Search

Background: Penile implant surgery is the standard surgical treatment for end-stage erectile dysfunction. However, the growing complexity of modern high-tech penile prostheses has increased the demand for more practical training opportunities. The most advanced contemporary training methods involve simulation training using cadavers, with costs exceeding $5,000 per cadaver, inclusive of biohazard fees. This study introduces an innovative and cost-efficient male urogenital simulator designed to enhance penile implant surgery training. Methods: Utilizing image segmentation of patient pre-operative computed tomography (CT) scans, combined with three-dimensional (3D) printing and silicone molding techniques, we developed a high-fidelity simulator replicating the anatomical structures of the male urogenital system. The simulator incorporates an innovative double-layer structural design encompassing the corpus spongiosum and glans, corpora cavernosa, testes, epididymides, and pelvic bones. Additionally, it utilizes a two-stage skin manufacturing process tailored for different skin regions. The simulator was produced at a low material cost of £10, with an average production time of 3 h. To evaluate its training efficacy, we conducted a penile implant surgery training session involving 15 urology trainees and surgeons ranging from specialty training levels ST3 to ST6. The session began with a demonstration of penile implant surgery and error detection. Trainees, averaging three per simulator, practiced corporotomy, dilation, measurement, penile prosthesis, and scrotal pump placement under expert guidance. Participants' feedback was collected using a Likert scale questionnaire, assessing learning, satisfaction, and anatomical accuracy. Results: Quantitative analysis of the questionnaire responses indicated highly positive feedback from the participants. Satisfaction rates surpassed 96% in learning effectiveness, over 89% in overall satisfaction, and 86% in anatomical accuracy demonstration. The simulator was favourably reviewed by both urology trainees and experienced surgeons, highlighting its utility as a practical training tool. Its low production cost and high precision make it a viable alternative to current training models. Conclusions: The development of this cost-efficient, anatomically accurate urogenital simulator through advanced imaging and additive manufacturing techniques represents a significant advancement in penile implant surgical training. This state-of-the-art simulator not only provides a realistic and practical training experience but also underscores the potential for 3D printing technologies to revolutionize medical education and training. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) has emerged as a transformative tool in surgery, particularly in telesurgery and telementoring. However, its potential to enhance data transmission efficiency and reliability in these fields remains unclear. While previous reviews have explored the general applications of telesurgery and telementoring in specific surgical contexts, this review uniquely focuses on AI models designed to optimise data transmission and mitigate delays. We conducted a comprehensive literature search on PubMed and IEEE Xplore for studies published in English between 2010 and 2023, focusing on AI-driven, surgery-related, telemedicine, and delay-related research. This review includes methodologies from journals, conferences, and symposiums. Our analysis identified a total of twelve AI studies that focus on optimising network resources, enhancing edge computing, and developing delay-robust predictive applications. Specifically, three studies addressed wireless network resource optimisation, two proposed low-latency control and transfer learning algorithms for edge computing, and seven developed delay-robust applications, five of which focused on motion data, with the remaining two addressing visual and haptic data. These advancements lay the foundation for a truly holistic and context-aware telesurgical experience, significantly transforming remote surgical practice and education. By mapping the current role of AI in addressing delay-related challenges, this review highlights the pressing need for collaborative research to drive the evolution of telesurgery and telementoring in modern robotic surgery. [ABSTRACT FROM AUTHOR]

Aims: To assess the outcomes of robotic surgery for patients with neurogenic lower urinary tract dysfunctions (NLUTD). Materials and methods: Studies evaluating the outcomes (efficacy and safety) of robot-assisted ileal conduit creation or artificial urinary sphincter (R-AUS) implantation or augmentation cystoplasty or continent urinary diversion creation in patients with NLUTD were included. The search strategy and studies selection were performed on Medline, Embase and Cochrane using the PICOS method according to the PRISMA statement (PROSPERO 2022 CRD42022333157). The comparator, if available, was the use of open or laparoscopic technique. Meta-analysis was performed whenever possible. The remaining articles were synthesized narratively. Results: Eight articles were included. Five described the outcomes of robot-assisted cystectomy with ileal conduit creation, two described the outcomes of augmentation cystoplasty and continent urinary diversion creation and one described R-AUS implantation in patients with NLUTD. The risk of bias was high. Three articles comparing the outcomes of robotic and open cystectomy and ileal conduit creation were suitable for meta-analysis. According to our meta-analysis, robot-assisted surgery had better outcomes compared to open surgery in terms of high-grade early postoperative complications (OR 0.39; 0.19–0.79; p = 0.01), days to bowel recovery (Cohen’s D = − 0.62 ± 0.14, p < 0.001), length of hospitalisation (Cohen’s D = − 0.28 ± 0.13; p = 0.03) and estimated blood loss (Cohen’s D = − 1.17 ± 0.14, p < 0.001).Regarding AUS implantation, augmentation cystoplasty and continent urinary diversion creation, the outcomes from the articles included in our systematic review showed a 16–40% overall early complication rate in case of augmentation cystoplasty and 22% in case of AUS implantation. Conclusions: Robot-assisted surgery may have several advantages over open surgery in the treatment of NLUTDs. However, current evidence is insufficient to draw firm conclusions. Further high-quality studies are needed to better understand the role of robotic surgery in the treatment of NLUTD. [ABSTRACT FROM AUTHOR]

