Using Bourdieu to explore graduate attributes in two online Master's programmes.

Within the expansion of postgraduate educational qualifications for health professionals, graduate attributes have become important markers of outcomes and value. However, it is not clear how or when graduate attributes develop, or how they are applied in professional practice after graduation. We interviewed 17 graduates from two online Master's programmes to explore their perceptions of how postgraduate study had influenced their practice and professional identity. Our thematic analysis produced three main themes (academic voice, infectious curiosity, and expanding worldview) which reflected changes in the participants' confidence, attitude, perspective, and agency across professional and academic settings. We then conducted a secondary phase of analysis using Bourdieu's concepts of 'field', 'capital', and 'habitus'. While graduate attributes have been conceptualised as the context-independent acquisition of traits that can be employed by individuals, Bourdieu's framework highlights their relational qualities: they are caught up in the cultural history and context of the student/professional, the reputation of the awarding institution, and the graduate's location within a network of professional peers.

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis.

BACKGROUND: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE: To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION: Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy.

Super-selective vascular control prior to robotic partial nephrectomy (also known as 'zero-ischemia') is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

Surgical complications after robot-assisted laparoscopic radical prostatectomy: the initial 1000 cases stratified by the clavien classification system.

BACKGROUND AND PURPOSE: Complications after robot-assisted prostatectomy are widely reported and varied. Our goal was to determine the incidence of surgical complications resulting from robot-assisted laparoscopic radical prostatectomy (RALP) during the initial phase of a new robotics program that was developed by two surgeons without laparoscopic or robotic fellowship training. A secondary goal was to see if experience changed the incidence of complications with this technology. PATIENTS AND METHODS: A prospectively maintained database was used to evaluate the first 1000 consecutive patients who were treated with RALP from January 2004 to June 2009. The database was reviewed for evidence of complications in the perioperative period. All patients underwent robot-assisted laparoscopic radical prostatectomy by two surgeons. Complications were confirmed and supplemented by retrospectively reviewing the departmental morbidity and mortality reports, as well as the hospital records. The Clavien classification system, a standardized and validated scale for complication reporting, was applied to all events. The complication rate was determined per 100 patients treated and tested with logistic regression for a relationship with surgeon experience. RESULTS: Ninety-seven (9.7%) patients experienced a total of 116 complications; 81 patients experienced a single complication and 16 patients experienced ≥2 complications. The majority of complications (71%) were either grade I or II. The complication rate decreased with experience when the first 500 cases were compared with the latter 500 cases (P=0.007). All the data were reviewed retrospectively. Involvement of residents/fellows increased as primary surgeon experience improved. CONCLUSIONS: Complications after RALP are most commonly minor, requiring expectant or medical management only, even during the initiation of a RALP program. The complication rate improved significantly during the study period.

Robot-assisted simple prostatectomy for severe benign prostatic hyperplasia.

PURPOSE: To validate the feasibility of robot-assisted simple retropubic prostatectomy (RSP) for men with severe benign prostatic hyperplasia (>80 g). PATIENTS AND METHODS: Institutional Review Board approval was not sought for this series. Men were offered RSP by two surgeons with a combined experience of >350 robot-assisted radical prostatectomies. The RSP replicated previously published robotic and laparoscopic techniques. Postoperative management consisted of continuous bladder irrigation and closed suction pelvic drainage without suprapubic catheterization. RESULTS: A total of nine men were treated. Indications for RSP included urinary retention in three patients, failed medical management in eight patients, and refusal of medical management in one. Average age was 68 years, mean prostate-specific antigen level was 17.4 ng/mL, and the average preoperative gland size (height-width-length volume) was 136.5 g (range 86-265 g). No operative or immediate postoperative complications occurred, and no transfusions were needed. Average blood loss, operative time, and console time were 206 mL, 183 minutes, and 147 minutes, respectively. Average pathologic adenoma volume was 112 g (range 53-220 g). Average hospitalization time and catheterization time were 32 hours and 13 days, respectively. The mean preoperative International Prostate Symptom Score was 17.8 compared with 7.77 at 6 months postoperatively (P=0.0096, 95% CI 2.83 - 17.40), with a mean follow-up time of 9.25 months. The mean Sexual Health Inventory for Men score was 12.7 preoperatively compared with 12.5 postoperatively (P=0.74, 95% confidence interval - 6.66-9.16). Persistent, severe urinary incontinence (4-6 pads per day) occurred in one patient. CONCLUSIONS: RSP is safe and reproducible when performed by experienced robotic surgeons and provides similar benefits to those associated with robot-assisted radical prostatectomy. In our limited experience, hemostasis was markedly decreased when compared with the open technique. Further investigation is necessary before widespread application of RSP.

Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial.

PURPOSE: Posterior rhabdosphincter reconstruction following radical prostatectomy was designed to improve early urinary continence. We executed a randomized clinical trial to test this conjecture in men undergoing robotic radical prostatectomy. MATERIALS AND METHODS: We conducted a phase II randomized clinical trial intended to detect a 25% difference in 3-month continence outcomes defined by a patient response of 0 or 1 to question 5 of the Expanded Prostate Cancer Index Composite questionnaire urinary domain, comparing standard running vesicourethral anastomosis (controls) to posterior rhabdosphincter reconstruction followed by standard running vesicourethral anastomosis (posterior rhabdosphincter reconstruction treated). Patients had clinically localized prostate cancer and were blinded. Surgeons were notified of computer randomization after prostate excision. Further continence outcomes were assessed by analysis of Expanded Prostate Cancer Index Composite questionnaire questions 1 and 12, International Prostate Symptom Score and 24-hour pad weights. Statistical significance was defined as p <0.05 RESULTS: A total of 94 patients were randomized, 47 to each arm. Preoperative clinical and functional variables were equivalent between study arms. There were no complications associated with either anastomotic technique. Of the 87 evaluable patients 62 (71.3%) met our 3-month continence definition. The null hypothesis was not rejected as 33 (81%) controls and 29 (63%) posterior rhabdosphincter reconstruction treated patients were continent at 3 months (chi-square p = 0.07, Fisher exact p = 0.1). Likewise there was no significant difference between arms in 24-hour pad weights (p = 0.14), International Prostate Symptom Score (p = 0.4), absence of daily leaks (p = 0.4) or perception of urinary function (p = 0.4). CONCLUSIONS: In this randomized clinical trial posterior rhabdosphincter reconstruction offered no advantage for return of early continence after robotic assisted radical prostatectomy.

Laparoscopic renal descensus for upper tract reconstruction.

We describe a modern use of laparoscopic renal descensus during the reconstruction of the upper urinary tract. The patient is a 76-year-old mononephric man with recurrent carcinoma in situ in the distal ureter. Using the described technique, we produced an additional 8 to 10 cm of ureteral length and performed a simple ureteroneocystotomy instead of using a traditional psoas hitch and Boari flap creation, bowel interposition, or autotransplantation. Laparoscopic renal descensus is an uncommonly used but simple procedure that may prevent the need for bladder mobilization or Boari flap creation, particularly in the setting of a hostile pelvis.

Changes in penile length after robot-assisted laparoscopic radical prostatectomy.

BACKGROUND AND PURPOSE: Radical prostatectomy is commonly performed for the treatment of patients with prostate cancer. Several studies have demonstrated a reduction in penile size after open radical retropubic prostatectomy. The objective of this study is to describe changes in penile length after after robot-assisted laparoscopic radical prostatectomy (RALRP). PATIENTS AND METHODS: We performed a randomized, open label, multicenter study in men with normal erectile function who underwent bilateral nerve-sparing radical prostatectomy. We evaluated changes in measured stretched penile length (SPL), a secondary end point of the study, in a subset of men from a single site who underwent RALRP by one surgeon. They were randomized to either intraurethral alprostadil 125 to 250 µg daily or oral sildenafil citrate 50 mg daily for 9 months. SPL was measured from pubic bone to coronal sulcus using a semirigid ruler before surgery and at 1, 3, 6, 9, 10, and 11 months. RESULTS: A total of 127 patients were enrolled and 94 completed the 11-month follow-up. The mean patient age was 56.5 years. Baseline mean SPL (cm) before surgery was 11.77 and decreased to 11.13 at 1 month (P<0.0001). A trend toward recovery of SPL was seen at 3 and 6 months. Mean SPL was not significantly different from baseline at 9, 10, and 11 months. CONCLUSIONS: This report describes changes in SPL over time after RALRP for prostate cancer. The expected decrease in length was observed shortly after surgery, but, by 9 months, penile length had returned to the preoperative measurement.

