Use of Artificial Intelligence for Medical Literature Search: Randomized Controlled Trial Using the Hackathon Format.

BACKGROUND: Mapping out the research landscape around a project is often time consuming and difficult. OBJECTIVE: This study evaluates a commercial artificial intelligence (AI) search engine (IRIS.AI) for its applicability in an automated literature search on a specific medical topic. METHODS: To evaluate the AI search engine in a standardized manner, the concept of a science hackathon was applied. Three groups of researchers were tasked with performing a literature search on a clearly defined scientific project. All participants had a high level of expertise for this specific field of research. Two groups were given access to the AI search engine IRIS.AI. All groups were given the same amount of time for their search and were instructed to document their results. Search results were summarized and ranked according to a predetermined scoring system. RESULTS: The final scoring awarded 49 and 39 points out of 60 to AI groups 1 and 2, respectively, and the control group received 46 points. A total of 20 scientific studies with high relevance were identified, and 5 highly relevant studies ("spot on") were reported by each group. CONCLUSIONS: AI technology is a promising approach to facilitate literature searches and the management of medical libraries. In this study, however, the application of AI technology lead to a more focused literature search without a significant improvement in the number of results.

A High-Fidelity Phantom for the Simulation and Quantitative Evaluation of Transurethral Resection of the Prostate.

Transurethral resection of the prostate (TURP) is a minimally invasive endoscopic procedure that requires experience and skill of the surgeon. To permit surgical training under realistic conditions we report a novel phantom of the human prostate that can be resected with TURP. The phantom mirrors the anatomy and haptic properties of the gland and permits quantitative evaluation of important surgical performance indicators. Mixtures of soft materials are engineered to mimic the physical properties of the human tissue, including the mechanical strength, the electrical and thermal conductivity, and the appearance under an endoscope. Electrocautery resection of the phantom closely resembles the procedure on human tissue. Ultrasound contrast agent was applied to the central zone, which was not detectable by the surgeon during the surgery but showed high contrast when imaged after the surgery, to serve as a label for the quantitative evaluation of the surgery. Quantitative criteria for performance assessment are established and evaluated by automated image analysis. We present the workflow of a surgical simulation on a prostate phantom followed by quantitative evaluation of the surgical performance. Surgery on the phantom is useful for medical training, and enables the development and testing of endoscopic and minimally invasive surgical instruments.

Validating Automated Kidney Stone Volumetry in CT and Mathematical Correlation with Estimated Stone Volume Based on Diameter.

OBJECTIVES: To validate AutoMated UroLithiasis Evaluation Tool (AMULET) software for kidney stone volumetry and compare its performance to standard clinical practice. MATERIALS AND METHODS: Maximum diameter and volume of 96 urinary stones were measured as reference standard by three independent urologists. The same stones were positioned in an anthropomorphic phantom and CT scans acquired in standard settings. Three independent radiologists blinded to the reference values took manual measurements of the maximum diameter and automatic measurements of maximum diameter and volume. An "expected volume" was calculated based on manual diameter measurements using the formula: [Formula: see text] Results: Ninety-six stones were analyzed in the study. We had initially aimed to assess 100. Nine were replaced during data acquisition due of crumbling and four had to be excluded because the automated measurement did not work. Mean reference maximum diameter was 13.3 mm (5.2-32.1 mm). Correlation coefficients among all measured outcomes were compared. The correlation between the manual and automatic diameter measurements to the reference was 0.98 and 0.91, respectively (p < 0.001). Mean reference volume was 1200 mm3 (10-9000 mm3). The correlation between the "expected volume" and automatically measured volume to the reference was 0.95 and 0.99, respectively (p < 0.001). CONCLUSIONS: Patients' kidney stone burden is usually assessed according to maximum diameter. However, as most stones are not spherical, this entails a potential bias. Automated stone volumetry is possible and significantly more accurate than diameter-based volumetric calculations. To avoid bias in clinical trials, size should be measured as volume. However, automated diameter measurements are not as accurate as manual measurements.

