4-Aminopyridine treatment for nerve injury resulting from radical retro-pubic prostatectomy: a single-center double-blind, randomized, placebo-controlled study.

BACKGROUND: Prostate cancer (PCa) is the most common non-cutaneous malignancy in men and leads to the second most common cause of cancer related mortality in men. Early detection of PCa allows for a potentially curative intervention. Most men will live over a decade from the time of their PCa diagnosis. Thus, treatments must balance curative interventions with their impact on quality of life. Radical prostatectomy (RP) is one such potentially curative intervention but often leads to erectile dysfunction (ED) and urinary incontinence (UI). Approximately 90,000 RPs are performed each year in the USA. Post-operative ED and UI is thought to occur in part from traumatic peripheral nerve injury (TPNI) to the neurovascular bundles that surround the prostate. Thus, patients undergoing RP may be a population that would benefit from clinical studies that look at TPNI. METHODS: The study is a single-institution, double-blinded placebo-controlled, randomized clinical trial in which patients immediately post-RP receive either 4-aminopyrdine (4AP) or placebo in a 1:1 fashion. The primary outcome is evaluation of the efficacy of 4AP in accelerating the early return of baseline erectile and urinary function post-radical prostatectomy. DISCUSSION: This study is critical as it could reduce the morbidity associated with RP, a commonly performed operation, and identify a patient population that may greatly benefit into further TPNI research. TRIAL REGISTRATION: ClinicalTrials.gov NCT03701581. Prospectively registered on October 10, 2018.

Cognitive load in tele-robotic surgery: a comparison of eye tracker designs.

PURPOSE: Eye gaze tracking and pupillometry are evolving areas within the field of tele-robotic surgery, particularly in the context of estimating cognitive load (CL). However, this is a recent field, and current solutions for gaze and pupil tracking in robotic surgery require assessment. Considering the necessity of stable pupillometry signals for reliable cognitive load estimation, we compare the accuracy of three eye trackers, including head and console-mounted designs. METHODS: We conducted a user study with the da Vinci Research Kit (dVRK), to compare the three designs. We collected eye tracking and dVRK video data while participants observed nine markers distributed over the dVRK screen. We compute and analyze pupil detection stability and gaze prediction accuracy for the three designs. RESULTS: Head-worn devices present better stability and accuracy of gaze prediction and pupil detection compared to console-mounted systems. Tracking stability along the field of view varies between trackers, with gaze predictions detected at invalid zones of the image with high confidence. CONCLUSION: While head-worn solutions show benefits in confidence and stability, our results demonstrate the need to improve eye tacker performance regarding pupil detection, stability, and gaze accuracy in tele-robotic scenarios.

Cognitive effort detection for tele-robotic surgery via personalized pupil response modeling.

PURPOSE: Gaze tracking and pupillometry are established proxies for cognitive load, giving insights into a user's mental effort. In tele-robotic surgery, knowing a user's cognitive load can inspire novel human-machine interaction designs, fostering contextual surgical assistance systems and personalized training programs. While pupillometry-based methods for estimating cognitive effort have been proposed, their application in surgery is limited by the pupil's sensitivity to brightness changes, which can mask pupil's response to cognitive load. Thus, methods considering pupil and brightness conditions are essential for detecting cognitive effort in unconstrained scenarios. METHODS: To contend with this challenge, we introduce a personalized pupil response model integrating pupil and brightness-based features. Discrepancies between predicted and measured pupil diameter indicate dilations due to non-brightness-related sources, i.e., cognitive effort. Combined with gaze entropy, it can detect cognitive load using a random forest classifier. To test our model, we perform a user study with the da Vinci Research Kit, where 17 users perform pick-and-place tasks in addition to auditory tasks known to generate cognitive effort responses. RESULTS: We compare our method to two baselines (BCPD and CPD), demonstrating favorable performance in varying brightness conditions. Our method achieves an average true positive rate of 0.78, outperforming the baselines (0.57 and 0.64). CONCLUSION: We present a personalized brightness-aware model for cognitive effort detection able to operate under unconstrained brightness conditions, comparing favorably to competing approaches, contributing to the advancement of cognitive effort detection in tele-robotic surgery. Future work will consider alternative learning strategies, handling the difficult positive-unlabeled scenario in user studies, where only some positive and no negative events are reliably known.

