Inter-observer variance of examiner scoring in urology Objective Structured Clinical Examinations.

INTRODUCTION: The Objective Structured Clinical Examination (OSCE) is an attractive tool of competency assessment in a high-stakes summative exam. An advantage of the OSCE is the ability to assess more realistic context, content, and procedures. Each year, the Queen's Urology Exam Skills Training (QUEST) is attended by graduating Canadian urology residents to simulate their upcoming board exams. The exam consists of a written component and an OSCE. The aim of this study was to determine the inter-observer consistency of scoring between two examiners of an OSCE for a given candidate. METHODS: Thirty-nine participants in 2020 and 37 participants in 2021 completed four stations of OSCEs virtually over the Zoom platform. Each candidate was examined and scored independently by two different faculty urologists in a blinded fashion at each station. The OSCE scoring consisted of a checklist rating scale for each question. An intra-class correlation (ICC) analysis was conducted to determine the inter-rater reliability of the two examiners for each of the four OSCE stations in both the 2020 and 2021 OSCEs. RESULTS: For the 2020 data, the prostate cancer station scores were most strongly correlated (ICC 0.746, 95% confidence interval [CI] 0.556-0.862, p<0.001). This was followed by the general urology station (ICC 0.688, 95% CI 0.464-0.829, p<0.001), the urinary incontinence station (ICC 0.638, 95% CI 0.403-0.794, p<0.001), and finally the nephrolithiasis station (ICC 0.472, 95% CI 0.183-0.686, p<0.001). For the 2021 data, the renal cancer station had the highest ICC at 0.866 (95% CI 0.754-0.930, p<0.001). This was followed by the nephrolithiasis station (ICC 0.817, 95% CI 0.673-0.901, p<0.001), the pediatric station (ICC 0.809, 95% CI 0.660-0.897, p<0.001), and finally the andrology station (ICC 0.804, 95% CI 0.649-0.895, p<0.001). A Pearson correlation coefficient was calculated for all stations, and all show a positive correlation with global exam scores. It is noteworthy that some stations were more predictive of overall performance, but this did not necessarily mean better ICC scores for these stations. CONCLUSIONS: Given a specific clinical scenario in an OSCE exam, inter-rater reliability of scoring can be compromised on occasion. Care should be taken when high-stakes decisions about promotion are made based on OSCEs with limited standardization.

Virtual OSCE examinations during COVID-19 A 360 satisfaction assessment from examiners and candidates.

INTRODUCTION: We sought to determine the satisfaction rates of examiners and candidates in a virtual Objective Structured Clinical Exam (OSCE) of graduating Canadian urology residents. METHODS: An annual mock exam, aimed at simulating the licencing urology exam for Canadian graduates, was moved to an online format for the 2020 cohort. This exam consists of an OSCE, and a written multiple-choice exam. The Telemedicine Satisfaction Questionnaire (TSQ), a previously validated tool for clinical encounters with three sub-domains (quality of care provided, similarity to face-to-face encounter, and perception of the interaction) was modified for the purposes of evaluating the OSCE encounter. The TSQ was sent electronically to all examiners and candidates after the exam. RESULTS: There were 14/16 responses from examiners (87.5%) and 24/39 responses from candidates (61.5%). Overall, the format was judged to be a good experience by 13/14 (92.9%) of examiners and 21/24 (87.5%) of candidates; however, when asked specifically if the virtual OSCE was an acceptable way to determine a candidate's competency to practice urology independently, only 8/14 (57.1%) of examiners and 15/24 (62.5%) of candidates agreed. CONCLUSIONS: This study demonstrates an overall good satisfaction rate among both examiners and candidates when using a teleconference format for a mock OSCE.

Impact of the COVID-19 pandemic on the burnout rates of graduating Canadian Urology residents.

