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Goldenberg MG. Surgical Artificial Intelligence in Urology: Educational Applications. Urol Clin North Am 2024; 51:105-115. [PMID: 37945096 DOI: 10.1016/j.ucl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Surgical education has seen immense change recently. Increased demand for iterative evaluation of trainees from medical school to independent practice has led to the generation of an overwhelming amount of data related to an individual's competency. Artificial intelligence has been proposed as a solution to automate and standardize the ability of stakeholders to assess the technical and nontechnical abilities of a surgical trainee. In both the simulation and clinical environments, evidence supports the use of machine learning algorithms to both evaluate trainee skill and provide real-time and automated feedback, enabling a shortened learning curve for many key procedural skills and ensuring patient safety.
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Affiliation(s)
- Mitchell G Goldenberg
- Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90033, USA.
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Eppler MB, Ganjavi C, Davis R, Sayegh AS, Hershenhouse JS, Mokhtar D, Knudsen JE, Tran J, Bhardwaj L, Shin JJS, Hemal S, Goldenberg MG, Miranda G, Sotelo R, Desai M, Gill I, Cacciamani GE. Criteria for enhancing reporting of perioperative transfusions in surgical and anaesthesiological studies. Br J Surg 2023; 110:1655-1658. [PMID: 37494634 DOI: 10.1093/bjs/znad235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/09/2023] [Accepted: 07/08/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Michael B Eppler
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Conner Ganjavi
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ryan Davis
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aref S Sayegh
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jacob S Hershenhouse
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Daniel Mokhtar
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - J Everett Knudsen
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John Tran
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lokesh Bhardwaj
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John J S Shin
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sij Hemal
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mitchell G Goldenberg
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gus Miranda
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rene Sotelo
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mihir Desai
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Inderbir Gill
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Giovanni E Cacciamani
- USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Sayegh AS, Eppler M, Sholklapper T, Goldenberg MG, Perez LC, La Riva A, Medina LG, Sotelo R, Desai MM, Gill I, Jung JJ, Kazaryan AM, Edwin B, Biyani CS, Francis N, Kaafarani HM, Cacciamani GE. Severity Grading Systems for Intraoperative Adverse Events. A Systematic Review of the Literature and Citation Analysis. Ann Surg 2023; 278:e973-e980. [PMID: 37185890 DOI: 10.1097/sla.0000000000005883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
INTRODUCTION The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. METHODS A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. RESULTS Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while 2 considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/nonself-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). CONCLUSION Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs, further improving patient safety.
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Affiliation(s)
- Aref S Sayegh
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Michael Eppler
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tamir Sholklapper
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA
| | - Mitchell G Goldenberg
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Laura C Perez
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anibal La Riva
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Luis G Medina
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rene Sotelo
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Mihir M Desai
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Inderbir Gill
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - James J Jung
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Airazat M Kazaryan
- Department of Surgery, Østfold Hospital Trust, Gralum, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Surgery, Fonna Hospital Trust, Odda, Norway
- Department of Surgery N 1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
- Department of Faculty Surgery N 2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Bjørn Edwin
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | | | - Nader Francis
- The Griffin Institute, Division of Surgery and Interventional Science-UCL, London, UK
| | - Haytham Ma Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
| | - Giovanni E Cacciamani
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Chu TN, Wong EY, Ma R, Yang CH, Dalieh IS, Hui A, Gomez O, Cen S, Ghazi A, Miles BJ, Lau C, Davis JW, Goldenberg MG, Hung AJ. A Multi-institution Study on the Association of Virtual Reality Skills with Continence Recovery after Robot-assisted Radical Prostatectomy. Eur Urol Focus 2023; 9:1044-1051. [PMID: 37277274 PMCID: PMC10693649 DOI: 10.1016/j.euf.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/13/2023] [Accepted: 05/23/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Virtual reality (VR) simulators are increasingly being used for surgical skills training. It is unclear what skills are best improved via VR, translate to live surgical skills, and influence patient outcomes. OBJECTIVE To assess surgeons in VR and live surgery using a suturing assessment tool and evaluate the association between technical skills and a clinical outcome. DESIGN, SETTING, AND PARTICIPANTS This prospective five-center study enrolled participants who completed VR suturing exercises and provided live surgical video. Graders provided skill assessments using the validated End-To-End Assessment of Suturing Expertise (EASE) suturing evaluation tool. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A hierarchical Poisson model was used to compare skill scores among cohorts and evaluate the association of scores with clinical outcomes. Spearman's method was used to assess correlation between VR and live skills. RESULTS AND LIMITATIONS Ten novices, ten surgeons with intermediate expertise (median 64 cases, interquartile range [IQR] 6-80), and 26 expert surgeons (median 850 cases, IQR 375-3000) participated in this study. Intermediate and expert surgeons were significantly more likely to have ideal scores in comparison to novices for the subskills needle hold angle, wrist rotation, and wrist rotation needle withdrawal (p < 0.01). For both intermediate and expert surgeons, there was positive correlation between VR and live skills for needle hold angle (p < 0.05). For expert surgeons, there was a positive association between ideal scores for VR needle hold angle and driving smoothness subskills and 3-mo continence recovery (p < 0.05). Limitations include the size of the intermediate surgeon sample and clinical data limited to expert surgeons. CONCLUSIONS EASE can be used in VR to identify skills to improve for trainee surgeons. Technical skills that influence postoperative outcomes may be assessable in VR. PATIENT SUMMARY This study provides insights into surgical skills that translate from virtual simulation to live surgery and that have an impact on urinary continence after robot-assisted removal of the prostate. We also highlight the usefulness of virtual reality in surgical education.