WATTS happening? Evaluation of thermal dose during holmium laser lithotripsy in a high-fidelity anatomic model.

PURPOSE: To evaluate the thermal profiles of the holmium laser at different laser parameters at different locations in an in vitro anatomic pelvicalyceal collecting system (PCS) model. Laser lithotripsy is the cornerstone of treatment for urolithiasis. With the prevalence of high-powered lasers, stone ablation efficiency has become more pronounced. Patient safety remains paramount during surgery. It is well recognized that the heat generated from laser lithotripsy has the potential to cause thermal tissue damage. METHODS: Utilizing high-fidelity, 3D printed hydrogel models of a PCS with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations-at the stone and away from the stone. RESULTS: Temperatures were highest closest to the laser tip with a decrease away from the laser. Fluid temperatures increased with longer laser-on times and higher ODCs. Thermal doses were greater with increased ODCs and the threshold for thermal injury was reached for ODCs of 75% and 100%. CONCLUSION: Temperature generation and thermal dose delivered are greatest closer to the tip of the laser fiber and are not dependent on power alone. Significant temperature differences were noted between four laser settings at a standardized power (40 W). Temperatures can be influenced by a variety of factors, such as laser-on time, operator duty cycle, and location in the PCS.

Getting hot in here! Comparison of Holmium vs. thulium laser in an anatomic hydrogel kidney model.

As laser technology has advanced, high-power lasers have become increasingly common. The Holmium: yttrium-aluminum-garnet (Ho:YAG) laser has long been accepted as the standard for laser lithotripsy. The thulium fiber laser (TFL) has recently been established as a viable option. The aim of this study is to evaluate thermal dose and temperature for the Ho:YAG laser to the TFL at four different laser settings while varying energy, frequency, operator duty cycle (ODC). Utilizing high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system (PCS) with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Ho:YAG laser or TFL. At a standard power (40W) and irrigation (17.9 ml/min), we evaluated four different laser settings with ODC variations with different time-on intervals. Temperature was measured at two separate locations. In general, the TFL yielded greater cumulative thermal doses than the Ho:YAG laser. Thermal dose and temperature were typically greater at the stone when compared away from the stone. Regarding the TFL, there was no general trend if fragmentation or dusting settings yielded greater thermal doses or temperatures. The TFL generated greater temperatures and thermal doses in general than the Ho:YAG laser with Moses technology. Temperatures and thermal doses were greater closer to the laser fiber tip. It is inconclusive as to whether fragmentation or dusting settings elicit greater thermal loads for the TFL. Energy, frequency, ODC, and laser-on time significantly impact thermal loads during ureteroscopic laser lithotripsy, independent of power.

Turning up the HEAT: Surgical simulation of the Moses 2.0 laser in an anatomic model.

INTRODUCTION: With advancements in laser technology, urologists have been able to treat urinary calculi more efficiently by increasing the energy delivered to the stone. With increases in power used, there is an increase in temperatures generated during laser lithotripsy. The aim of this study was to evaluate the thermal dose and temperatures generated with four laser settings at a standardized power in a high-fidelity, anatomic model. METHODS: Using high-fidelity, 3D printed hydrogel models of a pelvicalyceal collecting system with a synthetic BegoStone implanted in the renal pelvis, surgical simulation of ureteroscopic laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations: at the stone and ureteropelvic junction. RESULTS: Greater cumulative thermal doses and maximal temperatures were achieved with greater ODCs and longer laser activation periods. There were statistically significant differences between the thermal doses and temperature profiles of the laser settings evaluated. Temperatures were greater closer to the tip of the laser fiber. CONCLUSIONS: Laser energy and frequency play an important role in the thermal loads delivered during laser lithotripsy. Urologists must perform laser lithotripsy cautiously when aggressively treating large renal pelvis stones, as dangerous temperatures can be reached. To reduce the risk of causing thermal tissue injury, urologists should consider reducing their ODC and laser-on time.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial.

