Current status of urology surgical training in Europe: an ESRU–ESU–ESUT collaborative study

International consensus panel for transurethral resection of bladder tumours metrics: assessment of face and content validity

OBJECTIVE

To develop performance metrics that objectively define a reference approach to a transurethral resection of bladder tumours (TURBT) procedure, seek consensus on the performance metrics from a group of international experts.

METHODS

The characterisation of a reference approach to a TURBT procedure was performed by identifying phases and explicitly defined procedure events (i.e., steps, errors, and critical errors). An international panel of experienced urologists (i.e., Delphi panel) was then assembled to scrutinise the metrics using a modified Delphi process. Based on the panel's feedback, the proposed metrics could be edited, supplemented, or deleted. A voting process was conducted to establish the consensus level on the metrics. Consensus was defined as the panel majority (i.e., >80%) agreeing that the metric definitions were accurate and acceptable. The number of metric units before and after the Delphi meeting were presented.

RESULTS

A core metrics group (i.e., characterisation group) deconstructed the TURBT procedure. The reference case was identified as an elective TURBT on a male patient, diagnosed after full diagnostic evaluation with three or fewer bladder tumours of ≤3 cm. The characterisation group identified six procedure phases, 60 procedure steps, 43 errors, and 40 critical errors. The metrics were presented to the Delphi panel which included 15 experts from six countries. After the Delphi, six procedure phases, 63 procedure steps, 47 errors, and 41 critical errors were identified. The Delphi panel achieved a 100% consensus.

CONCLUSION

Performance metrics to characterise a reference approach to TURBT were developed and an international panel of experts reached 100% consensus on them. This consensus supports their face and content validity. The metrics can now be used for a proficiency-based progression training curriculum for TURBT.

"Self-Designed Simulation-Based Laparoscopic Training Program for Urology Residents: Results After 6 Years of Experience"

Introduction

Learning laparoscopy (LAP) is challenging and requires different skills to conventional open surgery. There is a recognized need for a standardized laparoscopic training framework within urology to overcome these difficulties and to shift learning curve from patient to skills laboratory. Simulation-based training has been widely commented, but implementation in real day practice is lacking. We present our "LAP training program for residents".

Material

Between 2017 and 2022, 11 residents participated in our self-designed program: Theoretical: (Moodle platform) basic knowledge and multimedia content for initiation into LAP. Evaluated through online exam. Practical: exercises for LAP skills acquisition were proposed and encouraged residents' practice in a box trainer available and experimental surgery sessions on a porcine model. On-site E-BLUS (European Basic Laparoscopic Urologic Skills) examination was performed annually. Feedback was obtained through an anonymous online survey.

Results

All residents positively evaluated the program. Theoretical: 82% passed the online exam. The most valued topics: LAP in special clinical situations, complications, instruments, and configuration of the operating room (OR). Practical: all residents increased dry-lab box practices. A total of 23 experimental surgical sessions were carried out. For 64%, simulation in the experimental OR was a necessary complement to achieve laparoscopic skills and allowed them to feel more confident. Forty-five percent considered it essential to improve their surgical technique. E-BLUS evaluation was valued as a means to achieve dexterity and safer surgery by 90%. Reduction in time and errors were observed through time, although only 2 passed the E-BLUS.

Conclusion

Our program for learning LAP includes the acquisition of knowledge, training of basic skills and surgical technique in a safe environment, as well as an objective evaluation. Encouraged practice of basic skills and surgical technique simulation and improved objective evaluation. It is structured, reproducible, systematic and has been positively valued, although it requires commitment for success.

ESRU-ESU-YAU_UROTECH Survey on Urology Residents Surgical Training: Are We Ready for Simulation and a Standardized Program?

Background

Currently, the landscape of surgical training is undergoing rapid evolution, marked by the initial implementation of standardized surgical training programs, which are further facilitated by the emergence of new technologies. However, this proliferation is uneven across various countries and hospitals.

Objective

To offer a comprehensive overview of the existing surgical training programs throughout Europe, with a specific focus on the accessibility of simulation resources and standardized surgical programs.

Design setting and participants

A dedicated survey was designed and spread in May 2022 via the European Association of Urology (EAU) mail list, to Young Urologist Office (YUO), Junior membership, European Urology Residents Education Program participants between 2014 and 2022, and other urologists under 40 yr, and via the EAU Newsletter.

Intervention

A 64-item, online-based survey in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) using the platform of Survey Monkey (Portland, OR, USA) was realized.

Outcome measurements and statistical analysis

The study involved an assessment of the demographic characteristics. Additionally, it explored the type of center, availability of various surgical approaches, presence of training infrastructure, participation in courses, organization of training, and participants' satisfaction with the training program. The level of satisfaction was evaluated using a Likert-5 scale. The subsequent sections delved into surgical training within the realms of open, laparoscopic, robotic, and endoscopic surgery, each explored separately. Finally, the investigation encompassed the presence of a structured training course and the availability of a duly validated final evaluation process.