The use of 3-dimensional (3D) technology has become increasingly popular across different surgical specialities to improve surgical outcomes. 3D technology has the potential to be applied to robotic assisted radical prostatectomy to visualise the patient's prostate anatomy to be used as a preoperative and peri operative surgical guide. This literature review aims to analyse all relevant pre-existing research on this topic. Following PRISMA guidelines, a search was carried out on PubMed, Medline, and Scopus. A total of seven studies were included in this literature review; two of which used printed-3D models and the remaining five using virtual augmented reality (AR) 3D models. Results displayed variation with select studies presenting that the use of 3D models enhances surgical outcomes and reduces complications whilst others displayed conflicting evidence. The use of 3D modelling within surgery has potential to improve various areas. This includes the potential surgical outcomes, including complication rates, due to improved planning and education. [ABSTRACT FROM AUTHOR]

Purpose: The effect of overactive bladder (OAB) on sexual health has been evaluated extensively for women but much less for men. Therefore, the aim of this study was to evaluate the relationship between OAB and men's sexual activity and the effect of OAB on erectile dysfunction (ED) and premature ejaculation (PE) in a large representative cohort of men at the population level. Methods: This study was based on computer-assisted web interviews that used validated questionnaires. The most recent census and the sample size estimation calculations were employed to produce a population-representative pool. Results: The study included 3001 men, representative of the population in terms of age and place of residence. The frequency of sexual intercourse was higher for respondents without OAB symptoms compared with persons who had OAB (p = 0.001), but there was no association between OAB symptoms and number of sexual partners (p = 0.754). Regression models did not confirm the effect of OAB on sexual activity (odds ratio 0.993, CI 0.974-1.013, p = 0.511). Both ED and PE were more prevalent in respondents with OAB symptoms compared with persons who lacked those symptoms (p < 0.001). Importantly, the effect of OAB on ED or PE was independent of age, comorbidities, and lifestyle habits (regression coefficients of 0.13 and 0.158 for ED and PE, respectively). Conclusion: Overactive bladder did not significantly affect men's sexual activity, but it significantly correlated with ED and PE. Our results suggest a need in daily clinical practice to screen for OAB symptoms for persons who report ED or PE. [ABSTRACT FROM AUTHOR]

Urinary tract infection (UTI) is a common condition defined as the presence of bacteria within the urine above a certain threshold (usually >100,000 m/L). The lifetime risk in women is estimated to be 50%, of whom 25% will develop recurrence within 6 months. Unfortunately, the use of antibiotics to treat and manage recurrent UTI (rUTI) is a growing problem, due to the burden of growing antibiotic resistance on public health. As such, new approaches to manage rUTI are being investigated and developed. Competitive inoculation via instillation of Escherichia coli 83972 or HU2117 in the bladder is a new prophylactic non-antimicrobial therapy for rUTIs. It utilizes the principle of the protective nature of asymptomatic bacteriuria to prevent recurrence of symptomatic UTIs. However, the effectiveness and safety of this technique remains unclear. This systematic review examined the current outcomes data on competitive inoculation as an effective and safe treatment for rUTI prophylaxis. Based on a limited number of studies, current evidence suggests that competitive inoculation is an effective and safe prophylactic measure against UTIs in a select group of patients with incomplete bladder emptying. However, administration of the technology is both resource and time intensive, and there is strong data demonstrating low successful colonisation rates. Competitive inoculation is an alternative to antibiotics only to rUTI patients with incomplete bladder emptying. There is no evidence to suggest that the technology would be suitable for other subsets of rUTI patients. Further randomized controlled trials should be conducted to improve the evidence base before drawing conclusions for clinical practice, and ideas to improve colonisation rates and simplify the administration process should be explored. [ABSTRACT FROM AUTHOR]