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Affiliation(s)
- Timothy N Chu
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Elyssa Y Wong
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Runzhuo Ma
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Cherine H Yang
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Istabraq S Dalieh
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Alvin Hui
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Oscar Gomez
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Steven Cen
- Department of Radiology, University of Southern California, Los Angeles, CA, USA
| | - Ahmed Ghazi
- Department of Urology, University of Rochester, Rochester, NY, USA
| | - Brian J Miles
- Department of Urology, Houston Methodist, Houston, TX, USA
| | - Clayton Lau
- Department of Urology, City of Hope, Duarte, CA, USA
| | - John W Davis
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Mitchell G Goldenberg
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Andrew J Hung
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA.
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Wong EY, Chu TN, Ma R, Dalieh IS, Yang CH, Ramaswamy A, Medina LG, Kocielnik R, Ladi-Seyedian SS, Shtulman A, Cen SY, Goldenberg MG, Hung AJ. Development of a Classification System for Live Surgical Feedback. JAMA Netw Open 2023; 6:e2320702. [PMID: 37378981 DOI: 10.1001/jamanetworkopen.2023.20702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Importance Live feedback in the operating room is essential in surgical training. Despite the role this feedback plays in developing surgical skills, an accepted methodology to characterize the salient features of feedback has not been defined. Objective To quantify the intraoperative feedback provided to trainees during live surgical cases and propose a standardized deconstruction for feedback. Design, Setting, and Participants In this qualitative study using a mixed methods analysis, surgeons at a single academic tertiary care hospital were audio and video recorded in the operating room from April to October 2022. Urological residents, fellows, and faculty attending surgeons involved in robotic teaching cases during which trainees had active control of the robotic console for at least some portion of a surgery were eligible to voluntarily participate. Feedback was time stamped and transcribed verbatim. An iterative coding process was performed using recordings and transcript data until recurring themes emerged. Exposure Feedback in audiovisual recorded surgery. Main Outcomes and Measures The primary outcomes were the reliability and generalizability of a feedback classification system in characterizing surgical feedback. Secondary outcomes included assessing the utility of our system. Results In 29 surgical procedures that were recorded and analyzed, 4 attending surgeons, 6 minimally invasive surgery fellows, and 5 residents (postgraduate years, 3-5) were involved. For the reliability of the system, 3 trained raters achieved moderate to substantial interrater reliability in coding cases using 5 types of triggers, 6 types of feedback, and 9 types of responses (prevalence-adjusted and bias-adjusted κ range: a 0.56 [95% CI, 0.45-0.68] minimum for triggers to a 0.99 [95% CI, 0.97-1.00] maximum for feedback and responses). For the generalizability of the system, 6 types of surgical procedures and 3711 instances of feedback were analyzed and coded with types of triggers, feedback, and responses. Significant differences in triggers, feedback, and responses reflected surgeon experience level and surgical task being performed. For example, as a response, attending surgeons took over for safety concerns more often for fellows than residents (prevalence rate ratio [RR], 3.97 [95% CI, 3.12-4.82]; P = .002), and suturing involved more errors that triggered feedback than dissection (RR, 1.65 [95% CI, 1.03-3.33]; P = .007). For the utility of the system, different combinations of trainer feedback had associations with rates of different trainee responses. For example, technical feedback with a visual component was associated with an increased rate of trainee behavioral change or verbal acknowledgment responses (RR, 1.11 [95% CI, 1.03-1.20]; P = .02). Conclusions and Relevance These findings suggest that identifying different types of triggers, feedback, and responses may be a feasible and reliable method for classifying surgical feedback across several robotic procedures. Outcomes suggest that a system that can be generalized across surgical specialties and for trainees of different experience levels may help galvanize novel surgical education strategies.
