Validation of laparoscopy and flexible ureteroscopy tasks in inanimate simulation training models at a large-scale conference setting

Objective:Simulation based training with training models is being increasingly used as a tool to help trainees mount the learning curve.However,validation studies of surgical simulators are often limited by small numbers.We aim to evaluate the feasibility of validating simulation-training tasks in laparoscopy and flexible ureteroscopy(FURS)rapidly at a large-scale conference setting for residents.Methods:Seventy-six urology residents from various Asian countries were assessed on their laparoscopic and FURS skills during the 14th Urological Association of Asia Congress 2016.Residents performed the peg transfer task from the fundamentals of laparoscopic surgery(FLS)and completed inspection of calyces and stone retrieval using a flexible ureteroscope in an en-dourological model.Each participant’s experience(no experience,1-30 or>30 procedures)in laparoscopy,rigid ureteroscopy(RURS)and FURS was self-reported.Results:Median time taken to complete the laparoscopic task decreased with increasing laparoscopic experience(209 s vs.177 s vs.145 s,p=0.008)whereas median time taken to complete the FURS tasks reduced with increasing FURS experience(405 s vs.250 s vs.163 s,p=0.003)but not with RURS experience(400.5 s vs.397 s vs.331 s,p=0.143),demonstrating construct validity.Positive educational impact of both tasks was high,with mean ratings of 4.16/5 and 4.10/5 respectively,demonstrating face validity.Conclusion:Our study demonstrates construct and face validities of laparoscopy and FURS simulation tasks among residents at a conference setting.Validation studies at a conference setting can be an effective avenue for evaluating simulation models and curriculum in the future.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non-en-bloc techniques:a multicenter,real-world experience of 5068 patients

We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate(EEP)comparing en-bloc(Group 1)versus 2-lobe/3-lobe techniques(Group 2).We performed a retrospective review of patients undergoing EEP for benign prostaticenlargement in 12 centers between January 2020 and January 2022.Data were presented as median and interquartile range(IQR).Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence(SUI)and mixed urinary incontinence(MUI).There were 1711 patients in Group 1 and 3357 patients in Group 2.Patients in Group 2were significantly younger(68[62–73]years vs 69[63–74]years,P=0.002).Median(interquartile range)prostate volume(PV)wassimilar between the groups(70[52–92]ml in Group 1 vs 70[54–90]ml in Group 2,P=0.774).There was no difference in preoperativeInternational Prostate Symptom Score,quality of life,or maximum flow rate.Enucleation,morcellation,and total surgical time weresignificantly shorter in Group 1.Within 1 month,overall incontinence rate was 6.3%in Group 1 versus 5.3%in Group 2(P=0.12),and urge incontinence was significantly higher in Group 1(55.1%vs 37.3%in Group 2,P<0.001).After 3 months,the overall rate ofincontinence was 1.7%in Group 1 versus 2.3%in Group 2(P=0.06),and SUI was significantly higher in Group 2(55.6%vs 24.1%in Group 1,P=0.002).At multivariable analysis,PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI.PV,surgical time,and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

A novel mortality risk score for emphysematous pyelonephritis:A multicenter study of the Global Research in the Emphysematous Pyelonephritis group

Background:Emphysematous pyelonephritis(EPN)is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality.We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission.Materials and methods:Patients diagnosed with EPN between 2013 and 2020 were retrospectively included.Data from 15 centers(70%)were used to develop the scoring system,and data from 7 centers(30%)were used to validate it.Univariable and mułtivariable logistic regression analyses were performed to identify independent factors related to mortality.Receiver operating characteristic curve analysis was performed to construct the sconng system and calculate the risk of mortality.A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points.The area under the curve was used to quantify the scoring system performance.An 8-point scoring system for the mortality risk was created(range,0-7).Results:In total,570 patients were included(400 in the test group and 170 in the validation group).Independent predictors of mortality in the multivariable logistic regression were included in the scoring system:quick Sepsis-related Organ Failure Assessment score≥2(2 points),anemia,paranephric gas extension,leukocyte count>22,000/pL,thrombocytopenia,and hyperglycemia(1 point each).The mortality rate was<5%for scores≤3,83.3%for scores 6,and 100%for scores 7.The area under the Curve was 0.90(95%confidence interval,0.84-0.95)for test and 0.91(95%confidence interval,0.84-0.97)for the validation group.Condusions:Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

Performance in the Fundamentals of Laparoscopic Surgery: Does it reflect global rating scales in the Objective Structured Assessment of Technical Skills in porcine laparoscopic surgery?