Purpose: The right gastric artery (RGA) supplies the lesser curvature of the stomach. The prevalence of variations in RGA origins can be of interests to students, surgeons, and radiologists who wish to increase their understanding of this vessel. The aim of this study was to perform a systematic review and meta-analysis on the origin of the RGA. Methods: The PRISMA 2020 checklist was followed. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. There were no constraints based on language or publication status. Database search, data extraction and risk of bias assessment were performed independently by two authors. A random-effects meta-analysis of the prevalence of different RGA origins was conducted. Results: A total of 9084 records were screened in the initial search. Fifteen studies were included, assessing 1971 right gastric arteries. The RGA arose most frequently from the Proper Hepatic Artery (PHA), with a pooled prevalence of 53.6% (95% CI 44.5–60.8%), followed by the Left Hepatic Artery (LHA) with a pooled prevalence of 25.9% (95% CI 18.6–32.8%), and the Gastroduodenal Artery (GDA) with a pooled prevalence of 8.89% (95% CI 4.62–13.9%). Less common origins were the Common Hepatic Artery (CHA) (6.86%, 95% CI 3.15–11.5%), the Right Hepatic Artery (RHA) (3.43%, 95% CI 0.93–7.04%), and Middle Hepatic Artery (MHA) (1.31%, 95% CI 0–3.44%). Conclusions: This meta-analysis provides an accurate estimate of the prevalence of different RGA origins. Anatomical knowledge combined with pre-operative planning and imaging can prevent iatrogenic injury during surgery. [ABSTRACT FROM AUTHOR]

Introduction: Sacral neuromodulation (SNM) is a treatment approved for use in several conditions including refractory overactive bladder (OAB) and voiding dysfunction. Chronic pelvic pain (CPP) is a debilitating condition for which treatment is often challenging. SNM shows promising effect in patients with refractory CPP. However, there is a lack of clear evidence, especially in long‐term outcomes. This systematic review will assess outcomes of SNM for treating CPP. Methods: A systematic search of MEDLINE, Embase, Cochrane Central and clinical trial databases was completed from database inception until January 14, 2022. Studies using original data investigating SNM in an adult population with CPP which recorded pre and posttreatment pain scores were selected. Primary outcome was numerical change in pain score. Secondary outcomes were quality of life assessment and change in medication use and all‐time complications of SNM. Risk of bias was assessed using the Newcastle Ottawa Tool for cohort studies. Results: Twenty‐six of 1026 identified articles were selected evaluating 853 patients with CPP. The implantation rate after test‐phase success was 64.3%. Significant improvement of pain scores was reported in 13 studies; three studies reported no significant change. WMD in pain scores on a 10‐point scale was −4.64 (95% confidence interval [CI] = −5.32 to −3.95, p < 0.00001) across 20 studies which were quantitatively synthesized: effects were maintained at long‐term follow‐up. Mean follow‐up was 42.5 months (0–59). Quality of life was measured by RAND SF‐36 and EQ‐5D questionnaires and all studies reported improvement in quality of life. One hundred and eighty‐nine complications were reported in 1555 patients (Clavien‐Dindo Grade I‐IIIb). Risk of bias ranged from low to high risk. Studies were case series and bias stemmed from selection bias and loss to follow‐up. Conclusion: Sacral Neuromodulation is a reasonably effective treatment of Chronic Pelvic Pain and significantly reduces pain and increases patients' quality of life with immediate to long‐term effects. [ABSTRACT FROM AUTHOR]

The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were 'robotic assisted', 'ureteric reimplantation', 'cystoplasty', 'ileal conduit', 'neobladder', 'sacrocolpopexy', 'colposuspension', 'artificial urinary sphincter', 'genitourinary fistula' and 'posterior urethral stenoses'. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the longterm efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training. [ABSTRACT FROM AUTHOR]

Purpose: Urinary incontinence remains common in men after prostatectomy. Current guidance suggests early corrective surgery to those that are still incontinent after trying Pelvic Floor Muscle Therapy, however, other treatments are now available. This review aims to evaluate all currently available treatment options for men with post-prostatectomy incontinence (PPI). Methods: A search of MEDLINE and CENTRAL databases on 2/2/2021 produced 879 articles. Any study evaluating incontinence before and after a treatment protocol was eligible for inclusion. After screening, 17 randomized control trials were included, and pre-defined data points were collected. Due to heterogeneity, pooled analysis was not possible, and a descriptive synthesis was produced in accordance with PRISMA guidelines. Cochrane Risk of Bias (RoB) tool was used to evaluate all studies. The search protocol and methods for this study was registered on the PROSPERO database before the search began, ID:(CRD42021229749). Results: 3/17(18%) of studies focussed on pharmacotherapy, 2/17(12%) on vibration therapies, 8/17(47%) on pelvic floor muscle therapy (PFMT), 3/17(18%) on electrical stimulation (ES), and 1/17 (6%) on extracorporeal magnetic innervation (ExMI) as their main intervention. The use of Duloxetine, Solifenacin, PFMT, ES, and ExMI all show effective reduction in incontinence in men suffering from PPI. No study in this review evaluated surgical managements for PPI. Conclusion: A large number of treatments are available for PPI using an array of different methods. For this reason, a variety of treatments could be considered before early invasive procedures, to prevent unnecessary surgery and its associated negative complications. [ABSTRACT FROM AUTHOR]

