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Introduction: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for patients with a large stone burden. There are a variety of methods to teach this important endourologic procedur...

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 e...

Objective: Avoiding surgical delay in the operating room (OR) is essential to provide timely, safe, and cost-effective care. The objective of this study was to identify the causes of OR delays and ...

Objective: To objectively assess the performance of graduating urology residents performing flexible ureterorenoscopy (fURS) using a simulation-based model and to set an entrustability standard or benchmark for use across the educational spectrum. Methods: Chief urology residents and attending endourologists performed a standardized fURS task (ureterorenoscopy and repositioning of stones) using a Boston Scientific© Lithovue ureteroscope on a Cook Medical© URS model. All performances were video-recorded and blindly scored by both endourology experts and crowd-workers (C-SATS) using the Ureteroscopic Global Rating Scale, plus an overall entrustability score. Validity evidence supporting the scores was collected and categorized. The Borderline Group (BG) method was used to set absolute performance standards for the expert and crowdsourced ratings. Results: A total of 44 participants (40 chief residents, 4 faculties) completed testing. Eighty-three percent of participants had performed >50 fURS cases at the time of the study. Only 47.7% (mean score 12.6/20) and 61.4% (mean score 12.4/20) of participants were deemed "entrustable" by experts and crowd-workers, respectively. The BG method produced entrustability benchmarks of 11.8/20 for experts and 11.4/20 for crowd-worker ratings, resulting in pass rates of 56.9% and 61.4%. Conclusion: Using absolute standard setting methods, benchmark scores were set to identify trainees who could safely carry out fURS in the simulated setting. Only 60% of residents in our cohort were rated as entrustable. These findings support the use of benchmarks to earlier identify trainees requiring remediation.

Introduction: Preoperative alpha-blockers have been proposed to improve intraoperative outcomes and patient stone-free status after ureteroscopy for ureteral stones. Materials and Methods: We searc...

Routine preoperative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures. This study assesses whether routine preoperative ECG before SWL is useful in patients at low risk for cardiac complications.A retrospective study of SWL at our center (2003-2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous five-lead ECG monitoring.Of 30,892 referrals, preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac work-up and 11 underwent uncomplicated SWL without cardiac intervention (2 had unknown history). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low-risk patients because of arrhythmia (3 had normal preoperative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted postoperatively because of cardiac complications (1 for atrial fibrillation and 1 for hypertension), of whom all had normal preoperative ECG. No patients presented to our emergency department with cardiac complications after SWL.In patients at low risk for cardiac complications, preoperative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted.

Ureteral stent length is important, as stents that are too long might worsen symptoms and too short are at higher risk of migration. The purpose of this study was to determine if patient or radiologic parameters correlate with directly measured ureteral length and if directly measured ureteral length predicts proper stent positioning.During stent placement, ureteral length (ureteropelvic junction to ureterovesical junction distance) was directly measured by endoscopically viewing a ureteral catheter (with 1-cm marking) emanating from the ureteral orifice. A 22, 24, or 26 cm stent was chosen to be closest to the measured ureteral length. For ureters26 cm, a 26 cm stent was chosen. Ends of an "ideally positioned" stent were fully curled in the renal pelvis and bladder, without crossing the bladder midline. Rates of ideal stent position were compared between patients with matching stent and ureteral lengths and those with stent lengths differing by ≥1 cm (mismatched). The measured ureteral length was correlated with patient height, L1-L5 height, and length measured on CT.Fifty-nine ureters from 57 patients were included. Height was reasonably correlated with L1-L5 height (Spearman correlation coefficient [rho] = 0.79), although both were poorly correlated with directly measured ureteral length (rho = 0.18 for height and 0.32 for lumbar height). Ureteral lengths measured on CT correlated well with direct measurement (rho = 0.63 for axial cuts and rho = 0.64 for coronal cuts). Matched stent length was associated with higher rates of ideal stent position than mismatched (100% vs 70.9%, p = 0.006).CT measurements, rather than height, correlate well with measured length and could be used to choose the appropriate stent length. Stents matching directly measured ureteral lengths are associated with high rates of ideal stent position.

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.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.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).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.

We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS).A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale.Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p 0.001) and surgeon level (R = 0.84, p 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p 0.001) for the unique surgery-specific assessment question.We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

A baseline kidneys, ureters, and bladder (KUB) radiograph, at the time of computed tomography (CT) for ureteral stones, might aid interpretation of future KUBs. The CT scout radiograph might render the baseline KUB redundant, however. We sought to assess the diagnostic utility of baseline KUB for patients with ureteral stones.Patients with ureteral stones were retrospectively identified. All had a baseline KUB in addition to CT and were reassessed after 4 to 60 days with KUB. Each patient's imaging was randomized 1:1 into either "KUBCT" or "CT" groups. Three urologists independently assessed the imaging: CT (with scout film) and baseline KUB in the KUBCT group, but only the CT (not KUB) in the CT group. Definitive stone assessment on follow-up KUB was defined as all three reviewers answering either Yes or No (not Indeterminate) to the question of stone passage or migration.Of 154 stones, the mean diameter was 4.8 ± 2.1 mm, density was 914 ± 300 Hounsfield units (HU), with 54.4% in the distal ureter. Stone visibility was 60.4% on KUB vs 43.5% on scout film (P0.001). Scout film visibility favored the CT group (52.7 vs 35.0%, P = 0.027). After adjusting for body mass index, skin-to-stone distance, size, density, and location, definitive assessment rates were higher in the KUBCT group (P = 0.047). When reviewers reassessed the CT group using the baseline KUB, they were able to do so definitively in an additional 16 (21.6%, P0.001). Definitive assessments were associated with higher rates of stone visibility on scout film (86.1 vs 21.1%, P0.001), KUB (86.1 vs 50.0%, P0.001), and larger (6.0 vs 3.7 mm, P0.001), denser stones (1046 vs 802 HU, P0.001).The addition of a baseline KUB to the CT scout film improves the ability of urologists to determine stone outcome when following patients with KUB imaging and might reduce the subsequent need for additional imaging.

