Urology Section Research Articles

Validation of the endoscopic stone treatment step 1 (EST-s1): a novel EAU training and assessment tool for basic endoscopic stone treatment skills-a collaborative work by ESU, ESUT and EULIS.

The endoscopic stone treatment step 1 (EST s1) protocol has been developed after 2years of collaborative work between different European Association of Urology (EAU) sections. In this study, we added construct validity evidence to the EST s1 curriculum. The EST-s1 curriculum includes four standardized tasks: flexible cystoscopy, rigid cystoscopy, semi-rigid URS and flexible URS. Validation was performed during the annual 2016 EUREP meeting in Prague. 124 participants provided information on their endoscopic logbook and carried out these 4 tasks during a DVD recorded session. Recordings were anonymized and blindly assessed independently by five proctors. Inter-rater reliability was checked on a sample of five videos by the calculation of intra-class correlation coefficient. Task-specific clinical background of participants was correlated with their personal performance on the simulator. Breakpoint analysis was used to define the minimum number of performed cases, to be considered "proficient". "Proficient" and "Non-proficient" groups were compared for construct validity assessment. Likert scale-based questionnaires were used to test content and to comment on when the EST-s1 exams should be undertaken within the residency program. 124 participants (105 final-year residents and 19 faculty members) took part in this study. The breakpoint analysis showed a significant change in performance curve at 36, 41, 67 and 206s, respectively, corresponding to 30, 60, 25 and 120 clinical cases for each of the 4 tasks. EST-s1 was scored as a valid training tool, correctly representing the procedures performed in each task. Experts felt that this curriculum is best used during the third year of residency training. Our validation study successfully demonstrated correlation between clinical expertise and EST-s1 tasks, adding construct validity evidence to it. Our work also demonstrates the successful collaboration established within various EAU sections.

Peri- and post-operative results of initial robot-assisted radical prostatectomies of a surgeon graduating from a structured fellowship.

Background: No validated training curriculum for robotic surgery exists so far. International scientific societies like ERUS (EAU Robotic Urology Section) seek to validate a structured training program for robotic surgeons. In 2014, ERUS launched Pilot Study II, a 6-month structured training program to allow a surgeon without prior robotic training to perform a complete RARP (robot-assisted radical prostatectomy) independently and effectively. Aim of the study: Here we report the detailed courses and training materials, specific surgical activities and perioperative efficacy and safety results of the first 52 RARP cases performed by a single surgeon after graduating from Pilot Study II. The aim is to compare these results with the literature and show if this sophisticated training helps patients undergoing this type of surgery achieve advantageous perioperative results. Material and methods: The fellowship was conducted from January to June 2014 and consisted of lectures on technical and non-technical skills, as well as e-learning, bedside assistance (at least 20), intensive training consisting of laboratory training (i.e., virtual reality simulation, dry lab (plastic model), wet lab on animal cadavers and living anaesthetized pigs) and dual-console live surgery followed by five months of modular training, where the trainee performed different steps of the surgery at the host center. After passing the final evaluation (a full recorded video of RARP evaluated blindly by robotic experts), the trainee was deemed capable of performing efficiently and safely a full case of RARP. Here we retrospectively report the content of training and perioperative results of the surgeon’s initial 52 RARPs performed from July 2014 to April 2015. Results: After graduating from the fellowship, the surgeon performed 52 cases of RARP. The mean patient age was 65.2 years, initial PSA 12.9 ng/ml, prostate volume 43.7 ml in TRUS, BMI 27.5, and 61% of patients had a prior abdominal or pelvic surgery. Because of internal regulations, every patient had a pelvic lymphadenectomy performed, three of whom had positive lymph nodes. The average estimated blood loss was 225.7 ml, and no patient needed intraoperative blood transfusion. The average console time was 174.2 minutes. Final full-mount pathology identified 23 patients (44.2%) with a locally advanced prostate cancer (T3 or T4). Positive surgical margins were present in three cases. A further 29 patients (55.8%) had locally confined disease (T2). Positive surgical margins were observed in 2 cases. Catheters were removed on the 5th postoperative day followed by a cystogram, with no urine leakage observed in 96.2% of cases. The safety of the procedure was good with one major (Clavien 4) and 13 minor (Clavien 1 and 2, i.e., uncomplicated urinary infection, urinary retention) complications. Conclusions: The study showed that graduating from an intensive and structured learning program in robotic surgery resulted in a faster learning curve, allowing the trainee to reach high safety parameters in performed surgeries. When compared with already published series, advantageous results could be observed. The study was limited by its retrospective design, the moderate number of patients and variables such as individual motivation, dexterity and attitude of the person in training. The advantages of such training should be further evaluated in controlled, multi-center trials.

