What is Transferred and How Much is Retained? A Simulation Study of Complex Surgical Skills.

INTRODUCTION: Studies indicate that learning surgical skills on low-fidelity models is equally beneficial to learning on high-fidelity models in terms of skills retention and transfer. However, it is unclear how low-fidelity simulation training impacts retention and transfer in novice learners, particularly on complex surgical tasks that incorporate multiple challenging skills. This study explores the capacity of complete novices to learn and transfer complex surgical skills from a low-fidelity model to a high-fidelity simulation after a delay. METHODS: Task-naïve medical and nonmedical undergraduate students (n = 62) participated in a three-phase prospective double-arm randomized (2:1) experimental study. Participants completed two skills training sessions (end-to-side anastomosis) on a low-fidelity bench model. After a 4-week delay, participants completed the task again either using the low-fidelity model or a high-fidelity model (cadaver) and were assessed using a validated checklist. RESULTS: There was a significant time × fidelity group interaction (P = 0.004). Simple effects analysis indicated the high-fidelity group (Mdiff = 4.18, P < 0.001) performed significantly worse (P = 0.003) in phase 3 relative to phase 2 compared to the low-fidelity group (Mdiff = 0.75, P = 0.39). Post hoc logistic regression analysis indicated that radial suturing technique and economy of motion skills were less likely to be completed correctly for those in the high-fidelity group. CONCLUSIONS: These findings suggest that for novice populations, relying on low-fidelity simulation training as a source of teaching complex skills may not provide a reliable transfer to high-fidelity models and in turn clinical settings.

Chronic pain associated with penile prostheses may persist despite revision or explantation.

INTRODUCTION: Inflatable penile prosthesis (IPP) implantation is the gold standard treatment for medically refractory erectile dysfunction. New chronic pain after IPP implantation is rarely discussed and the optimal treatment is unclear. We evaluated whether IPP re-operation for a primary indication of chronic pain improves patients' symptoms. Our secondary aim was to explore factors associated with resolution or persistence of pain after IPP reoperation. METHODS: We conducted a retrospective analysis of 315 patients who had an IPP revision or explantation at two high-volume prosthetic centers between May 2007 and May 2017. We excluded patients who had device malfunction, pain for <2 months, pain associated with infection or erosion, and patients without long-term followup data. Persistent pain was diagnosed based on patient self-report. RESULTS: A total of 31 patients met our criteria for having undergone a surgical revision (n=18) or explantation (n=13) for pain relief. Eighteen (58%) patients had persistent pain despite surgical intervention. Only patients who had pain secondary to a device malposition improved after re-operation (n=13). A prior diagnosis of a chronic pain syndrome was associated with persistent pain despite intervention. Pain improvement was not associated with age, comorbid conditions, duration of implant, or the number of surgical revisions performed. CONCLUSIONS: Surgical intervention for chronic penile prosthesis pain is unlikely to relieve symptoms, particularly for patients with chronic pain disorders. Patients should be counselled that IPP reoperative procedures as a treatment for pain should be avoided unless the device is identified to be malpositioned, and consideration of alternative therapeutic options may be more beneficial.

Point-of-care ultrasonography for the diagnosis of testicular torsion: a practical resident curriculum.

Background: Prompt Doppler ultrasonography to aid in diagnosis is often key to managing testicular torsion, but there may be delays in access; a faster, more widely available alternative is point-of-care ultrasonography (POCUS). The purpose of this study was to develop and evaluate a scrotal POCUS curriculum for urology and emergency medicine residents. Methods: Content experts in urology, emergency medicine and diagnostic imaging collaborated in a modified Delphi method to design a practical didactic curriculum for scrotal POCUS for the identification of testicular torsion. Training included 3 online video teaching modules and a 1-hour hands-on teaching session with standardized adult patients. We evaluated participants' competency in scrotal POCUS using a validated scale. We assessed participants' knowledge, comfort and confidence in performing scrotal POCUS before and after the intervention and at 3 months. Results: Twenty-four urology (n = 12) and emergency medicine (n = 12) residents participated in the curriculum. After hands-on practice, 23 participants (96%) were deemed competent at scrotal POCUS. Pre-post testing showed significant improvement in knowledge (mean score 63% v. 80%, p < 0.001), comfort (mean Likert score 0.6 v. 3.6, p < 0.001) and confidence (mean Likert score 1.0 v. 2.1, p < 0.001) after the intervention. These effects were maintained at the 3-month assessment. Conclusion: The scrotal POCUS curriculum was effective and acceptable to both urology and emergency medicine residents. The findings suggest that scrotal POCUS can be learned effectively through a short hands-on session and didactic instruction.

