not their comfort with breastfeeding. Discussion: The videos seem to have been most helpful in assisting learners with confidence with helping breastfeeding mothers and knowledge of breastfeeding. The videos also improved student comfort but were less effective in increasing residents' comfort as residents generally self-rated their comfort level as high preceding the video curriculum. These videos provide an effective way to begin sensitizing learners to the importance of breastfeeding, common challenges, and potential solutions for new mothers.

Struggling urology trainee: a qualitative study into causes of underperformance.

BACKGROUND: Urological surgical trainees who underperform are difficult to identify, manage and require significant resources in an already stretched system relying on pro bono supervisors that often have no formal training. While there are commentaries on how to manage underperforming surgical trainees, there is a lack of data detailing the complex reasons for underperformance. It is important to understand the complexities contributing to underperformance so that improved remediation plans can be developed which can better help trainees meet expectations and succeed. METHODS: In this qualitative study, individual semi-structured interviews were conducted with key persons identified as having very high levels of background knowledge and involvement with current underperforming urological surgery trainees. Transcribed interviews were thematically analysed. RESULTS: Ten interviews were conducted, including nine urology consultants and one educational manager. Five themes were identified: underperformance is a small but profound issue; spiral of failure; the changing trainee; lack of insight and under supported supervisors and posts. CONCLUSION: Causes of underperformance in urology trainees are complex and multifactorial. Behavioural issues were considered the most likely cause, which are also the most challenging to remedy. However, in addition to trainee factors, causative factors related to supervision and training were identified. Addressing all of these issues is paramount if effective remediation of these trainees is to occur.

Core body temperature during competition in the heat: National Boys' 14s Junior Championships.

OBJECTIVE: To examine on-court core body temperature (T(C)) and sweat loss, as well as pre- and post-play hydration status, in elite adolescent tennis players during a national championships event in a hot climate. METHODS: Eight healthy, fit, young male tennis players (mean (SD) age 13.9 (0.9) years; mass 56.0 (10.7) kg; height 169.2 (14.7) cm) were evaluated during first-round singles competition at the National Boys' 14s Junior Championships in the heat (wet-bulb globe temperature (WBGT) 29.6 (0.4) degrees C). Five of those same players were also evaluated during a same-day doubles match (WBGT 31.3 (0.5) degrees C). RESULTS: During doubles (4.37 (0.35) h after singles), pre-play urine specific gravity (USG) (1.025 (0.002); p = 0.06) and total sweat loss (1.9 (0.2) litres; p = 0.10) tended to be higher before and during doubles, respectively, compared to singles. However, percentage change in body mass (-0.5 (0.3) %) tended to be comparatively less (p = 0.08), even though the doubles matches were generally longer (106.6 (11.2) vs 78.8 (10.9) min; p = 0.09) and the degree minutes total was greater (p = 0.04). T(C) increased (p<0.001) during singles and remained elevated, even after 10 min following the end of play. Notably, pre-play (singles) USG was strongly associated (p = 0.005) with the players' final T(C) (38.7 (0.3) degrees C) recorded at the end of singles play. CONCLUSION: Junior tennis players who begin a match not well hydrated could have progressively increasing thermal strain and a greater risk for exertional heat illness as the match advances.

Adiposity is related to gender differences in impaired stress-induced pressure natriuresis.

The purpose of this study was to determine if there are gender differences in stress-induced pressure natriuresis and to examine the effects of adiposity on these differences. The subjects were 151 boys and 141 girls 15 to 18 years of age who underwent a 5-hour stress protocol (2-hour prestress, 1-hour stress, 2-hour poststress) after being brought into similar levels of sodium balance. The gender-by-condition interaction was significant for systolic and diastolic blood pressure (P=0.001 for both), and the effect of condition was significant for sodium excretion (P=0.001). Systolic blood pressure was higher for boys throughout the protocol (P=0.001 for each) and correlated with body mass index at each condition (range in r=0.28 to 0.35; P<0.001 for each). Hemodynamically, in boys body mass index was correlated with cardiac output during stress (r=0.23; P=0.006), which was correlated with systolic blood pressure (r=0.21; P=0.01). With respect to natriuresis, body mass index was inversely correlated with sodium excretion during stress (r=-0.22; P=0.008) and positively correlated with angiotensin II in a subsample of boys (n=89: r=0.31; P=0.003). The inverse correlation between angiotensin II and sodium excretion during stress approached significance (r=-0.17; P<0.06). Similar results were not observed for girls. In conclusion, gender differences in stress-induced pressure natriuresis appear to be related to the influence of adiposity on both blood pressure and natriuresis.