Wireless Acoustic-Surface Actuators for Miniaturized Endoscopes.

Endoscopy enables minimally invasive procedures in many medical fields, such as urology. However, current endoscopes are normally cable-driven, which limits their dexterity and makes them hard to miniaturize. Indeed, current urological endoscopes have an outer diameter of about 3 mm and still only possess one bending degree-of-freedom. In this article, we report a novel wireless actuation mechanism that increases the dexterity and that permits the miniaturization of a urological endoscope. The novel actuator consists of thin active surfaces that can be readily attached to any device and are wirelessly powered by ultrasound. The surfaces consist of two-dimensional arrays of microbubbles, which oscillate under ultrasound excitation and thereby generate an acoustic streaming force. Bubbles of different sizes are addressed by their unique resonance frequency, thus multiple degrees-of-freedom can readily be incorporated. Two active miniaturized devices (with a side length of around 1 mm) are demonstrated: a miniaturized mechanical arm that realizes two degrees-of-freedom, and a flexible endoscope prototype equipped with a camera at the tip. With the flexible endoscope, an active endoscopic examination is successfully performed in a rabbit bladder. The results show the potential medical applicability of surface actuators wirelessly powered by ultrasound penetrating through biological tissues.

Is Endoscopic Vasectomy Just a Dream: An ex vivo Study on Feasibility and Reliability of Endoluminal Occlusion of Porcine Vas Deferens.

INTRODUCTION AND AIM: Surgical vasectomy remains the gold standard for fertility control in men. Endoluminal occlusion of the seminal ducts, thus avoiding an external incision, may become an appealing alternative to this approach. As our group has shown, nontraumatic endoscopic inspection of the seminal ducts is feasible in the human cadaver. We investigated the feasibility and reliability of occlusion using several commercially available medical sealing agents in the porcine vas deferens (VD). METHODS AND MAIN OUTCOME MEASURES: Tests were conducted using 25 porcine spermatic ducts (10 cm length) ex vivo. The explanted specimens were fixed and cannulated using the Seldinger technique. We administered 5 different agents (n-butyle-2-cyanoacrylate, n-butyle-2-cyanoacrylate in combination with a platinum vascular coil, Tissucol Duo S®, Gelita Spon® and AFP Plug®) endoluminally. Tightness was evaluated after 5, 15, 60, 360, 720, and 1,440 min for each of the five grades, respectively, using a solution of methylene blue and saline injected under controlled pressure of 300 mm Hg followed by histological examination. RESULTS: All agents were administered into the porcine seminal ducts (4 out of 5 via a ureteric catheter). Gelita Spon® and Tissucol Duo S® did not occlude the lumen sufficiently, whereas n-butyle-2-cyanoacrylate, n-butyle-2-cyanoacrylate in combination with coil, Tissucol Duo and AFP Plug® performed satisfactorily. In particular, cyanoacrylate combined with a coil was able to close the seminal duct tightly and for a long time. Histological findings confirmed this sealant's gapless adhesion. AFP Plug® application revealed similarly good results. However, its form needs to be optimized to ensure its suitability for endoscopic use. CONCLUSION: Various developments regarding minimally invasive fertility control methods have been underway for decades. Further miniaturization of endoscopy and novel materials may pave the way for endoscopic fertility control in males in the future. We demonstrated the potential of commercially available medical sealing agents to reliably occlude the porcine VD.

Algorithm-Based Motion Magnification for Video Processing in Urological Laparoscopy.