Contexte: Le diagnostic rapide d'une torsion testiculaire à l'aide d'une échographie Doppler est souvent crucial à la prise en charge de ce trouble. Or, comme l'accès à cet examen peut être limité, l'échographie portable constitue une solution de rechange rapide et largement accessible. La présente étude visait la mise au point et l'évaluation d'un programme de formation sur l'échographie portable scrotale destiné aux résidents en urologie et en médecine d'urgence. Méthodes: Des experts en urologie, en médecine d'urgence et en imagerie diagnostique se sont servis d'une méthode Delphi modifiée pour concevoir un programme de formation sur l'échographie portable visant à faciliter le diagnostic de la torsion testiculaire. Ce programme comprenait 3 modules d'apprentissage vidéo en ligne, ainsi qu'une séance pratique d'une heure auprès de patients adultes normalisés. Nous avons évalué les compétences des participants en matière d'échographie portable scrotale au moyen d'une échelle validée. Nous avons également évalué les connaissances, l'aisance et le niveau de confiance des participants à l'égard de cet examen avant et immédiatement après la formation, puis 3 mois plus tard. Résultats: Au total, 24 résidents en urologie (n = 12) et en médecine d'urgence (n = 12) ont suivi le programme de formation. Après la séance pratique, 23 participants (96 %) avaient les compétences nécessaires à la réalisation d'une échographie portable scrotale. La comparaison des résultats obtenus avant et immédiatement après la formation a montré une augmentation significative des connaissances (note moyenne : 63 % c. 80 %; p < 0,001), de l'aisance (moyenne à l'échelle de Likert : 0,6 c. 3,6; p < 0,001) et du niveau de confiance (moyenne à l'échelle de Likert : 1,0 c. 2,1; p < 0,001) des participants. Les effets de la formation étaient toujours présents 3 mois plus tard. Conclusion: Le programme de formation sur l'échographie portable scrotale s'est avéré efficace et acceptable pour les résidents en urologie et en médecine d'urgence. Les résultats obtenus laissent croire qu'une formation pédagogique et une courte séance d'apprentissage pratique permettent l'enseignement efficace de l'échographie portable scrotale.

Longitudinal experience with Studer neobladders: Outcomes and complications.

INTRODUCTION: This study aims to assess the longer-term functional, anatomical, and metabolic outcomes of patients who underwent Studer neobladder (SNB) urinary diversion. METHODS: A retrospective review of patients who underwent SNB at a single center from 1995-2017 (n=116) was performed. Demographics, comorbidities, pathological data, and longer-term functional, anatomical, and metabolic outcomes were collected from hospital records. The primary outcome was voiding function of patients at most recent followup. Secondary outcomes included postoperative complications, renal function, nephrolithiasis, infections, and metabolic outcomes. RESULTS: Excluding those with incomplete followup data, 72 patients with a minimum followup of one year were included for analysis. Median followup was 70±11 months, with 52.8% of patients having ≥5 years of followup. Clean intermittent catheterization (CIC) was used by 22.2% of patient at most recent followup, which was mostly necessitated by bladder overdistension, deteriorating renal function, or recurrent urosepsis despite timed voiding. Patients experienced more daytime and nighttime urinary incontinence in the early postoperative setting, which improved over time. Generally, renal function declined over time; poorer long-term renal function was predicted by hydronephrosis within one year (p=0.002). CONCLUSIONS: Longer-term followup of SNB reveals significant but manageable complications. Gradual decline in renal function was common. Strict adherence to bladder emptying protocols (e.g., timed voiding or CIC) may reduce incidence of renal deterioration, metabolic disorders, and urinary dysfunction. Early onset (<1 year) of hydronephrosis may indicate a need for intervention to preserve long-term renal function.

What to Do With Renal Cysts in Children?

