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Hughes C, Mosa H, Johnson S, Parr J, Anbarasan R, Kulkarni M, Mathur A. Can paediatric surgical registrars safely perform supervised hypospadias surgery? J Pediatr Urol 2024:S1477-5131(24)00071-8. [PMID: 38388301 DOI: 10.1016/j.jpurol.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/10/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors. METHODS We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2). RESULTS 270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair). DISCUSSION Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement. CONCLUSION Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.
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Affiliation(s)
- Charlotte Hughes
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Hazem Mosa
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
| | - Sandra Johnson
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
| | - Joanne Parr
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
| | - Ravindar Anbarasan
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
| | - Milind Kulkarni
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
| | - Azad Mathur
- Paediatric Urology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich, UK
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Margolin EJ, Schoenfeld D, Miles CH, Merrill SB, Raman JD, Thompson RH, Reese AC, Parekh DJ, Brown ET, Klausner A, Williams DH, Lee RK, Zaslau S, Guzzo TJ, Shenot PJ, Anderson CB, Badalato GM. Longitudinal Changes in the Operative Experience for Junior Urology Residents. Urology 2023; 179:32-38. [PMID: 37400019 DOI: 10.1016/j.urology.2023.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/04/2023] [Accepted: 03/29/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.
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Affiliation(s)
- Ezra J Margolin
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Daniel Schoenfeld
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Caleb H Miles
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | | | - Jay D Raman
- Department of Urology, Penn State Health, Hershey, PA
| | | | - Adam C Reese
- Department of Urology, Temple University Lewis Katz School of Medicine, Philadelphia, PA
| | - Dipen J Parekh
- Desai Sethi Urology Institute at University of Miami Miller School of Medicine, Miami, FL
| | - Elizabeth T Brown
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC
| | - Adam Klausner
- Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Richard K Lee
- Department of Urology, Weill Cornell Medical Center, New York, NY
| | - Stanley Zaslau
- Department of Urology, West Virginia University, Morgantown, WV
| | - Thomas J Guzzo
- Division of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Patrick J Shenot
- Department of Urology, Thomas Jefferson University, Philadelphia, PA
| | | | - Gina M Badalato
- Department of Urology, Columbia University Irving Medical Center, New York, NY.
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Baas W. EDITORIAL COMMENT. Urology 2022; 167:28-29. [PMID: 36153100 PMCID: PMC9492319 DOI: 10.1016/j.urology.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Wesley Baas
- University of Cincinnati College of Medicine, Cincinnati, OH
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Alpert SA. EDITORIAL COMMENT. Urology 2022; 167:28. [PMID: 36153101 PMCID: PMC9492318 DOI: 10.1016/j.urology.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Seth A Alpert
- Department of Urology, Nationwide Children's Hospital and, The Ohio State University Wexner Medical Center, Columbus, OH
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Fuller TW. AUTHOR REPLY. Urology 2022; 167:29. [PMID: 36153102 DOI: 10.1016/j.urology.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
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Daily AM, DiNatale RG, Koenig HG, Lee UJ, Fuller TW. Effect of COVID-19 on Graduating Urology Resident Case Logs: Analysis of the Accreditation Council of Graduate Medical Education National Data Reports. Urology 2022; 167:24-29. [PMID: 35779710 PMCID: PMC9242693 DOI: 10.1016/j.urology.2022.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the national case logs of the first graduating urologic resident cohorts to have trained during the COVID-19 pandemic for effects on surgical volumes. METHODS The nationally aggregated Accreditation Council for Graduate Medical Education urology resident case logs were obtained for graduates of academic years (AYs) 2015-2016 through 2020-2021. Case volume differences for tracked index categories were compared between AYs with a 1-way analysis of variance. Data were then combined into pre-COVID and COVID-affected resident cohorts and differences in average cases logged were analyzed with 2-tailed student's t-tests. RESULTS Graduating urology residents logged an average of 1322 (SD 24.8) cases over their residency during the examined period. Total cases had multiple statistical differences between AYs but the only index category with a statistically significant decrease for a COVID-affected AY compared to pre-COVID AY was pediatric majors: AY 2020-2021 logged fewer cases than AY 2015-2016 (53.9 vs 63.0, P = .004) and AY 2018-2019 (53.9 vs 61.2, P = .04). When aggregated into pre- and COVID-affected cohorts, both pediatric minor (123.4 vs 117.5, P = .049) and pediatric major (61.4 vs 56.8, P = .003) case averages decreased for the COVID-affected cohort of residents, but no adult index category decreased. CONCLUSION National graduating urology resident surgical volume for adult index categories was maintained through the pandemic. Pediatric cases saw a statistical decrease in volume of questionable clinical significance. This does not eliminate concern that individuals may have experienced a detrimental impact on their resident education.
