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BACKGROUND Non-muscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance with frequent repeat treatments. There is evidence that the quality of the initial surgical procedure (Transurethral resection of bladder tumour (TURBT)) and timely administration of postoperative bladder chemotherapy significantly reduces cancer recurrence rates and improves outcomes such as cancer progression and mortality. There is some survey-based evidence that TURBT practice varies significantly across surgeons and sites1. There is evidence from clinical trials that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumour, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. OBJECTIVE This study primarily aims to determine if feedback of and education about surgical quality indicators can improve performance, and secondarily if this can reduce cancer recurrence rates. METHODS This study is an observational, international, multi-centre study with an embedded cluster randomised trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. RESULTS The study has 4 co-primary outcomes which are 4 TURBT quality indicators: a surgical performance factor; an adjuvant treatment factor; and two documentation factors. A key secondary outcome is the early cancer recurrence rate. CONCLUSIONS Local and/or national ethical and institutional approvals or exemptions will be obtained at each participating site. The study results will be published in peer-reviewed journals and presented at national and international scientific congresses. CLINICALTRIAL The study is registered with clinicaltrials.org (NCT05154084).

Aim Robotic surgical training has historically lacked evidence-based standardisation. The Fundamentals of Robotic Surgery (FRS) curriculum addresses this by incorporating proficiency-based modules which certify trainees’ skills. However, the curriculum is self-directed and non-interactive. We aim to determine the effectiveness of interactive virtual classroom training (VCT) as an adjunct to the FRS curriculum for robotic skills training. Method 11 novice surgical trainees were randomly allocated to two groups. Both groups completed a one-week robotic skills induction. In week two, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week three, the groups received the alternate intervention. The primary outcome was measured using the validated robotic-objective structured assessment of technical skills (R-OSAT). Results 11 participants completed the training curriculum; all were included in analyses. Both groups demonstrated significantly improved proficiency upon completion of the training. At time point 1 (end of week two) Group A achieved a statistically significant greater mean proficiency score compared to Group B (44.80 vs 35.33 points, p=0.006). At time point 2 (end of week three), there was no significant difference in Group A's mean score from time point 1. In contrast, Group B showed significant improvement in mean proficiency by 9.67 points from time point 1 (95% CI 5.18–14.15, p=0.003). Conclusions VCT is an effective training adjunct to the FRS curriculum for the learning of basic robotic skills. With the steep learning curve in robotic surgery training, VCT offers interactive learning and can increase training effectiveness.

Introduction Virtual classroom training (VCT) is a novel educational method that permits accessible, distanced interactive expert instruction. We aimed to evaluate the efficacy of VCT in comparison to face-to-face training (FFT) and non-interactive computer-based learning (CBL) for basic surgical skills training. Method 72 participants recruited from five London medical schools underwent stratified block randomisation into three equal intervention groups based on subjective and objective suturing experience. VCT was delivered via the BARCO weConnect platform and FFT was provided by expert instructors. Optimal student-to-teacher ratio was used, 12:1 for VCT and 4:1 for FFT. The assessed task was interrupted suturing with hand-tied knots. The primary outcome was post-intervention Objective Structured Assessment of Technical Skills (OSATS) score, adjudicated by two blinded experts and adjusted for baseline proficiency. Results VCT was non-inferior to FFT (adjusted difference 0.44, 95% CI: -0.54 to 1.75, delta 0.675), VCT was superior to CBL (adjusted difference 1.69, 95% CI 0.41 to 2.96) and FFT was superior to CBL (adjusted difference 1.25, 95% CI 0.20 to 2.29). FFT alone was associated with student travel expenses (mean £4.88, SD 3.70). Instructor hours used per student for VCT and FFT were 0.25 and 0.75, respectively. Conclusions VCT has a similar educational benefit to FFT and is a suitable modality of high-quality surgical skills education. VCT provides greater accessibility and resource efficiency compared to FFT. VCT satisfies the requirement for social distancing during the COVID-19 pandemic and is better than non-interactive CBL. VCT has the potential to improve global availability and accessibility of surgical skills training.

Aims Robotic surgery is an evolving surgical technique, requiring specialist training. The standardised Fundamentals of Robotic Surgery (FRS) curriculum incorporates proficiency-based modules to certify the skills of novice trainees. However, the curriculum is self-directed and non-interactive. We aim to determine the effectiveness of interactive virtual classroom training (VCT) in concordance with the FRS for robotic skills training. Methods 11 novice surgical trainees were randomly allocated to two training groups. Both groups completed a one-week robotic skills induction. In week two, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week three, the groups received the alternate intervention. The primary outcome was measured using the validated R-OSAT score. This was collected post-intervention at time point 1(end of week two) and time point 2(end of week three). Results Participants attained higher mean proficiency scores with both the FRS curriculum and VCT, compared to the FRS curriculum alone. At timepoint 1, Group A achieved a greater mean proficiency score compared to Group B (44.80 vs 35.33, p=0.006). At timepoint 2, there was no significant difference in mean proficiency score in Group A from timepoint 1. In contrast, Group B, who received adjunctive VCT showed significant improvement in mean proficiency by 9.67points from timepoint 1 (95% CI 5.18–14.15, p=0.003). Conclusion VCT is an effective training adjunct to the FRS curriculum for learning basic robotic skills. With the steep learning curve in robotic surgery training, VCT offers interactive learning and can increase training effectiveness and accessibility.