Editorial introductions

Editorial introductions

Worldwide survey of flexible ureteroscopy practice: a survey from European Association of Urology sections of young academic urologists and uro-technology groups.

IntroductionTo understand the current practice of flexible ureteroscopy (fURS), we conducted a worldwide survey among urologists with a special interest in endourology.Material and methodsA 42-question survey was designed after an initial consultation with European Association of Urology young academic urologists (YAU) and uro-technology (ESUT) groups. This was distributed via the SurveyMonkey® platform and an ESUT meeting to cover practice patterns and techniques in regard to ureteroscopy usage worldwide.ResultsA total of 114 completed responses were obtained. A safety guidewire was reportedly used by 84.5% of endourologists, an access sheath was always or almost always used by 71% and a reusable laser fibre was used by two-thirds of respondents. While a combination of dusting and fragmentation was used by 47% as a preferred mode of intra-renal stone treatment, some used dusting (43%) or fragmentation with basketing (10%).Disposable scopes were only used by 40% and three quarters of them used it for challenging cases only. Antibiotic prophylaxis was limited to a single peri-operative dose by two-thirds (67%) of respondents. The procedural time was limited to between 1–2 hours by two-thirds (70%) of respondents and very rarely (7.4%) it exceeded 2 hours. The irrigation method varied between manual pump (46%), mechanical irrigation (22%) or gravity irrigation (27%).ConclusionsOur survey shows a wide variation in the available endourological armamentarium and surgical practice amongst urologists. However, there seems to be a broad agreement in the use of peri-operative antibiotics, access sheath usage, method of stone treatment and the use of post-operative stent.

Information for Authors

Information for Authors

Comparison among the available stone treatment techniques from the first European Association of Urology Section of Urolithiasis (EULIS) Survey: Do we have a Queen?

PurposeThe miniaturization of instruments has had an impact on stone management. The aims of this study were to highlight surgeon preferences among Retrograde Intra Renal Surgery (RIRS), Regular, Mini-, UltraMini- and Micro- Percutaneous Nephrolithotomy (PCNL) for urolithiasis and to compare the effectiveness and safety of these techniques in a real-life setting.MethodsA 12-item survey regarding endourological techniques was conducted through Survey Monkey among attendees of the 2013 European Association of Urology Section of Urolithiasis meeting. We asked responders to share data from the last 5 cases they performed for each technique. Procedures were stratified according to stone size and the centres’ surgical volume. Techniques were compared in terms of effectiveness and safety. Analyses were performed on the overall group and a subgroup of 1–2 cm stones.ResultsWe collected data from a total of 420 procedures by 30, out of 78, urologists who received the survey (response rate 38%): 140 RIRS, 141 Regular-PCNL (>20 Ch), 67 Mini-PCNL (14–20 Ch), 28 UltraMini-PCNL (11–13 Ch) and 44 Micro-PCNL (4,8–8 Ch). Techniques choice was influenced by stone size and the centre’s surgical volume. Effectiveness and safety outcomes were influenced by stone size, independently of the technique. The stone-free rate was significantly lower in Micro-PCNL compared to Regular-PCNL. This was not confirmed for 1–2 cm stones. All techniques presented a lower complication rate than Regular-PCNL, with Mini-PCNL being the most protective technique compared to Regular-PCNL.ConclusionsStone size seems to drive treatment choice. Miniaturized PCNL techniques are widely employed for 1–2 cm stones, in particular in higher surgical volume centres. Mini-PCNL and RIRS are growing in popularity for stones > 2 cm. Mini-PCNL seems to be a good compromise, being the most effective and safe procedure among PCNL techniques. RIRS is characterized by satisfactory stone-free and low complication rates.