Vascular pseudoaneurysms in urology: clinical characteristics and management.

BACKGROUND AND PURPOSE: Vascular pseudoaneurysm is a well-documented complication that results after injury to an arterial wall. We review the urologic literature for all reported postprocedural and post-traumatic cases of pseudoaneurysm. METHODS: A comprehensive review of the peer-reviewed literature was performed for reported cases of vascular pseudoaneurysm, with emphasis on clinical presentation and treatment options. RESULTS: Vascular pseudoaneurysm is a high-pressure collection of blood that communicates directly with an arterial vessel. The clinical presentation varies, depending on the location and size of the lesion, and can be quite dramatic and potentially life threatening. There may be an increasing incidence of pseudoaneurysms after minimally invasive and laparoscopic techniques. Selective and superselective embolization is the preferred treatment for patients with vascular pseudoaneurysms. CONCLUSIONS: Vascular pseudoaneurysm is an important but rare complication that is increasingly reported after minimally invasive urologic surgery. This diagnosis necessitates a high index of suspicion and radiologic acumen. Treatment is individually tailored to each patient, but selective embolization appears to be the standard of care.

"Learning curve" may not be enough: assessing the oncological experience curve for robotic radical prostatectomy.

The use of robot-assisted laparoscopic radical prostatectomy (RALP) is widespread in the community. A definitive RALP "learning curve" has not been defined and existing learning curves do not account for urologists without prior advanced laparoscopic skills. Therefore, an easily evaluable metric, the "oncological experience curve," would be clinically useful to all urologists performing RALP. Positive surgical margin (PSM) status for all subjects undergoing RALP during the first 4 years of a single surgeon's experience was assessed. Univariate and multivariate analyses and logistic regression identified predictors of PSM creation and their correlation with surgeon case volume. The oncological experience curve was defined as the case point at which only pT2 stage, not surgeon volume (and thus surgeon inexperience), predicted PSM in the logistic regression. A total of 469 consecutive subjects comprised our cohort. Overall pT2 and pT3 PSM rates were 20% and 40%, respectively. Preoperative prostate-specific antigen, pathologic stage, and year of surgery were associated with PSM occurrence. Pathologic stage exclusively correlated to PSM in pT2 specimens for the first time during the fourth year, after 290 subjects had been treated. pT2 PSM rate before and after Case 290 was 25% and 10%, respectively (p < 0.001). The oncological experience curve is a clinically meaningful measure to evaluate the RALP learning curve for non-fellowship-trained urologists. The oncological experience curve may be much longer than the previously reported learning curves. Surgeons should consider whether they can build enough experience to minimize suboptimal oncological outcomes before embarking on or continuing a RALP program.

Bladder cryoablation in a porcine model: evaluation of three surgical approaches and cryolesion predictability.

PURPOSE: To determine the feasibility of bladder cryoablation (BC) applied laparoscopically, percutaneously, and transurethrally in a porcine survival study. The expected and observed area of cell death after BC was also examined. MATERIALS AND METHODS: Nine pigs were divided equally into the three treatment groups. Cryoablation was performed with two freeze-thaw cycles after the bladder had been insufflated with CO2. Each animal was observed for 7 days after the procedure for treatment-related complications. After cystectomy, each specimen was examined pathologically to determine the degree and dimension of cell death achieved. RESULTS: BC applied via the laparoscopic and percutaneous approach is feasible and safe. No BC-related complications occurred in these two groups. A complication resulting from BC developed in all three animals that were treated cystoscopically, including two intraperitoneal bladder perforations at the time of BC necessitating immediate sacrifice, and one enterovesical fistula discovered at cystectomy. Transmural necrosis was demonstrated in seven of seven animal specimens that survived to the end of the protocol. The observed diameter of tissue necrosis was highly predictable based on the reported cryoprobe isotherms given by the manufacturer. CONCLUSION: All locations within the bladder can be successfully and predictably treated with cryoablation. Of the three approaches, laparoscopically administered BC appears to be the most safe and consistent method. Transurethral BC was not safe with the equipment available without laparoscopic assistance to prevent bowel complications.