PURPOSE: Minimally invasive surgery is in constant further development and has replaced many conventional operative procedures. If vascular structure movement could be detected during these procedures, it could reduce the risk of vascular injury and conversion to open surgery. The recently proposed motion-amplifying algorithm, Eulerian Video Magnification (EVM), has been shown to substantially enhance minimal object changes in digitally recorded video that is barely perceptible to the human eye. We adapted and examined this technology for use in urological laparoscopy. MATERIALS AND METHODS: Video sequences of routine urological laparoscopic interventions were recorded and further processed using spatial decomposition and filtering algorithms. The freely available EVM algorithm was investigated for its usability in real-time processing. In addition, a new image processing technology, the CRS iimotion Motion Magnification (CRSMM) algorithm, was specifically adjusted for endoscopic requirements, applied, and validated by our working group. RESULTS: Using EVM, no significant motion enhancement could be detected without severe impairment of the image resolution, motion, and color presentation. The CRSMM algorithm significantly improved image quality in terms of motion enhancement. In particular, the pulsation of vascular structures could be displayed more accurately than in EVM. CONCLUSIONS: Motion magnification image processing technology has the potential for clinical importance as a video optimizing modality in endoscopic and laparoscopic surgery. Barely detectable (micro)movements can be visualized using this noninvasive marker-free method. Despite these optimistic results, the technology requires considerable further technical development and clinical tests.

Soft 3D-Printed Phantom of the Human Kidney with Collecting System.

Organ models are used for planning and simulation of operations, developing new surgical instruments, and training purposes. There is a substantial demand for in vitro organ phantoms, especially in urological surgery. Animal models and existing simulator systems poorly mimic the detailed morphology and the physical properties of human organs. In this paper, we report a novel fabrication process to make a human kidney phantom with realistic anatomical structures and physical properties. The detailed anatomical structure was directly acquired from high resolution CT data sets of human cadaveric kidneys. The soft phantoms were constructed using a novel technique that combines 3D wax printing and polymer molding. Anatomical details and material properties of the phantoms were validated in detail by CT scan, ultrasound, and endoscopy. CT reconstruction, ultrasound examination, and endoscopy showed that the designed phantom mimics a real kidney's detailed anatomy and correctly corresponds to the targeted human cadaver's upper urinary tract. Soft materials with a tensile modulus of 0.8-1.5 MPa as well as biocompatible hydrogels were used to mimic human kidney tissues. We developed a method of constructing 3D organ models from medical imaging data using a 3D wax printing and molding process. This method is cost-effective means for obtaining a reproducible and robust model suitable for surgical simulation and training purposes.

Flexible Vesiculovasoscopy Using a Microoptical System in a Human Cadaver Model: An Experimental Approach for Atraumatic Endoscopy of the Seminal Tract.

OBJECTIVES: The most common pathologies of the seminal tract are persistent hematospermia, seminal vesicle stones, and seminal duct obstruction. Endoscopic diagnostic work-up of the seminal tract is impeded by complex anatomy and lack of technical equipment. To date, there is no standardized endoscopic approach. The purpose of this study was to investigate the applicability and feasibility of a flexible microoptical device for atraumatic endoscopy of the seminal tract in a male human cadaver. MATERIALS AND METHODS: The transurethral endoscopic examination was performed on a male cadaver. No premortal interventions or diseases of the genitourinary tract had been reported. The seminal orifice was identified via cystoscopy and accessed by the Seldinger technique using a hydrophilic guidewire and ureteral catheter. Retrograde endoscopic inspection of the distal seminal tract was performed using a miniaturized flexible endoscope. An antegrade endoscopic inspection of the seminal tract was carried out via high scrotal access to the vas deferens. RESULTS: Structures of the seminal tract, such as the ejaculatory duct, seminal vesicles, and distal portion of the ductus deferentes, were visualized using the miniaturized endoscope. Image quality allowed identification of anatomical structures and characterization of tissue properties. The technical limitations we observed involved the system's maneuverability. CONCLUSIONS: Initial results of this novel endoscopic approach to the seminal tract using a flexible microoptical system are encouraging. However, considerable anatomical limitations of the targeted organs necessitate further refinements of the technical equipment. This approach might improve diagnostics and treatment of genitourinary diseases. Future surgical techniques may include intraseminal laser therapy or endoocclusion to monitor fertility in men.

Endoscopically Determined Stone Clearance Predicts Disease Recurrence Within 5 Years After Retrograde Intrarenal Surgery.