BACKGROUND AND OBJECTIVE: The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis. METHODS: We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy. KEY FINDINGS AND LIMITATIONS: A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d. CONCLUSIONS AND CLINICAL IMPLICATIONS: Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making. PATIENT SUMMARY: In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis.

Evaluation of Mixed Reality Technologies for Remote Feedback and Guidance During Transrectal Ultrasound Biopsy Simulation: A Prospective, Randomized, Crossover Study.

OBJECTIVE: To compare equivalency of remote to in-person training during simulated transrectal ultrasound-guided prostate biopsy, we combined three technologies (mixed reality [MR] software, smart glasses, and hydrogel simulation model). Taken together, telemonitoring harnesses data streaming to provide real-time supervision and technical assistance for surgical procedures from an expert at a remote geographical location. METHODS: Nineteen students were randomized into two groups (MR-first and in-person-first) and proctored to measure prostate volume and perform 14-biopsies over seven sessions: pretest, two MR/in-person-guided training sessions, mid-test, crossover into two in-person/MR-guided training sessions, and post-test. MR sessions utilized Vuzix smart glasses with MR software (HelpLightning) to share the student's first-person perspective and Zoom to project the ultrasound screen to a remote instructor. Training and test sessions utilized single-color and seven-color prostate models, respectively. Accuracy of biopsy cores from test sessions were compared. Perception of instruction following each training session using 5-point Likert scales across five domains was assessed. Preference of instruction modality was assessed qualitatively. RESULTS: Comparison of mid-test performance following two training sessions was similar across the two groups (MR-first 63.8% vs in-person-first 57.6%, P = .340). Following crossover, difference in post-test performance of the MR-first group and the in-person-first group approached significance (MR-first 80.2% vs in-person-first 70.8%, P = .050). Student evaluation of MR and in-person instruction following training sessions was similar across the five metrics. CONCLUSION: MR-based remote learning is equally effective when compared to traditional in-person instruction.

Twice-Weekly Versus Once-Weekly Membrane Sweeping in the Prevention of Post-Term Pregnancy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events.

From Consensus to Validation: A Multicenter Study for Design and Development of a Holmium Laser Enucleation of the Prostate Hydrogel Simulation Platform.

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as a new gold standard for treatment of benign prostatic hyperplasia; however, its steep learning curve hinders generalization of this technique. Therefore, there is a need for a benchtop HoLEP simulator to reduce this learning curve and provide training. We have developed a nonbiohazardous HoLEP simulator using modern education theory and validated it in a multicenter study. Materials and Methods: Six experts established key components for a HoLEP simulator through a Delphi consensus over three rounds including 250 questions. After consensus, a digital design was created and approved by experts, then used to fabricate a physical prototype using three-dimensional printing and hydrogel molding. After a process of iterative prototype testing, experts completed a survey assessing the simulator with a 5-point Likert scale for final approval. The approved model was validated with 56 expert and novice participants at seven institutions using subjective and objective performance metrics. Results: Consensus was reached on 85 of 250 questions, and experts found the physical model to adequately replicate 82.5% of required features. Objective metrics were statistically significant (p < 0.0001) when comparing experts and novices for enucleation time (37.4 ± 8.2 vs 16.7 ± 6.8 minutes), adenoma weight (79.6 ± 20.4 vs 36.2 ± 9.9 g), and complications (6 vs 22), respectively. Conclusion: We have effectively completed a multicenter study to develop and validate a nonbiohazardous benchtop simulator for HoLEP through modern education theory. A training curriculum including this simulator is currently under development.

Cervical Cancer Screening Barriers Among Citizens of Jeddah.