The purpose of this review was to summarize and compare the efficacy among surgical interventions in terms of symptomatic relief in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). The review protocol was published on PROSPERO. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) 2020 checklist was followed. Following database search, a narrative synthesis was performed. Data pertaining symptom scores, pain levels, and voiding frequency following surgery were summarized by calculating percentage change in these parameters. Multiple surgical treatments were identified. These included injections of hyaluronic acid (HA), botulinum toxin A (Botox A), triamcinolone, resiniferatoxin (RTX), platelet‐rich plasma, and 50% dimethyl sulfoxide (DMSO) solution, neuromodulation, hydrodistension (HD), resection/fulguration of Hunner lesions, resection of ilioinguinal and iliohypogastric nerves, reconstructive surgery, and cystectomy. This review found no evidence suggesting that HD and RTX injections can ameliorate IC/BPS symptoms. Current evidence suggests that sacral neuromodulation, cystectomy, and transurethral resection/fulguration of Hunner lesions could lead to symptomatic relief in IC/BPS. Further research into the efficacy of Botox A, triamcinolone, 50% DMSO solution, and HA instillations is required. However, the best treatment options cannot be reliably stated due to the low level of evidence of the studies identified. Further research should report outcomes for Hunner‐type IC and BPS separately given their differing histopathological characteristics. Performing high‐quality randomized controlled trials could be hindered by the low prevalence of the condition and a small proportion of patients progressing to surgery. [ABSTRACT FROM AUTHOR]

Background: Virtual reality (VR) training is widely used for surgical training, supported by comprehensive, high-quality validation. Technological advances have enabled the development of procedural-based VR training. This study assesses the effectiveness of procedural VR compared to basic skills VR in minimally invasive surgery. Methods: 26 novice participants were randomised to either procedural VR (n = 13) or basic VR simulation (n = 13). Both cohorts completed a structured training programme. Simulator metric data were used to plot learning curves. All participants then performed parts of a robotic radical prostatectomy (RARP) on a fresh frozen cadaver. Performances were compared against a cohort of 9 control participants without any training experience. Performances were video recorded and assessed blindly using GEARS post hoc. Results: Learning curve analysis demonstrated improvements in technical skill for both training modalities although procedural training was associated with greater training effects. Any VR training resulted in significantly higher GEARS scores than no training (GEARS score 11.3 ± 0.58 vs. 8.8 ± 2.9, p = 0.002). Procedural VR training was found to be more effective than both basic VR training and no training (GEARS 11.9 ± 2.9 vs. 10.7 ± 2.8 vs. 8.8 ± 1.4, respectively, p = 0.03). Conclusions: This trial has shown that a structured programme of procedural VR simulation is effective for robotic training with technical skills successfully transferred to a clinical task in cadavers. Further work to evaluate the role of procedural-based VR for more advanced surgical skills training is required. [ABSTRACT FROM AUTHOR]

Objective: Different simulation modalities may be utilised in a curricular fashion to benefit from the strengths of each training model. The aim of this study is to evaluate a novel multi-modality ureterorenoscopy (URS) simulation curriculum in terms of educational value, content validity, transfer of skills and inter-rater reliability. Methods: This international prospective study recruited urology residents (n = 46) with ≤ 10 URS experience and no prior simulation training. Participants were guided through each phase of the expert-developed SIMULATE URS curriculum by trainers and followed-up in the operating room (OR). Video recordings were obtained during training. A post-training evaluation survey was distributed to evaluate content validity and educational value, using descriptive statistics. Performance was evaluated using the objective structured assessment of technical skills (OSATS) scale to measure improvement in scores throughout the curriculum. Pearson's correlation coefficient and Cohen's kappa tests were utilised to investigate correlation and agreement between raters. Results: Participants reported gaining OR-transferrable skills (Mean: 4.33 ± 0.67) and demonstrated marked improvement in throughout the curriculum, transferred to the OR for both semi-rigid URS (p = 0.004) and flexible URS (p = 0.007). 70% of participants were successfully followed-up in the OR (n = 32). No differences were identified with the additional use of fresh frozen cadavers (p = 0.85, p = 0.90) and the URO Mentor VR simulator (p = 0.13, p = 0.22). A moderate level of correlation was noted on the video OSATS assessments, between two expert assessors (r = 0.70), but a poor agreement with the live rating. Conclusion: The SIMULATE URS training curriculum received high educational value from participants, who demonstrated statistically significant improvement with consecutive cases throughout the curriculum and transferability of skills to the OR in both semi-rigid and flexible URS. [ABSTRACT FROM AUTHOR]

