Training, Simulation, the Learning Curve, and How to Reduce Complications in Urology

Endourological society fellowship program: a real contribution to improve surgical outcomes of stone patients treated with ureteroscopy

PURPOSE

We assessed the impact of the one-year endourological society fellowship program (ESFP) on the achievement of optimal surgical outcomes (OSO) in stone patients treated with ureteroscopy (URS).

MATERIALS AND METHODS

We identified 303 stone patients treated with URS from January 2018 to June 2022 by five experienced surgeons (ES). Of those, two attended ESFP. OSO was defined as the presence of residual fragments ≤ 4 mm at 1-month post-operative imaging (Ultrasound + X - Ray or CT scan). Descriptive statistics explored patients' characteristics and the rate of OSO according to the attendance of ESFP. Uni- and multivariate logistic regression analyses (UVA and MVA) tested the impact of stone characteristics, surgical data, ESFP, and imaging technique on the rate of OSO. The LOWESS curve explored the graphical association between stone size and the multivariable-adjusted probability of OSO in the two groups of surgeons.

RESULTS

Of 303 patients, 208 (69%) were treated by the two surgeons who attended ESFP. OSO was achieved in 66% and 52% of patients treated by ES with and without ESFP, respectively (p = 0.01). At UVA, ESFP (OR = 1.78; 95% CI = 1.09-2.90), stone diameter (OR = 0.92; 95% CI = 0.88-0.96), stone location (kidney vs. ureter; OR = 0.34; 95% CI = 0.21-0.58), imaging technique (CT scan vs. Ultrasound + X-Ray; OR = 0.28; 95% CI = 0.16-0.47) predicted OSO achievement (all p < 0.05). At MVA analyses, ESFP was associated with OSO (OR = 2.24; 95% CI = 1.29-3.88; p < 0.05), along with the other aforementioned variables. The LOWESS curve showed that the greater the stone size, the greater the difference in OSO in the two groups of surgeons.

CONCLUSIONS

ESFP positively affects OSO achievement after URS, especially in patients with a high stone burden.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE

To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system.

METHODS

Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups.

RESULTS

Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected.

CONCLUSION

The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

Deep Learning Model for Real‑time Semantic Segmentation During Intraoperative Robotic Prostatectomy

Background and objective

Recently, deep learning algorithms, including convolutional neural networks (CNNs), have shown remarkable progress in medical imaging analysis. Semantic segmentation, which segments an unknown image into different parts and objects, has potential applications in robotic surgery in areas where artificial intelligence (AI) can be applied, such as in AI-assisted surgery, surgeon training, and skill assessment. We aimed to investigate the performance of a CNN-based deep learning model in real-time segmentation in robot-assisted radical prostatectomy (RALP).

Methods

Intraoperative videos of RALP procedures were obtained. The reinforcement U-Net model was used for segmentation. Segmentation of the images of instruments, bladder, prostate, and seminal vesicle-vas deferens was performed. The dataset was preprocessed and split randomly into training, validation, and test data in a 7:2:1 ratio. Dice coefficient, intersection over union (IoU), and accuracy by class, which are commonly used in medical image segmentation, were calculated to evaluate the performance of the model.

Key findings and limitations

From 120 patient videos, 2400 images were selected for RALP procedures. The mean Dice scores for the identification of the instruments, bladder, prostate, and seminal vesicle-vas deferens were 0.96, 0.74, 0.85, and 0.84, respectively. Overall, when applied to the test data, the model had a mean Dice coefficient value of 0.85, IoU of 0.77, and accuracy of 0.85. Limitations included the sample size, lack of diversity in the methods of surgery, incomplete surgical processes, and lack of external validation.

Conclusions and clinical implications

The CNN-based segmentation provides accurate real-time recognition of surgical instruments and anatomy in RALP. Deep learning algorithms can be used to identify anatomy within the surgical field and could potentially be used to provide real-time guidance in robotic surgery.

Patient summary

We demonstrate the potential effectiveness of deep learning segmentation in robotic prostatectomy procedures. Deep learning algorithms could be used to identify anatomical structures within the surgical field and may provide real-time guidance in robotic surgery.

Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents

OBJECTIVE

To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents.

MATERIALS AND METHODS

ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test.

RESULTS

A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001).

CONCLUSION

Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Defining the Learning Curve for Endoscopic Ear Skills Using a Modular Trainer: A Multi-Institutional Study

OBJECTIVE

Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development.

STUDY DESIGN

Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer.