Results and limitations

There were 375 responders with a completion rate of 82%. Among them, 75% were identified as male, 50.6% were young urologists, 31.7% were senior residents, and 17.6% were junior residents. A significant majority of participants (69.6%) were affiliated with academic centers. Regarding the presence of dry lab training facilities, only 50.3% of respondents indicated its availability. Among these centers, 46.7% were primarily focused on laparoscopy training. The availability of virtual and wet lab training centers was even more limited, with rates of 31.5% and 16.2%, respectively. Direct patient involvement was reported in 80.5% of cases for open surgery, 58.8% for laparoscopy, 25.0% for robotics, and 78.6% for endourology. It is worth noting that in <25% of instances, training followed a well-defined standardized program comprising both preclinical and clinical modular phases. Finally, the analysis of participant feedback showed that 49.7% of respondents expressed a satisfaction rating of either 4 or 5 points with respect to the training program. The limitations of our study include the low response rate, predominance of participants from academic centers, and absence of responses from individuals not affiliated with the EAU network.

Conclusions

The current distribution of surgical training centers falls short of ensuring widespread access to standardized training programs. Although dry lab facilities are relatively well spread, the availability of wet lab resources remains restricted. Additionally, it appears that many trainees' initial exposure to surgery occurs directly with patients. There is a pressing need for continued endeavors to establish uniform training routes and assessment techniques across various surgical methodologies.

Patient summary

Nowadays, the surgical training landscape is heterogeneous across different countries. The implementation of a standardized training methodology to enhance the overall quality of surgical training and thereby improving patient outcomes is needed.

Robotic Medtronic Hugo™ RAS System Is Now Reality: Introduction to a New Simulation Platform for Training Residents

The use of robotic surgery (RS) in urology has grown exponentially in the last decade, but RS training has lagged behind. The launch of new robotic platforms has paved the way for the creation of innovative robotics training systems. The aim of our study is to test the new training system from Hugo™ RAS System-Medtronic. Between July 2020 and September 2022, a total of 44 residents from urology, gynaecology and general surgery at our institution participated in advanced robotic simulation training using the Hugo™ RAS simulator. Information about sex, age, year of residency, hours spent playing video games, laparoscopic or robotic exposure and interest in robotics (90.9% declared an interest in robotics) was collected. The training program involved three robotic exercises, and the residents performed these exercises under the guidance of a robotics tutor. The residents' performance was assessed based on five parameters: timing, range of motion, panoramic view, conflict of instruments and exercise completion. Their performance was evaluated according to an objective Hugo system form and a subjective assessment by the tutor. After completing the training, the residents completed a Likert scale questionnaire to gauge their overall satisfaction. The rate of the residents' improvement in almost all parameters of the three exercises between the first and the last attempts was statistically significant (p < 0.02), indicating significant progress in the residents' robotic surgical skills during the training. The mean overall satisfaction score ± standard deviation (SD) was 9.4 ± 1.2, signifying a high level of satisfaction among the residents with the training program. In conclusion, these findings suggest that the training program utilizing the Hugo™ RAS System is effective in enhancing robotic surgical skills among residents and holds promise for the development of standardized robotics training programs in various surgical specialties.

Development and Application of a Novel and Efficient Skills Assessment Tool: A Pilot Initiative to Measure Vasectomy Competency on a Smartphone

OBJECTIVE

To develop and evaluate a mobile phone-based skills assessment tool that measures procedural competency of urology residents learning to perform a common, non-robotic urology procedure as a means of tracking current skillset and improvement over time.

METHODS

The assessment tool was a Qualtrics survey accessed via a smartphone link that breaks down a vasectomy into 6 critical steps. Level of competency was measured on a scale of '1-novice' to '5-expert.' Nine residents from Post graduate year (PGY)-1 to PGY-5 were evaluated by one instructor after completing a vasectomy (86 single-side cases recorded over a 6-month period). We compared individual trainees to each other, analyzed performance (improvement) over time, and evaluated competency against cohort and program averages.

RESULTS

As an example, a single resident ('Resident 2,' N = 11 cases) was compared to cohort (PGY, M = 7.5/resident) and program (all residents, M = 7.4/resident). Results indicate similar skillfulness across Step 1 (puncturing and isolation of vas and hand positioning; P > 0.1), but marginally lower competency on Step 2 (opening of vasal sheath to expose/isolate vas; vs. cohort: P = 0.076, vs. residents: P = 0.082). Significantly lower competency on Steps 3-6 (all P < 0.04) suggests targeted teaching could improve cautery technique, fascial interposition, hemostasis, and positioning of stumps.

CONCLUSION

Our mobile-based skills assessment is a low cost, novel, and efficient assessment that would support current Accreditation Council for Graduate Medical Education (ACGME) goals to increase competency-based residency training. This tool is easily created and accessed, provides real-time feedback to learners, and can be used for individual and group assessment at a single timepoint or longitudinally.

Impact of Robotic Technologies on Prostate Cancer Patients' Choice for Radical Treatment

Prostate cancer (PCa) surgery has a strong impact on men's social and sexual lives. For this reason, many patients ask for robotic surgery. To assess the rate of lost patients due to the lack of a robotic platform (RPl) at our center, we retrospectively selected 577 patients who underwent prostate biopsy between 2020 and 2021 who were eligible for radical prostatectomy (RP) (ISUP ≥ 2; age ≤ 70 yr). Patients eligible for surgery who decided to be operated received a phone call interview asking the reason for their choice. Overall, 230 patients (31.7%) underwent laparoscopic-assisted radical prostatectomy (LaRP) at our center, while 494 patients (68.3%) were not treated in our hospital. Finally, 347 patients were included: 87 patients (25.1%) underwent radiotherapy; 59 patients (17%) were already under another urologist's care; 113 patients (32.5%) underwent robotic surgery elsewhere; and 88 patients (25.4%) followed the suggestion of friends or relatives based on their surgical experience. Despite no surgical technique for RP having shown superiority in terms of oncological or functional outcomes, patients eligible for PCa treatment decided to be operated on elsewhere because of the lack of an RPl. Our results show how the presence of an RPl may increase the case volume of RP by 49% at our center.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

Patients' perceptions of quality of care delivery by urology residents: A nationwide study

OBJECTIVE

To present the results of a nationwide survey among urological patients to evaluate their perception of the quality of care provided by residents.