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Affiliation(s)
- Elyssa Y Wong
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Timothy N Chu
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Runzhuo Ma
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Istabraq S Dalieh
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Cherine H Yang
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Ashwin Ramaswamy
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Luis G Medina
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Rafal Kocielnik
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena
| | - Seyedeh-Sanam Ladi-Seyedian
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Andrew Shtulman
- Thinking Lab, Department of Psychology, Occidental College, Los Angeles, California
| | - Steven Y Cen
- Department of Radiology, University of Southern California, Los Angeles
| | - Mitchell G Goldenberg
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
| | - Andrew J Hung
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles
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Ding C, Khondker A, Goldenberg MG, Kwong JC, Lajkosz K, Potter E, Millman A, Krakowsky Y, Perlis N. Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis. Can Urol Assoc J 2022; 17:121-128. [PMID: 36486178 PMCID: PMC10073518 DOI: 10.5489/cuaj.8108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Penile inversion vaginoplasty (PIV) remains the gold standard technique for vaginoplasty, a gender-affirming feminizing surgery, but has been associated with urinary complications; however, there is little literature synthesizing urinary complications after PIV surgery, and there is a need to compile these complications to counsel patients pre- and postoperatively on managing surgical expectations. In this systematic review, we summarize the prevalence of urinary complications following PIV.
Methods: We searched the MEDLINE, EMBASE, CINAHL, and Scopus databases in July 2020. The primary outcome was the prevalence of urinary and surgical complications in patients after penile inversion vaginoplasty. Pooled prevalence was determined from extrapolated data. ROBINS-I tool was used to assess study quality. The study was prospectively registered on PROSPERO (CRD42020204139).
Results: Of 843 unique records, 27 articles were pooled for synthesis, with 3388 patients in total. Overall patient satisfaction ranged from 80–100%. The most common urological complications included poor/splayed stream (11.7%, 95% confidence interval [CI] 5.7–19.3), meatal stenosis (6.9%, 95% CI 2.7–12.7), and irritative symptoms (frequency, urgency, nocturia) (11.5%, 95% CI 2.6–25.1). Other urinary complications included retention requiring catheterization (5.1%, 95% CI 0.3–13.8), incontinence (8.7%, 95% CI 3.4–15.6), urethral stricture (4.6%, 95% CI 1.2–9.8), and urinary tract infection (5.6%, 95% CI 2.7–9.4). Most pooled studies had moderate risk of bias.
Conclusions: The available evidence suggests that there is a low prevalence of urinary complications following PIV. Overall, there is a need for standardization of data in transgender surgical care to better understand surgical outcomes and improve postoperative management.
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Affiliation(s)
- Christina Ding
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Adree Khondker
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Jethro C.C. Kwong
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Katherine Lajkosz
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Emery Potter
- Transition-Related Surgery Program, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Alexandra Millman
- Transition-Related Surgery Program, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Division of Urology, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Yonah Krakowsky
- Transition-Related Surgery Program, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Division of Urology, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Nathan Perlis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Goldenberg MG, Cacciamani GE. Re: Gopal Sharma, Milap Shah, Puneet Ahluwalia, et al. Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy. Eur Urol Focus. In press. https://doi.org/10.1016/j.euf.2022.09.004. Eur Urol Focus 2022:S2405-4569(22)00274-7. [DOI: 10.1016/j.euf.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022]
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Kasa K, Burns D, Goldenberg MG, Selim O, Whyne C, Hardisty M. Multi-Modal Deep Learning for Assessing Surgeon Technical Skill. Sensors (Basel) 2022; 22:7328. [PMID: 36236424 PMCID: PMC9571767 DOI: 10.3390/s22197328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
This paper introduces a new dataset of a surgical knot-tying task, and a multi-modal deep learning model that achieves comparable performance to expert human raters on this skill assessment task. Seventy-two surgical trainees and faculty were recruited for the knot-tying task, and were recorded using video, kinematic, and image data. Three expert human raters conducted the skills assessment using the Objective Structured Assessment of Technical Skill (OSATS) Global Rating Scale (GRS). We also designed and developed three deep learning models: a ResNet-based image model, a ResNet-LSTM kinematic model, and a multi-modal model leveraging the image and time-series kinematic data. All three models demonstrate performance comparable to the expert human raters on most GRS domains. The multi-modal model demonstrates the best overall performance, as measured using the mean squared error (MSE) and intraclass correlation coefficient (ICC). This work is significant since it demonstrates that multi-modal deep learning has the potential to replicate human raters on a challenging human-performed knot-tying task. The study demonstrates an algorithm with state-of-the-art performance in surgical skill assessment. As objective assessment of technical skill continues to be a growing, but resource-heavy, element of surgical education, this study is an important step towards automated surgical skill assessment, ultimately leading to reduced burden on training faculty and institutes.