OBJECTIVE: To explore the current practice patterns for the management of renal cysts internationally among pediatric urologists and nephrologists. MATERIALS AND METHODS: A survey composed of 21 questions and 4 clinical scenarios was distributed to pediatric urologists and nephrologists. Survey questions evaluated optimal imaging modality, management, and follow-up period. Interspecialty comparisons were made using chi-square analysis where appropriate. RESULTS: A total of 183 respondents completed the survey (128 pediatric urologists, 37 pediatric nephrologists, and 19 other specialists). Most (57%) respondents agreed or strongly agreed with using an ultrasound based Bosniak classification to categorize renal cysts in children. The most commonly used follow-up intervals were 6-12 months for pediatric urologists and 1-2 years for pediatric nephrologists. Symptomatic mass effect (80.9%), gross hematuria (79.2%), or family history were the most common reasons for escalating surveillance. Pediatric nephrologists were more likely to increase follow-up with development of bilateral simple renal cysts (P = .008) or chronic kidney disease (P = .027) when compared to pediatric urologists. Laparoscopic marsupialization (39.4%) was the most common treatment for a simple renal cyst in a symptomatic child. Modified Bosniak III cysts had more heterogeneity in treatment based on the physician responses. CONCLUSION: There is currently no consensus on the optimal protocol for the surveillance, imaging, or treatment of renal cysts in children. Most respondents agree that using an ultrasound-based Bosniak classification is reasonable. A call to action is therefore necessary for the development of registries and guidelines on the management of pediatric renal cysts and their associated malignancies.

Repair of Iatrogenic Urethral and Bladder Neck Injury Due to Missed Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome.

Mayer-Rokitansky-Küster-Hauser syndrome is a congenital malformation disorder resulting in agenesis of the proximal vagina, absence of cervix, and variable development of the uterus. This report describes the repair of a complex iatrogenic urethrovaginal injury due to a missed diagnosis of Mayer-Rokitansky-Küster-Hauser. Our treatment utilized a primary urethroplasty through a transvaginal approach with bladder neck reconstruction and a Martius flap for secondary coverage. Urinary continence was restored postoperatively.

Indications for Penile Prosthesis Revision: Lessons Learned to Limit Technical Causes of Reoperation.

INTRODUCTION: Reoperations are necessary in approximately 30% of penile prostheses over 15 years following original implantation. AIM: To determine the most common indications for initial penile prosthesis reoperation at our institution and to describe technical alterations that have improved postoperative outcomes. METHODS: A retrospective review of all patients who underwent penile prosthesis reoperation surgery at a single, high-volume Canadian center between 2006 and 2018 was performed. Patient demographic information, prosthetic device factors, and surgical complications were analyzed. MAIN OUTCOME MEASURE: The primary outcomes were the indications for and variables associated with initial penile prosthesis reoperation. RESULTS: During the study period, 99 first-time penile prosthesis reoperations were performed out of 1,161 penile prosthesis procedures (Figure 1). This included 14 (14.1%) explants, 32 (32.3%) revisions, and 53 (53.5%) explant and reimplants. Indications for reoperation included 49 (49.5%) mechanical failures, 28 (28.3%) technical causes (such as correction of malposition or device herniation), and 12 (12.1%) procedures to treat chronic postoperative pain. Median follow-up was 78.5 months, and median time to reoperation was 46 months. Mechanical failures commonly occurred in the tubing (n = 13, 26.5%) and cylinders (n = 13, 26.5%). The most frequently repositioned component was the valve pump (n = 11, 39.3%). Infection-related indications for reoperation were uncommon (n = 10, 10.1%). CLINICAL IMPLICATIONS: More than a quarter of penile prosthesis reoperations may have been preventable with alterations in surgical technique, device positioning, and postoperative care. STRENGTHS AND LIMITATIONS: This study evaluates a range of indications for initial penile prosthesis reoperation performed by a high-volume single surgeon over a 12-year period. Limitations include the retrospective nature of the study, loss of patients to follow-up, and lack of etiological determinants of prosthesis failure. CONCLUSIONS: Reoperation for device repositioning and herniation was required for more than a quarter of the initial penile prosthesis implants. Modifications in surgical technique and perioperative care can help reduce the incidence of these technical causes for reoperation. Chan EP, Punjani N, Campbell JD, et al. Indications for Penile Prosthesis Revision: Lessons Learned to Limit Technical Causes of Reoperation. J Sex Med 2019; 16:1444-1450.