METHODS

An anonymous survey was distributed to patients who were referred to 22 Italian academic institutions. The survey aimed to investigate the professional figure of the urology resident as perceived by the patient.

RESULTS

A total of 2587 patients were enrolled in this study. In all, 51.6% of patients were able to correctly identify a urology resident; however, almost 40% of respondents discriminated residents from fully trained urologists based exclusively on their young age. Overall, 98.2% patients rated the service provided by the resident as at least sufficient. Urology trainees were considered by more than 50% of the patients interviewed to have good communication skills, expertise and willingness. Overall, patients showed an excellent willingness to be managed by urology residents. The percentage of patients not available for this purpose showed an increasing trend that directly correlated with the difficulty of the procedure. Approximately 5-10% of patients were not willing to be managed by residents for simple procedures such as clinical visits, cystoscopy or sonography, and up to a third of patients were not prepared to undergo any surgical procedure performed by residents during steps in major surgery, even if the residents were adequately tutored.

CONCLUSIONS

Our data showed that patients have a good willingness to be managed by residents during their training, especially for medium- to low-difficulty procedures. Furthermore, the majority of patients interviewed rated the residents' care delivery as sufficient. Urology trainees were considered to have good communication skills, expertise and willingness.

Standardized evaluation of satisfaction within urology residents during clinical training: Implementation of a new urological residency rotation program at the university hospital Frankfurt

Background

Structured curricula are demanded to improve training programs of future urologists. This study aimed to evaluate the acceptance of the newly implemented residency rotation program at the University Hospital Frankfurt. Primary endpoint was resident's satisfaction with the current residency rotation program. Secondary endpoint was the fulfilment of the objectives and expectations by residents.

Methods

A standardized 15-item, online-based survey was sent to every urologic resident of the University Hospital Frankfurt, completing their rotation between August 2020 and August 2022. In addition to baseline characteristics, training and working conditions were assessed. Descriptive statistics were applied.

Results

In total 15 rotations of the Residency Rotation Program at the University Hospital Frankfurt were evaluated, including urologic practice (5/15), Intermediate Care Unit (4/15), urooncology (4/15) and clinical exchange to St. Gallen (2/15). Overall, the majority were very (67%) or rather satisfied (2%) with their rotation. Of the pre-rotation defined objectives, 71% were fulfilled, 18% partially fulfilled and 8% not fulfilled. With respect to the expectations, 67% were fulfilled, 19% partly fulfilled and 4% were not fulfilled. All residents would recommend their respective rotations.

Conclusion

Our results demonstrate that the residency rotation program at the University Hospital Frankfurt enjoys a high level of acceptance as well as a positive impact on urologic training. Satisfaction with the completed rotation was convincing, most of the expectations and objectives for the respective rotation could be fulfilled. These results help to ensure the quality of urologic curricula and to improve the structure of training programs for future urologists.

Organ harvesting as a mandatory training step of all PGY1 and PGY2 surgical residents

To the Editor, Good surgical training is essential for the formation of excellent surgeons, consequently providing the best possible care for our patients in the future. Considering the increase in surgeon shortage over the last two decades (estimated between 14,300 and 23,400 by the year 2032 only in the US), it is important for filling the national health system's needs as well [...].

Functional urology: Practice patterns and training aspirations among urologists in Brazil

PURPOSE

Urology has rapidly evolved during the last decades, incorporating new technologies faster than most specialties. The challenge to maintain a competent workforce that is prepared to deliver proper contemporary treatment has become increasingly difficult and newly graduated urologists throughout the world typically lack the skills to practice many urological subspecialties. We performed a survey to evaluate the practice patterns and educational aspirations in functional urology (FU) among Brazilian urologists.

METHODS

A web-based survey was sent to board-certified Brazilian urologists to collect data on clinical practice and training aspirations in four subareas of FU: female urology, urodynamics, postprostatectomy incontinence (PPI), and neurourology. We evaluated urologists' clinical and surgical workload in each subarea and investigated educational training aspirations to identify areas and training formats of interest.

RESULTS

A total of 366 urologists (mean age 47.7 + 10.7 years) completed the survey. Mean time since completion of residency was 17.9 + 11.9 years. Of the respondents, 176 (53%) perform urodynamics, 285 (83.1%) SUI surgeries, 159 (47.6%) PPI surgeries, 194 (58.1%) third line OAB procedures, 168 (48.9%) pelvic organ prolapse (POP), and 88 (26.3%) bladder augmentation. Mid-urethral sling is the most performed SUI surgery and transobturator is the preferred route (64.0%). For those performing POP surgery, 40.5% use mesh in at least 50% of their cases, and the vaginal route is used in most cases (75.4%) for apical prolapse. For PPI, 64.6% use artificial sphincter in most surgeries and only 8.1% perform at least 5 surgeries/year. Being fellowship-trained and working in an academic hospital are associated with a higher chance of being active in FU. Most urologists are interested in receiving training in PPI, female SUI, and POP and a hands-on course is the preferred educational method (81%).