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Affiliation(s)
- Kevin Kasa
- Orthopaedic Biomechanics Lab, Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - David Burns
- Orthopaedic Biomechanics Lab, Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Mitchell G. Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Omar Selim
- Department of Surgery, Royal Victoria Regional Health Center, Barrie, ON L4M 6M2, Canada
| | - Cari Whyne
- Orthopaedic Biomechanics Lab, Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Michael Hardisty
- Orthopaedic Biomechanics Lab, Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
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Kwong JCC, McLoughlin LC, Haider M, Goldenberg MG, Erdman L, Rickard M, Lorenzo AJ, Hung AJ, Farcas M, Goldenberg L, Nguan C, Braga LH, Mamdani M, Goldenberg A, Kulkarni GS. Standardized Reporting of Machine Learning Applications in Urology: The STREAM-URO Framework. Eur Urol Focus 2021; 7:672-682. [PMID: 34362709 DOI: 10.1016/j.euf.2021.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
The Standardized Reporting of Machine Learning Applications in Urology (STREAM-URO) framework was developed to provide a set of recommendations to help standardize how machine learning studies in urology are reported. This framework serves three purposes: (1) to promote high-quality studies and streamline the peer review process; (2) to enhance reproducibility, comparability, and interpretability of results; and (3) to improve engagement and literacy of machine learning within the urological community.
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Affiliation(s)
- Jethro C C Kwong
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Canada
| | - Louise C McLoughlin
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Canada
| | - Masoom Haider
- Joint Department of Medical Imaging, University of Toronto, Toronto, Canada; AI, Radiomics and Oncologic Imaging Research Lab, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | | | - Lauren Erdman
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada; Vector Institute, Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew J Hung
- Catherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California Institute of Urology, Los Angeles, CA, USA
| | - Monica Farcas
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Larry Goldenberg
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chris Nguan
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luis H Braga
- Division of Urology, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Muhammad Mamdani
- Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Canada; Vector Institute, Toronto, Ontario, Canada; Unity Health Toronto, Toronto, Ontario, Canada
| | - Anna Goldenberg
- Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Canada; Department of Computer Science, University of Toronto, Toronto, Ontario, Canada; Vector Institute, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Temerty Centre for AI Research and Education in Medicine, University of Toronto, Toronto, Canada.
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Gupta A, Lawendy B, Goldenberg MG, Grober E, Lee JY, Perlis N. Can video games enhance surgical skills acquisition for medical students? A systematic review. Surgery 2021; 169:821-829. [PMID: 33419578 DOI: 10.1016/j.surg.2020.11.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To systematically assess literature examining the impact of being a gamer or participating in video-game-based training on surgical skills acquisition amongst medical students. BACKGROUND Video games and surgical procedures share similar skills such as visuospatial abilities and hand-eye coordination; therefore, video games can be a valuable tool for surgical training amongst medical students. However, comprehensive, up-to-date systematic reviews are necessary to confirm. METHODS A systematic literature search of PubMed, MEDLINE, and EMBASE was performed in April 2020 with no limits set on the date of publication. Observational and randomized controlled studies were included. Quality and bias were assessed using the Newcastle-Ottawa Scale for nonrandomized studies and the Grading of Recommendations Assessment, Development and Evaluation system for randomized studies. RESULTS A total of 575 participants from 16 studies were included. The most common surgical skills tested were laparoscopy (n = 283, from 8 studies) and robotic surgery (n = 199, from 5 studies). A history of gaming and video-game-based training were associated with improved metrics in robotic surgery and laparoscopy, respectively. Neither was beneficial in arthroscopy or bronchoscopy. Studies using the Wii U and Underground reported significant improvement in overall laparoscopic performance. CONCLUSION Video games demonstrate potential as adjunctive training in surgical skill education, with a history of gaming and video-game-based training being beneficial in robotic surgery and laparoscopy, respectively. Methodological heterogeneity amongst included studies limit the ability to make conclusive decisions; thus, future studies with long-term follow-up, larger sample sizes, outcomes stratified by video-game characteristics, and up-to-date technology are necessary.
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Affiliation(s)
- Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bishoy Lawendy
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mitchell G Goldenberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sprott Department of Surgery, Division of Urology, University Health Network, Toronto, ON, Canada
| | - Ethan Grober
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Surgery, Division of Urology, Sinai Health System, Toronto, ON, Canada
| | - Jason Y Lee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sprott Department of Surgery, Division of Urology, University Health Network, Toronto, ON, Canada
| | - Nathan Perlis
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sprott Department of Surgery, Division of Urology, University Health Network, Toronto, ON, Canada.
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Yu N, Saadat H, Finelli A, Lee JY, Singal RK, Grantcharov TP, Goldenberg MG. Quantifying the "Assistant Effect" in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance. J Surg Res 2020; 260:307-314. [PMID: 33370599 DOI: 10.1016/j.jss.2020.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/12/2020] [Accepted: 11/01/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP). METHODS Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors. RESULTS 92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P = 0.011), and prior laparoscopic experience (P < 0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho = 0.248, P = 0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P = 0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing. CONCLUSIONS This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.
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Affiliation(s)
- Nancy Yu
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Hossein Saadat
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Antonio Finelli
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Rajiv K Singal
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Teodor P Grantcharov
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; International Centre for Surgical Safety, St. Michael's Hospital, Toronto, Canada
| | - Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; International Centre for Surgical Safety, St. Michael's Hospital, Toronto, Canada.