SETTING

Two academic teaching hospitals.

SUBJECTS

Otolaryngology residents.

MAIN OUTCOME MEASURES

Trial completion times; rate of improvement over time.

RESULTS

Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001).

CONCLUSIONS

Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.

Learning Curve for Ultrasound Assessment of Myometrial Infiltration in Endometrial Cancer Visualizing Videoclips: Potential Implications for Training

BACKGROUND

Diagnostic accuracy for estimating myometrial infiltration by ultrasound in endometrial cancer requires experience. The objective of this study is to determine the learning curve (LC) for assessing myometrial infiltration in cases of endometrial cancer using transvaginal ultrasound (TVS).

METHODS

Five trainees (one staff radiologist and four fourth-year OB/GYN residents) participated in this study. All trainees had experience in performing TVS, but none of them had specific training on the assessment of myometrial infiltration. Trainees were given one specific lecture about the topic, and then they observed videoclips from 10 cases explained by the trainer. After this, all trainees visualized 45 videoclips of uterine ultrasound scans of endometrial cancer cases. The assessment of myometrial infiltration was based on the subjective impression. Definitive histology was used as a reference standard. Trainees stated whether myometrial infiltration was ≥50% or <50%. LC-CUSUM and standard CUSUM graphics were plotted to determine how many cases were needed to reach competence, allowing a mistake rate of 15%.

RESULTS

All trainees completed the study. LC-CUSUM graphics showed that three trainees reached competence at the 33rd, 35th and 36th case, respectively. All three of them kept the process under control after reaching competence. One trainee reached competence but did not maintain it in the cumulative analysis. One trainee did not reach competence.

CONCLUSION

Our study suggests that 30-40 cases would be needed to be trained for assessing myometrial infiltration by TVS by visual interpretation of videoclips by most trainees.

The learning curve for retrograde intrarenal surgery: A prospective analysis

INTRODUCTION

retrograde intrarenal surgery (CRIR) is an evolving tool. Its learning curve is not well established, despite the common use of flexible ureteroscopes today. Our aim is to estimate the number of procedures needed for one to perform RIRS consistently.

MATERIAL AND METHODS

a urology resident had his first 80 RIRS for nephrolithiasis analyzed quantitatively and qualitatively. The procedures were divided into 4 groups containing 20 surgeries each (I to IV), according to their order, for comparison.

RESULTS

there was no difference in stone sizes between groups. All qualitative variables varied significantly between groups (p<0.001), except between III and IV. In the quantitative analysis, there was a difference between groups I and IV in time for double-J catheter placement (p=0.012). There was an increasing difference in sheath placement time (p<0.001) and in total operative time (p=0.004). The time fot stone treatment (p=0.011) was significant only between groups I, II and III. There was difference in total sheath time only between groups I and III (p=0.023). Stone free status did not change between groups.

DISCUSSION

the differences between the qualitative and quantitative variables show the relation between number of surgeries performed and proficiency in the procedure. Intergroup comparisons show sequential optimization of parameters.

CONCLUSIONS

we found that 60 is a reasonable number of surgeries to be performed in order to reach the plateau of RIRSs learning curve.

Validation of standardized training system for robot-assisted radical prostatectomy: comparison of perioperative and surgical outcomes between experienced surgeons and novice surgeons at a low-volume institute in Japan

INTRODUCTION

Although robot-assisted radical prostatectomy (RARP) has become a standard treatment modality in patients with prostate cancer (PCa), RARP is a complicated and difficult surgical procedure due to the risk of serious surgery-related complications. This study aimed to evaluate the validation of a standardized training system for RARP in patients with PCa at a single institute.

MATERIAL AND METHODS

We retrospectively reviewed the clinical and pathological records of 155 patients with PCa who underwent RARP at Gifu University between August 2018 and April 2021. We developed an institutional program for new surgeons based on the separation of the RARP procedure into six checkpoints. The primary endpoints were surgical outcomes and perioperative complications among three groups (expert, trainer, and novice surgeon groups).

RESULTS

The console time was significantly longer in the novice surgeon group than in the other groups. Regarding bladder neck dissection, ligation of lateral pedicles, and vesicourethral anastomosis, the operative time was significantly shorter in the expert group than in the other groups. Surgery-related complications occurred in 15 patients (9.7%).

CONCLUSIONS

Our training system for RARP might help reduce the influence of the learning curve on surgical outcomes and ensure that the surgeries performed at low-volume institutions are safe and effective.