To assess the role of live porcine simulation in robotic surgical skills training. A qualitative and quantitative survey was conducted of participants of a live porcine robotic simulation course undertaken in a regional training centre. Data on participants' experience, robotic surgical ability, the educational impact and outcomes from the course were collected. Thirty-nine participants from four different countries completed the survey. Clinical experience varied; however, prior robotic surgical experience (median 0 cases, range 0–100) and technical ability were low. The perceived usefulness, effectiveness and realism of the training course were all highly scored. Participants rated the most useful course components as port placement and docking, basic robotic skills training and repair of a bladder injury. Training resulted in significant increases in technical ability (p < 0.0001). Following the course, 49% of participants continued to either train or perform robotic surgery. This survey demonstrates that live porcine simulation for robotic surgery is a highly valued, acceptable and feasible form of training. The majority of participants were relatively inexperienced but nonetheless significant improvements in technical ability were reported. The results of this survey support the use of live porcine training for robotic surgery. [ABSTRACT FROM AUTHOR]

Objective: In the last decade non-technical skills (NTS) have emerged as a vital area for improvement within surgery. This study aims to develop and evaluate a Non-technical Skills for Urological Surgeons (NoTSUS) training curriculum and assessment scale. Methods: This international, longitudinal and observational study began with a 3-round Delphi methodology to refine curriculum contents and rating scale. Sessions with up to four participants were delivered where each candidate undertook an independent scenario within the validated full immersion simulation environment. Candidates were assessed using both the NoTSS (Non-technical Skills for Surgeons) and NoTSUS rating scales by NTS-trained and non-trained experts. A post-training evaluation survey was distributed. Results: 62 participants comprising trainees (n = 43) and specialists (n = 19) undertook the NoTSUS course. The NoTSS and NoTSUS scales correlated well, with a mean difference of 3.3 in the overall total (p = 0.10, r = 0.53). However, there was significant differences in scores between the NoTSS-trained and non-trained raters (n = 28, p = 0.03). A one-way ANOVA test revealed significant improvement throughout the four simulation scenarios in each session (p = 0.02). The NoTSUS curriculum received positive feedback from participants and demonstrated educational value and acceptability. Conclusions: The NoTSUS curriculum has demonstrated high educational value for NTS training aimed at urologists, with marked improvement throughout sessions. Correlation of NoTSUS and NoTSS scales proves its suitability for evaluating NTS in future training. Demonstration of inter-rater reliability indicates that the scale is reliable for use in assessment by expert faculty members. Furthermore, qualitative feedback from participants suggests gain of transferrable skills over the course. [ABSTRACT FROM AUTHOR]

Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of.39 (95% CI:.12,.67, P =.005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills. [ABSTRACT FROM AUTHOR]

Objectives: To develop a wet laboratory training model for learning core laparoscopic surgical skills and evaluating learners' competency level outside the operating room. Methods: Participants completed three tasks (task 1: tissue dissection around the aorta; task 2: tissue dissection and division of the renal artery; task 3: renal parenchymal closure). Each performance was video recorded and subsequently evaluated by two experts, according to the Global Operative Assessment of Laparoscopic Skills and task‐specific metrics that we developed (Assessment Sheet of Laparoscopic Skills in Wet Lab score). Mean scores were used for analyses. The subjective mental workload was also assessed (NASA Task Load Index). Results: The 54 participants included 32 urologists, eight young trainees and 14 medical students. A total of 13 participants were categorized as experts (≥50 laparoscopic surgeries), eight as intermediates (10–49) and 33 as novices (0–9). There were significant differences in the Global Operative Assessment of Laparoscopic Skills and Assessment Sheet of Laparoscopic Skills in Wet Lab scores among the three groups in all three tasks. Higher NASA Task Load Index scores were observed in novices, and there were significant differences in tasks 1 (Kruskal–Wallis test, P = 0.0004) and 2 (P = 0.0002), and marginal differences in task 3 (P = 0.0745) among the three groups. Conclusions: Our training model has good construct validity, and differences in the NASA Task Load Index score reflect previous laparoscopic surgical experiences. Our findings show the ability to assess both laparoscopic surgical skills and mental workloads, which could help educators comprehend trainees' level outside the operating room. Given the decreasing opportunity to carry out pure laparoscopic surgeries because of the dissemination of robotic surgery, especially in urology, our model can offer practical training opportunities. [ABSTRACT FROM AUTHOR]

Background: Radical orchidectomy in patients who are subsequently diagnosed with benign testicular tumours represents an overtreatment due to the deleterious effects on endogenous testosterone, fertility and body image. For these reasons, the option of partial orchidectomy (PO) should be considered in certain groups of patients. Patients with bilateral tumours (synchronous or metachronous) or a solitary testis where the lesion is no greater than 30% of the volume of the testis could be considered for a PO. Evidence has shown that PO is effective for small testicular masses with excellent survival and recurrence rates. Objectives: Highlight the feasibility of maintaining post‐operative fertility or normal semen parameters and endocrine function following PO. Materials and Methods: Data for this review were obtained through a search of the PubMed database. Papers were required to be in English and focus on adult human males. Results: Eligible and relevant papers were assessed for data regarding fertility, semen parameters and endocrine function following PO for a small testicular mass (STM). Conclusion: It is possible to preserve both fertility and endocrine function after PO. Although patients may still require adjuvant radiotherapy for concomitant intratubular germ cell neoplasia (ITGCN) which results in subfertility, endocrine function is still conserved. However, it is possible to postpone radiotherapy and continue with clinical surveillance for the purposes of fertility preservation. [ABSTRACT FROM AUTHOR]

