Easily accessible, up-to-date and standardised training model in Urology: E-Learning Residency training programme (ERTP).

OBJECTIVES: There is no standardised and up-to-date education model for urology residents in our country. We aimed to describe our National E-learning education model for urology residents. METHODOLOGY: The ERTP working group; consisting of urologists was established by the Society of Urological Surgery to create E-learning model and curriculum in April 2018. Learning objectives were set up in order to determine and standardise the contents of the presentations. In accordance with the Bloom Taxonomy, 834 learning objectives were created for a total of 90 lectures (18 lectures for each PGY year). Totally 90 videos were shot by specialised instructors and webcasts were prepared. Webcasts were posted at uropedia.com.tr, which is the web library of the Society of Urological Surgery. The satisfaction of residents and instructors was evaluated with feedbacks. An assessment of knowledge was measured with the multiple-choice exam. RESULTS: A total of 43 centres and 250 urology residents were included in ERTP during the academic year 2018/2019. There were 93/55/43/34/25 urology residents at 1st/2nd/3rd/4th and 5th year of residency, respectively. Majority of the residents (99.1%) completed the ERTP. The overall satisfaction rate of residents and instructors were 4.29 and 4.67 (min: 1 so bad, max: 5 so good). An assessment exam was performed to urology residents at the end of the ERTP and the mean score was calculated as 57.99 points (min: 20, max: 82). CONCLUSION: As a result of the COVID-19 pandemic, most of the educational programmes had to move online platforms. We used this reliable and easily accessible e-learning platform for the standardisation of training in urology on national basis. We aim to share this model with international residency training programmes.

The Effect of Diagnostic Ureterorenoscopy on Intravesical Recurrence in Patients Undergoing Nephroureterectomy for Primary Upper Tract Urinary Carcinoma.

OBJECTIVE: The objective of this study is to evaluate the effect of diagnostic ureterorenoscopy (URS) prior to radical nephroureterectomy (RNU) on intravesical recurrence (IVR), in patients with primary upper urinary tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Retrospective analysis of 354 patients, who underwent RNU for UTUC from 10 urology centers between 2005 and 2019, was performed. The primary endpoint was the occurrence of IVR after RNU. Patients were divided into URS prior to RNU (Group 1) and no URS prior to RNU (Group 2). Rates of IVR after RNU were compared, and a Cox proportional hazards model was used to evaluate potential predictors of IVR. RESULTS: After exclusion, a total of 194 patients were analyzed: Group 1 n = 95 (49.0%) and Group 2 n = 99 (51.0%). In Group 1, a tumor biopsy and histopathological confirmation during URS were performed in 58 (61.1%). The mean follow-up was 39.17 ± 39.3 (range 12-250) months. In 54 (27.8%) patients, IVR was recorded after RNU, and the median recurrence time within the bladder was 10.0 (3-144) months. IVR rate was 38.9% in Group 1 versus 17.2% in Group 2 (p = 0.001). In Group 1, IVR rate was 43.1% in those undergoing intraoperative biopsy versus 32.4% of patients without biopsy during diagnostic URS (p =0.29). Intravesical recurrence-free survival (IRFS) was longer in Group 2 compared to Group 1 (median IRFS was 111 vs. 60 months in Groups 2 and 1, respectively (p< 0.001)). Univariate analysis revealed that IRFS was significantly associated with URS prior to RNU (HR: 2.9, 95% CI 1.65-5.41; p < 0.001). In multivariate analysis, URS prior to RNU (HR: 3.5, 95% CI 1.74-7.16; p < 0.001) was found to be an independent prognostic factor for IRFS. CONCLUSION: Diagnostic URS was associated with the poor IRFS following RNU for primary UTUC. The decision for a diagnostic URS with or without tumor biopsy should be reserved for cases where this information might influence further treatment decisions.

Multicenter Multireader Evaluation of an Artificial Intelligence-Based Attention Mapping System for the Detection of Prostate Cancer With Multiparametric MRI.

