Live-case demonstrations in pediatric urology: Ethics, patient safety, and clinical outcomes from an 8-year institutional experience

The Oncobiome in Gastroenteric and Genitourinary Cancers

Early evidence suggests a strong association of microorganisms with several human cancers, and great efforts have been made to understand the pathophysiology underlying microbial carcinogenesis. Bacterial dysbiosis causes epithelial barrier failure, immune dysregulation and/or genotoxicity and, consequently, creates a tumor-permissive microenvironment. The majority of the bacteria in our body reside in the gastrointestinal tract, known as gut microbiota, which represents a complex and delicate ecosystem. Gut microbes can reach the pancreas, stomach and colon via the bloodstream. Oral bacterial translocations can also occur. In the stomach, pancreas and colon, low microbial diversity is associated with cancer, in particular with a bad prognosis. The urogenital tract also harbors unique microbiota, distinct from the gut microbiota, which might have a role in the urinary and female/male reproductive cancers’ pathogenesis. In healthy women, the majority of bacteria reside in the vagina and cervix and unlike other mucosal sites, the vaginal microbiota exhibits low microbial diversity. Genital dysbiosis might have an active role in the development and/or progression of gynecological malignancies through mechanisms including modulation of oestrogen metabolism. Urinary dysbiosis may influence the pathogenesis of bladder cancer and prostate cancer in males. Modulation of the microbiome via pre, pro and postbiotics, fecal or vaginal microbiota transplantation and engineering bacteria might prove useful in improving cancer treatment response and quality of life. Elucidating the complex host-microbiome interactions will result in prevention and therapeutic efficacy interventions.

Live Case Demonstrations are Essential for the Success of Pediatric Urology Meetings in India

Purpose:

The purpose of the study was to survey the opinion of delegates attending national pediatric urology meeting regarding live case demonstrations (LCDs) to see whether these can be replaced with taped case demonstrations (TCDs) in future.

Methods:

A questionnaire-based survey was conducted at the end of the 3-day annual conference and live operative workshop in pediatric urology. Apart from general data such as age of the respondent and type of practice setting, four key questions on LCDs with yes/no responses included: would you have attended this meeting if there were no LCDs? Are unedited videos (TCDs) as effective as LCDs for teaching? Do you think LCDs should be continued? Would you allow your child to be operated in LCD by an expert? For question 3, the outcomes were compared between junior surgeons (<45-year-old) and senior surgeons (>45-year-old).

Results:

On analysis, 88/140 (62%) respondents (95% confidence interval [CI]: 54%–70%) said that they would not have attended the meeting if there were no LCDs; 70/139 (50%) respondents (95% CI: 42%–58%) felt that TCDs may be an effective alternative to LCDs; 129/144 (90%) respondents (95% CI: 83%–94%) felt that LCDs should be continued. For question 4, 101/129 (79%) said they would allow their child to be operated in LCD by an expert, while 28 (21%) did not agree for their child to be operated in LCD. There was no significant difference between junior and senior surgeons regarding support for LCDs (P = 0.15).

Conclusions:

In the Indian scenario, LCDs were favored as an essential part of pediatric urology meeting, attract more participation, and are likely to be important for the success of the meeting.

Live surgery of colorectal endometriosis broadcasted from a surgeon's routine operating theater is not associated with higher complications rate

INTRODUCTION

Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract.

MATERIAL AND METHODS

We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast.

RESULTS

Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%).

CONCLUSIONS

Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.

Infant Robot-assisted Laparoscopic Pyeloplasty: Outcomes at a Single Institution, and Tips for Safety and Success

BACKGROUND

Since its first description, multiple reports proved efficacy and safety of the robotic platform. Further progress has been made allowing for the application of robotic surgery to smaller patients, including infants. Despite the early favorable results, the use of robot surgery in infants is still controversial and more studies are needed to confirm its benefits.

OBJECTIVE

To our knowledge, we present the largest single-institution case series of robot-assisted laparoscopic pyeloplasty (RAL-P) in infants, aiming to contribute to the current literature with a guide for key technical steps and safety tips for infant RAL-P.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective review of a prospectively maintained database. The study protocol was approved by the institutional review board.

SURGICAL PROCEDURE

Only infants (≤12 mo of age) with a diagnosis of congenital ureteropelvic junction obstruction (UPJO) undergoing primary robotic dismembered pyeloplasty were included in the study.

MEASUREMENTS

We critically reviewed the clinical outcomes, described the main steps of the operation, and shared tips for a safe approach.