Purpose: With non-technical skills (NTS) deficits being recognised as a major cause for error in surgery, there is an increasing interest in their training and evaluation. A growing number of training courses are emerging and some NTS curricula have also been created. Many different training methods are described in the literature but there is still uncertainty with regards to their optimum combination within a curriculum. Methods: A literature review of the electronic database Medline was performed. All articles published before December 2018 were screened by abstract and included if deemed relevant by the author. The included articles' reference lists were also screened for further relevant studies. Results: Simulation training is accepted as the most effective way to train NTS. Within simulation training, it is shown that the 'igloo' full immersion/distributed simulation environment is appropriate for teaching NTS in urological scenarios where a designated operating room or space is not available. The use of multiple settings, for example wards and clinics as well as the operating room, is advantageous, as is training in an interprofessional team. Classroom teaching also plays a role in NTS training as an adjunct to simulation, with evidence that it improves some parameters of NTS. All levels, including qualified surgeons, benefit from NTS training; however, adaptation to both trainee level and specialty is important. Although less time consuming, training juniors and seniors together mainly benefits juniors, and training NTS at the same time as technical skills detracts from the quality of teaching. Debriefing is an important part of training and should be well structured; there are many debriefing models in existence, allowing for choice of method based on examiner preference and participant demographic. Furthermore, examiners should be well briefed in their task and trained in NTS assessment. Conclusion: To move forward, studies should combine tried and tested learning techniques into a curriculum covering all training levels, which should then be validated and followed up long term to ensure a positive impact on patient safety. [ABSTRACT FROM AUTHOR]

Background: Virtual reality (VR) and dry-lab simulation have been widely validated for robotic surgical training. Both modalities are used during the early stages of the learning curve, yet, no comparative analysis of the two modalities has been undertaken. This study compares the effectiveness of VR and dry-lab simulation for basic robotic surgical skill training. Methods: A comparative study of 43 robotic novices was undertaken at two centers in the United Kingdom and Italy. Participants were allocated to either VR or dry-lab simulation and completed a robotic simulation training program. On completion, all participants were assessed by performing a urethrovesical anastomosis on a synthetic model. Technical proficiency was measured by two trained raters using the Global Evaluative Assessment of Robotic Skills (GEARS) tool. All participants completed a qualitative posttraining assessment questionnaire. Results: Baseline characteristics were equal between the two groups. Both VR and dry-lab training led to a significant improvement in technical proficiency. Overall mean GEARS scores increased by 5.6 and 2.5 following dry-lab and VR simulation training, respectively (p = 0.034). Dry-lab training showed significantly greater improvements than VR simulation, but only after the third training session. Both techniques were highly rated by participants. Conclusions: Both VR and dry-lab simulation were effective in improving robotic surgical skill but were not equal. For more advanced skill training, dry-lab training was found to be superior to VR simulation. Dry-lab training offers specific benefits to robotic surgical training and should remain a principal component of the simulation curriculum. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effectiveness of motor imagery (MI) for technical skill and non‐technical skill (NTS) training in minimally invasive surgery (MIS). Subjects and Methods: A single‐blind, parallel‐group randomised controlled trial was conducted at the Vattikuti Institute of Robotic Surgery, King's College London. Novice surgeons were recruited by open invitation in 2015. After basic robotic skills training, participants underwent simple randomisation to either MI training or standard training. All participants completed a robotic urethrovesical anastomosis task within a simulated operating room. In addition to the technical task, participants were required to manage three scripted NTS scenarios. Assessment was performed by five blinded expert surgeons and a NTS expert using validated tools for evaluating technical skills [Global Evaluative Assessment of Robotic Skills (GEARS)] and NTS [Non‐Technical Skills for Surgeons (NOTSS)]. Quality of MI was assessed using a revised Movement Imagery Questionnaire (MIQ). Results: In all, 33 participants underwent MI training and 29 underwent standard training. Interrater reliability was high, Krippendorff's α = 0.85. After MI training, the mean (sd) GEARS score was significantly higher than after standard training, at 13.1 (3.25) vs 11.4 (2.97) (P = 0.03). There was no difference in mean NOTSS scores, at 25.8 vs 26.4 (P = 0.77). MI training was successful with significantly higher imagery scores than standard training (mean MIQ score 5.1 vs 4.5, P = 0.04). Conclusions: Motor imagery is an effective training tool for improving technical skill in MIS even in novice participants. No beneficial effect for NTS was found. [ABSTRACT FROM AUTHOR]