CONCLUSIONS

Most urologists in Brazil are involved in the evaluation and treatment of FU patients, but few have a large volume of patient visits and surgical procedures. Completing a fellowship program and working in an academic practice are associated with a higher chance of being a FU practitioner. There is a high interest in training for PPI, female SUI, and POP.

Current status of urological training and differences between institutions

OBJECTIVES

Appropriate training of urology residents is important to secure not only high-quality patient care, but also the bright future of our specialty. We aimed to investigate residency training from the perspective of qualification and standardization and to evaluate surgical education, publication output, working conditions, future plans, and overall satisfaction, in a comprehensive way.

METHODS

We conducted a survey of urology chief residents/recent graduates in Turkey to identify differences between institutions and deficiencies in urology resident training. A total of 155 chief residents/recently graduated specialists were contacted by phone and a survey was completed.

RESULTS

The survey response rate was 96.1%. Respondents had high proficiency in endourology (97.3%), similar to Canada and European countries. However, they reported a lack of proficiency in laparoscopy (28.9%) and functional urology (26.2%). Also, no one had completed a robotic procedure as first surgeon. A total of 75.2% respondents had no first author publication, and 10.1% had no first author abstract presentation. There was no significant difference between institution types with or without certification. There was a satisfaction rate of 87.2% among participants.

CONCLUSIONS

It was observed that qualified and standardized training could has not been achieved and the positive effects of certification have not been seen yet. There is a lack of modernization in all aspects of education, and there is no standardized curriculum addressing academic research. Therefore, there is a risk that future urologists will have insufficient skills. We hope this study serves as a guide for modernization and standardization in urology training.

Urology residency training in Greece. Results from the first national resident survey

BACKGROUND AND OBJECTIVES

This is the first national survey assessing Greek Urology residency programs. The main objective of this study is to assess the level of confidence and perception of Greek Urology residents regarding their educational program and detect areas of improvement.

MATERIAL AND METHODS

A 51-question survey was developed via an electronic platform and answered by 91 out of 104 Greek residents from March 2019 until May 2019. Fisher's exact test, chi-squared test and Kruskal-Wallis test were used with statistical significance set at p = .05.

RESULTS

The median overall satisfaction regarding surgical training was 6/10 regardless of working schedule, working in a University Department, PGY or number of residents in clinic. Most residents have not performed any scrotal ultrasound or pressure-flow-studies; however, they are more familiar with KUB ultrasound. Double-J stent insertion and cystoscopy were common procedures for residents. Bureaucracy was reported as a major issue by 70.4% of residents. ESWL has not been performed by 80.2% of residents, 58.2% residents performed less than 10 ureteroscopies, and only the last year trainees performed more than 10 TURBT and TURP. Most residents mentioned to rarely perform basic steps in many open or laparoscopic urological procedures. Surprisingly, 59.3% of residents have not published any study in peer-reviewed journals. Regarding satisfaction, 44% rarely feel satisfied at work and 59.3% sometimes suffer from burnout. Response rate reached 87.5%.

CONCLUSIONS

Considering the results from this survey, regulatory authorities should join forces to establish a structured curriculum of clinical, surgical and research training in Urology across Europe.

Scoping review: hotspots for COVID-19 urological research: what is being published and from where?

PURPOSE

Contemporary, original research should be utilised to inform guidelines in urology relating to the COVID-19 pandemic. This comprehensive review aimed to: identify all up-to-date original publications relating to urology and COVID-19, characterise where publications were from, and outline what topics were investigated.

METHODS

This review utilised a search strategy that assessed five electronic databases, additional grey literature, and global trial registries. All current published, in-press, and pre-print manuscripts were included. Eligible studies were required to be original research articles of any study design, reporting on COVID-19 or urology, in any of study population, intervention, comparison, or outcomes. Included studies were reported in a narrative synthesis format. Data were summarised according to primary reported outcome topic. A world heatmap was generated to represent where included studies originated from.

RESULTS

Of the 6617 search results, 48 studies met final inclusion criteria, including 8 pre-prints and 7 ongoing studies from online registries. These studies originated from ten countries according to first author affiliation. Most studies originated from China (n = 13), followed by Italy (n = 12) and USA (n = 11). Topics of the study included pathophysiological, administrative, and clinical fields: translational (n = 14), COVID-19-related outcomes (n = 5), urology training (n = 4), telemedicine (n = 7), equipment and safety (n = 2), urology in general (n = 4), uro-oncology (n = 3), urolithiasis (n = 1), and kidney transplantation (n = 8).

CONCLUSION

This review has outlined available original research relevant to COVID-19 and urology from the international community. This summary may serve as a guide for future research priorities in this area.

Educational program in onco-urology for young urologists: What are their needs?

PURPOSE

The emergence of new communication media such as digital contents are progressively replacing more traditional medias in the field of educational programs. Our purpose was to assess urologist in training aspirations regarding urological education.

METHODS

Members of a national urologist in training association were sent an anonymous online questionnaire regarding their medical formation in the field of urology. Responders interest for urological sub-specialty or education support (new tools and traditional support) were evaluated through a 5-point Likert scale.

RESULTS

Overall, 109 young urologists (26%) responded to the survey. Most of the respondents worked during their training in an academic hospital (n=89, 82%). The three favorite tools for training chosen by the responders were: videos, workshop or masterclass, and podcasts (responders very interested were respectively n=64 (58.7%), n=50 (45.9%), and n=49 (45%)). E-mail newsletters were reported as the less useful educational tool by participants (n=38, 34.9%). Participants were very interested in improving their surgical skills and their radiological knowledge. Responders who were the most attracted by PCa were much more looking to improve their systemic treatment and radiological knowledges.