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Aditya I, Kwong JCC, Canil T, Lee JY, Goldenberg MG. Response to Alken re: "Current Educational Interventions for Improving Technical Skills of Urology Trainees in Endourological Procedures: A Systematic Review" by Aditya et al. J Endourol 2020; 34:734. [PMID: 32640843 DOI: 10.1089/end.2020.29092.iad] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ishan Aditya
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Thomas Canil
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
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Aditya I, Kwong JCC, Canil T, Lee JY, Goldenberg MG. Current Educational Interventions for Improving Technical Skills of Urology Trainees in Endourological Procedures: A Systematic Review. J Endourol 2020; 34:723-731. [PMID: 31691593 DOI: 10.1089/end.2019.0693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Endourology continues to grow with the introduction of new technologies into clinical practice. Simulators and training models have been developed to improve comfort and proficiency in endoscopic procedures. The purpose of this systematic review was to examine the current educational interventions utilized to improve the performance of endourology trainees and to critically appraise the strengths and limitations of each. Methods: A search of the Ovid MEDLINE, EMBASE, PsycINFO, and the Cochrane Library databases was performed to identify literature focused on current educational interventions for improving technical skills of trainees in endourologic procedures. The Medical Education Research Study Quality Instrument (MERSQI) was used to evaluate the methodological quality of the abstracted articles. Results: Of the 2236 articles identified, 22 met the inclusion criteria. The types of educational interventions included: bench/wet lab models, virtual reality simulators, and instructional courses. Metrics used to quantify the impact of these interventions include global rating scales, Objective Structured Assessment of Technical Skills (OSATS) scores, and task-specific checklists. The setting of these evaluations comprises both virtual reality simulators and live surgery. Conclusions: In the surgical education literature, simulation-based training and assessment continues to play a prominent role in urologic training. The educational interventions highlighted in this review address various aspects of endourology, from stone management to transurethral resection. Additional work is needed to correlate technical performance in clinical and nonclinical settings with patient outcomes and develop a focused approach to nontechnical skill training.
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Affiliation(s)
- Ishan Aditya
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Thomas Canil
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
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Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol 2019; 38:1369-1372. [PMID: 31363833 DOI: 10.1007/s00345-019-02886-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/23/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Efforts to improve the safety of patients in the operating room have focused on mitigating harm through the standardization of system, team, and human level factors. This article highlights existing and future methods for enhancing safety in the perioperative setting, and the theory and principles that underpin them. METHODS Evidence surrounding the development and implementation of select surgical safety interventions is discussed. RESULTS Work in human factors and engineering that has inspired safety interventions such as the WHO Safety Checklist, and more recently operating room recorders, represents a movement away from traditional, retrospective or reactive methods of studying surgical safety, to prospective and proactive ones. CONCLUSIONS Future work will examine the effectiveness of these interventions for improving patient outcomes and minimizing iatrogenic harm.
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Affiliation(s)
- Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Dean Elterman
- Division of Urology, Department of Surgery, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
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Abstract
The clinical learning environment for the postgraduate education of physicians significantly influences the learning process and the outcomes of learning. Two critical aspects of the learning environment, when viewed through a psychology lens are (1) constructs from psychology relevant to learning, such as cognitive load theory and learner self-efficacy; and (2) psychological attributes of the context in which learning occurs such as psychological safety and "Just Culture". In this paper, we address selected psychological aspects of the clinical learning environment, with a particular focus on the establishment and sustainment of psychological safety in the clinical learning environment for physicians. Psychological safety is defined as individuals' perceptions that they can speak out in the learning or working context without consequences for their professional standing or risks to their status on work teams or groups. We close with seven critical strategies for use by educators, learners, health systems leaders, and other stakeholders to contribute to a clinical environment that optimizes learning. These dimensions can also provide avenues for future research to enhance the community's understanding of psychological constructs operating in the clinical learning environment.