OBJECTIVE. The purpose of this study was to evaluate in a multicenter dataset the performance of an artificial intelligence (AI) detection system with attention mapping compared with multiparametric MRI (mpMRI) interpretation in the detection of prostate cancer. MATERIALS AND METHODS. MRI examinations from five institutions were included in this study and were evaluated by nine readers. In the first round, readers evaluated mpMRI studies using the Prostate Imaging Reporting and Data System version 2. After 4 weeks, images were again presented to readers along with the AI-based detection system output. Readers accepted or rejected lesions within four AI-generated attention map boxes. Additional lesions outside of boxes were excluded from detection and categorization. The performances of readers using the mpMRI-only and AI-assisted approaches were compared. RESULTS. The study population included 152 case patients and 84 control patients with 274 pathologically proven cancer lesions. The lesion-based AUC was 74.9% for MRI and 77.5% for AI with no significant difference (p = 0.095). The sensitivity for overall detection of cancer lesions was higher for AI than for mpMRI but did not reach statistical significance (57.4% vs 53.6%, p = 0.073). However, for transition zone lesions, sensitivity was higher for AI than for MRI (61.8% vs 50.8%, p = 0.001). Reading time was longer for AI than for MRI (4.66 vs 4.03 minutes, p < 0.001). There was moderate interreader agreement for AI and MRI with no significant difference (58.7% vs 58.5%, p = 0.966). CONCLUSION. Overall sensitivity was only minimally improved by use of the AI system. Significant improvement was achieved, however, in the detection of transition zone lesions with use of the AI system at the cost of a mean of 40 seconds of additional reading time.

Can computer-aided diagnosis assist in the identification of prostate cancer on prostate MRI? a multi-center, multi-reader investigation.

For prostate cancer detection on prostate multiparametric MRI (mpMRI), the Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) and computer-aided diagnosis (CAD) systems aim to widely improve standardization across radiologists and centers. Our goal was to evaluate CAD assistance in prostate cancer detection compared with conventional mpMRI interpretation in a diverse dataset acquired from five institutions tested by nine readers of varying experience levels, in total representing 14 globally spread institutions. Index lesion sensitivities of mpMRI-alone were 79% (whole prostate (WP)), 84% (peripheral zone (PZ)), 71% (transition zone (TZ)), similar to CAD at 76% (WP, p=0.39), 77% (PZ, p=0.07), 79% (TZ, p=0.15). Greatest CAD benefit was in TZ for moderately-experienced readers at PI-RADSv2 <3 (84% vs mpMRI-alone 67%, p=0.055). Detection agreement was unchanged but CAD-assisted read times improved (4.6 vs 3.4 minutes, p<0.001). At PI-RADSv2 ≥ 3, CAD improved patient-level specificity (72%) compared to mpMRI-alone (45%, p<0.001). PI-RADSv2 and CAD-assisted mpMRI interpretations have similar sensitivities across multiple sites and readers while CAD has potential to improve specificity and moderately-experienced radiologists' detection of more difficult tumors in the center of the gland. The multi-institutional evidence provided is essential to future prostate MRI and CAD development.

Does previous open nephrolithotomy affect the outcomes and complications of percutaneous nephrolithotomy in children?