IntroductionRobotic surgery training has lacked evidence-based standardisation. We aimed to determine the effectiveness of adjunctive interactive virtual classroom training (VCT) in concordance with the self-directed Fundamentals of Robotic Surgery (FRS) curriculum.MethodsThe virtual classroom is comprised of a studio with multiple audio-visual inputs to which participants can connect remotely via the BARCO weConnect platform. 11 novice surgical trainees were randomly allocated to two training groups (A and B). In week one, both groups completed a robotic skills induction. In week two, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week three, the groups received the alternate intervention.The primary outcome was measured using the validated robotic-objective structured assessment of technical skills (R-OSAT) at the end of week two (timepoint 1) and three (timepoint 2).ResultsAll participants completed the training curriculum and were included in the final analyses. At timepoint 1, Group A achieved a statistically significant greater mean proficiency score compared to Group B (44.80vs35.33 points, p=0.006). At timepoint 2, there was no significant difference in mean proficiency score in Group A from timepoint 1. In contrast, Group B, who received further adjunctive VCT showed significant improvement in mean proficiency by 9.67 points from timepoint 1 (95% CI 5.18-14.15, p=0.003).ConclusionVCT is an effective, accessible training adjunct to self-directed robotic skills training. With the steep learning curve in robotic surgery training, VCT offers interactive, expert-led learning and can increase training effectiveness and accessibility.

To develop and validate a coding framework to identify interventions for upper tract obstructive uropathy (UTOU) in men with locally advanced and metastatic prostate cancer (PCa) using administrative hospital data to assess clinical outcomes. There are no population-based studies on the incidence, treatment, and outcomes of this complication.Patients newly diagnosed with PCa between April 2014 and March 2019 were identified in the English cancer registry. A coding framework based on procedure (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures fourth edition) and diagnostic (International Classification of Diseases, 10th edition) codes was developed and validated. Subsequent clinical outcomes were determined using Hospital Episodes Statistics to determine the utility of the intervention.A total of 77 010 patients newly diagnosed with locally advanced, and 30 083 patients with metastatic PCa were identified. Of these, 1951 (1.8%) patients underwent an intervention for UTOU according to our coding framework: 830 (42.5%) had locally advanced disease and 1121 (57.5%) had metastatic disease. In all, 844 (43.3%) had a percutaneous nephrostomy (PCN), 473 (24.2%) had a PCN with antegrade stent, and 634 (32.5%) had a retrograde stent. The mean follow-up was 43.2 months. The cumulative incidence of the use of these interventions at 1, 3, and 5 years was 2.5%, 3.6% and 4.2% in men with metastases compared to 0.5%, 0.9% and 1.4% in men with locally advanced disease.A new coding framework, developed to identify procedures for UTOU was applied in the largest study to date of UTOU in men with primary locally advanced and metastatic PCa. Results demonstrated that 2% of men with locally advanced PCa and 4% of men with metastatic PCa require an intervention to resolve UTOU within 5 years of their PCa diagnosis.

Mentoring is critically important for the personal and professional development of a surgeon. Early career stage mentoring by same-gender role models may help ameliorate the gender imbalance in surgery based on our understanding of barriers for women pursuing surgical careers. A novel method of establishing these relationships is speed mentoring. This study aims to examine the impact of a one-day speed-mentoring session with same gender mentors on a cohort's perceptions of a career in surgery.This prospective pre-post study compared attitudes and perceptions of a career in surgery before and after a speed-mentoring session with female surgeons. Mentees were assigned into groups of 1 or 2 and were paired with a female surgeon for 8 minutes. Each mentee group then rotated to another mentor for the same amount of time and this process continued for a total of twelve sessions. Mentees completed a 19-point questionnaire before and after the speed mentoring intervention.This multicenter study included participants from across the United Kingdom.Inclusion criteria were female gender and medical student or foundation year doctor (internship year 1 or 2) status. Three hundred and forty participants participated in the intervention, 191 were included in the analysis.Following intervention, the percentage of participants who agreed that having a family would negatively impact a woman's surgical career progression significantly decreased from 46.6% to 23.0%. The percentage of participants who agreed that an "old boys' club" attitude exists in surgery also significantly decreased (73.8%-58.1%). The percentage of participants who agreed it was more difficult for a woman to succeed in her surgical career than a man significantly decreased (73.8%-64.9%). One hundred and eighty-three (96%) participants agreed that mentorship is important for career progression and 153 (71.2%) participants stated that they did not have someone who they considered a mentor.Conducting a speed mentoring program with same-gender role models significantly changed female medical students' and junior doctors' perceptions of women in surgery. The results suggest that such programs may be effective tools for facilitating mentor-mentee relationships and could be employed by surgical organizations to encourage a diverse uptake into surgery.