INTRODUCTION: The cervix, a cylindrical structure made of stroma and epithelium, is the lowest point of the uterus. A tissue-proven biopsy of the cervix with histological confirmation is necessary for aberrant cytologic results of Papanicolaou (Pap) smears to rule out cervical cancer. This study investigates barriers to cervical cancer screening among women. METHODOLOGY:  A cross-sectional study including 665 Saudi Arabian women residing in Jeddah between the ages of 21 and 65 years was carried out from May to November 2023. A four-part online survey was used to gather the data, which included questions about demographics, cervical cancer screening status, screening barriers, and predictors of cervical cancer screening. RESULTS: The most common barrier to Pap test screening was "have not been to a doctor/no regular provider" (39.7%, N = 251), followed by "lack of provider recommendation/or limited or no information in the community" (30.4%, N = 192) and "low priority/did not perceive need/being healthy" (27.7%, N = 175). CONCLUSION: The study provides valuable insights into the factors influencing cervical cancer screening in Jeddah, Saudi Arabia. The low prevalence of screening indicates a need for increased awareness and targeted interventions to improve uptake.

Can preoperative planning using IRIS™ three-dimensional anatomical virtual models predict operative findings during robot-assisted partial nephrectomy?

Objective: To evaluate the predictive validity of IRIS™ (Intuitive Surgical®, Sunnyvale, CA, USA) as a planning tool for robot-assisted partial nephrectomy (RAPN) by assessing the degree of overlap with intraoperative execution. Methods: Thirty-one patients scheduled for RAPN by four experienced urologists were enrolled in a prospective study. Prior to surgery, urologists reviewed the IRIS™ three-dimensional model on an iphone Operating System (iOS) app and completed a questionnaire outlining their surgical plan including surgical approach, and ischemia technique as well as confidence in executing this plan. Postoperatively, questionnaires assessing the procedural approach, clinical utility, efficiency, and effectiveness of IRIS™ were completed. The degree of overlap between the preoperative and intraoperative questionnaires and between the planned approach and actual execution of the procedure was analyzed. Questionnaires were answered on a 5-point Likert scale and scores of 4 or greater were considered positive. Results: Mean age was 65.1 years with a mean tumor size of 27.7 mm (interquartile range 17.5-44.0 mm). Hilar tumors consisted of 32.3%; 48.4% of patients had R.E.N.A.L. nephrometry scores of 7-9. On preoperative questionnaires, the surgeons reported that in 67.7% cases they were confident that they can perform the procedure successfully, and on intraoperative questionnaires, the surgeons reported that in 96.8% cases IRIS™ helped achieve good spatial sensation of the anatomy. There was a high degree of overlap between preoperative and intraoperative questionnaires for the surgical approach, interpreting anatomical details and clinical utility. When comparing plans for selective or off-clamp, the preoperative plan was executed in 90.0% of cases intraoperatively. Conclusion: A high degree of overlap between the preoperative surgical approach and intraoperative RAPN execution was found using IRIS™. This is the first study to evaluate the predictive accuracy of IRIS™ during RAPN by comparing preoperative plan and intraoperative execution.

Tranexamic acid versus misoprostol for management of postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials.

AIM: To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH). METHODS: Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model. RESULTS: Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group. CONCLUSION: There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents.

Recent Advances in Surgical Simulation For Resident Education.

PURPOSE OF REVIEW: Surgical simulation has become a cornerstone for the training of surgical residents, especially for urology residents. Urology as a specialty bolsters a diverse range of procedures requiring a variety of technical skills ranging from open and robotic surgery to endoscopic procedures. While hands-on supervised training on patients still remains the foundation of residency training and education, it may not be sufficient to achieve proficiency for graduation even if case minimums are achieved. It has been well-established that simulation-based education (SBE) can supplement residency training and achieve the required proficiency benchmarks. RECENT FINDINGS: Low-fidelity modules, such as benchtop suture kits or laparoscopic boxes, can establish a strong basic skills foundation. Eventually, residents progress to high-fidelity models to refine application of technical skills and improve operative performance. Human cadavers and animal models remain the gold standard for procedural SBE. Recently, given the well-recognized financial and ethical costs associated with cadaveric and animal models, residency programs have shifted their investments toward virtual and more immersive simulations. Urology as a field has pushed the boundaries of SBE and has reached a level where unexplored modalities, e.g., 3D printing, augmented reality, and polymer casting, are widely utilized for surgical training as well as preparation for challenging cases at both the residents, attending and team training level.