OBJECTIVE: To assess the impact of coronavirus disease 2019 (COVID-19) on burnout rates in Canadian Urology trainees. SUBJECTS AND METHODS: A total of 37 chief residents representing all 12 Canadian Urology residency programmes attended a preparatory examination in December 2019 pre-pandemic and 39 chief residents attended virtually in November 2020 during the pandemic. The Maslach Burnout Inventory (MBI) for medical professionals' questionnaire was administered anonymously to both groups. The MBI covers emotional exhaustion, depersonalisation, and personal accomplishment. Descriptive statistics were used to analyse the data. RESULTS: There was a 100% response rate in the convenience sample (n = 37) in 2019 and 64.1% response rate (n = 25) in 2020. Overall, 70% of chief residents in Canadian Urology programmes showed evidence of burnout in 2019 compared to 88% in 2020 (P = 0.101). There was a statistically significant difference between the two cohorts in emotional exhaustion (mean [sd] 16.2 [5.6] in 2019 and 20.2 [6.2] in 2020, P = 0.011) and personal accomplishment scores (mean [sd] 32.2 [4.5] in 2019 and 30.6 [3.6] in 2020, P = 0.039). CONCLUSIONS: This study is the first to examine the impact of the pandemic on burnout rates in Urology trainees. Burnout rates are high in trainees at baseline, and the pandemic appears to have exacerbated emotional exhaustion, and personal accomplishment, but not overall burnout rates. Vigilance and proactive steps need to be implemented to alleviate this crisis.

Ambulatory percutaneous nephrolithotomy is safe and effective in patients with extended selection criteria.

INTRODUCTION: Ambulatory percutaneous nephrolithotomy (PCNL) has been limited to highly selected patients. The objective of our study was to compare complication and stone-free rates after ambulatory PCNL in standard selection criteria vs. extended criteria patients. METHODS: We conducted a retrospective review of prospective data on all patients who underwent ambulatory PCNL at one academic center from 2007-2018. Extended criteria patients were defined as one or more of: age >75 years, body mass index (BMI) >30 kg/m2, American Society of Anesthesiologists (ASA) score >2, bilateral stones, solitary kidney, transplant kidney, complete staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone-free rates. RESULTS: We identified 118 patients, of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, and complete staghorn stones in 4% of patients. There was no difference in complication (12% vs. 18%, p=0.56), emergency department visit (12% vs. 18%, p=0.56), or re-admission (4% vs. 5%, p=1) rates between standard and extended criteria patients, respectively. Of the complications, 85% were Clavien-Dindo grade 1. Stone-free rates were not different between standard (84%) and extended (83%) criteria patients (p=1). No extended criteria variables were associated with complications in multivariable analysis. CONCLUSIONS: Complication and stone-free rates were not different between standard and extended selection criteria patients undergoing ambulatory PCNL. This data indicates that many of the preoperative patient and stone factors that have previously been used as exclusion criteria for ambulatory PCNL are not strictly necessary.

Evaluation of inter-professional communication and leadership skills among graduating Canadian urology residents.

INTRODUCTION: The importance of developing inter-professional communication and leadership skills among residents is well-recognized; however, formal tools to assess these skills are lacking. The goal of our study was to assess the leader and communicator roles in graduating urology residents using a validated self-assessment form developed for business students that focuses on inter-professional skills. METHODS: Chief residents (n=36) were evaluated with surveys of communication and leadership skills. The same surveys were administered through email to the residents' program directors (PDs). Resident self-assessment and PD assessment were compared using paired and non-paired t-tests. RESULTS: Graduating urology residents' self-assessment of their communication and leadership skills did not differ from assessments made by their PDs (77.6 vs. 74.4%; p=0.19); however, there were outlier candidates in whom PD assessment differed substantially from self-assessment on both surveys. Graduating urology residents scored themselves higher on self-awareness (82.6 vs. 77%; p= 0.05) and lower on stress management (67.7 vs. 77%; p= 0.01) compared to their PDs. Resident self-assessment scores were similar to business students on both communication and leadership surveys. Limitations were the small sample size and lack of survey evaluation by those surveyed. CONCLUSIONS: Graduating urology residents' self-assessment of their own communication and leadership skills did not differ greatly from assessment by their PDs or a sample of business students. Comparison of self-assessment evaluations and evaluations by PDs allowed us to identify outliers in whom self-assessment and PD-assessment markedly differed, which may allow for more focused and meaningful feedback.

