Survey of senior resident training in urologic laparoscopy, robotics and endourology surgery in Canada

A Good Craftsperson Knows Their Tools: Understanding of Laser and Ureter Mechanics in Training Urologists

Introduction: Recent decades have seen a move to minimally invasive techniques to manage urolithiasis. Trainees are expected to develop competency in common endourology procedures. Knowledge of ureter mechanics and the theory behind new technologies is important to ensure safe and efficient techniques. We aim to evaluate the exposure to endourology, self-reported competency in common techniques and knowledge of basic ureter biomechanics and technology in training urologists. Methods: An online survey was circulated to all training urologists in the Republic of Ireland. Questions focused on self-reported competency, clinical knowledge, ureter mechanical properties and laser technology. Results: Thirty responses were received with a range of 1-8 years of urology experience (mean=4 years). The respondents reported high levels of exposure to endourology with the majority reporting competency in flexible ureterorenoscopy (FURS) (n=18, 60%) and semi-rigid ureteroscopy (URS) (n=21, 70%). The respondents demonstrated good clinical knowledge but variable knowledge of laser settings, laser thermodynamics and ureter mechanics. Half of the respondents (n=15, 50%) correctly described fragmentation laser settings, with 10 trainees (n=33%) accurately identifying both factors that increase ureteral access sheath (UAS) insertion force. Most of the respondents (n=20, 67%) described the proximal ureter as the site with the greatest compliance, while the site of the greatest force during ureteroscope insertion was correctly identified by 17% (n=5). Conclusion: To our knowledge, this represents the first study evaluating urologist understanding of laser technology and the mechanical properties of the human ureter. Despite trainees reporting high levels of experience in endourology, there is a variable understanding of the principles of laser technology and ureter mechanics. Further research and education are needed with a focus on laser safety, suitable laser settings and the safe limit of insertion forces.

Robotic Surgery Training: Current Trends and Future Directions

The use of robotic surgery in urology has grown exponentially in the past 2 decades, but robotic surgery training has lagged behind. Most graduating residents report a lack of comfort independently performing common robotic urologic surgeries, despite an abundance of available resources. There is a general consensus on the key components of a comprehensive robotics curriculum, and well-validated tools have been developed to assess trainee competency. However, no single curriculum has emerged as the gold standard on which individual programs can build their own robotics curricula.

Training of Brazilian Urology residents in laparoscopy: results of a national survey

Objectives

To evaluate the familiarity of Brazilian urology residents with laparoscopy, methods of training and perspectives.

Material and methods

a questionnaire with 23 questions was sent by e-mail to all urological residents of 86 Urology Residence Programs certified by the Brazilian Society of Urology (BSU).

Results

225 valid answers (85% of all residents) responded. Most residences belong to academic hospitals mainly in the Southeast region of Brazil. Women account for 5% of residents and 82% of programs perform less than 100 procedures per year. Residents have access to LESS, RAL and 98% to surgical laparoscopy and 87% of these participate actively at the surgery, but 84.9% do not have access to RAL. The most common laparoscopic procedure is radical nephrectomy (73.2%), but only 28.8% of residents acted as surgeons, and third year residents (R3) are those that mainly performed this procedure (statistical significance, p <0.05). 61% of residents do not participate in hands-on courses or fellowship in laparoscopy, among those who attended these fellowships, 23.47% were sponsored by BSU in equal regions of the country. Although there are several opportunities of training in laparoscopy, 42% of residents do not have access to any kind of preparation and 52% have no structured specific program. R3 perception of laparoscopy experience is significantly higher than R2 and R1 residents. Almost 30% of them affirms that they are prepared for professional life regarding urologic laparoscopy.

Conclusion

Brazilian urologic residents have access to laparoscopy and actively participate in the learning process. Robotic surgery is expanding in the country, although still very far from residents. Brazilian resident, at the end of medical residency, is motivated to perform laparoscopic procedures.