OBJECTIVE: To analyze the success and complication rates of percutaneous nephrolithotomy (PCNL) performed in pediatric patients and to compare outcomes of the patients undergoing primary PCNL with those of patients who had undergone previous open nephrolithotomy. MATERIALS AND METHODS: Between 2000 and 2011, PNL procedures were performed in 123 renal units (RU) of 111 children. We compared RU on which previous open surgery had been performed (group 1 RU = 26) on the same kidney with RU that had not been involved in previous surgery (group 2 RU = 97). Patient characteristics, pre- and postoperative hematocrit and creatinin levels, operative time, fluoroscopic screening time, stone free rate, complications and hospitalization time were documented and compared. RESULTS: There were no significant differences between the groups in sex, stone burden, pre- and postoperative hematocrit levels. Mean age and pre- and postoperative creatinin levels were significantly higher in group 1 (p < 0.05). Mean operative time, fluoroscopic screening time and hospitalization times were similar in each group (p > 0.05). The stone free rates after PCNL were 65.4% in group 1 and 81.4% in group 2 (p > 0.05). Multiple access rate was higher in group 1; however, this was not statistically significant (27% vs. 15%, p > 0.05). CONCLUSION: PCNL can be performed in pediatric patients who have previously undergone open nephrolithotomy but the success rates may be lower and risk of bowel injury higher. NCCT should be considered preoperatively for patients who have previously undergone open renal surgeries to investigate the presence of retrorenal colons. Our study includes relatively few patients with a history of open surgery and we believe that additional clinical studies with larger numbers of patients are needed to confirm our initial findings.

Percutaneous nephrolithotomy in children with cystine stone: long-term outcomes from a single institution.

PURPOSE: We determined the effectiveness of percutaneous nephrolithotomy in children with cystine stones and present the long-term outcomes. MATERIALS AND METHODS: We reviewed the data of 65 renal units in 51 children who underwent percutaneous nephrolithotomy for cystine stones between 2000 and 2012. Of the patients 19 (37%) had undergone ipsilateral renal surgery and 11 (22%) had undergone extracorporeal shock wave lithotripsy. Children were designated as being stone-free or having residual stone (any evidence of persistent stone fragments irrespective of size). Medical treatment with α-mercaptopropionylglycine, potassium citrate or potassium sodium hydrogen citrate was recommended for all patients after stone analysis. RESULTS: Median stone burden was 3.3 cm(2) (range 1 to 13) and median patient age was 6 years (1 to 17). Stone-free status was achieved in 41 renal units (63.1%). Stone-free status was increased to 73.8% with additional endoscopic procedures. The remaining patients with residual stones were followed. Complication rate was 15.4%. A total of 35 children (68.6%) receiving regular medical treatment were followed for a median of 95 months (range 6 to 136). The recurrence rate for children achieving stone-free status was 31.2%, and the regrowth rate for children with residual stones was 29.4%. CONCLUSIONS: Percutaneous nephrolithotomy is a safe and effective treatment for children with cystine stones. Our high recurrence and regrowth rates emphasize that our treatment schedule is inadequate to prevent recurrent cystine calculi. Additional investigation is needed to determine the optimal medical therapy for preventing recurrence and regrowth of cystine stones.

The use of a laparoscopic bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy: a novel technique.

PURPOSE: To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated. RESULTS: Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity. CONCLUSIONS: The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy.

Optimal control of the dorsal venous complex (DVC) is a critical step in robot-assisted radical prostatectomy (RARP). If DVC is not controlled properly, bleeding may occur during the apical dissection. On the other hand, if it is controlled well, a bloodless field is attained and, thus, a precise apical dissection and urethral division is possible. Suture ligation is the most common technique used for dorsal vein control, while some authors recommend using an endovascular stapler. Recently, athermal division and selective suture ligation technique has been reported for DVC control. We describe a new technique: Use of a bulldog clamp to control the DVC during RARP. The control of the DVC with a bulldog clamp allows a bloodless field with precise apical dissection and provides preservation of maximum urethral length while avoiding sphincteral injury.

Laparoscopic treatment of unilocular renal hydatid cyst mimicking a simple cyst in a child.

A 110 x 70 x 60-mm hydatid cyst in the right kidney of a 5-year-old boy was treated using a laparoscopic approach. The renal hydatid cyst was not identified before the operation. There were no complications related to surgery and therapy. The child was under follow-up for 12 months and there was no evidence of recurrence on ultrasonography and computed tomography during this period. To our knowledge, this is the first case of renal hydatid cyst treated by laparoscopic approach in a child.