Impact of a training program on the performance of graduating Canadian residents on a national urology exam: Results of the last 20 years.

INTRODUCTION: Many factors impact the performance of graduating residents on certification exams. It is thought that most factors are related to the individual candidate's ability, motivation, and work ethic. Less understood, however, is whether a training program has any impact on the preparation and performance of its graduates on certification exams. We present 20 years of results of a national preparatory exam that all graduating residents complete about three months before the Royal College of Physicians and Surgeons of Canada (RCPSC) qualifying urology exam. This exam, known colloquially as QUEST, aims to simulate the RCPSC exam with written and oral components. We aimed to analyze the impact of a training program on the performance of its residents. METHODS: A retrospective review of exam results from 1997-2016 was conducted. During that time, 495 candidates from all 12 Canadian urology training programs undertook the exam. The performance of graduating residents from each individual program was grouped together for any given year. The different programs were anonymized, as the aim of this study is to assess the impact of a training program and not to rate the different programs. Statistical analysis using one-way ANOVA was conducted. RESULTS: All training programs fall within one standard deviation of the mean for the written component, the oral component, and the overall score. The residents of four training programs had statistically better scores than the overall mean of the written component. The residents of three out of these four training programs also had statistically better scores than the overall mean of the oral component and the overall results of the exam. CONCLUSIONS: Most Canadian training programs prepare their residents adequately for this simulated certification exam in urology. However, there are some training programs that consistently prepare graduating residents to outperform their peers.

Growth rates and outcomes of observed large renal masses.

INTRODUCTION: The natural history of small renal masses has been well defined, leading to the recommendation of active surveillance in some patients with limited life expectancy. However, this information is less clear for large renal masses (LRM), leading to ambiguity for management in the older, comorbid patient. The objective of this study was to define the natural history, including the growth rate and metastatic risk, of LRM in order to better counsel patients regarding active surveillance. METHODS: This was a retrospective review of patients with solid renal masses >4 cm that had repeated imaging identified from an institutional imaging database. Patient comorbidities and outcomes were obtained through retrospective chart analysis. Outcomes assessed included tumour growth and metastatic rates, as well as cancer-specific (CSS) and overall survival (OS) usimg Kaplan-Meier methodology. RESULTS: We identified 69 patients between 2005 and 2016 who met the inclusion criteria. Mean age at study entry was 75.5 years; mean tumour maximal dimension at study entry was 5.6 cm. CSS was 83% and OS 63% for patients presenting without metastasis, with a mean followup of 57.5 months. The mean growth rate of those that developed metastasis during followup (n=15) was 0.98 cm/year (95% confidence interval [CI] 0.33-1.63) as compared to those that did not develop metastasis (n=46), with a growth rate of 0.67 cm/year (95% CI 0.34-1) (non-significant). Seven patients had evidence of metastasis at the baseline imaging of their LRM and had subsequent growth rate of 1.47 cm/year (95% CI 0.37-2.57) (non-significant) CONCLUSIONS: Compared to small renal masses, LRM are associated with higher metastasis rates and lower CSS and more rapid growth rates. Selection criteria for recommending observation of LRM in older, comorbid patients should be more conservative than for small renal masses.

Attitudes of graduating Canadian urology residents on the job market: Is it getting better or are we just spinning our wheels?