OBJECTIVE: To assess stone-related events (SREs) requiring retreatment in a series of 100 consecutive patients treated by retrograde intrarenal surgery (RIRS) for renal stones and to evaluate potential risk factors thereof. PATIENTS AND METHODS: The primary outcome was incidence of SRE (medical or surgical treatment). Secondary outcomes included side of SRE, time to SRE, and late complications. Analysis of potential risk factors included high-risk stone formers (HRSFs), obesity, high stone burden, and lower pole stones. In addition, we evaluated endoscopically determined small residual fragments (SRF) of <1 mm (i.e., fragments too small for retrieval) as an independent risk factor. RESULTS: Eighty-five of the 99 patients were followed up for a mean of 59 months (31-69), among whom 26 (30.1%) had SRE. Thirty-four of the 85 (40%) patients were HRSFs, 22 of whom experienced SRE (both sides) during follow-up (64.7%, p < 0.001). Eight of the 17 patients (47.1%) with SRF experienced ipsilateral side SRE compared with 13 (19.1%) of the 68 without SRF (p = 0.022, hazard ratio 2.823, 95% confidence interval [95% CI] 1.16, 6.85). Risk for ipsilateral SRE was unaffected by the presence of SRF among HRSFs (p = 0.561). Of low-risk patients with SRF, 33.3% experienced ipsilateral SRE, while those without SRF experienced no ipsilateral SRE (p < 0.001). CONCLUSION: Endoscopically determined stone clearance predicts disease recurrence within 5 years after RIRS. Even SRF are an important risk factor for future stone-related (ipsilateral) events; therefore, patients with residual fragments of any size should not be labeled "stone free" and endoscopic stone treatment should aim at complete stone clearance.

Level of evidence, sponsorship, conflict of interest policy and commercial impact of PubMed-listed clinical urolithiasis-related trials in 2014.

OBJECTIVES: To evaluate published trials on urolithiasis regarding level of evidence, type of sponsorship and declared conflicts of interest (COIs), and to elucidate a potential commercial impact. MATERIALS AND METHODS: We performed a systematic PubMed(®) literature search using a predefined Boolean search term to identify PubMed-listed clinical research studies on urolithiasis in 2014 (fourth quarter). All authors screened the results for eligibility criteria and two independent reviewers evaluated and performed data extraction of predefined endpoints, including level of evidence, declaration of COI and sponsorship/funding (as indicated in the published print version), and commercial impact. RESULTS: A total of 110 clinical trials in urolithiasis listed in PubMed met the inclusion criteria. Levels of evidence 1, 2, 3 and 4 were found in 15%, 14%, 21% and 51% of trials, respectively. A COI was indicated in a total of 90% of publications, 93% of which declared no existing conflict of interest. Sponsorship was indicated in 36% of publications, 55% of which stated public funding, 33% institutional funding, 10% industrial funding and 2% both public and industrial funding. A total of 11% of the published trials were rated as having a high commercial impact. CONCLUSION: The present study provides evidence of increasing levels of evidence for published clinical trials on urolithiasis in 2014 (as compared with earlier data). Ninety percent of publications indicated conflicts of interest, whereas sponsoring of studies was declared only by one-third. A considerable number of trials involved issues of high commercial impact. Recently established legal programmes and voluntary acts on self-reporting of financial relationships will enhance transparency in the future; however, increased public funding will be needed to further promote the quality of trials on urolithiasis.

Stereoscopic (3D) versus monoscopic (2D) laparoscopy: comparative study of performance using advanced HD optical systems in a surgical simulator model.