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.

Laparoscopic Training in Urology Residency Programs: A Systematic Review

Background/Aims

Laparoscopy is a widespread surgical approach for many urological conditions. Achieving prof-ciency in laparoscopic surgery requires considerable effort due to the steep learning curve. Several residency programs include standardized laparoscopic training periods in their curricula. Our aim was to systematically analyze the evidence on the current status of training in laparoscopy in different residency programs in urology.

Methods

We performed a systematic review of PubMed/Medline and the Cochrane library, in February 2018, according to the Preferred Reporting Items for the Systematic Review and Meta-Analyses Statement. Identified reports were reviewed according to the previously defined inclusion criteria. Eight publications, comprising a total of 985 urology residents, were selected for inclusion in this analysis.

Results

There was a wide variation between training programs in terms of exposure to laparoscopy. Most residents considered that training in lap-aroscopy was inadequate during residency and had a low degree of confidence in independently performing laparo-scopic procedures by the end of the residency. Only North American residents reported high degrees of confidence in the possibility of performing laparoscopic procedures in the uture, whereas the remaining residents, namely from European countries, reported considerably lower degrees of confidence.

Conclusion

There were considerable differences between national urology residency programs in terms of exposure to laparoscopy. Most residents would prefer higher exposure to laparoscopy throughout their residencies.

Introduction of an ex-vivo pig model for teaching percutaneous nephrolithotomy access techniques

INTRODUCTION

In North America, obtaining access for percutaneous nephrolithotomy (PCNL) is not often performed by urologists. Hands-on training sessions help to ensure this skill continues within the urological community. An ex-vivo pig kidney model was developed for simulation. This model uses porcine tissues with a fluoroscopic C-arm and standard PCNL equipment. The bullseye or triangulation techniques are both possible. We propose this as a high-fidelity tool for teaching PCNL access.

METHODS

The pig kidney, fat, ribs, flank, and skin were arranged anatomically on a table with fluoroscopy. Hands-on training was provided to residents and urologists using the ex-vivo pig model and a silicone-based percutaneous access model. Questionnaires were given at the end of the session.

RESULTS

There was a total 14 responders for each model, with incomplete responses on two surveys. A total of 15% of responders for the pig model and 7% of responders for the silicone model had previous percutaneous access experience. For the pig model, 93% of trainees agreed or strongly agreed that the model was easy to use, and 79% of the silicone model trainees felt the same. After the session, 50% of silicone model trainees and 86% of pig model trainees reported increased confidence in their ability to obtain PCNL access. All the pig model trainees and 71% of the silicone model trainees felt that the simulation activity was worthwhile.

CONCLUSIONS

The inexpensive but anatomically realistic ex-vivo pig model using real-world equipment provides trainees with an excellent tool to learn PCNL access.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy

INTRODUCTION

The rapid diffusion of the surgical robot has been controversial because of the technology's high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy.

METHODS

We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors.

RESULTS

In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy.

CONCLUSIONS

Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Laparoscopy training in Belgium: results from a nationwide survey, in urology, gynecology, and general surgery residents

BACKGROUND

The purpose of this study was to investigate the exposure of Belgian residents in urology, general surgery, and gynecology to laparoscopic surgery and to training of laparoscopic skills in dedicated training facilities.

METHODS

Three similar specialty-specific questionnaires were used to interrogate trainees in urology, general surgery, and gynecology about their exposure to laparoscopic procedures, their acquired laparoscopic experience, training patterns, training facilities, and motivation. Residents were contacted via their Belgian specialist training organization, using Survey Monkey as an online survey tool. Data were analyzed with descriptive statistics.

RESULTS

The global response rate was 58%. Only 28.8% of gynecology respondents, 26.9% of urology respondents, and 52.2% of general surgery respondents felt they would be able to perform laparoscopy once they had finished their training. A total 47% of urology respondents, 66.7% of general surgery respondents, and 69.2% of gynecology respondents had a surgical skills lab that included laparoscopy within their training hospital or university. Most training programs did not follow the current evidence about proficiency-based structured simulation training with deliberate practice.