INTRODUCTION: The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term. RESULTS: We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% - aRR 2.57, 95% CI 2.47-2.68; CPG2: 68.6% vs. 52.6% - aRR 1.27, 95% CI 1.25-1.29; CPG3: 76.7% vs. 67.1% - aRR 1.12, 95% CI 1.10-1.13; CPG4: 82.6% vs. 72.4% - aRR 1.09, 95% CI 1.08-1.10; CPG5: 78.2% vs. 71.7% - aRR 1.06, 95% CI 1.04-1.07) CONCLUSIONS: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.

Robot-assisted radical prostatectomy (RARP) is the conventional surgical treatment option for localised prostate cancer. We investigated factors which may be associated with recovery of early urinary continence (EUC), including the use of the Retzius-sparing technique (RS-RARP). From March 2018 to December 2018, 501 consecutive patients underwent RARP at our high-volume institution. Four hundred and thirty-one patients had complete follow-up data and were included in our analyses. EUC was defined as zero pad use and social urinary continence (SUC) was defined as ≤ 1 pad/24-h period at 3 months following surgery. Patient demographics and clinical factors such as age, body mass index (BMI), neurovascular bundle (NVB) sparing, RS-RARP operative technique and operating surgeon (consultant, trainee) were recorded. Median age was 64.0 years (IQR 57.0-69.0 years) with a median BMI of 27.0 (IQR 25.0-29.9). RS-RARP accounted for 59 of the 431 (13.7%) patients. 196 (45.5%), 142 (32.9%) and 86 (20.0%) received a bilateral, unilateral and nil NVB sparing, respectively. EUC was achieved by 241 patients (55.9%) and SUC was achieved in 339 (78.7%) patients. Multivariable logistic regression analysis suggests younger age (HR 1.04, 95% CI 1.01-1.07, p = 0.014) and RS-RARP technique (HR 2.19, 95% CI 1.15-4.16, p = 0.017) were independently associated with EUC at 3 months even after adjusting for BMI, external membranous urethral length and NVB sparing. Our results suggest that RS-RARP technique is independently predictive of EUC even after accounting for confounding factors. These findings should be further validated in a prospective or randomised trial.

Objective: We assessed the safety and feasibility of minimally invasive robot-assisted surgery for horseshoe kidney (HSK). Method: A prospectively maintained data set for consecutive patients undergoing robotic kidney surgery was reviewed for patients with HSK. Cases were performed by experienced robotic surgeons, across two high-volume centres between 2016 and 2020. Results: Seven patients underwent robotic surgery for HSK, comprising three partial nephrectomies for renal masses, one nephroureterectomy and three benign nephrectomies for non-functioning kidneys. The median age was 53 (interquartile range (IQR) = 47–60) years and median body mass index (BMI) was 25 (IQR = 25–26.5). Median console time was 120 (IQR = 118–215) minutes and median estimated blood loss was 150 (IQR = 125–250) mL. The median pre- and post-operative estimated glomerular filtration rate (eGFR) was 76 (IQR = 72–90) and 71 (IQR = 60–81), respectively. There were no higher-grade complications (Clavien–Dindo III–IV) and one Clavien–Dindo grade II complication (wound infection treated with IV antibiotics). Median length of stay (LOS) was 2 days and there were no 30-day readmissions. Negative margins were achieved in 75% of tumour resections. Conclusion: We report one the largest series of robot-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in centralised high-volume centres with acceptable perioperative outcomes. Established benefits of minimally invasive surgery, such as reduced LOS and low complication rates, were demonstrated. Level of evidence: 4

ObjectivesTo assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function outcomes. Additionally, to determine whether there are differences in continence or safety outcomes.Subjects/patients and methodsData was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period. PDE5i therapy was started: immediately (day 1-2) post-op in 29%, early (day 3-14) post-op in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op with a median follow-up time of 43 days.ResultsThe median age was 64 and the median BMI was 27. 9% of the series had Charlson Co-Morbidities. There were no significant differences in pre-operative characteristics between the therapy groups.Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral.Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate therapy, 7 and 14.8% of early therapy and 9.7 and 9.5% of late therapy (p=0.9 and p=0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p=0.017 and p=0.045).Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication or readmission outcomes.ConclusionIn patients with bilateral nerve sparing RARP, immediate post-operative PDE5i therapy may protect EF. Early onset (3-14 days) may also provide a benefit compared to initiating PDE5i therapy later (after 14 days). Expediting therapy for patients undergoing unilateral nerve sparing may also provide a benefit; however, the differences are less pronounced. Immediate or early PDE5i therapy also improved early continence outcomes for patients with bilateral nerve sparing, compared to late therapy. There were no differences in compliance, complication or readmission rates between the groups. Therefore, immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.