PURPOSE: To compare task performances of novices and experts using advanced high-definition 3D versus 2D optical systems in a surgical simulator model. METHODS: Fifty medical students (novices in laparoscopy) were randomly assigned to perform five standardized tasks adopted from the Fundamentals of Laparoscopic Surgery (FLS) curriculum in either a 2D or 3D laparoscopy simulator system. In addition, eight experts performed the same tasks. Task performances were evaluated using a validated scoring system of the SAGES/FLS program. Participants were asked to rate 16 items in a questionnaire. RESULTS: Overall task performance of novices was significantly better using stereoscopic visualization. Superiority of performances in 3D reached a level of significance for tasks peg transfer and precision cutting. No significant differences were noted in performances of experts when using either 2D or 3D. Overall performances of experts compared to novices were better in both 2D and 3D. Scorings in the questionnaires showed a tendency toward lower scores in the group of novices using 3D. CONCLUSIONS: Stereoscopic imaging significantly improves performance of laparoscopic phantom tasks of novices. The current study confirms earlier data based on a large number of participants and a standardized task and scoring system. Participants felt more confident and comfortable when using a 3D laparoscopic system. However, the question remains open whether these findings translate into faster and safer operations in a clinical setting.

Clinical significance of residual fragments in 2015: impact, detection, and how to avoid them.

PURPOSE: Residual fragments are common after stone treatment. Little is known about clinical outcomes relevant to the patient. This comprehensive review of the literature highlights the impact of residual fragments, modes of detection, and treatment strategies to avoid residual fragments in shock wave therapy, ureteroscopy, and percutaneous nephrolithotomy. METHODS: A comprehensive review of current literature was performed using PubMed(®), MEDLINE(®), Embase™, Ovid(®), Google Scholar™, and the Cochrane Library. Publications relevant to the subject were retrieved and critically appraised. RESULTS: Residual fragments after treatment for urinary stones have a significant impact on a patient's well-being and future course. (Ultra-) low-dose non-contrast computed tomography detects small residuals most reliably. In shock wave lithotripsy, adherence to basic principles helps to improve results. Various techniques and devices facilitate complete stone clearance in conventional and miniaturized percutaneous nephrolithotomy and (flexible) ureteroscopy. Promising new technologies in shock waves, lasers, and robotics (and potentially microrobotics) are on the horizon. CONCLUSIONS: Residual fragments are relevant to patients. Contemporary treatment of urolithiasis should aim at complete stone clearance.

Focused Dual-energy CT Maintains Diagnostic and Compositional Accuracy for Urolithiasis Using Ultralow-dose Noncontrast CT.

OBJECTIVE: To evaluate the diagnostic accuracy of a new energy and radiation dose-reduced protocol for noncontrast computed tomography (NCCT) with dual-energy CT (DECT) analysis and its potential for the compositional analysis of uric acid (UA)- or non-uric acid (N-UA)-containing calculi. METHODS: A retrospective evaluation was carried out in 61 patients who underwent dose-reduced DECT (tube A: 140 kV/55 mAs; tube B: 80 kV/303 mAs) with a tube current 38.8% lower than that set by the manufacturer. A protocol combining low-dose CT and targeted DE scans was used. Urinary stones were detected and classified as UA- or N-UA-containing or mixed based on DE software results. The accuracy of the compositional analysis was controlled by correlation with conventional infrared-based analysis. RESULTS: The compositional stone differentiation was correct in 58 of 61 (95.1%) patients. The sensitivity of detecting pure UA-containing and pure N-UA-containing stones was 100%. The specificity of detecting UA- and pure N-UA-containing stones was 100% and 78.57%, respectively, as 3 of 7 mixed urinary stones (small fragments <4 mm) were classified as N-UA calculi. The total radiation dose in patients with body mass index <25 and >25 kg/m(2) was 1.2 and 2.5 mSv, respectively. CONCLUSION: Lowering the DECT tube current by up to 38% of the manufacturer's recommendations allows a reduced radiation dose without impairing detection accuracy and stone compositional analysis. Compared with previous studies, this protocol might significantly decrease patient radiation exposure without affecting the quality of results.

Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of analgesic consumption and treatment-related patient satisfaction in patients with renal stones 10-35 mm.