Background: Ureteropelvic junction obstruction (UPJO) is characterised by an obstruction compromising the passage of urine from the renal pelvis into the ureter, and can be corrected by Robot-Assisted Laparoscopic Pyeloplasty (RALP). We aimed to evaluate the surgical outcomes of RALP, and examine the rates of true pain resolution following the procedure.Methods: We retrospectively explored the records of all patients who underwent RALP between April 2005 and January 2017. Measures of success were defined as the prevention of deterioration in split renal function and resolution of obstruction, and the resolution or improvement in subjective pain levels.Results: 83 patients were included in this series. Mean patient age was 40.8 years. 38 patients had a left sided RALP, whilst 45 underwent RALP on the right. Crossing vessels were identified in 53.0% of patients. Mean operative time was 148.0 min. 68 patients had pain as their presenting feature. Following RALP, the pain resolved in 69.2% (n = 47), improved in 26.5% (n = 18), and remained the same in 4.4% (n = 3). 11.8% (n = 8) of patients required referral to other specialities for pain management. Success from a radiological perspective of cleared obstruction and arrest of deteriorating renal function was 97.6%.Conclusions: Our individual outcomes demonstrate a high success rate regarding resolution of obstruction and preventing deterioration in renal function. We also report that a number of patients, who despite meeting the radiological criteria to undergo RALP, had alternate underlying causes for their pain symptoms. For this reason, we propose that the primary measure of success for RALP should be based on renal function and radiological outcomes, rather than the outcomes relating to pain. Both surgeons and patients should be aware that whilst RALP is a highly successful procedure, persistence of pain may be due to overlapping clinical conditions which can be managed by a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Background: With the increased use of simulation for surgical training, there is a need for objective forms of assessment to evaluate trainees. The Global Evaluative Assessment of Robotic Skills (GEARS) is widely used for assessing skills in robotic surgery, but there are no recognised checklist scoring systems. This study aimed to develop a checklist for suturing in robotic surgery.Methods: A suturing checklist for needle driving and knot tying was constructed following evaluation of participants performing urethrovesical anastomoses. Key procedural steps were identified from expert videos, while assessing novice videos allowed identification of common technical errors. 22 novice and 13 expert videos were marked on needle driving, while 18 novices and 10 experts were assessed on knot tying. Validation of the finalised checklist was performed with the assessment of 39 separate novices by an expert surgeon and compared to GEARS scoring.Results: The internal consistency of the preliminary checklist was high (Cronbach's alpha = 0.870 for needle driving items; 0.736 for knot tying items), and after removal of poorly correlating items, the final checklist contained 23 steps. Both the needle driving and knot tying categories discriminated between novices and experts, p < 0.005. While the GEARS score demonstrated construct validity for needle driving, it could not significantly differentiate between novices and experts for knot tying, p = 0.286. The needle driving category significantly correlated with the corresponding GEARS scores (rs = 0.613, p < 0.005), but the correlation for knot tying was insignificant (rs = 0.296, p = 0.127). The pilot data indicates the checklist significantly correlated with the GEARS score (p < 0.005).Conclusion: This study reports the development of a valid assessment tool for suturing in robotic surgery. Given that checklists are simple to use, there is significant scope for this checklist to be used in surgical training. [ABSTRACT FROM AUTHOR]

Background: To establish objective benchmarks at the level of a competent robotic surgeon across different exercises and metrics for the RobotiX Mentor virtual reality (VR) simulator suitable for use within a robotic surgical training curriculum.Methods: This retrospective observational study analysed results from multiple data sources, all of which used the RobotiX Mentor VR simulator. 123 participants with varying experience from novice to expert completed the exercises. Competency was established as the 25th centile of the mean advanced intermediate score. Three basic skill exercises and two advanced skill exercises were used.Setting: King's College London.Participants: 84 Novice, 26 beginner intermediates, 9 advanced intermediates and 4 experts were used in this retrospective observational study.Results: Objective benchmarks derived from the 25th centile of the mean scores of the advanced intermediates provided suitably challenging yet also achievable targets for training surgeons. The disparity in scores was greatest for the advanced exercises. Novice surgeons are able to achieve the benchmarks across all exercises in the majority of metrics.Conclusion: We have successfully created this proof-of-concept study, which requires validation in a larger cohort. Objective benchmarks obtained from the 25th centile of the mean scores of advanced intermediates provide clinically relevant benchmarks at the standard of a competent robotic surgeon that are challenging yet also attainable. That can be used within a VR training curriculum allowing participants to track and monitor their progress in a structured and progressional manner through five exercises. Providing clearly defined targets, ensuring that a universal training standard has been achieved across training surgeons. [ABSTRACT FROM AUTHOR]