A curva de aprendizado em cirurgia retrógrada intrarrenal: Uma análise prospectiva

RESUMO Introdução: a cirurgia retrógrada intrarrenal (CRIR) é ferramenta em evolução. Sua curva de aprendizado não está bem estabelecida, apesar do uso comum dos ureteroscópios flexíveis atualmente. O objetivo é estimar o número de procedimentos necessários para se realizar CRIR consistentemente. Material e Métodos: Um residente de urologia teve suas primeiras 80 CRIR para tratamento de nefrolitíase analisadas quantitativa e qualitativamente. Os procedimentos foram divididos em 4 grupos contendo 20 cirurgias cada (I a IV), de acordo com sua ordem, para comparação. Resultados: Não houve diferença nos tamanhos dos cálculos entre grupos. Todas as variáveis qualitativas apresentaram variação significativa entre os grupos (p<0,001), exceto entre III e IV. Na análise quantitativa houve diferença entre os grupos I e IV no tempo de colocação do cateter duplo J (p=0,012). Houve uma diferença crescente no tempo de colocação da bainha (p<0,001) e no tempo operatório total (p=0,004). O tempo para o tratamento do cálculo (p=0,011) foi significativo apenas entre os grupos I, II e III. Houve diferença no tempo total de bainha apenas entre os grupos I e III (p=0,023). Taxa livre de cálculos não se alterou entre os grupos. Discussão: as diferenças observadas entres as variáveis qualitativas e quantitativas evidenciam a relação entre o número de cirurgias realizadas e a proficiência no procedimento. As comparações intergrupo mostram otimização sequencial dos parâmetros. Conclusões: estima-se que 60 é um número razoável de cirurgias para que se atinja o platô da curva de aprendizado.

Determination of Face and Content Validity of Cadaveric Model for Holmium Anatomic Endoscopic Enucleation of the Prostate Training: An ESUT AEEP Group Study

Background

Bench and virtual reality nonbiological simulator models for anatomic endoscopic enucleation of the prostate (AEEP) surgery have been reported in the literature. These models are acceptable but have limited practical applications.

Objective

To validate a fresh-frozen human cadaver model for holmium AEEP training and assess its content validity.

Design, setting, and participants

Holmium AEEP operations on fresh-frozen cadavers performed by an experienced surgeon were recorded, and a video, including the main steps of the operation, was produced.

Outcome measurements and statistical analysis

The video and an accompanying questionnaire were subsequently distributed electronically to ESUT AEEP study group experts and associates (N = 32) for assessment of the AEEP training model. A ten-point Likert global rating scale was used to measure the content validity.

Results and limitations

A total of 26 answers were returned (81%). The experts agreed on the model’s suitability for AEEP training (mean Likert score: 8). According to the responses, “identifying anatomic structures and landmarks” was the most valuable aspect of the model in terms of AEEP training (median Likert score: 9). Conversely, the experts found the model’s ability, in terms of demonstrating laser and tissue reactions, to be weak (median Likert score: 6)

Conclusions

Based on the content validity assessment, the fresh-frozen cadaver-training model for laser AEEP seems to be a promising model for demonstrating and learning the correct prostate enucleation technique.

Patient summary

An increasing number of researchers have proposed that anatomic endoscopic enucleation of the prostate (AEEP) should replace transurethral resection of the prostate surgery and become the gold standard for treatment of bladder outlet obstruction due to benign prostatic hyperplasia. AEEP requires anatomic familiarity for enucleation, technical knowledge, and a solid training program before starting with the first cases. This is the first cadaver study to assess the content validity of a fresh-frozen human cadaver model for AEEP training.

Introducing 3D printed models of the upper urinary tract for high-fidelity simulation of retrograde intrarenal surgery

PURPOSE

Training in retrograde intrarenal surgery for the treatment of renal stone disease is a challenging task due to the unique complexity of the procedure. This study introduces a series of 3D printed models of upper urinary tract and stones designed to improve the training process.

METHODS

Six different models of upper urinary tract were algorithmically isolated, digitally optimized and 3D printed from real-life cases. Soft and hard stones in different sizes were produced from 3D printed moulds. The models were fitted onto a commercially available part-task trainer and tested for retrograde intrarenal surgery.