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Affiliation(s)
- Adam M Daily
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Renzo G DiNatale
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Hannah G Koenig
- Research and Academics, Virginia Mason Franciscan Health, Seattle, WA
| | - Una J Lee
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Thomas W Fuller
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA.
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Herrera O, Mostafa S, Da Lomba T, Judge C, Andolfi C, Stahoviak K, Gundeti MS. A 10-step procedure for distal hypospadias repair with 50% resident involvement is safe and effective. UROLOGY VIDEO JOURNAL 2021. [DOI: 10.1016/j.urolvj.2021.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Collins C, Dudas L, Johnson M, Davenport D, Bernard A, Beck S, Muchow R, Pittman T, Talley C. ACGME Operative Case Log Accuracy Varies Among Surgical Programs. JOURNAL OF SURGICAL EDUCATION 2020; 77:e78-e85. [PMID: 32950429 DOI: 10.1016/j.jsurg.2020.08.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/29/2020] [Accepted: 08/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs. DESIGN This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME). SETTING Single academic tertiary-care medical center (University of Kentucky, Lexington, KY). PARTICIPANTS Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed. RESULTS There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p < 0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p < 0.001) consistent for NS and GS, but not OS. CONCLUSIONS This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.
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Affiliation(s)
- Courtney Collins
- University of Kentucky, Department of Surgery, Lexington, Kentucky
| | - Lauren Dudas
- West Virginia University, Department of Surgery, Morgantown, West Virginia
| | - Mason Johnson
- University of Kentucky, Department of Surgery, Lexington, Kentucky
| | - Daniel Davenport
- University of Kentucky, Department of Surgery, Lexington, Kentucky
| | - Andrew Bernard
- University of Kentucky, Department of Surgery, Lexington, Kentucky
| | - Sandra Beck
- University of Kentucky, Department of Surgery, Lexington, Kentucky
| | - Ryan Muchow
- University of Kentucky, Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky
| | - Thomas Pittman
- University of Kentucky, Department of Neurosurgery, Lexington, Kentucky
| | - Cynthia Talley
- Medical University of South Carolina, Charleston, South Carolina.
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Wingate J, Joyner B, Sweet RM, Hagedorn JC, Johnsen NV. Inter-Resident Variability in Urologic Operative Case Volumes Over Time: A Review of the ACGME Case Logs From 2009 to 2016. Urology 2020; 142:49-54. [PMID: 32335085 DOI: 10.1016/j.urology.2020.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the effect of the changing landscape of urologic residency education and training on resident operative exposure and inter-resident variability. METHODS The Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating urology chief residents were reviewed from Academic Year (AY) 2009-2010 to 2016-2017. Cases were stratified into the 4 ACGME categories - general urology, endourology, oncology, and reconstruction. Linear regression models analyzed the association between training year, volume, and type of cases performed. Inter-resident variability in case exposure was calculated by the difference between the ACGME reported 10th and 90th percentiles. RESULTS During the study period, the mean number of cases performed per resident was 1092 (standard deviation 32.7). Although there was no significant change in total case volume, there were changes within case categories. Endoscopic, retroperitoneal oncology, and male reconstruction case volume all increased significantly (Δ20.1%, Δ 5.1%, Δ 8.2%, respectively, all P < .05). This was balanced with a concomitant decrease in pelvic oncology and female reconstruction cases (Δ 10.0% and Δ 14.5%, respectively, both P < .05). There was a 27.8% increase in laparoscopic/robotic cases (P < .001). The ratio difference between the 10th percentile and 90th percentile ranged from a low of 2.5 for retroperitoneal oncology cases to a high of 5.2 for extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. CONCLUSION From AY2009-2010 to 2016-2017, residency case volume has remained constant, but there has been a change in types of cases performed and proliferation of minimally invasive techniques. Significant variability of inter-resident operative experience was noted.
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Affiliation(s)
| | - Byron Joyner
- Children's Hospital and Regional Medical Center, Division of Pediatric Urology, Division of Urology, Seattle, WA
| | - Robert M Sweet
- Department of Urology, University of Washington, Seattle, WA
| | | | - Niels V Johnsen
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
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