INTRODUCTION: There has been increasing awareness of employment difficulties for physicians, especially surgeons, in Canada over the past few years. Our objective was to elucidate the attitudes and experiences of graduating Canadian urology residents in obtaining employment. METHODS: We surveyed four separate cohorts of graduating urology residents in 2010, 2011, 2016, and 2017. Responses from the 2010 and 2011 cohorts were combined and compared to the combined results of the 2016 and 2017 cohorts. Mean Likert responses were compared using unpaired t-tests. An agreement score was created for those responding with "strongly agree" and "agree" on the Likert scale. RESULTS: A total of 126 surveys were administered with a 100% response rate. The job market was rated as poor or very poor by 64.9% and 58.4% of graduates in 2010/2011 and 2016/2017, respectively (p=0.67). Lack of resources was identified as the biggest barrier to improved employment in both cohorts. Networking at meetings and staff urologists at their institution were the most important factors aiding employment identified by both cohorts. The ideal practice was academic or academically associated community practices in a large urban area, with 5-10 partners for both cohorts. CONCLUSIONS: The majority of graduating urology residents viewed the job market as poor or very poor and this did not change over a six-year period. It is unclear how much personal preference for location and practice type drove the somewhat negative outlook of employment opportunities, as the majority of residents were seeking large urban, academic, or academically associated community practices in competitive locations.

Study habits of Canadian urology residents: Implications for development of a competence by design curriculum.

INTRODUCTION: The purpose of this study was to evaluate the study habits of Canadian urology residents throughout their residency training. METHODS: A survey was administered to all final-year Canadian urology residents over a two-year period. Sixty-seven respondents answered a survey consisting of 54 questions scored on a 10-point Likert score. The survey addressed study habits throughout training, motivations for studying, and preferred resources used. RESULTS: Dedication to studying was directly correlated with proximity to the Royal College of Physicians and Surgeons of Canada (RCPSC) exam. Ninety-six percent of residents reported studying over 10 hours per week during their chief year compared to 0% during their junior year. As residents progressed in their training, preparation for the Royal College exam became the greatest motivator for studying. There was considerable variability in study methods and study resources used throughout training. In their chief year, residents found such resources as the textbook Campbell-Walsh, AUA updates, CUA and AUA guidelines, and the study notes of former trainees to be valuable for their preparation. Teaching rounds, journal clubs, and reading current urological literature were found to be les helpful. Forty-six percent of all residents surveyed indicated that they would prefer writing their RCPSC exam one year earlier than the current timing. CONCLUSIONS: This study provides insight into study habits of Canadian urology residents. This data may be helpful in shaping the future of urology training programs and examinations within Canada and elsewhere.

Attitudes and experiences of residents in pursuit of postgraduate fellowships: A national survey of Canadian trainees.

INTRODUCTION: There have been significant pressures on urology training in North America over the last decade due to both the constantly evolving skill set required and the external demands around delivery of urological care, particularly in Canada. We explore the attitudes and experience of Canadian urology residents toward their postgraduate decisions on fellowship opportunities. METHODS: The study consisted of a self-report questionnaire of 4 separate cohorts of graduating urology residents from 2008 to 2011. The first cohort graduating in 2008 and 2009 were sent surveys through SurveyMonkey.com after graduation from residency; those graduating in 2010 and 2011 were prospectively invited as a convenience sample attending a Queen's Urology Examination Skills Training Program review course just prior to graduation. The survey included both open- and closed-ended questions, employing a 5-point Likert scale, and explored the attitudes and experience of fellowship choices. Likert scores for each question were reported as means ± standard deviation (SD). Descriptive and correlative statistics were used to analyze the responses. In addition, an agreement score was created for those responding with "strongly agree" and "agree" on the Likert scale. RESULTS: A total of 104 surveys were administered, with 84 respondents (80.8% response rate). As a whole, 84.9% of respondents agreed that they pursued fellowships; oncology and minimally invasive urology were the most popular choices throughout the 4 years. Respondents stated that reasons for pursuing a fellowship included: interest in pursuing an academic career (mean 3.73± 1.1 (SD): agreement score 61.1%) as well as acquiring marketable skills to obtain an urology position (3.59 ± 1.3: 64.4%). Most agreed or strongly agreed (84.9%) that a reason for pursing a fellowship was an interest in focusing their practice to this sub-specialty area. In comparison, most graduates disagreed that a reason for pursuing a fellowship was that residency did not equip them with the necessary skills to practice urology (2.49 ± 1.2: 19%). Most (81.2%) of graduates agreed they knew enough about academic urology to know if it would be a suitable career choice for them versus 54.7% regarding community urology (p < 0.0001). Surprisingly, only 61.7% of residents agreed that they completed a community elective during training, and most felt they would have benefited from additional elective time in the community. CONCLUSIONS: Urology residents graduating from Canadian programs pursue postgraduate training to enhance their surgical skill set and to achieve marketability, but also to facilitate a potential academic career. Responses from the trainees suggest that exposure to community practice appears suboptimal and may be an area of focus for programs to aid in career counselling and professional development.