A Multi-institution Study on the Association of Virtual Reality Skills with Continence Recovery after Robot-assisted Radical Prostatectomy.

BACKGROUND: Virtual reality (VR) simulators are increasingly being used for surgical skills training. It is unclear what skills are best improved via VR, translate to live surgical skills, and influence patient outcomes. OBJECTIVE: To assess surgeons in VR and live surgery using a suturing assessment tool and evaluate the association between technical skills and a clinical outcome. DESIGN, SETTING, AND PARTICIPANTS: This prospective five-center study enrolled participants who completed VR suturing exercises and provided live surgical video. Graders provided skill assessments using the validated End-To-End Assessment of Suturing Expertise (EASE) suturing evaluation tool. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A hierarchical Poisson model was used to compare skill scores among cohorts and evaluate the association of scores with clinical outcomes. Spearman's method was used to assess correlation between VR and live skills. RESULTS AND LIMITATIONS: Ten novices, ten surgeons with intermediate expertise (median 64 cases, interquartile range [IQR] 6-80), and 26 expert surgeons (median 850 cases, IQR 375-3000) participated in this study. Intermediate and expert surgeons were significantly more likely to have ideal scores in comparison to novices for the subskills needle hold angle, wrist rotation, and wrist rotation needle withdrawal (p < 0.01). For both intermediate and expert surgeons, there was positive correlation between VR and live skills for needle hold angle (p < 0.05). For expert surgeons, there was a positive association between ideal scores for VR needle hold angle and driving smoothness subskills and 3-mo continence recovery (p < 0.05). Limitations include the size of the intermediate surgeon sample and clinical data limited to expert surgeons. CONCLUSIONS: EASE can be used in VR to identify skills to improve for trainee surgeons. Technical skills that influence postoperative outcomes may be assessable in VR. PATIENT SUMMARY: This study provides insights into surgical skills that translate from virtual simulation to live surgery and that have an impact on urinary continence after robot-assisted removal of the prostate. We also highlight the usefulness of virtual reality in surgical education.

Predicting Surgical Experience After Robotic Nerve-sparing Radical Prostatectomy Simulation Using a Machine Learning-based Multimodal Analysis of Objective Performance Metrics.

INTRODUCTION: Machine learning methods have emerged as objective tools to evaluate operative performance in urological procedures. Our objectives were to establish machine learning-based methods for predicting surgeon caseload for nerve-sparing robot-assisted radical prostatectomy using our validated hydrogel-based simulation platform and identify potential metrics of surgical expertise. METHODS: Video, robotic kinematics, and force sensor data were collected from 35 board-certified urologists at the 2022 AUA conference. Video was annotated for surgical gestures. Objective performance indicators were derived from robotic system kinematic data. Force metrics were calculated from hydrogel model integrated sensors. Data were fitted to 3 supervised machine learning models-logistic regression, support vector machine, and k-nearest neighbors-which were used to predict procedure-specific learning curve proficiency. Recursive feature elimination was used to optimize the best performing model. RESULTS: Logistic regression predicted caseload with the highest AUC score for 5/7 possible data combinations (force, 64%; objective performance indicators + gestures, 94%; objective performance indicators + force, 90%; gestures + force, 93%; objective performance indicators + gestures + force, 94%). Support vector machine predicted the highest AUC score for objective performance indicators (82%) and gestures (94%). Logistic regression with recursive feature elimination was the most effective model reaching 96% AUC in predicting case-specific experience. Most contributory features were identified across all model types. CONCLUSIONS: We have created a machine learning-based algorithm utilizing a novel combination of objective performance indicators, gesture analysis, and integrated force metrics to predict surgical experience, capable of discriminating between surgeons with low or high robot-assisted radical prostatectomy caseload with 96% AUC in a standardized, simulation-based environment.

Three-dimensional printed hydrogel model vs cadaver: comparing inflatable penile prosthesis training and evaluation.