CONCLUSIONS

Urologic-oncology was a priority regarding education for urologists in training. A majority of participants expressed a lack in their surgical education, revealing a reduced OR access and underlining utilization of new tools such as simulation. New digital contents such as social media or podcast achieved high interest for the participants, instead of more traditional media. There is a need that educational content evolve and uses new digital media.

LEVEL OF EVIDENCE

3.

Urology residency training in Greece. Results from the first national resident survey

BACKGROUND AND OBJECTIVES

This is the first national survey assessing Greek Urology residency programs. The main objective of this study is to assess the level of confidence and perception of Greek Urology residents regarding their educational program and detect areas of improvement.

MATERIAL AND METHODS

A 51-question survey was developed via an electronic platform and answered by 91 out of 104 Greek residents from March 2019 until May 2019. Fisher's exact test, chi-squared test and Kruskal-Wallis test were used with statistical significance set at p=.05.

RESULTS

The median overall satisfaction regarding surgical training was 6/10 regardless of working schedule, working in a University Department, PGY or number of residents in clinic. Most residents have not performed any scrotal ultrasound or pressure-flow-studies; however, they are more familiar with KUB ultrasound. Double-J stent insertion and cystoscopy were common procedures for residents. Bureaucracy was reported as a major issue by 70.4% of residents. ESWL has not been performed by 80.2% of residents, 58.2% residents performed less than 10 ureteroscopies, and only the last year trainees performed more than 10 TURBT and TURP. Most residents mentioned to rarely perform basic steps in many open or laparoscopic urological procedures. Surprisingly, 59.3% of residents have not published any study in peer-reviewed journals. Regarding satisfaction, 44% rarely feel satisfied at work and 59.3% sometimes suffer from burnout. Response rate reached 87.5%.

CONCLUSIONS

Considering the results from this survey, regulatory authorities should join forces to establish a structured curriculum of clinical, surgical and research training in Urology across Europe.

Is urologist burnout different on the other side of the pond? A European perspective

The rate of burnout among physicians appears to be on the rise and urologist are no exception. In fact, urology appears to be one of the specialties most affected, with European urologists reporting burnout rates of up to 54% and those working in the United States up to 68%.Herein, we review the relatively few studies looking at burnout in European urologists to estimate its prevalence and discuss what could be done to reverse the trend. A total of seven studies were identified assessing burnout in urologists in Europe and Turkey. While the rates vary (9.3-68%), they indicate that burnout is prevalent within urology, with data from other studies suggesting there is a rising trend. Although the topic has been studied for many years, with an increased focus in the last decade, little seems to have been done to improve the situation.

New Technologies for Kidney Surgery Planning 3D, Impression, Augmented Reality 3D, Reconstruction: Current Realities and Expectations

Purpose of review

We aim to summarize the current state of art about 3D applications in urology focusing on kidney surgeries. In addition we aim to provide a snapshot about future perspective of intraoperative applications of augmented reality (AR).

Recent findings

A variety of applications in different fields have been proposed. Many applications concern current realities and 3D reconstruction, while some others are about future perspective. The majority of recent studies have focused their attention on preoperative surgical planning, patient education, surgical training, and AR.

Summary

The disposability of 3D models in healthcare scenarios might improve surgical outcomes, learning curves of novice surgeons and residents, as well as patients’ understanding and compliance, allowing a more shared surgical decision-making.

A training model to teach early management of priapism

BACKGROUND

Ischaemic priapism is a urological emergency with early treatment required to prevent irreversible loss of erectile function. Corporal aspiration is the first step in management. Currently, there are no satisfactory training models to develop skills in a controlled environment. We have therefore developed a novel training model to teach trainees the steps of penile aspiration in a safe and representative way.

MATERIALS AND METHODS

We have developed a priapism model using an old catheterisation teaching model. Face validity of the model was assessed by participants and experienced urologists teaching on a urology boot camp. All had managed at least 5 cases of actual priapism. Responses were reported using a 5-point Likert Scale. Data were analysed using IBM SPSS Statistics V25. The intra-class correlation was calculated using a «One-way Random model».

RESULTS

Eleven urologists and seven trainees participated in the evaluation. The model appearance was reported as the best simulation trait of the priapism model. Tactile feedback from needle insertion for aspiration was also felt to be realistic with 72.6% reporting it as «Good» or «very good» and 85.7% reported the model to be realistic for needle insertion. Intra-class correlation amongst experts was 0.552. Majority of trainees (83.3%) reported a realistic simulation. All evaluators agreed or strongly agreed that the model provided a good simulated experience that would be useful in training.

CONCLUSION

Our model provides a realistic simulation of corporal aspiration. It can be used repeatedly. Overall, the proposed model appears to be a promising tool for training junior doctors in the initial management of ischaemic priapism.

3D imaging technologies in minimally-invasive kidney and prostate cancer surgery: which is the urologists' perception?

BACKGROUND

Many specific 3D imaging technologies are currently available for the practising urologists. Aim of the study was to assess their perception about different 3D imaging tools in the field of prostate and kidney cancer surgery.