We developed a genitourinary skills training (GUST) curriculum for incoming third year medical students (MS3) and performed a follow-up study of comfort with and utilization of these skills.GUST consisted of a didactic lecture followed by skills sessions including standardized patient testicular examination (TE) and digital rectal examination (DRE), male and female Foley catheter (MFC and FFC) placement training, suture-knot tying, and a faculty-directed small group learning session. Precourse and postcourse, and 6 and 18 months after the course, MS3 rated comfort with each skill (Likert scale 0-5), and quantified skill usage. Results were compared with 4th year students (MS4) who had not undergone GUST.Participants were 281 MS3 GUST students and 44 MS4. Post-GUST, mean comfort on a Likert scale (0=uncomfortable) increased for all four skills (88.2%-96.9% vs 8.3%-18.5%, P0.0001). This was maintained at the 6-month and 18-month follow up time points (P0.0001). At 18 months, MS3 trended toward higher comfort with TE compared with MS4 (74 vs 54%, P=0.068), while with the other skills, both groups showed equal comfort. MS4 learned exam skills from faculty and MFC and FFC from nurses on the wards. Eleven percent of MS4 were never formally taught TE or DRE. MS3 and MS4 performed TE and/or DRE on8% of newly admitted patients.MS3 described improved comfort with the GU skills at all time points during follow-up. This was particularly important because both MS3 and MS4 reported using their skills infrequently during their clinical training years.

Performing warm-up exercises before athletic competition or stage performance is very common; however, most surgeons do not "warm up" before performing complex surgery. We analyzed the intraoperative effects of warming up before surgery in an experienced laparoscopic surgeon.A retrospective review of all laparoscopic partial (LPN) and radical nephrectomies (LRN) completed by an experienced laparoscopic surgeon (RVC) were analyzed according to whether warm-up exercises were performed before surgery. Routine warm-up consisted of 15 to 20 minutes of pelvic trainer suturing exercises (forehand and backhand sutures and knot tying), using both hands. Intraoperative and postoperative parameters were examined.LRN and LPN subjects were well matched among the warm-up group and nonwarm-up group. Patients in the LPN warm-up group did have significantly larger tumors (3.7 cm vs 2.4 cm, P=0.02). Despite larger tumors, surgical time was significantly less in the warm-up group (227 min vs 281 min, P=0 .04), and total operating room time trended toward significance (320 min vs 371 min, P=0.0501). Similarly, in the LRN group, operative times and total operating room time was significantly less in the preoperative warm-up group (P=0.0068 and P=0.014, respectively). Intraoperative and postoperative complications, estimated blood loss, positive margin rate, warm ischemia time, length of stay, changes in hemoglobin and creatinine levels from baseline were not significantly different between the two groups.Performing warm-up exercises before complex laparoscopic surgery may improve operative times and performance in the operating room, especially for complex laparoscopic surgeries.

The robotic surgical platform has allowed for improved ergonomics, tremor filtration, and more precise surgical movements during minimally invasive surgery. We examined the impact of the da Vinci(®) Surgical System on the lateralization of manual dexterity, or handedness, innate to most surgeons.Manual dexterity assessments were conducted among 19 robotic novices using two different skills tests: The Purdue Pegboard Test and a needle targeting test. After an initial robotic basic skills training seminar, subjects underwent testing using both open and robotic approaches. Test performance using both approaches was then compared among all subjects.The majority of subjects (84%) were right handed, and all subjects described their dominant hand as significantly or moderately more dexterous than their nondominant hand. The participants had significant differences between the dominant and nondominant hand in open skills tasks using the Purdue Pegboard test (15.4 vs 14.6 pegs, P=0.023) and needle targeting test (4.5 vs 3.7 targets, P=0.015). When the same tasks were performed using the robot, the differences in handedness were no longer observed (P=0.203, P=0.764).The da Vinci robot is capable of eliminating innate dexterity or handedness among novice surgical trainees. This provides evidence of another beneficial aspect of robot-assisted surgery over traditional laparoscopic surgery and may facilitate operative performance of complex tasks.

The da Vinci surgical platform is becoming increasingly available and utilized. Due to the lack of haptic feedback, visual cues are necessary to estimate grip forces and tissue tensions during surgery. We directly measured the grip forces of robotic EndoWrist instruments using the three available da Vinci robotic surgical platforms.Robotic instruments were tested in the da Vinci S, Si, and Standard systems. A load cell was placed in a housing unit that allowed for measurement of the grip forces applied by the tip of each robotic instrument. Each instrument was tested six times, and all data were analyzed using Student's t-tests or analysis of variance when appropriate.Slight differences in grip force were seen when the instrument was tested through 2 degrees of freedom at the tip (p = 0.02, analysis of variance) and when comparing a new instrument to an older instrument (p = 0.001 at the neutral position). There was no statistical difference in grip force between the left and right robotic arms. There was a broad range of grip forces between the various robotic instruments. The lowest grip force was registered in the double fenestrated grasper (2.26 ± 0.15 N), whereas the highest was seen in the Hem-o-lok clip applier (39.92 ± 0.89 N). In comparison to the S and Si, the Standard platform appeared to have significantly higher grip forces.Different grip forces were observed among the various robotic instruments commonly used during urologic surgery and between the Standard and the S and Si platforms.

Introduction: A retrocaval ureter (RCU) is a rare clinical entity that results from the abnormal persistence of the subcardinal vein. It is more common among males and usually presents in ...