PURPOSE: To compare ultra-mini PCNL (UMP) and flexible ureteroscopy (fURS) for the treatment of medium- to large-sized renal stones with a focus on patients' postsurgical cumulative analgesic consumption and treatment-related satisfaction. METHODS: Twenty-five patients treated by UMP between April 2013 and October 2014 were matched to data of 25 fURS patients from an existing database. Clinical outcome parameters were recorded prospectively. Postoperative analgesic consumption was assessed using the Cumulative Analgesic Consumption Score (CACS), and satisfaction was measured with the Freiburg Index of Patient Satisfaction (FIPS) questionnaire. RESULTS: Perioperative outcome parameters showed no significant differences except for mean operating times (fURS 98.52 min, UMP 130.12 min [p = 0.002]) and hospital stay (fURS 67.2 h, UMP 91.5 h [p = 0.04]). Primary stone-free rate was 96 % in fURS and 92 % in UMP. Complications Clavien grade 2 or 3 occurred in 16 % of UMP patients and in 4 % of fURS patients. Postsurgical cumulative analgesic consumption was almost identical in both groups with CACSs of 6.96 (0-15) for fURS and 6.8 (0-23) for UMP. Patients' satisfaction was high in both techniques: FIPS score in fURS 1.67 (1-3) and 1.73 (1-4) in UMP (scale 1-6). CONCLUSIONS: Treatment of medium- to large-sized renal stones is safe and highly effective by both UMP and fURS. Moreover, both treatments yield comparable postsurgical analgesic requirements and high patient satisfaction scores. Patient-related factors (anatomical and stone related) and availability of technical equipment and surgical expertise appear to be the most important determining factors in treatment planning.

An anti-ubiquitin antibody response in transitional cell carcinoma of the urinary bladder.

BACKGROUND: To use combinatorial epitope mapping ("fingerprinting") of the antibody response to identify targets of the humoral immune response in patients with transitional cell carcinoma (TCC) of the bladder. METHODS: A combinatorial random peptide library was screened on the circulating pool of immunoglobulins purified from an index patient with a high risk TCC (pTa high grade plus carcinoma in situ) to identify corresponding target antigens. A patient cohort was investigated for antibody titers against ubiquitin. RESULTS: We selected, isolated, and validated an immunogenic peptide motif from ubiquitin as a dominant epitope of the humoral response. Patients with TCC had significantly higher antibody titers against ubiquitin than healthy donors (p<0.007), prostate cancer patients (p<0.0007), and all patients without TCC taken together (p<0.0001). Titers from superficial tumors were not significantly different from muscle invasive tumors (p = 0.0929). For antibody response against ubiquitin, sensitivity for detection of TCC was 0.44, specificity 0.96, positive predictive value 0.96 and negative predictive value 0.41. No significant titer changes were observed during the standard BCG induction immunotherapy. CONCLUSIONS: This is the first report to demonstrate an anti-ubiquitin antibody response in patients with TCC. Although sensitivity of antibody production was low, a high specificity and positive predictive value make ubiquitin an interesting candidate for further diagnostic and possibly immune modulating studies.

Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10-20 mm.

PURPOSE: Latest publications state equal efficacy of a recently introduced new percutaneous technique ("ultra-mini PCNL", UMP) and flexible ureteroscopy (fURS) in the treatment of medium-size urinary stones. Today we face challenges concerning cost-effectiveness and reduction of in-hospital length of stay. In this retrospective study, we compare clinical outcome parameters and costs of treatment (endoscopes and disposables) of both techniques. METHODS: Thirty patients treated by UMP at two tertiary university centres were matched to 30 fURS patients from previously recorded databases. Data analysis included operating time, length of stay, stone-free rates (SFR), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures) and costs for disposable materials and instruments (endoscopes, as calculated per procedure). RESULTS: We found no significant differences in operating times (UMP vs. fURS: 121/102 min), hospital length of stay (2.3/2.0 days), SFR (84/87 %) and complications (7/7 %). Costs for disposable materials and endoscopes were 656 euro (UMP) and 1,160 euro (fURS) per procedure. CONCLUSIONS: UMP and fURS are both safe and effective in the treatment of medium-size urinary stones. Costs for endoscopes and disposable materials are significantly lower in UMP.