Report on XV meeting of EAU Robotic Urology Section in 2018

On 5–7 September 2018 the fifteenth annual meeting of EAU Robotic Urology Section (ERUS) took place in Marseille, France. ERUS meeting is regarded as a scientific platform for every urologist who is interested in latest technical advances and continuous progress of urological science and practice. Among the widely discussed topics were organization of surgical care in hospitals equipped with surgical robot, education and training of robotic urological surgeons, use of early recovery protocols in robotic urology and many others. Prototypes and concepts of new robotic surgical systems soon to appear on the market were demonstrated at ERUS-2018. During the live surgery session worldwide-known urologists demonstrated about 20 surgical interventions with comments and explanations for every step in real time.

The History of Urology at the Minneapolis Veterans Affairs Health Care System

ObjectiveThe Section of Urology at the Minneapolis Veteran's Affairs (VA) Medical Center has a long history of contributions to Urology including the Gleason Score, Fuhrman Grading system, testicular tumor marker development and the birth of Endourology. The objective of this manuscript is to compile and present the Urologic history of the Minneapolis VA. MethodsThe Urologic literature and institutional records originating from the Minneapolis VA Medical Center from 1946-2017 were reviewed and presented herein. ResultsThe Minneapolis VA Health Care System originated in 1921 and currently employs 5 Urologist who serve over 16,000 veterans per year. Historic achievements from the Minneapolis VA Section of Urology include the development of the Veteran's Affairs Cooperative Research Group (VACURG) which was instrumental to development of the Gleason grading system for prostate cancer in 1965. Additional urologic oncology achievements originating from the Minneapolis VA Section of Urology included the development of the diagnostic utility of tumor markers in testis cancer in 1976 and The Fuhrman Grading System in 1982. Perhaps the greatest contribution to the field of Urology was the birth of Endourology at the Minneapolis VA in the late 1970s under the direction of Dr. Paul Lange. Currently the Minneapolis VA is a premier center for Evidence Based Urology by housing Cochrane Urology and the U.S. Grading of Recommendations Assessment, Development and Evaluation network (US GRADE). ConclusionSince 1946, the section of Urology at the Minneapolis VA has contributed basic science, clinical technique and evidence based medicine to the field of Urology while providing care to the nation's veterans.

Information for Authors

Information for Authors

P76 - Robot-Assisted kidney transplantation with regional hypothermia using grafts with multiple vessels: Results from the EAU Robotic Urology Section (ERUS) working group

P76 - Robot-Assisted kidney transplantation with regional hypothermia using grafts with multiple vessels: Results from the EAU Robotic Urology Section (ERUS) working group

Editorial introductions

Editorial introductions

PE81 - EAU Robotic Urology Section Host Centres certification: Current status of training in robotic Urology in Europe

PE81 - EAU Robotic Urology Section Host Centres certification: Current status of training in robotic Urology in Europe

Information for Authors

Information for Authors

Information for Authors

Information for Authors

Effect of a two-day extensive continuing medical education course on participants' knowledge of clinical and operative urology.

Continuing Medical Education (CME) is an established method for facilitating the lifelong learning and developing knowledge, skills and attitudes to ensure delivery of a medical care which is up-to-date, evidence based, safe and patient-centered. An extensive 2 day urology course was conducted to meet the needs of learners. The purpose of the current study was to measure the effect of this CME activity on the knowledge of the participants. This quasi-experimental, single group pre-, and post-test study measured the gain in learning as a result of the two-day extensive CME course conducted by the section of Urology at Department of Surgery, the Aga Khan University, Karachi-Pakistan. Gain in knowledge, defined as the difference between the pre-test and the post-test scores, was taken as a measure of course effectiveness. The test comprised of 40 one-best type carefully constructed multiple choice questions (MCQs). Item analyses were also performed. Forty-five out of a total of 70 participants from within and outside the city completed both pre and post-tests and were included in the study. The mean age of the subjects was 33.3+6.7 years. Of these 45 participants, 68.9% (n=31) of them were trainees at different levels. Mean gain in knowledge was 12.7±6.8% (p<0.01; 95% CI: 4.17-5.79). Mean test scores improved significantly from 37.8±11.3% to 50.3±10.8%. Difference in pre and post scores due to age, gender, practice type or years since start of training was not significant. The reliability of the test using Cronbach's α was 0.634. CME sessions when designed and delivered carefully are effective means of increasing the knowledge significantly. Pre- and post-test is a reliable and valid strategy to measure gain in participants' knowledge.