CONCLUSION

Belgian resident training facilities for laparoscopic surgery should be optimized.

Royal College surgical objectives of urologic training: A survey of faculty members from Canadian training programs

INTRODUCTION

According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation.

METHODS

We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures.

RESULTS

The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesicovaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures.

CONCLUSIONS

There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.

Are Canadian urology residency programs fulfilling the Royal College expectations?: A survey of graduated chief residents

INTRODUCTION

We assess outgoing Canadian urology chief residents' well-being, their satisfaction with their surgical training, and their proficiency in surgical procedures throughout their residency program.

METHODS

In 2012 an anonymous survey was sent by email to all 29 graduated urology chief residents across Canada. The survey included a list of all urologic surgical procedures listed by the Royal College of Physicians and Surgeons of Canada (RCPSC). According to the A/B/C classification used to assess competence in these procedures (A most competent, C least competent), we asked chief residents to self-classify their competence with regards to each procedure and we compared the final results to the current RCPSC classification.

RESULTS

The overall response rate among chief residents surveyed was 97%. An overwhelming majority (96.4%) of residents agreed that the residency program has affected their overall well-being, as well as their relationships with their families and/or partners (67.8%). Overall, 85.7% agreed that research was an integral part of the residency program and 78.6% have enrolled in a fellowship program post-graduation. Respondents believed that they have received the least adequate training in robotic surgery (89.3%), followed by female urology (67.8%), andrology/sexual medicine/infertility (67.8%), and reconstructive urology (61.4%). Interestingly, in several of the 42 surgical procedures classified as category A by the RCPSC, a significant percentage of residents felt that their proficiency was not category A, including repair of urinary fistulae (82.1%), pediatric indirect hernia repair and meatal repair for glanular hypospadias (67.9%), open pyeloplasty (64.3%), anterior pelvic exenteration (61.6%), open varicocelectomy (60.7%) and radical cystoprostatectomy (33.3%). Furthermore, all respondents (100%) believed they were deficient in at least 1 of the 42 category A procedures, while 53.6 % believed they were deficient in at least 10 of the 42 procedures.

CONCLUSIONS

Most residents agree that their residency program has affected their overall well-being as well as their relationships with their families and/or partners. There is also a clear deficiency in what outgoing residents perceive they have achieved and what the RCPSC mandates. Future work should concentrate on addressing this discrepancy to assure that training and RCPSC expectations are better aligned.

Training of European urology residents in laparoscopy: results of a pan-European survey

OBJECTIVE

To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012. Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated. Data was analysed with descriptive statistics.

RESULTS

In all, 219 European urology residents answered the survey. Conventional laparoscopy was available in 74% of the respondents' departments, while robotic surgery was available in 17% of the departments. Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least 'satisfactory'; 32% of the residents did not attend any course or fellowship on laparoscopy. Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory. The motivation to perform laparoscopy was rated as 'high' or 'very high' by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor. Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

Comparative assessment of three standardized robotic surgery training methods

OBJECTIVES

To evaluate three standardized robotic surgery training methods, inanimate, virtual reality and in vivo, for their construct validity. To explore the concept of cross-method validity, where the relative performance of each method is compared.

MATERIALS AND METHODS

Robotic surgical skills were prospectively assessed in 49 participating surgeons who were classified as follows: 'novice/trainee': urology residents, previous experience <30 cases (n = 38) and 'experts': faculty surgeons, previous experience ≥30 cases (n = 11). Three standardized, validated training methods were used: (i) structured inanimate tasks; (ii) virtual reality exercises on the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA, USA); and (iii) a standardized robotic surgical task in a live porcine model with performance graded by the Global Evaluative Assessment of Robotic Skills (GEARS) tool. A Kruskal-Wallis test was used to evaluate performance differences between novices and experts (construct validity). Spearman's correlation coefficient (ρ) was used to measure the association of performance across inanimate, simulation and in vivo methods (cross-method validity).