Splice variant transcripts of the anterior gradient 2 gene as a marker of prostate cancer.

Anterior gradient 2 (AGR2) is a gene predominantly expressed in mucus-secreting tissues or in endocrine cells. Its expression is drastically increased in tumors including prostate cancer. Here we investigated whether AGR2 transcript levels can be used as a biomarker to detect prostate cancer (PCa). Using a PCR-based approach, we could show that in addition to the wild-type (AGRwt long and short) transcripts, five other AGR2 splice variants (SV) (referred to as AGR2 SV-C, -E, -F, -G and -H) were present in cancer cell lines. In tissue biopsies, SV-H and AGR2wt (short) distinguished between benign and PCa (p ≤ 0.05 n = 32). In urine exosomes, AGR2 SV-G and SV-H outperformed serum PSA. Receiver operating characteristic (ROC) curves showed the highest discriminatory power of SV-G and SV-H in predicting PCa. AGR2 SV-G and SV-H are potential diagnostic biomarkers for the non-invasive detection of PCa using urine exosomes.

Bringing excellence into urology: How to improve the future training of residents?

THE PROBLEM: The demographic development of society leads to an increased demand for physicians. Particularly in the surgical disciplines, there is a noticeably declining interest among graduates from medical schools worldwide. For reasons discussed in detail, this applies especially to urology. SOLUTIONS: We indicate possibilities on how to counteract this trend, by improving the training for urology residents. Whereas some major changes for the better have already been introduced into the curricula in some countries, others will have to be further specified in the future. This article gives an overview of the requirements of a specific training programme, from a planning phase to its certification. Aspects such as the selection of candidates, the goals of a good training programme, and an implementation strategy are presented. Essential elements of a urology resident programme for effective coaching, improving medical skills (e.g. in surgical laboratories), knowledge revision, progress evaluation, and retrospection are discussed critically, giving an understanding of the crucial requirements of a good and attractive education in urology. CONCLUSION: A structured and well organised training programme might attract additional medical students towards urology and contribute significantly to the further development of the speciality. This can be seen as an initiative to counteract the decline of urology as an attractive field of interest to upcoming generations of physicians, and therefore to ensure urological care of the highest quality that patients deserve.

Standardized flexible ureteroscopic technique to improve stone-free rates.

OBJECTIVE: To present a unique completely standardized sequence of steps performed before, during, and after flexible ureteroscopy (FURS) that achieves superior results for FURS treatment of renal calculi. MATERIALS AND METHODS: The "Freiburg FURS technique" includes the following steps: (a) preoperative ureteral stenting; (b) placement of 2 hydrophilic wires; (c) semirigid ureteroscopy before FURS; (d) the use of a large access sheath (14F-16F) if multiple ureteral passages are expected; (e) the use of a 2-working channel flexible endoscope; (f) a modified active flushing system; and (g) an advanced holmium laser technique with complete stone extraction. We performed a prospective analysis of 153 consecutive FURS procedures for nephrolithiasis from August 2009 to July 2011. RESULTS: Data analysis revealed an "immediate" stone-free rate of 96.7% (as confirmed by endoscopy, fluoroscopy, and ultrasonography), a medium of 2.3 stones, and a cumulative stone size of 10.5 mm (range 3-43). The operative time was 67 minutes (range 20-160). The use of an access sheath was required in 71% of the patients and the postoperative use of a double-J stent in 57% of patients. Complications (Clavien grade II and III) developed in 9.1% of patients (including 7 with minimal perforation that required ureteral stenting for 1 month, 3 with secondary flank pain/hydronephrosis requiring double-J stenting and hospitalization, and 4 with fever or urinary tract infections requiring antibiotic therapy. Follow-up examinations after 3 months showed no late complications. CONCLUSION: The modified FURS technique provided clinically superior results with a low complication rate. However, the approach requires the use of considerable resources, both technical and surgical and financial.