Information for Authors

Information for Authors

European experience of robot-assisted kidney transplantation: minimum of 1-year follow-up.

To evaluate functional results, graft survival and late complications in patients who underwent robot-assisted kidney transplantation (RAKT) and who had a minimum of 1 year of follow-up data, and to analyse the correlations between surgical data and functional results at a minimum of 1-year postoperatively and between renal function in the immediate postoperative period and after 1 year. A common prospectively collected RAKT database was created by the European Robotic Urological Section (ERUS) RAKT working group, which included eight different European centres. In each centre RAKTs were performed with kidneys from living donors. Data on demographic variables, surgical results, graft survival, functional outcomes (creatinine and estimated glomerular filtration rate [eGFR]) on postoperative days 7 and 30 and at 1 year, and late complications were extracted from the common database. A total of 147 RAKTs were performed by the ERUS RAKT working group. Of the 147 patients, 83 had at least 1-year follow-up (mean [range] 21 [13-27] months). Of these 83 patients, 30 were women. The patients' median (range) age was 43 (30-75) years, body mass index was 25.3 (20-40) kg/m2 , pre-transplantation serum creatinine was 517 (198-1 414) μmol/L and estimated GFR (eGFR) was 10 (3-29) mL/min per 1.73 m2 . Of the 83 cases, 46 were pre-emptive. The median (range) overall ischaemia time was 116 (53-377) min. The median (range) rewarming time was 60 (35-110) min. At 1-year follow-up, the median (range) serum creatinine was 131 (66-244) μmol/L, with a median (range) eGFR of 57.4 (28-97) mL/min per 1.73 m2 . There was no statistically significant difference between functional data at postoperative day 30 and those at 1 year for creatinine (P = 0.78) or eGFR (P = 0.91). Regarding the correlation between the surgical data and the functional outcomes, the data showed that overall operating time and rewarming time did not affect the graft function at 1 year. Three cases of graft loss occurred as a result of massive arterial thrombosis within the first postoperative week. Late complications comprised one case of ureteric stenosis and one case of graft pyelonephritis. No late vascular complications or cases of incisional hernia were recorded. Findings at 1-year follow-up indicate RAKT from a living donor to be a safe procedure in a properly selected group of recipients. RAKT was associated with a low complication rate and there was maintenance of excellent graft survival and function. This is the first and largest study to report functional results after RAKT from a living donor with a minimum follow-up of 1 year.