Surgical options in the management of ureteropelvic junction obstruction.

Ureteropelvic junction obstruction (UPJO) is a common cause of upper urinary tract obstruction that can be clinically silent or lead to symptoms such as pain, chronic urinary tract infections, and urinary stone disease. UPJO does not always mandate treatment, but when an indication for correction is present, there are several minimally invasive surgical options available. Surgical reconstruction represents the gold-standard treatment for UPJO, although endoscopic pyelotomy is a well established and efficacious alternative.

PSA velocity is associated with gleason score in radical prostatectomy specimen: marker for prostate cancer aggressiveness.

OBJECTIVES: Conflicting evidence has been reported on the association of prostate-specific antigen velocity (PSAV) with Gleason score in prostate needle biopsy specimens. The Gleason score is an important prognostic indicator for men with prostate cancer, and, in modern practice, it frequently affects treatment decisions. To our knowledge, the relationship between preoperative PSAV and Gleason score in the radical prostatectomy specimen has not been formally demonstrated. METHODS: A total of 1049 men treated with radical prostatectomy had data on PSAV and Gleason score. Statistical analysis was performed to examine the relationship between the preoperative PSAV and the prostatectomy Gleason score and other adverse tumor features. RESULTS: The median preoperative PSAV was 0.84, 0.97, and 1.39 ng/mL/y in men with a Gleason score of 6, 7, and 8-10, respectively (P = .05). A PSAV greater than 2 ng/mL/y was significantly associated with a prostatectomy Gleason score of 7 or greater on univariate and multivariate analysis. In addition, the preoperative PSAV was significantly lower in men with organ-confined disease (0.82 vs 1.17 ng/mL/y, respectively, P = .002). CONCLUSIONS: Our results have further validated PSAV as a marker for prostate cancer aggressiveness. The preoperative PSAV was a significant independent predictor of the Gleason score and non-organ-confined disease in the radical prostatectomy specimen. Thus, PSAV could be useful in treatment decision-making and in assessing the likelihood of long-term cancer control in men with prostate cancer.

Bladder neck contractures related to the use of Hem-o-lok clips in robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: Recently, several large series of robot-assisted laparoscopic radical prostatectomy (RALP) have described a low incidence of bladder neck contractures (BNC). We have had a similar experience at our institution. Our objective is to describe our experience with BNC after RALP and a novel relationship to the use of Hem-o-lok Clips (HOLC). METHODS: We reviewed a database of patients who underwent RALP at our institution from January 2004 to September 2007 and identified patients with BNC or complications related to the use of HOLC. We performed a retrospective chart review to attempt to determine the cause of each BNC. We also performed a PubMed search and review of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. RESULTS: Of 524 patients undergoing RALP, 4 had a BNC develop, 2 of the BNCs were associated with HOLC migration and erosion into the vesicourethral anastomosis, and 1 was found to have HOLC migration within the bladder. A fifth patient had an anastomotic leak develop secondary to a HOLC that migrated into the bladder neck. Two similar cases of HOLC-related migration have been reported to MAUDE. CONCLUSIONS: When early BNC or unexplained urinary retention occurs after RALP, one should have a high index of suspicion for migration of HOLC. Clip use should be minimized on tissue immediately adjacent to the anastomosis, and every effort should be made to retrieve loose clips after the procedure.

Thromboembolic complications of cancer: epidemiology, pathogenesis, diagnosis, and treatment.

The association between malignancy and clinical thrombosis has been recognized for nearly 140 years. The purpose of this review is to examine our current understanding of thrombosis as a complication of cancer and cancer therapy. The review includes a discussion of the epidemiology, pathophysiology, diagnosis and treatment.