METHODS

All the attendees of the 8th Techno-Urology-Meeting were asked to fill a questionnaire regarding the role of 3D virtual reconstruction PDFs, 3D printing models, Augmented-Reality (AR) and mixed reality technology in the setting of surgical planning, patient counselling, intraoperative guidance and training for kidney and prostate cancer surgery; Moreover the different materials used for 3D printing were compared to assess the most suitable in reproducing the organ and tumor features, as well as their estimated cost and production time.

RESULTS

The population consisted of 180 attendees. Overall, AR was the preferred option for intraoperative guidance and training, in both prostate (55% and 38.3%) and kidney cancer surgery (58.3% and 40%). HoloLens was perceived as the best imaging technology for the surgical planning (50% for prostate and 60% for kidney), whereas printed models for patients counselling (66.7% for prostate and 61.7% for kidney). Fused deposition models were deemed as the best printing technology in representing kidney anatomy and renal tumor location (40%), while silicon (46.7%) and Polyjet (36.7%) models for prostate anatomy and cancer location. Finally, attendees demonstrated poor knowledge of 3D printing costs and production times.

CONCLUSIONS

Our study shows the perceptions of a heterogeneous surrogate of practising urologists about the role and potential applications of 3D imaging technologies in daily surgical practice.

Trends in Positioning for Robotic Prostatectomy: Results From a Survey of the Endourological Society

Purpose: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery.

Methods: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests.

Results: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning.

Conclusions: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one’s surgical team might allow for novel and safer approaches.

Exploring the Residents' Perspective on Smart learning Modalities and Contents for Virtual Urology Education: Lesson Learned During the COVID-19 Pandemic

PURPOSE

The COVID-19 outbreak has substantially altered residents' training activities. While several new virtual learning programs have been recently implemented, the perspective of urology trainees regarding their usefulness still needs to be investigated.

METHODS

A cross-sectional, 30-item, web-based Survey was conducted through Twitter from April 4th, 2020 to April 18th, 2020, aiming to evaluate the urology residents' perspective on smart learning (SL) modalities (pre-recorded videos, webinars, podcasts, and social media [SoMe]), and contents (frontal lessons, clinical case discussions, updates on Guidelines and on clinical trials, surgical videos, Journal Clubs, and seminars on leadership and non-technical skills).

RESULTS

Overall, 501 urology residents from 58 countries completed the survey. Of these, 78.4, 78.2, 56.9 and 51.9% of them considered pre-recorded videos, interactive webinars, podcasts and SoMe highly useful modalities of smart learning, respectively. The contents considered as highly useful by the greatest proportion of residents were updates on guidelines (84.8%) and surgical videos (81.0%). In addition, 58.9 and 56.5% of responders deemed seminars on leadership and on non-technical skills highly useful smart learning contents. The three preferred combinations of smart learning modality and content were: pre-recorded surgical videos, interactive webinars on clinical cases, and pre-recorded videos on guidelines.

CONCLUSION

Our study provides the first global «big picture» of the smart learning modalities and contents that should be prioritized to optimize virtual Urology education. While this survey was conducted during the COVID-19 outbreak, our findings might have even more impact in the future.

Urology simulation boot camp: A perspective from non-UK delegates

BACKGROUND

Medical simulation has become an integral part of modern-day surgical training. Despite its benefits, it is still not widely incorporated in the curriculum of trainees. The Urology Boot Camp (USBC) is an innovative 5-day course aimed at trainees entering the UK training scheme. Since its implementation, there's been increasing interest by non-UK trainees.

OBJECTIVE

To assess the experiences of non-UK trainees in the USBC, both quantitatively and qualitatively, including skills progression analysis.

DESIGN, SETTING AND PARTICIPANTS

This double-group cohort retrospective study included 20 delegates from non-UK countries and 76 trainees from UK who attended the USBC in 2017 and 2018. Trainees undertook pre- and post-course MCQs, pre-course operative experience questionnaires and a 12-month post-course survey on the usefulness of the skills acquired.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Differences in mean MCQ scores between UK and non-UK delegates at baseline and after the course were assessed by the independent T-test. Each core urology procedural skill was evaluated by an expert and graded according to a Likert scale (1-5). The Kruskal-Wallis test was used to assess the differences in the scores between both groups on endourological techniques. A Likert scale (1-5) was used to grade the participants' answers to the post-course 12-month survey.

RESULTS AND LIMITATIONS

Trainees from UK scored significantly higher in the pre-course MCQ assessment, however after completion of the boot camp, no significant difference was noted. There were no differences between the groups at e-BLUS completion times, and both groups significantly improved their results. A 12-month post-course survey on the utility of training during the boot camp and qualitative evaluation of the course by overseas delegates was very positive.

CONCLUSIONS

The USBC is a valuable learning experience that leads to improvement of technical and soft skills of UK and non-UK trainees alike.

A simple novel training model for teaching suprapubic catheter (SPC) exchange

OBJECTIVES

To develop a suprapubic catheter (SPC) training model as no specific realistic training model exists to replicate SPC exchange where a catheter tract is present.

MATERIALS AND METHODS

We describe a novel, anatomically realistic, animal simulator model for use in SPC training, which was trialed at a national urology simulation boot camp by new urology trainees and validated by expert urologists. A scale reproduction of an abdominal wall was created using a porcine abdominal wall. A segment of small bowel was stitched around a size 16F Foley catheter to form a tract. Abdominal wall tissue was excised cylindrically to create an opening, and the small bowel tract was passed through the abdominal wall and sutured anteriorly, producing a realistic SPC tract: inferiorly, the tract was anastomosed to a porcine urinary bladder. This model was evaluated by 10 expert urologists for content validity with an 8-item 5-point rating scale used to evaluate domains relevant to the simulator.