FR-22 FROM "END OF UROLOGY" TO ENDOUROLOGY: UROLOGIC LEGACY OF THE THE MINNEAPOLIS VA

You have accessJournal of UrologyHistory Forum1 Apr 2018FR-22 FROM "END OF UROLOGY" TO ENDOUROLOGY: UROLOGIC LEGACY OF THE THE MINNEAPOLIS VA Giulia Lane, Maria Uloko, Vikram Narayan, and Cesar Ercole Giulia LaneGiulia Lane More articles by this author , Maria UlokoMaria Uloko More articles by this author , Vikram NarayanVikram Narayan More articles by this author , and Cesar ErcoleCesar Ercole More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.3042AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Minneapolis VA Section of Urology has contributed to Urologic research and trained leaders in Urology since its affiliation with the University of Minnesota in 1946. It is the birthplace to the Gleason score, the Fuhrman grading system and Endourology. Herein we recount the Urologic contributions of the Minneapolis VAMC. METHODS A review of Urologic literature from the Minneapolis VAMC from 1946 to present. RESULTS Researchers at the Minneapolis VAMC helped shaped early innovations in Urologic Oncology. The VA Cooperative Urologic Research Group (VACURG) was developed by Dr. George Mellinger, Chief of Urology, in 1959. Dr. Mellinger enlisted Dr. Donald Gleason's aid in the development of a grading system for prostate cancer for the VACURG. Dr. Gleason's Grading system, first presented in 1965, has become the sole recommended grading system for prostate cancer. In the realm of renal tumors, Dr. Susan Fuhrman devised the Fuhrman Grading system in 1982 at the Minneapolis VAMC pathology department. The Fuhrman grading system gained popularity and has been found to be a prognostic factor for renal carcinoma. Dr. Paul Lange (VAMC Urology Chief 1977-86) alongside Dr. Thomas Hakala and Dr. Elwin Fraley (Chairman of Urology at the University of Minnesota 1969-93), studied the tumor markers for testicular cancer at the Minneapolis VAMC, providing evidence for the benefit of their clinical use.Dr. Fraley trained and recruited the Urologists that created the field of Endourology. In 1978, Dr. Arthur Smith and Dr. Lange published the first account of antegrade ureteral stent placement through a percutaneous nephrostomy tract, which was performed at the Minneapolis VAMC. Dr. Fraley coined the term Endo-Urology in 1979 and helped popularize the techniques through training courses in Minneapolis. Today, the Minneapolis VAMC is a lead institution for evidence based Urology through the work of Dr. Timothy Wilt and Dr. Philip Dahm. Dr. Wilt served as lead investigator in the the Prostate Cancer Intervention versus Observation Trial (PIVOT) and member of the United States Preventative Task Force (USPSTF) on prostate specific antigen. Dr. Dahm currenlty leads the the Cochrane Urology Collaborative Review Group from the Minneapolis VAMC. The VAMC also serves as a lead institution U.S. Grading Recommendations Assessment, Develop and Evaluation (GRADE) network. CONCLUSIONS The Minneapolis VA Section of Urology has produced leaders in Urology who contributed to the field of Urologic Oncology, founded the field of Endourology and continue to promote evidence based Urology. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1249 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Giulia Lane More articles by this author Maria Uloko More articles by this author Vikram Narayan More articles by this author Cesar Ercole More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

EUROPEAN SECTION OF ONCOLOGICAL UROLOGY (ESOU): NEW DATA IN 2017

EUROPEAN SECTION OF ONCOLOGICAL UROLOGY (ESOU): NEW DATA IN 2017

A Survey of the Current Practice Patterns of Contralateral Testis Fixation in Unilateral Testicular Conditions

To query the current contralateral testis fixation (CTF) practice patterns among pediatric urologists in different clinical situations that could result in monorchism. An online survey was sent to members of the Urology Section of the American Academy of Pediatrics. The survey included questions addressing CTF practice patterns in 14 clinical scenarios. Responses were anonymously submitted, blindly reviewed, and analyzed. Among 53 respondents, 62.3% had academic appointments and 73.6% had an exclusive pediatric urology practice. All participants agreed on CTF necessity in testicular torsion beyond the neonatal period. CTF was advocated by 84.9% in prenatal torsion, 96.2% in postnatal torsion, and 94.3% in delayed torsion presentation. Emergent intervention was favored by 64.4% in prenatal and 98% in postnatal torsion. Only 1 participant (1.9%) preferred CTF with a unilateral testicular tumor and 5 (9.4%) in trauma substantiating an orchiectomy. There was less consensus on CTF in torsed undescended testis (79.3% in prepubertal and 81.13% in postpubertal), testicular nubbin in a child (40.4%), palpable atrophic undescended testis (13.2%), and unilateral bell-clapper anomaly (47.2%). In situations other than torsion, lack of strong evidence was the commonest reason not to perform CTF. The majority of responding pediatric urologists currently performs CTF in neonatal torsion. Although there is a general consensus on CTF in testicular torsion outside the neonatal period, CTF remains controversial in other clinical situations, warranting further research. The decision for CTF should involve patients, parents, and treating physicians.