RESULTS AND LIMITATIONS

From January 2012 to August 2019, 44 infants underwent RAL-P for UPJO--33 (75%) males and 11 (25%) females. All robotic cases were completed successfully, with no laparotomic conversions. The median age and weight were 4 (1-12) mo and 6.8 (3.8-10.5) kg, respectively. The mean operative time was 142 (±25) min. The mean estimated blood loss was 7 (±3.6) ml, and no intraoperative complications occurred. The mean length of hospital stay (LOS) was 1.4 (±0.7) d. Seven (15.6%) patients had postoperative complications-one (2%) ileus (Clavien-Dindo grade [CDG] I), four (9%) urinary tract infections (CDG II), and two (4.5%) port-site hernias (CDG III). At a median follow-up of 19 mo, the success rate was 100%.

CONCLUSIONS

Given the successful outcomes, benefits of decreased LOS, and improved cosmesis, RAL-P is an appealing management option for UPJO in infants. Market release of new systems, further miniaturization of instruments, and more affordable costs will hopefully be shedding light on more complex applications.

PATIENT SUMMARY

Infants (≤12 mo of age) diagnosed with ureteropelvic junction obstruction undergoing primary robotic dismembered pyeloplasty were selected and included in this study. No intraoperative complications or conversion to an open approach occurred. Seven patients (16%) developed postoperative complications-one (2%) postoperative ileus, four (9%) urinary tract infections, and two (4.5%) port-site hernias. At a median follow-up of 19 (7-66) mo, the success rate was 100%.

Risks and Benefits of Live Surgical Broadcast: A Systematic Review

CONTEXT

Live surgical broadcast (LSB), also known as live surgery, has become a popular format for many types of surgical education meetings. However, concerns have been raised in relation to patient safety, ethical issues, and the actual educational value of LSB.

OBJECTIVE

To summarize current evidence on LSB with a focus on the risks of complications and the educational impact.

EVIDENCE ACQUISITION

We performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies up to December 2020. We identified original articles reporting on patient outcomes, educational value, current use, and development of LSB. We also interrogated surgical society guidelines for position statements on LSB.

EVIDENCE SYNTHESIS

Our literature search identified 46 studies spanning six surgical specialties, with urology being the most frequent. Approximately half of the studies reported on outcomes of surgical procedures during LSB. In urology, the few comparative studies available did not suggest higher complication rates in LSB, whereas data for other surgical fields highlighted evidence of worse outcomes. Four studies assessed the educational value of LSB via survey administration, for which the evidence is limited and of low quality. Thirteen guidelines and position statements on live surgery were identified among major surgical societies, including the European Association of Urology (EAU). Some surgical societies have expressly prohibited the use of LSB at their major meetings. The perspective of surgeons performing and/or attending live surgical sessions was evaluated in six studies, and four studies looked at urologists' perception of LSB compared to semi-LSB. Limitations of this systematic review include the limited number of studies available, the low quality of the evidence, and data heterogeneity.

CONCLUSIONS

Evidence regarding outcomes of LSB is limited. Almost all the studies do not show a higher risk of complications or worse outcomes for patients undergoing a procedure during LSB. Only one study on gastrointestinal surgery reported that LSB outcomes were worse. Ongoing concerns have led to specific guidelines by several scientific societies, including the EAU, with the ultimate aim of minimizing surgical risks and maximizing patient safety.

PATIENT SUMMARY

Live surgery events are often part of surgical conferences. Data in the literature show mixed outcomes for operations performed during live surgery events, but with no increase in complication rates. Safety and ethical concerns remain. Other educational tools, such as prerecorded videos and live surgery transmission from the home institution of the operating surgeon might become preferred options in the future. This review was prospectively registered on the PROSPERO website (www.crd.york.ac.uk/PROSPERO, registration number CRD42020194023).

The emergence of virtual education during the COVID-19 pandemic: The past, present, and future of the plastic surgery education

BACKGROUND

Since the global outbreak of coronavirus disease-2019 (COVID-19), plastic surgeons were forced to transition from traditional didactics to virtual lectures to practice "social distancing." As this method of education continues to be widely used, understanding the current trend of its usage is critical. In this study, we performed a survey study of virtual lecture attendees and presenters to determine current usage and general consensus on virtual lectures in plastic surgery education.

METHODS

An electronic survey was sent to attendees and presenters of virtual lectures using Google Forms. Demographic data, webinar usage patterns, and views on virtual lectures were collected.