RESULTS

The domains were scored between 1 and 5 by 10 expert urologists, 1 being «strongly disagree» and 5 being «strongly agree». The average expert ratings of the domains were then calculated and tabulated following the training course. There was an average global rating of 4.2/5 for the model, with an average usefulness for training score of 4.6/5.

CONCLUSION

The feedback from experts and trainees (informal) was overwhelmingly positive. On average, our experts reported high satisfaction with their experience using this simulator as a training tool.

Simulator Availability Index: a novel easy indicator to track training trends. Is Europe currently at a urological training recession risk?

Introduction

To evaluate the European trend regarding the availability of surgical simulators and to propose a novel index to easily track this trend.

Material and methods

During European Urology Residents Education Program, from 2014 to 2018, residents were asked through an anonymous survey about the availability of specific simulator training boxes at their department. The Simulator Availability Index (SAI) was made by the ratio between the number of departments with at least one box trainer and the total number of departments evaluated.

Results

The SAI decreased in five years from 0.47 to 0.41 for laparoscopic trainers, while the already low initial SAI (0.17) decreased by up to 0.05 in four years for both ureteroscopy (URS) and transurethral resection (TUR) trainers.

Conclusions

A self-analysis may be advisable in order to improve the spread of information and investigate whether any specific reasons may be responsible for this trend. The SAI might be a simple but useful tool to monitor and evaluate this trend in the context of national training plans.

Cadaveric Penile Prosthesis Workshop training improves surgical confidence levels of urologists: South Asian Society for Sexual Medicine course survey

OBJECTIVES

To analyze the impact of South Asia's first cadaveric hands-on workshop on urologists' training in inflatable penile prosthesis surgery.

METHODS

A total of 72 urologists/andrologists participated in the 2019 South Asian Society for Sexual Medicine Pre-congress Penile Prosthesis hands-on workshop. The workshop included 4 h of lectures and 2 h of hands-on cadaveric laboratory experience using three-piece inflatable penile prosthesis. The Shapiro-Wilk test was used on self-rated procedural confidence levels, which proved the normality. A non-parametric McNemar test was used to examine the change in the number of correct answers.

RESULTS

Of those who attended the cadaver laboratory, just 45 who answered the survey both before and after the workshop were included for analysis. Significant objective improvements were noted in procedural knowledge test scores (44.30 ± 0.027 vs 72.44 ± 0.024, P < 0.05) and median surgical confidence levels (4 vs 3 and 2, P < 0.001) of the urologists after the completion of the workshop.

CONCLUSIONS

Cadaveric hands-on workshop training improves urologists' procedural knowledge and surgical confidence levels in carrying out three-piece inflatable penile prosthesis surgery. The feasibility of such workshops should be considered in increasing the surgical expertise of general urologists in prosthetic urology.

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol

BACKGROUND

The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training.

METHODS

The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis.

RESULTS

Sixteen hands-on training expert tutors and 47 3^rd-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate").

CONCLUSIONS

Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.

COVID-19's Impact on Italian Urology

The COVID-19 pandemic has impacted our lives, our habits and our healthcare system. Italy is one of the countries affected first and more aggressively from the outbreak. Our rapidity has been guide for other healthcare systems from around the World. We describe the impact of COVID-19 on Urology, how the Urological scientific community responded to the emergency and our experience in a high-volume Roman University hospital. The aim of our work is to share our experience providing suggestions for other global hospitals on how to manage the COVID-19 emergency.

Endourology (Lithiasis). Management, surgical considerations and follow-up of patients in the COVID-19 era

PURPOSE

To provide recommendations on the endourological management of lithiasis in the scenario of the COVID-19 pandemic.

MATERIALS AND METHODS

A non-systematic review in PubMed and the grey literature, as well as recommendations by a panel of stakeholders was made, regarding management, surgical considerations and follow-up of patients affected by lithiasis in the COVID-19 era.

RESULTS

Under the current outbreak and COVID-19 pandemic scenario, patients affected by lithiasis should be prioritized into low, intermediate and high risk categories, to decide their delay and save resources, healthcare personnel, beds and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Delaying lithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may be useful in guiding these patients, reducing visits and unnecessary exposure.

CONCLUSIONS

categorization and prioritization of patients affected by lithiasis is crucial for management, surgical selection and follow-up. Protocols, measures and additional efforts should be carried out in the current situation of the COVID-19 pandemic.

Urologic surgery in a safe hospital during the COVID-19 pandemic scenario

BACKGROUND

The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non-urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased.

METHODS

We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019.

RESULTS

We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures.

CONCLUSIONS

Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.

COVID19 pandemic impacts on anxiety of French urologist in training: Outcomes from a national survey

INTRODUCTION

The COVID-19 outbreak in France is disturbing our health system. Urologists in training who are already known to have burnout, are in the front line to face this disease. The aim of our study was to assess the psychological impact of COVID-19 pandemic on young French urologists in training.

MATERIAL AND METHODS

A self-administered anonymous questionnaire evaluating the pandemic added stress, and its negative impact on work and training quality, was e-mailed to the members of the French Association of Urologists in Training (AFUF). The association includes all French junior and senior residents. The survey lasted 3 days. Multivariable analyses using logistic regression was performed to identify the predictive factors.