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Affiliation(s)
- Kelly J Caverzagie
- a Division of General Internal Medicine, Department of Internal Medicine , University of Nebraska College of Medicine , Omaha , Nebraska , United States
| | - Mitchell G Goldenberg
- b Division of Urology, Department of Surgery , University of Toronto , Toronto , Ontario , Canada
| | - Jena M Hall
- c Department of Obstetrics and Gynecology , Queen's University , Kingston , Ontario , Canada
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Goldenberg MG, Kerbel B, Singal RK. Improving access to surgical innovation in the community: Implementation of shared access model in Canadian healthcare. Can Urol Assoc J 2019; 13:E300-E302. [PMID: 30763234 DOI: 10.5489/cuaj.5248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brent Kerbel
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rajiv K Singal
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Kwong JC, Lee JY, Goldenberg MG. Understanding and Assessing Nontechnical Skills in Robotic Urological Surgery: A Systematic Review and Synthesis of the Validity Evidence. J Surg Educ 2019; 76:193-200. [PMID: 29958854 DOI: 10.1016/j.jsurg.2018.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/17/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Robotic urological surgery (RUS) has seen widespread adoption across institutions in the last decade. To match this rapid growth, it is imperative to develop a structured RUS curriculum that addresses both technical and nontechnical competencies. Emerging evidence has shown that nontechnical skills form a critical component of RUS training. The purpose of this review is to examine the validity evidence of available nontechnical skills assessment tools in RUS. METHODS A literature search of MEDLINE, EMBASE, and PsycINFO was conducted to identify primary articles using nontechnical skills assessment tools in RUS. Messick's validity framework and the Medical Education Research Study Quality Instrument were utilized to evaluate the quality of the validity evidence of the abstracted articles. RESULTS Of the 566 articles identified, 12 used nontechnical skills assessment tools in RUS. The metrics used ranged from self-assessment using global rating scales, to objective measures such as electroencephalography. The setting of these evaluations ranged from immersive and virtual reality-based simulators to live surgery. CONCLUSIONS Limited effort has been made to develop nontechnical skills assessment tools in RUS. Recently, there has been a shift from subjective to objective measures of nontechnical performance, as well as the development of assessments specific to RUS. However, the validity evidence supporting these nontechnical assessments is limited at this time, including their relationship to technical skills, and their impact on surgical outcomes.
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Affiliation(s)
- Jethro Cc Kwong
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Matta R, Wallis CJ, Goldenberg MG, Hird AE, Klaassen Z, Kulkarni G, Kodama RT, Herschorn S, Nam RK. Variation and Trends in Antidepressant Prescribing for Men Undergoing Treatment for Nonmetastatic Prostate Cancer: A Population-based Cohort Study. Eur Urol 2019; 75:3-7. [DOI: 10.1016/j.eururo.2018.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
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Goldenberg MG, Fok KH, Ordon M, Pace KT, Lee JY. Simulation-Based Laparoscopic Surgery Crisis Resource Management Training-Predicting Technical and Nontechnical Skills. J Surg Educ 2018; 75:1113-1119. [PMID: 29273339 DOI: 10.1016/j.jsurg.2017.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To develop a unique simulation-based assessment using a laparoscopic inferior vena cava (IVC) injury scenario that allows for the safe assessment of urology resident's technical and nontechnical skills, and investigate the effect of personality traits performance in a surgical crisis. METHODS Urology residents from our institution were recruited to participate in a simulation-based training laparoscopic nephrectomy exercise. Residents completed demographic and multidimensional personality questionnaires and were instructed to play the role of staff urologist. A vasovagal response to pneumoperitoneum and an IVC injury event were scripted into the scenario. Technical and nontechnical skills were assessed by expert laparoscopic surgeons using validated tools (task checklist, GOALS, and NOTSS). RESULTS Ten junior and five senior urology residents participated. Five residents were unable to complete the exercise safely. Senior residents outperformed juniors on technical (checklist score 15.1 vs 9.9, p < 0.01, GOALS score 18.0 vs 13.3, p < 0.01) and nontechnical performance (NOTSS score 13.8 vs 10.1, p = 0.03). Technical performance scores correlated with NOTSS scores (p < 0.01) and pass/fail rating correlated with technical performance (p < 0.01 for both checklist and GOALS), NOTSS score (p = 0.02), and blood loss (p < 0.01). Only the conscientiousness dimension of the big five inventory correlated with technical score (p = 0.03) and pass/fail rating (p = 0.04). CONCLUSIONS Resident level of training and laparoscopic experience correlated with technical performance during a simulation-based laparoscopic IVC injury crisis management scenario, as well as multiple domains of nontechnical performance. Personality traits of our surgical residents are similar and did not predict technical skill.
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Affiliation(s)
- Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Kai H Fok
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, University of Toronto, Ontario, Canada
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Goldenberg MG, Lee JY, Kwong JCC, Grantcharov TP, Costello A. Implementing assessments of robot-assisted technical skill in urological education: a systematic review and synthesis of the validity evidence. BJU Int 2018; 122:501-519. [PMID: 29603869 DOI: 10.1111/bju.14219] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To systematically review and synthesise the validity evidence supporting intraoperative and simulation-based assessments of technical skill in urological robot-assisted surgery (RAS), and make evidence-based recommendations for the implementation of these assessments in urological training. MATERIALS AND METHODS A literature search of the Medline, PsycINFO and Embase databases was performed. Articles using technical skill and simulation-based assessments in RAS were abstracted. Only studies involving urology trainees or faculty were included in the final analysis. RESULTS Multiple tools for the assessment of technical robotic skill have been published, with mixed sources of validity evidence to support their use. These evaluations have been used in both the ex vivo and in vivo settings. Performance evaluations range from global rating scales to psychometrics, and assessments are carried out through automation, expert analysts, and crowdsourcing. CONCLUSION There have been rapid expansions in approaches to RAS technical skills assessment, both in simulated and clinical settings. Alternative approaches to assessment in RAS, such as crowdsourcing and psychometrics, remain under investigation. Evidence to support the use of these metrics in high-stakes decisions is likely insufficient at present.