Spontaneous regression of metastatic pulmonary renal cell carcinoma in the setting of sarcomatoid differentiation of the primary tumour.

We present a case of spontaneous regression of pulmonary metastases from renal cell carcinoma (RCC) with sarcomatoid differentiation, prior to intervention. The patient presented with conventional type RCC with Furhman Grade 4/4 and sarcomatoid differentiation, complicated by pulmonary metastases. Palliative systemic therapy was planned, but prior to the onset of treatment, serial computed tomography scans demonstrated regression of metastatic disease. Spontaneous regression of metastases is rare, but well-documented in conventional clear cell RCC. To the best of our knowledge, this has not previously been described in the setting of sarcomatoid differentiation of the primary tumour.

Review of the efficacy and safety of cryoablation for the treatment of small renal masses.

PURPOSE: Small renal masses are increasingly being discovered incidentally on imaging for another reason. The standard of care of these masses involves excision by open or laparoscopic techniques. Recently, ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, have taken a more prominent role in the treatment algorithm of these masses. We evaluate the effectiveness and safety of cryoablation to treat renal tumours. METHODS: A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: the Cochrane Library, PUBMED, EMBASE and LILACS. RESULTS: There was no clinical trial identified in the literature. Thus, we described the results from 23 case series and retrospective studies with a reasonable sample size (number of reported patients in each study ≥30), with a total of 2104 analyzed tumours from 2038 patients. There was wide variability in the outcomes reported, but success rates were generally good. Follow-up was generally short, but some series reported outcomes at 5 years. The most common complications reported were hemorrhage (some of the patients requiring transfusion), perinephric hematoma and urine leaks. CONCLUSION: Cryoablation presents a feasible treatment for patients with small renal masses. Only short-term data are available and, as such, meaningful conclusions regarding long-term cancer control cannot be made. More rigorous studies are needed.

Laparoscopic partial nephrectomy: The McMaster University experience.

INTRODUCTION: : Laparoscopic partial nephrectomy (LPN) remains one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumour. We report a large Canadian series of laparoscopic partial nephrectomy with intermediate follow-up. METHODS: : Between September 2000 and August 2008, 152 consecutive laparoscopic partial nephrectomies were performed at our centre. Demographic, pathological and clinical data were collected through a retrospective review of the charts. RESULTS: : The average tumour size was 2.68 cm (Range: 0.5-8.8. The vast majority of tumours were malignant (80%). All margins were negative, except for 2 patients who underwent an immediate re-resection. There were no local recurrences or distant metastasis during the follow-up period of 44.3 months. Most procedures required hilar clamping (93.4%) with a mean WIT of 34 minutes, with a clear trend for declining WIT with increasing experience. Five procedures were converted to laparoscopic radical nephrectomy, 10 converted to a hand-assisted procedure, and 1 was converted to an open partial nephrectomy. The average blood loss was 162 cc. Complications related to the procedure were classified according to the Clavien grading system. The average drop in the glomerular filtration rate was calculated by the Modification of Diet in Renal Disease (MDRD) Study equation between preoperative and 2.5 months postoperative was 8.6 mL/min/1.73 m(2). CONCLUSIONS: : LPN is a challenging procedure that requires advanced laparoscopic skills. LPN is feasible with excellent oncological outcomes, and an acceptable complication profile. The short-term impact on overall renal function is minimal. The most common postoperative complication was pseudo-aneurysm requiring embolization, which reinforces the intra-operative need for meticulous and a quick suture-ligation of blood vessels during LPN.

Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies.

UNLABELLED: Study Type - Therapy (systematic review). Level of Evidence 2b What's known on the subject? and What does the study add? The oncological success of partial nephrectomy in the treatment of small renal masses is well established. However, partial nephrectomy has largely supplanted the radical approach. In the last decade, laparoscopy has been adopted as the new surgical approach for the treatment of renal cell carcinoma. Laparoscopy offers the advantage of lower analgesic use, shorter hospital stay, and quicker recovery time. More recently, ablative technologies have been investigated as an alternative to laparoscopic partial nephrectomy. These techniques can often be performed percutaneously in the radiology suite, or laparoscopically without the need for hilar clamping. However, only the cryoablation and radiofrequency ablation modalities have had widespread use with several series reporting short to intermediate results. This review shows that both cryoablation and radiofrequency ablation are promising therapies in patients with small renal tumours (<4 cm), who are considered poor candidates for more involved surgery. OBJECTIVE: • To determine the current status of the literature regarding the clinical efficacy and complication rates of cryoablation vs radiofrequency ablation in the treatment of small renal tumours. METHODS: • A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: MEDLINE, EMBASE and LILACS. • Inclusion criteria were (i) case series design with more than one case reported, (ii) use of cryoablation or radiofrequency ablation, (iii) patients with renal cell carcinoma and, (iv) outcome reported as clinical efficacy. • When available, we also quantified the complication rates from each included study. • Proportional meta-analysis was performed on both outcomes with a random-effects model. The 95% confidential intervals were also calculated. RESULTS: • Thirty-one case series (20 cryoablation, 11 radiofrequency ablation) met all inclusion criteria. • The pooled proportion of clinical efficacy was 89% in cryoablation therapy from a total of 457 cases. There was a statistically significant heterogeneity between these studies showing the inconsistency of clinical and methodological aspects. • The pooled proportion of clinical efficacy was 90% in radiofrequency ablation therapy from a total of 426 cases. There was no statistically significant heterogeneity between these studies. • There was no statistically significant difference regarding complications rate between cryoablation and radiofrequency ablation. CONCLUSIONS: • This review shows that both ablation therapies have similar efficacy and complication rates. • There is urgency for performing clinical trials with long-term data to establish which intervention is most suitable for the treatment of small renal masses.

Extracapsular versus intracapsular allograft nephrectomy: impact on allosensitization and surgical outcomes.

INTRODUCTION: Our objective was to compare the impact of extra-capsular (ECAN) versus intracapsular allograft nephrectomy (ICAN) on allosensitization and surgical outcomes. METHODS: Between 1990 and 2004, 96 allograft nephrectomies were performed at our institution. Of these, 29 procedures were performed within 1 month of the transplant and were therefore omitted from analysis. Overall, the results of 44 ECAN and 23 ICAN were reviewed. RESULTS: The mean operative times were 110.9 versus 130.4 min for ICAN versus ECAN (p = 0.02) and the estimated blood loss was 226 mL for ICAN versus 483 mL for ECAN (p = 0.004). Intraoperative and postoperative complications were low using either technique and differences were not statistically significant. Overall, the preoperative to postoperative change in the percentage of panel reactive antibody was +2.1% for ICAN versus +1.2% for ECAN (NS) at 3 to 12 months postoperatively, respectively (NS). The percentage of patients relisted was 33.3% versus 54.3% (NS), and the percentage of patients re-transplanted once relisted was also very similar: 63.2% for ECAN versus 66.7% for ICAN (NS), after a mean follow-up of 4.5 and 8.4 years, respectively. CONCLUSIONS: ICAN can be performed with shorter operative times and less blood loss versus the extracapsular approach. As well, this operative approach does not appear to affect allosensitization and the ability to re-transplant patients.