RESULTS

Each step of the procedure was simulated with extraordinary resemblance to real-life cases. The unique anatomical intricacy of each model and type of stones allowed us to reproduce surgeries of increasing difficulty. As the case-load required to achieve proficiency in retrograde intrarenal surgery is high, benchtop simulation could be integrated in training programs to reach good outcomes and low complication rates faster. Our models match incredible anatomical resemblance with low production cost and high reusability. Validation studies and objective skills assessment during simulations would allow comparison with other available benchtop trainers and the design of stepwise training programs.

CONCLUSIONS

3D printing is gaining a significant importance in surgical training. Our 3D printed models of the upper urinary tract might represent a risk-free training option to hasten the achievement of proficiency in endourology.

Validation of a Bench-Top Training Model for Retrograde Intrarenal Surgery

OBJECTIVE

To validate the in-house built Styrofoam box bench-top training model for retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

This study was performed in the setting of a half-day RIRS course. During the course, participants performed RIRS on a locally built bench-top model. We recruited 26 participants, comprising 20 trainees and 6 experts. Trainees and experts were asked to fill a self-administered questionnaire assessing various components of RIRS to assess the face and content validity. For construct validity, experts using Objective Structured Assessment of Technical Skills (OSATS) rated trainees and the mean OSATS score of junior versus senior residents was compared.

RESULTS

As per trainees, the model was 86% (4.3/5) realistic, which was backed by experts who found this model to be 87.6% (4.38/5) realistic. The overall face validity of the model was 86.4% (4.32/5). The overall content validity of this model was 83.4% (4.17/5). Majority of the participants thought that this tool is useful for learning technique (4.38 ± 0.49) and safe-conduct (4.31 ± 0.73) of the procedure. The trainees concurred that the skills acquired are transferable to the operating room (4.23 ± 0.76). However, the construct validity by comparing mean OSATS score of junior versus senior residents was 19.5 ± 3.5 and 23 ± 4.5. A p value of 0.11 could not be established.

CONCLUSION

This study has demonstrated the face, content, and construct validity of the bench-top training model for RIRS. Further evaluation is necessary to compare its effectiveness against other available models to demonstrate concurrent validity.

Development and validation of non-guided bladder-neck and neurovascular-bundle dissection modules of the RobotiX-Mentor® full-procedure robotic-assisted radical prostatectomy virtual reality simulation

Background

Full‐procedure virtual reality (VR) simulator training in robotic‐assisted radical prostatectomy (RARP) is a new tool in surgical education.

Methods

Description of the development of a VR RARP simulation model, (RobotiX‐Mentor®) including non‐guided bladder neck (ngBND) and neurovascular bundle dissection (ngNVBD) modules, and assessment of face, content, and construct validation of the ngBND and ngNVBD modules by robotic surgeons with different experience levels.

Results

Simulator and ngBND/ngNVBD modules were rated highly by all surgeons for realism and usability as training tool. In the ngBND‐task construct, validation was not achieved in task‐specific performance metrics. In the ngNVBD, task‐specific performance of the expert/intermediately experienced surgeons was significantly better than that of novices.

Conclusions

We proved face and content validity of simulator and both modules, and construct validity for generic metrics of the ngBND module and for generic and task‐specific metrics of the ngNVBD module.

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial

Background

Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.

Methods

Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.

Results

Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).

Conclusions

Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.

Trial registration

ISRCTN 83733979

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.

The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings

Introduction

Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context.

Methods

A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol).

Results

The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74).

Conclusion

Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.

Comprehensive training in robotic surgery

PURPOSE OF REVIEW

Robotic training in urology can be poorly structured, lack a basic skills foundation, and may not include teaching in important nontechnical human factor skills vital to the safe delivery of robotic care. Assessment of acquired skills is not routine. There is a need for structured and standardized curricular to deliver validated training and final assessment. The present reviews the current literature on training methods for robotic surgery, and examines the evidence for their effect on performance, where available.

RECENT FINDINGS

There is good evidence for the beneficial effect of dry lab simulators on robotic skills acquisition, but less for cadaveric and animal models. Two urological authorities have developed comprehensive curricula for robotic training that take a novice robotic surgeon through the full stages of robotic skills acquisition. These are in the early stages of development and validation but have stimulated the development of curricula in other specialties.

SUMMARY

The future landscape for robotic urology training is likely to include structured, mandated, and centralized training, possibly administered by urological organizations. There will be roles for telementoring, advanced education for robotic trainers, and regular revalidation of expert robotic surgeons.

Simulation-based training for flexible cystoscopy – A randomized trial comparing two approaches

Background

Simulation-based training allows trainees to experiment during training and end-of-training tests could increase motivation and retention. The aim of this trial was to determine if a simulation-based training program including directed self-regulated learning and post-testing improved clinical outcomes compared to a traditional simulation-based training program.