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Affiliation(s)
| | - Jason Y Lee
- Division of Urology, University of Toronto, Toronto, ON, Canada
| | | | - Teodor P Grantcharov
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anthony Costello
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
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Goldenberg MG, Nabhani J, Wallis CJD, Chopra S, Hung AJ, Schuckman A, Djaladat H, Daneshmand S, Desai MM, Aron M, Gill IS, Satkunasivam R. Feasibility of expert and crowd-sourced review of intraoperative video for quality improvement of intracorporeal urinary diversion during robotic radical cystectomy. Can Urol Assoc J 2017; 11:331-336. [PMID: 29382445 DOI: 10.5489/cuaj.4442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Development of uretero-ileal stricture (UIS) after robotic-assisted radical cystectomy (RARC) may be dependent on surgical technique. Video review of intraoperative technique is an emerging paradigm for surgical quality improvement. We examined whether surgeon-perceived risk of UIS or crowd-sourced assessment of robotic skill are associated with the development of UIS. METHODS We conducted a case-control study comparing the operative technique of uretero-ileal anastomoses resulting in clinically significant UIS with the contralateral anastomosis for the same patient. De-identified videos were analyzed by 1) five high-volume surgeons; and 2) crowd workers (Crowd-Sourced Assessment of Technical Skill, C-SATS) to determine Global Evaluative Assessment of Robotic Skill (GEARS) score. Mantel-Haenszel common odds ratio (OR) estimates were calculated to assess the association between surgeon performance and the development of UIS. Logistic regression models were used to examine the association between GEARS scores and the development of UIS. RESULTS A total of 10 UIS videos were compared to eight control videos by five surgeons and 2142 crowd workers. Expert surgeons systematically evaluated intraoperative footage, however, no association between the expert mode response and UIS (OR 0.42; 95% confidence interval [CI] 0.05-3.45; p=0.91) was identified. Crowd-sourced assessment was not predictive of UIS (p=0.62). CONCLUSIONS We used video review to systematically analyze procedure-specific content and technique. The inability of surgeons to predict UIS may reflect the questionnaire, uncontrolled patient factors, or a lack of power. Crowd-sourced GEARS score was unsuccessful in predicting UIS after RARC.
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Affiliation(s)
- Mitchell G Goldenberg
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jamal Nabhani
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sameer Chopra
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Andrew J Hung
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Anne Schuckman
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Hooman Djaladat
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Siamak Daneshmand
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Mihir M Desai
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Monish Aron
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Inderbir S Gill
- USC Institute of Urology and Norris Comprehensive Cancer Centre, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Raj Satkunasivam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Affiliation(s)
- Mitchell G. Goldenberg
- International Centre for Surgical Safety, Keenan Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada2Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James Jung
- International Centre for Surgical Safety, Keenan Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada2Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Teodor P. Grantcharov
- International Centre for Surgical Safety, Keenan Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada2Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Abstract
INTRODUCTION There is limited, yet compelling evidence supporting the role of surgeon technical performance in influencing patient outcomes. To date, this concept has been underexplored in endourologic procedures. We hypothesized that a surgeon's technical performance plays a role in predicting an early return to continence after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS We conducted a retrospective, matched case-control analysis of prospectively collected unedited RARP endoscopic videos performed by a single surgeon. A blinded observer with expertise in intraoperative video analysis evaluated clinically relevant steps of RARP using the global evaluative assessment of robotic skill (GEARS) and the generic error rating tool (GERT). The primary outcome was continence status at 3 months postoperatively, defined as patient use of less than or equal to a single precautionary pad. Mann-Whitney U tests examined differences in predictor variables between cases and controls, and multivariate analysis was conducted using binary logistic regression models. RESULTS Twenty-four incontinent patients were matched for age, body mass index, preoperative International Prostate Symptoms Score, use of posterior/anterior hitch, prostate weight, and learning curve position. No statistically significant difference in errors between groups was observed using the GERT. On multivariate analysis, overall case GEARS score was independently predictive of 3-month continence status (odds ratios [OR] = 0.55, 95% confidence interval [CI] 0.33-0.91), as were urethrovesical anastomosis (OR = 0.70, 95% CI 0.50-0.97) and bladder neck GEARS scores (OR = 0.69, 95% CI 0.51-0.94). CONCLUSIONS Our study generates the hypothesis that there may be a link between surgeon technical performance and functional outcomes in RARP. This relationship may have implications for the accreditation and training of future urologists and warrants further investigation.