Objective:To correlate the utility of the Fundamentals of Laparoscopic Surgery(FLS)manual skills program with the Objective Structured Assessment of Technical Skills(OSATS)global rating scale in evaluating operative performance.Methods:The Asian Urological Surgery Training and Educational Group(AUSTEG)Laparoscopic Upper Tract Surgery Course implemented and validated the FLS program for its usage in laparoscopic surgical training.Delegates’basic laparoscopic skills were assessed using three different training models(peg transfer,precision cutting,and intra-corporeal suturing).They also performed live porcine laparoscopic surgery at the same workshop.Live surgery skills were assessed by blinded faculty using the OSATS rating scale.Results:From March 2016 to March 2019,a total of 81 certified urologists participated in the course,with a median of 5 years of post-residency experience.Although differences in task time did not reach statistical significance,those with more surgical experience were visibly faster at completing the peg transfer and intra-corporeal suturing FLS tasks.However,they took longer to complete the precision cutting task than participants with less experience.Overall OSATS scores correlated weakly with all three FLS tasks(peg transfer time:r=0.331,r^(2)=0.110;precision cutting time:r=0.240,r^(2)=0.058;suturing with intracorporeal knot time:r=0.451,r^(2)=0.203).Conclusion:FLS task parameters did not correlate strongly with OSATS globing rating scale performance.Although FLS task models demonstrated strong validity,it is important to assimilate the inconsistencies when benchmarking technical proficiency against real-life operative competence,as evaluated by FLS and OSATS,respectively.

Prospective validation of %p2PSA and the Prostate Health Index, in prostate cancer detection in initial prostate biopsies of Asian men, with total PSA 4-10 ng ml-1

Despite its widespread use for prostate cancer screening, low specificity makes PSA a suboptimal biomarker, especially in the diagnostic ＂gray zone＂ of 4-10 ng ml-1, False-positives lead to unnecessary biopsies with attendant morbidities. This is the first prospective validation study of %p2PSA and the Prostate Health Index （PHI） in Asian men presenting with a total PSA between 4.0 and 10 ng m1-1. We studied 157 Asian men between 50 and 75 years old, with normal per rectal prostate examinations, undergoing their first prostate biopsy, using a standardized biopsy protocol, for PSA levels of 4-10 ng ml-1, Thirty （19.1%） were found to have prostate cancer on biopsy. Statistically significant differences between patients with and without prostate cancer were found for total PSA, p2PSA, %p2PSA, and PHh The areas under the curve of the receiver operating characteristic curve for total PSA, %fPSA, %p2PSA, and PHI were 0.479, 0.420, 0.695, and 0.794, respectively. PHI predicts prostatic biopsies results best. At a sensitivity of 90%, the specificity （95% CI） of PHI was 58.3%, more than triple the specificity of total PSA at 17.3%, potentially avoiding 77 （49%） unnecessary biopsies. Similar to studies in mainly Caucasian populations, we have prospectively shown that %p2PSA and PHI greatly outperform total and free to total PSA ratio, in the detection of prostate cancer at first biopsy. Higher PHi levels also correspond to increasing the risk of detecting GS ≥7 cancers. We have validated the use of PHI to aid decision-making regarding prostate biopsies in Asian men with serum PSA between 4 and 10 ng ml-1.Despite its widespread use for prostate cancer screening, low specificity makes PSA a suboptimal biomarker, especially in the diagnostic ＂gray zone＂ of 4-10 ng m1-1, False-positives lead to unnecessary biopsies with attendant morbidities. This is the first prospective validation study of %p2PSA and the Prostate Health Index （PHI） in Asian men presenting with a total PSA between 4.0 and 10 ng mI-L We studied 157 Asian men between 50 and 75 years old, with normal per rectal prostate examinations, undergoing their first prostate biopsy, using a standardized biopsy protocol, for PSA levels of 4-10 ng mI-L Thirty （19.1%） were found to have prostate cancer on biopsy. Statistically significant differences between patients with and without prostate cancer were found for total PSA, p2PSA, %p2PSA, and PHI. The areas under the curve of the receiver operating characteristic curve for total PSA, %fPSA, %p2PSA, and PHI were 0.479, 0.420, 0.695, and 0.794, respectively. PHI predicts prostatic biopsies results best. At a sensitivity of 90%, the specificity （95% CI） of PHI was 58.3%, more than triple the specificity of total PSA at 17.3%, potentially avoiding 77 （49%） unnecessary biopsies. Similar to studies in mainly Caucasian populations, we have prospectively shown that %p2PSA and PHI greatly outperform total and free to total PSA ratio, in the detection of prostate cancer at first biopsy. Higher PHi levels also correspond to increasing the risk of detecting GS 〉7 cancers. We have validated the use of PHI to aid decision-making regarding prostate biopsies in Asian men with serum PSA between 4 and 10 nR ml-1.