BACKGROUND: Penile prosthesis implantation offers a durable, safe, and effective treatment option for male erectile dysfunction; however, many urologists feel apprehensive and uncomfortable placing penile prostheses due to limited training, low surgical experience, and intra- and postoperative complication management. AIM: To compare a previously validated hydrogel inflatable penile prosthesis (IPP) training model with cadaver simulations across 4 main categories: anatomic replication and realism, procedural replication and realism, educational effectiveness, and efficacy and safety. METHODS: An overall 88 participants (15 attendings, 18 fellows, and 55 residents) performed guided IPP placements on a cadaver and a hydrogel model. Based on a 5-point Likert scale, postsurveys were used to assess the participants' opinions regarding anatomic replication and realism, procedural replication and realism, educational effectiveness, and safety between the hydrogel model and cadavers. OUTCOMES: A direct head-to-head scenario was created, allowing participants to fully utilize the hydrogel model and cadaver, which ensured the most accurate comparison possible. RESULTS: A total of 84% agreed that the hydrogel model replicates the relevant human cadaveric anatomy for the procedure, whereas 69% agreed that the hydrogel tissue resembles the appearance of cadaveric tissue. Regarding the pubic bone, outer skin, corporal bodies, dartos layer, and scrotum, 79%, 74%, 82%, 46%, and 30% respectively agreed that the hydrogel tissue resembled the texture/behavior of cadavers. Furthermore, 66% of participants agreed that the hydrogel model replicates all the procedural steps. Specifically, participants agreed that the model replicates the skin incision/dartos dissection (74%), placement of stay suture and corporotomy (92%), corporal dilation (81%), measurement of prosthetic size (98%), reservoir placement (43%), IPP placement (91%), scrotal pump placement (48%), and skin closure (51%). Finally, 86%, 93%, and 78% agreed that the hydrogel model is useful for improving technical skills, as a teaching/practicing tool, and as an evaluation tool, respectively. To conclude, 81% of participants stated that they would include the hydrogel model platform in their current training. CLINICAL IMPLICATIONS: By replicating the IPP procedure, the hydrogel model offers an additional high-fidelity training opportunity for urologists, allowing them to improve their skills and confidence in placing penile prostheses, with the goal of improving patient surgical outcomes. STRENGTHS AND LIMITATIONS: The hydrogel training model allows users to perform the entire IPP placement procedure with high anatomic realism and educational effectiveness, maintaining many of the high-fidelity benefits seen in cadavers while improving safety and accessibility. CONCLUSION: Ultimately, this high-fidelity nonbiohazardous training model can be used to supplement and bolster current IPP training curriculums.

Simulation-based Ultrasound Curriculum for Novice Clinicians to Assess Neonatal Endotracheal Tube Position.

Background: To evaluate the efficacy of a simulation-based mastery curriculum to train clinicians with limited-to-no sonography experience how to use ultrasound (US) to assess neonatal endotracheal tube (ETT) positioning. Methods: In a single-centered, prospective, educational study, 29 neonatology clinicians participated in a simulation-based mastery curriculum composed of a didactic lecture, followed by a one-on-one simulation session using a newly designed, three-dimensional (3D) printed US phantom model of the neonatal trachea and aorta. After mastery training, clinicians were evaluated with a performance checklist on their skills obtaining US images and assessing ETT positioning in the US phantom model. They also completed pre- and postcurriculum knowledge assessment tests and self-assessment surveys. The data were analyzed using Wilcoxon signed rank tests and repeated measures analysis of variance. Results: The mean checklist score improved significantly during three attempts (mean difference: 2.6552; 95% confidence interval [CI]: 2.2578-3.0525; P < 0.0001). The mean time to perform US decreased significantly from the first to third attempt (mean difference: -1.8276 min; 95% CI: -3.3391 to - 0.3161; P = 0.0196). In addition, there was a significant improvement in median knowledge assessment scores (50% vs. 80%; P < 0.0001) and survey ratings on knowledge and self-efficacy (P < 0.0001). Conclusion: Clinicians with limited-to-no sonography experience demonstrated improved knowledge and skill acquisition in using US to assess ETT positioning through simulation-based mastery training. The use of 3D modeling enhances simulation experiences and optimizes the quality of training during limited opportunities to achieve procedural competency in a controlled environment before further application into the clinical setting.