RESULTS

Two hundred and seventy-five (55.5%) of the 495 AFUF members responded to the questionnaire. More than 90% of responders felt more stressed by the pandemic. Fellows and senior residents were more likely to feel that the crisis had an important impact on their work quality (OR=1.76, IC95=[1.01-3.13]), even more when COVID 19 patients were present in their department (OR=2.31, IC95=[1.20-4.65]). Past medical history of respiratory disease (OR=2.57, IC95=[1.31-5.98]) and taking in charge COVID19 patients (OR=1.85, IC95=[0.98-3.59]) were additional risk factors.

CONCLUSION

COVID19 pandemic has a negative impact on young French urologists in training and on their work and training quality. Managing their psychosocial well-being during this time is as important as managing their physical health.

LEVEL OF EVIDENCE

3.

Evaluation of the "Teaching Guide for Basic Laparoscopic Skills" as a stand-alone educational tool for hands-on training sessions: a pilot study

INTRODUCTION AND OBJECTIVES

Standardization of hands-on training (HoT) has profoundly impacted the educational field in the last decade. To provide quality training sessions on a global scale, the European School of Urology Training group developed a teaching guide for tutors in 2015. Our study aims to understand whether this guide alone can provide information enough to match the performance improvement guaranteed by an expert tutor.

MATERIAL AND METHODS

4 randomized groups of participants underwent HoT sessions with different teaching modalities: an expert surgeon (group 1), an expert E-BLUS tutor (group 2), E-BLUS guide alone (group 3), no tutor (group 4). Groups 1 and 2 were respectively provided with two different tutors to avoid biases related to personal tutor ability. Along the training session, each participant could perform five trials on two E-BLUS tasks: Peg transfer and Knot tying. During trials 1 and 5, completion time and number of errors were recorded for analysis with Pi-score algorithm. The average per-group Pi-scores were then compared to measure different performance improvement results.

RESULTS

60 participants from Italy were enrolled and randomized into four groups of 15. Pi-scores recorded on Peg transfer task were 24,6 (group 1), 26,4 (group 2), 42,2 (group 3), 11,7 (group 4). Pi-scores recorded on Knot tying task were 33,2 (group 1), 31,3 (group 2), 37,5 (group 3), 18,6 (group 4).

CONCLUSION

Compared to a human tutor, standardized teaching with the EBLUS guide may produce similar performance improvement. This evidence opens doors to automated teaching and to several novelties in hands-on training.

National discrepancies in residency training of open simple prostatectomy for benign prostatic enlargement: Redefining our gold standard

INTRODUCTION

In light of the recent Canadian Urological Association (CUA) and other urological associations' (America Urological Association, European Association of Urology) recommendations for the treatment of benign prostate hyperplasia (BPH) with lower urinary tract symptoms (LUTS), open simple prostatectomy (OSP) remains the recommended approach for large prostates with measured volumes over 80 cc. We sought to assess the current state of OSP and other BPH surgical training across Canadian urology residency programs and the use of guideline-recommended imagery prior to BPH surgery.

METHODS

A survey was distributed among Canadian urology program directors in June 2019. We identified the various surgical modalities available for the treatment of BPH offered by each program and obtained the annual number of OSP performed at each academic residency program. Additionally, we evaluated if preoperative transrectal ultrasound (TRUS) of the prostate was routinely performed to obtain the prostate volume during patient counselling, as recommended by 2018 CUA guidelines.

RESULTS

All 13 program directors from the Canadian urology programs responded to our survey. OSP and monopolar transurethral resection of the prostate (TURP) remain the most common across programs and are practiced in all centers. Greenlight photo-vaporization, bipolar TURP, holmium laser enucleation of the prostate, and robot-assisted simple prostatectomy were practiced in 76.8%, 69.2%, 23.1%, and 23.1% of centers, respectively. The mean number of OSP per academic training program was 4.7 cases annually. Moreover, only five (38%) academic centers routinely performed a preoperative TRUS to evaluate prostate volume for BPH counselling.

CONCLUSIONS

Although recognized and referenced as the BPH gold standard for the treatment of prostates over 80 cc, Canadian urology trainees' annual OSP exposure remains extremely limited. Considering the degree of importance given (category A) to the direct observation (of a minimum of five) of this intervention during residency training in the new Royal College's practice guidelines, it may be unrealistic to reach these national standards considering the annual case OSP volumes in Canadian academic urology faculties.

Is remote live urologic surgery a reality? Evidences from a systematic review of the literature

INTRODUCTION AND OBJECTIVES

The possibility of performing remote-surgery has been the goal to achieve, since the early development of the first surgical robotic platforms. This systematic review aims to analyse the state of the art in the field and to provide an overview of the possible growth of this technology.

METHODS

All English language publications on Telementoring and Telesurgery for minimally invasive urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed^®, Scopus^®, and Web of Science™ databases (up to June 2019).

RESULTS

Our electronic search identified a total of 124 papers in PubMed, Scopus, and Web of Science. Of these, 81 publications were identified for detailed review, which yielded 22 included in the present systematic review. Our results showed that remote surgery has been under-utilised until today, mostly due to the lack of appropriate telecommunication technologies.

CONCLUSION

Remote live surgery is a growing technology that is catalyzing incremental interest. Despite not being yet reliable today on a regular basis in its most advanced applications, thanks to the advent of novel data-transmission technologies, telepresence might become a critical educational methodology, highly impacting the global healthcare system.