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Affiliation(s)
- Mitchell G Goldenberg
- 1 Division of Urology, University of Toronto , Toronto, Canada .,2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
| | - Larry Goldenberg
- 3 Department of Surgery, University of Toronto , Toronto, Canada
| | - Teodor P Grantcharov
- 2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
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Goldenberg MG, Garbens A, Szasz P, Hauer TM, Grantcharov TP. Establishing Absolute Standards for Technical Performance. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Goldenberg MG, Garbens A, Szasz P, Hauer T, Grantcharov TP. Systematic review to establish absolute standards for technical performance in surgery. Br J Surg 2016; 104:13-21. [PMID: 27686465 DOI: 10.1002/bjs.10313] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/12/2016] [Accepted: 08/10/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Standard setting allows educators to create benchmarks that distinguish between those who pass and those who fail an assessment. It can also be used to create standards in clinical and simulated procedural skill. The objective of this review was to perform a systematic review of the literature using absolute standard-setting methodology to create benchmarks in technical performance. METHODS A systematic review was conducted by searching MEDLINE, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Abstracts of retrieved studies were reviewed and those meeting the inclusion criteria were selected for full-text review. The quality of evidence presented in the included studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI), where a score of 14 or more of 18 indicates high-quality evidence. RESULTS Of 1809 studies identified, 37 used standard-setting methodology for assessment of procedural skill. Of these, 24 used participant-centred and 13 employed item-centred methods. Thirty studies took place in a simulated environment, and seven in a clinical setting. The included studies assessed residents (26 of 37), fellows (6 of 37) and staff physicians (17 of 37). Seventeen articles achieved a MERSQI score of 14 or more of 18, whereas 20 did not meet this mark. CONCLUSION Absolute standard-setting methodologies can be used to establish cut-offs for procedural skill assessments.
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Affiliation(s)
- M G Goldenberg
- Department of Surgery, University of Toronto, Toronto, Canada
| | - A Garbens
- Department of Surgery, University of Toronto, Toronto, Canada
| | - P Szasz
- Department of Surgery, University of Toronto, Toronto, Canada
| | - T Hauer
- Department of Surgery, University of Toronto, Toronto, Canada
| | - T P Grantcharov
- Department of Surgery, University of Toronto, Toronto, Canada
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McVey R, Goldenberg MG, Bernardini MQ, Yasufuku K, Quereshy FA, Finelli A, Pace KT, Lee JY. Baseline Laparoscopic Skill May Predict Baseline Robotic Skill and Early Robotic Surgery Learning Curve. J Endourol 2016; 30:588-92. [PMID: 26915663 DOI: 10.1089/end.2015.0774] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Robotic surgery is associated with a learning curve unique to each trainee. Knowledge about a trainee's baseline skill and learning curve would facilitate the development of a more individualized training curriculum. The aim of our study was to determine whether baseline laparoscopic skill is predictive of one's baseline robotic skill and short-term learning curve. METHODS Trainees from four different surgical specialties were included in the study. Each trainee participated in a 4-week, simulation-based robotic surgery basic skills training course. Precourse, baseline laparoscopic and robotic skills were assessed using validated test tasks; a basic peg transfer (PT) and an advanced intracorporeal suturing and knot tying (ISKT) task. Trainee robotic skill was assessed again 1 week postcourse. Each task performance was video recorded and scored by two blinded expert surgeons. RESULTS A total of 32 trainees were included; 14 urology, 7 gynecology, 8 thoracic Sx, 3 general Sx. Most (91%) were senior residents or clinical fellows and 50% had no prior robotic experience. There were no differences in baseline laparoscopic and robotic skill related to reported prior robotic experience. Between specialties, no differences were seen on baseline laparoscopic skill and only small differences were seen on baseline robotic skill. Both baseline Lap PT (p = 0.01) and Lap ISKT (p = 0.01) performances correlated with baseline robotic ISKT performance, but not robotic PT scores. Only baseline Lap ISKT performance correlated with postcourse robotic PT (p = 0.01) and ISKT (p < 0.01) performance. Baseline robotic ISKT scores, but not PT scores, correlated with postcourse robotic performance (p = 0.02 for PT, p < 0.01 for ISKT). CONCLUSIONS In this study, a trainee's baseline laparoscopic skill correlated with certain baseline robotic skills. Better baseline performance on an advanced, but not basic, laparoscopic and robotic skill task may correlate with a shorter learning curve for basic robotic skills. Further exploration of this finding may yield better training curricula.
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Affiliation(s)
- Ruaidhri McVey
- 1 Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre , Toronto, Canada
| | | | - Marcus Q Bernardini
- 3 Department of Gynecologic Oncology, University Health Network , Toronto, Canada
| | - Kazuhiro Yasufuku
- 4 Department of Thoracic Surgery, University of Toronto , Toronto, Canada
| | - Fayez A Quereshy
- 5 Department of General Surgery, University Health Network , Toronto, Canada
| | - Antonio Finelli
- 6 Department of Urology, University Hospital Network , Toronto, Canada
| | - Kenneth T Pace
- 2 Department of Urology, St. Michael's Hospital , Toronto, Canada
| | - Jason Y Lee
- 2 Department of Urology, St. Michael's Hospital , Toronto, Canada
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