RESULTS

Novice and expert surgeons had previously performed a median (range) of 0 (0-20) and 300 (30-2000) robotic cases, respectively (P < 0.001). Construct validity: experts consistently outperformed residents with all three methods (P < 0.001). Cross-method validity: overall performance of inanimate tasks significantly correlated with virtual reality robotic performance (ρ = -0.7, P < 0.001) and in vivo robotic performance based on GEARS (ρ = -0.8, P < 0.0001). Virtual reality performance and in vivo tissue performance were also found to be strongly correlated (ρ = 0.6, P < 0.001).

CONCLUSIONS

We propose the novel concept of cross-method validity, which may provide a method of evaluating the relative value of various forms of skills education and assessment. We externally confirmed the construct validity of each featured training tool.

Status of robotic-assisted surgery among Canadian urology residents

BACKGROUND

Robotic-assisted surgery (RAS) has been rapidly adopted in urology, especially in the United States. Although less prevalent in Canada, RAS is a growing and controversial field that has implications for resident training. We report on the status and perception of RAS among Canadian urology residents.

METHODS

: All Canadian urology residents from anglophone programs were contacted by email and asked to participate in an online survey. Current resident exposure to, and perception of, RAS was assessed.

RESULTS

: Of the residents contacted (n = 128), 50 (39%) completed the survey. Of the respondents, 52% have been involved in RAS. Those who have not been involved in RAS express lower interest and lesser knowledge of RAS. Ninety-two percent of respondents feel the use of RAS will increase, although only 29% feel this is feasible in Canada. Just 24% and 36% feel RAS to be superior to open and laparoscopic techniques, respectively. Sixty-eight percent of residents in programs with a robot viewed it as detrimental to training, whereas 81% of residents in programs without one viewed its absence to either have no impact, or even be beneficial. Both groups expressed a desire for more experience with RAS.

CONCLUSION

: The resident experience with respect to RAS is mixed. Overall, residents view RAS as an expanding field with potentially negative impacts on their present training, although they appear to desire the acquisition of more experience in RAS. We plan to monitor the evolution of these perceptions over next four years.

Trends in urology resident exposure to minimally invasive surgery for index procedures: a tale of two countries

OBJECTIVE

To interrogate case-log data for American and Canadian urology residents to define trends in minimally invasive surgery (MIS) and open surgery and compare operative experiences between these 2 groups.

METHODS

Case-log data from 2004 to 2009 for American urology residents was compared with Canadian residents for 8 index cases, which are routinely performed in both an MIS and open approach. These included nephrectomy (donor, radical, simple, partial), prostatectomy (radical), adrenalectomy, pyeloplasty, and nephroureterectomy.

RESULTS

Linear regression analysis demonstrated a significant increase in the percentage of MIS radical prostatectomies performed by American residents (11.2%-52%), compared with Canadian residents (0.74%-11.2%). There was also a significant increase in the percentage of MIS donor nephrectomies by Canadian residents (5.6%-68.7%), compared with American residents (70.1%-89.1%). For Canadian residents, exposure to the following 3 MIS procedures increased significantly over open approaches: adrenalectomy, radical prostatectomy, and donor nephrectomy. For American residents, all index procedures with the exception of adrenalectomy underwent a significant increasing trend (all p < 0.05).

CONCLUSIONS

Trends for 8 index procedures confirm a continuing shift towards MIS for the majority of procedures in both countries. Differences may be only temporal and relate to dissimilar health care delivery models with a resultant lag in the adoption of laparoscopy and robotics in Canada. The impact of these trends upon ultimate surgical competence of graduates remains to be seen.

The training of Canadian urology residents: Whither open surgery?

Collapse