RESULTS

A total of 417 surveys were received. Prior to the COVID-19 era, 39.1percent of attendees did not use virtual lectures and 45.6percent of presenters did not give webinars at all. Both groups reported that the lack of opportunities and need were the most common cause of no use of lectures or webinars. After the outbreak, 35.4percent of attendees now use virtual lectures daily and 51.4percent of presenters give lectures weekly. Over 90percent of the study population reported a positive experience with the virtual lectures due to increased interaction, convenience, outreach, and usability. Finally, over 75percent stated that virtual lectures might replace classroom lectures in the future.

CONCLUSION

Our study shows that a majority of plastic surgeons have begun to use and give virtual lectures daily after the COVID-19 outbreak. Virtual education is a powerful and versatile tool that has great potentials, and it may continue to serve as a part of surgical training in the future.

Outcomes of EAU-endorsed Live Surgical Events over a 5-year Period (2015-2020) and Updated Guidelines from the EAU Live Surgery Committee

CONTEXT

Live surgery events (LSEs) have been used in all surgical fields for education and training and to demonstrate new techniques. The European Association of Urology (EAU) live surgery guidelines were established in 2014.

OBJECTIVE

To review the compliance of outcomes for procedures performed at EAU-affiliated LSEs with the 2014 guidelines and to establish updated guidelines for LSEs and semi-LSEs.

EVIDENCE ACQUISITION

Patients from EAU-affiliated LSEs were included for all surgical procedures carried out between January 2015 and January 2020. All these events were pre-evaluated by the EAU Live Surgery Committee and met the criteria for an EAU LSE, with outcomes recorded and submitted to the registry. Data were collected for the type of procedure and for intraoperative and short- and long-term complications.

EVIDENCE SYNTHESIS

A total of 246 procedures were performed across 18 LSEs, with an annual volume ranging from 19 to 74 procedures. These included 109 (44.3%) robot-assisted procedures, 21 (8.5%) laparoscopic procedures, 10 (4%) transurethral bladder procedures, 11 (4.4%) prostate enucleation procedures, 72 (29.2%) endourological procedures, and 23 (9.3%) andrology or reconstruction procedures. A total of 77 different surgical techniques and variations for 55 different types of surgery were performed as LSEs over the past 5 yr. There were 44 (17.8%) short-term complications and 11.3% (nine/79) long-term complications observed, with Clavien grade III/IV complications seen in 5.2% and 7.5% of cases over short- and long-term follow-up, respectively.

CONCLUSIONS

The 5-yr outcomes for EAU LSEs show that they are safe and follow previous guidelines set by the panel. It seems likely that the fine balance between patient safety and educational value might be best achieved if LSEs are performed by local surgeons in their parent hospital with patients and staff they know, and that technological advances will make live streaming a seamless process. The current EAU Live Surgery Committee has updated the guidelines on LSEs and provided new guidelines for semi-live events.

PATIENT SUMMARY

We reviewed 5-year outcomes for live surgery events endorsed by the European Association of Urology. We found that the operations carried out at these events were safe and followed the guidelines previously set. We have updated the guidelines and provided new guidelines for semi-live events.

Learning benefits of live surgery and semi-live surgery in urology-informing the debate with results from the International Meeting of Reconstructive Urology (IMORU) VIII

Purpose

To analyze the perceived learning opportunities of participants of the International Meeting on Reconstructive Urology (IMORU) VIII for both live surgery demonstrations (LSD) and semi-live surgery demonstrations (SLSD). Safety and educational efficacy of LSD and SLSD at live surgery events (LSE) have been debated extensively, however, objective data comparing learning benefits are missing.

Methods

We conducted a detailed survey, which employed the Kirkpatrick model, a well-established assessment method of training models, to investigate participants preferences as well as the learning benefit of LSE. Furthermore, we employed an audience response system and the Objective Structured Assessment of Technical Skills (OSATS), a well-established assessment method of surgery skills, to let our participants rate the perceived learning opportunity of LSD and SLSD.

Results

Of 229 participants at the IMORU VIII, 39.7% returned our questionnaires. 90% stated that they prefer LSD. On all levels of Kirkpatrick’s training evaluation model, the IMORU received high ratings, suggesting a high learning benefit. For the assessment of OSATS, a total of 23 surgical cases were evaluable. For all six utilized items, LSD scored significantly better ratings than SLSD.

Conclusion

Our study suggests that there is still a rationale for LSD, as participants attributed a statistically significant higher learning benefit to LSD over SLDS. Evaluation of the survey showed that for LSE such as the IMORU VIII, a high learning benefit can be expected. Considering that most of our participants are active surgeons with high caseloads, their opinion on the educational value of LSE is of high relevance.