Methods

A randomized trial was conducted involving 32 participants without prior experience in endoscopic procedures. The intervention group practiced independently in a simulation centre and got a post-test whereas the control group received traditional instructions and demonstrations before being allowed to practice. Three weeks after the intervention the participants performed cystoscopies on two consecutive patients. Clinical performance was assessed using a global rating scale (GRS) with established evidence of validity. Independent samples t-test, Cronbach's α, Pearson's r, and paired samples t-test were used for statistical analysis.

Results

Twenty-five participants performed two cystoscopies on patients. There was no significant difference between the two study groups with respect to mean GRS of performance (p = 0.63, 95 % CI; -2.4–3.9). The internal consistency of the global rating scale was high, Cronbach's α = 0.91. Participants from both study groups demonstrated significant improvement between the first and second clinical procedures (p = 0.004, 95 % CI, 0.8–3.5). Eight (32%) and 15 (60%) participants demonstrated adequate clinical skills in their first and second procedure, respectively.

Conclusions

No significant differences were found on the clinical transfer when comparing the two programs. Neither of our training programs was able to ensure consistent, competent performance on patients and this finding could serve as an important argument for simulation-based mastery learning where all training continues until a pre-defined level of proficiency is met.

Trial registrations

The trial was submitted before enrolment of participants to the Regional Scientific Ethics Committee of the Capital Region which established that ethical approval was not necessary (H-4-2014-122). The trial was registered at Clinicaltrials.gov (NCT02411747).

Benefits and Limitations of Transurethral Resection of the Prostate Training With a Novel Virtual Reality Simulator

PURPOSE

Profound endourological skills are required for optimal postoperative outcome parameters after transurethral resection of the prostate (TURP). We investigated the Karl Storz (Tuttlingen, Germany) UroTrainer for virtual simulation training of the TURP.

MATERIALS AND METHODS

Twenty urologists underwent a virtual reality (VR) TURP training. After a needs analysis, performance scores and self-rated surgical skills were compared before and after the curriculum, the realism of the simulator was assessed, and the optimal level of experience for VR training was evaluated. Statistical testing was done with SPSS 25.

RESULTS

Forty percent of participants indicated frequent intraoperative overload during real-life TURP and 80% indicated that VR training might be beneficial for endourological skills development, underlining the need to advance classical endourological training. For the complete cohort, overall VR performance scores (P = 0.022) and completeness of resection (P < 0.001) significantly improved. Self-rated parameters including identification of anatomical structures (P = 0.046), sparing the sphincter (P = 0.002), and handling of the resectoscope (P = 0.033) became significantly better during the VR curriculum. Participants indicated progress regarding handling of the resectoscope (70%), bleeding control (55%), and finding the correct resection depth (50%). Although overall realism and handling of the resectoscope was good, virtual bleeding control and correct tissue feedback should be improved in future VR simulators. Seventy percent of participants indicated 10 to 50 virtual TURP cases to be optimal and 80% junior residents to be the key target group for VR TURP training.

CONCLUSIONS

There is a need to improve training the TURP and VR simulators might be a valuable supplement, especially for urologists beginning with the endourological desobstruction of the prostate.

The safety of urologic robotic surgery depends on the skills of the surgeon

PURPOSE

To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

METHODS

A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

RESULTS

Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

CONCLUSION

To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.

The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation

BACKGROUND

No validated training program for robot-assisted partial nephrectomy (RAPN) exists.

OBJECTIVE

To define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

A modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

To define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann-Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence.

RESULTS AND LIMITATIONS

Consensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p>0.05). Conversely, operative time was longer after cRAPN (p<0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p<0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.

CONCLUSIONS

The European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.

PATIENT SUMMARY

Patients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.

Urology resident training in laparoscopic surgery - results of the first national survey in Poland

Introduction

For many urological procedures the open approach is being replaced by the laparoscopic approach. Laparoscopy technique requires special training conditions. A well-designed, step-by step training program is significantly important for shortening the learning curve.

Aim

The purpose of the study was to evaluate urology residents’ (UR) experience in laparoscopic procedures, training patterns and facilities available in departments of urology in Poland.

Material and methods

The survey developed by the authors included 18 questions concerning laparoscopy training and was distributed among UR who participated in 2 courses in laparoscopic surgery for UR in Poland in 2017. The survey consisted of questions regarding the number of laparoscopic procedures, acquired laparoscopic experience, laparoscopic simulation training and motivation for further learning.

Results

Of the 2017 invited UR in Poland, 108 (34%) completed the survey. Seventy-two (78%) UR from the study group have access to laparoscopic surgery in their department. Only 20 (25%) of urology departments are equipped with a laparoscopy box and a small number of UR perform regular training. As a primary operator basic (varicocele repair) and advanced (e.g. radical nephrectomy, radical prostatectomy, nephron-sparing surgery) laparoscopic procedures are performed respectively by 55 (71%) UR and 8 (10%) UR. Most residents evaluated their laparoscopic skills as poor (15, 19%), very poor (31, 40%) or absent (10, 13%), while only 22 (28%) evaluated them as at least satisfactory.

Conclusions

Laparoscopic technique is available in most Polish training centers. However, the majority of UR consider their skills unsatisfactory. Additionally, a large number of Polish UR do not have access to intensive training. UR considered that their availability of training courses and fellowships is low. Surgical exposure among Polish UR comprises mainly minor laparoscopic procedures.

Utilising the Delphi Process to Develop a Proficiency-based Progression Train-the-trainer Course for Robotic Surgery Training

CONTEXT

As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important.

OBJECTIVE

To provide guidance on an optimised "train-the-trainer" (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training.

EVIDENCE ACQUISITION

The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

EVIDENCE SYNTHESIS

There was 100% consensus that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90.

CONCLUSIONS

Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation.

PATIENT SUMMARY

As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised "train-the trainer" curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts' knowledge of surgical training.

[Evaluation of the learning curve of laparoscopic radical cystectomy for cancer: Morbidity and oncological results]

INTRODUCTION

The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes.

PATIENT AND METHODS

This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007 to March 2016, (93 patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method.

RESULTS

Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1 and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1 and P2 respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703).

CONCLUSION

This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications.

LEVEL OF EVIDENCE

3.

Virtual Reality and Simulation for Progressive Treatments in Urology

In urology technologies and surgical practices are constantly evolving and virtual reality (VR) simulation has become a significant supplement to existing urology methods in the training curricula of urologists. However, new developments in urology also require training and simulation for a wider application. In order to achieve this VR and simulation could play a central role. The purpose of this article is a review of the principal applications for VR and simulation in the field of urology education and to demonstrate the potential for the propagation of new progressive treatments. Two different cases are presented as examples: exposure therapy for paruresis and virtual cystoscopy for diagnosis and surgery of bladder cancer. The article uses research and publications listed in openly accessible directories and is organized into 3 sections: The first section covers features of VR and simulation technologies. The second one presents confirmed applications of current technologies in urology education and showcases example future applications in the domain of bladder treatment and surgery. The final section discusses the potential of the technology to improve health care quality.

Strategies for New Skill Acquisition by Practicing Surgeons

OBJECTIVE

To understand how practicing surgeons utilize available training methods, which methods are perceived as effective, and important barriers to using more effective methods.

DESIGN

Online survey designed to characterize surgeon utilization and perception of available training methods.

SETTING

Two large Midwestern academic health centers.

PARTICIPANTS

150 faculty surgeons.

METHODS

Nominal values were compared using a McNemar's Test and Likert-like values were compared using a paired t-test (IBM SPSS Statistics v. 21.0; New York, NY).

RESULTS

Survey response rate was 81% (122/150). 98% of surgeons reported learning a new procedure or technology after formal training. Many surgeons reported scrubbing in expert cases (78%) and self-directed study (66%), while few surgeons (6%) completed a mini-fellowship. The modalities used most commonly were scrubbing in expert cases (34%) and self-directed study (27%). Few surgeons (7%) believed self-directed study would be most effective, whereas 31% and 16% believed operating under supervision and mini-fellowships would be most effective, respectively. Surgeons believed more effective methods "would require too much time" or they had "confidence in their ability to implement safely."

CONCLUSIONS

Practicing surgeons use a variety of training methods when learning new procedures and technologies, and there is disconnect between commonly used training methods and those deemed most effective. Confidence in surgeon's ability was cited as a reason for this discrepancy; and surgeons found time associated with more effective methods to be prohibitive.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

BACKGROUND

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve.

OBJECTIVE

To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons.

DESIGN AND METHODS

We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure.

RESULTS

In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure.

DISCUSSION

We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients.

CONCLUSIONS

Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.