We aimed to assess male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition in heterosexual and homosexual men using all available data. A systematic literature review was conducted searching for studies that assessed male circumcision as a method to prevent HIV acquisition in homosexual and/or heterosexual men. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov were searched in March 2017. A random effects model was used to calculate a pooled risk ratio (RR) and its associated 95% confidence interval (CI). In total, 49 studies were included in this meta‐analysis. The overall pooled RR for both homosexual and heterosexual men was 0.58 (95% CI 0.48–0.70), suggesting that circumcision was associated with a reduction in HIV risk. Circumcision was found to be protective for both homosexual and heterosexual men (RR: 0.80, 95% CI 0.69–0.92 and 0.28, 95% CI 0.14–0.59, respectively). Heterosexual men had a greater RR reduction (72% compared with 20% for homosexual men). There was significant heterogeneity among the studies (χ2 = 1378.34, df = 48; I2 = 97%). This meta‐analysis shows that male circumcision was effective in reducing HIV risk for both heterosexual and homosexual men. [ABSTRACT FROM AUTHOR]

Background: Non-technical skills (NTS) are being increasingly recognised as vital for safe surgical practice. Numerous NTS rating systems have been developed to support effective training and assessment. Yet despite the additional challenges posed by robotic surgery, no NTS rating systems have been developed for this unique surgical environment. This study reports the development and validation of the first NTS behavioural rating system for robotic surgery.Methods: A comprehensive index of all relevant NTS behaviours in robotic surgery was developed through observation of robotic theatre and interviews with robotic surgeons. Using a Delphi methodology, a panel of 16 expert surgeons was consulted to identify behaviours important to NTS assessment. These behaviours were organised into an appropriate assessment template. Experts were consulted on the feasibility, applicability and educational impact of ICARS. An observational trial was used to validate ICARS. 73 novice, intermediate and expert robotic surgeons completed a urethrovesical anastomosis within a simulated operating room. NTS were tested using four scripted scenarios of increasing difficulty. Performances were video recorded. Robotic and NTS experts assessed the videos post hoc using ICARS and the standard behavioural rating system, NOn-Technical Skills for Surgeons (NOTSS).Results: 28 key non-technical behaviours were identified by the expert panel. The finalised behavioural rating system was organised into four principle domains and seven categories. Expert opinion strongly supported its implementation. ICARS was found to be equivalent to NOTSS on Bland-Altman analysis and accurately differentiated between novice, intermediate and expert participants, p = 0.01. Moderate agreement was found between raters, Krippendorff's alpha = 0.4. The internal structure of ICARS was shown to be consistent and reliable (median Cronbach alpha = 0.92, range 0.85-0.94).Conclusion: ICARS is the first NTS behavioural rating system developed for robotic surgery. Initial validation has shown it to be an effective and reliable tool. Implementation of ICARS will supported structured training and assessment of NTS within the robotic surgical curriculum. [ABSTRACT FROM AUTHOR]

Background Pressures on surgical education from restricted working hours and increasing scrutiny of outcomes have been compounded by the development of highly technical surgical procedures requiring additional specialist training. Mental training ( MT), the act of performing motor tasks in the 'mind's eye', offers the potential for training outside the operating room. However, the technique is yet to be formally incorporated in surgical curricula. This study aims to review the available literature to determine the role of MT in surgical education. Methods EMBASE and Medline databases were searched. The primary outcome measure was surgical proficiency following training. Secondary analyses examined training duration, forms of MT and trainees level of experience. Study quality was assessed using Consolidated Standards of Reporting Trials scores or Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group. Results Fourteen trials with 618 participants met the inclusion criteria, of which 11 were randomized and three longitudinal. Ten studies found MT to be beneficial. Mental rehearsal was the most commonly used form of training. No significant correlation was found between the length of MT and outcomes. MT benefitted expert surgeons more than medical students or novice surgeons. Conclusion The majority studies demonstrate MT to be beneficial in surgical education especially amongst more experienced surgeons within a well-structured MT programme. However, overall studies were low quality, lacked sufficient methodology and suffered from small sample sizes. For these reasons, further research is required to determine optimal role of MT as a supplementary educational tool within the surgical curriculum. [ABSTRACT FROM AUTHOR]

In the pre-targeted therapy era, palliative cytoreductive nephrectomy combined with cytokine immunotherapy was the standard treatment protocol for the management of metastatic renal cell carcinoma. The introduction of targeted therapies has improved response rates, median survival and overall prognosis when compared to immunotherapy. The role of cytoreductive nephrectomy in providing an independent survival advantage when used alongside immunotherapy has been demonstrated by two randomised controlled trials. However, with the new shift in improved treatment outcomes from cytokine immunotherapy to targeted therapies, the continuing role of cytoreductive nephrectomy as a viable surgical treatment method remains controversial. [ABSTRACT FROM AUTHOR]

Objectives To develop benchmark scores of competency for use within a competency based virtual reality ( VR) robotic training curriculum. Subjects and Methods This longitudinal, observational study analysed results from nine European Association of Urology hands-on-training courses in VR simulation. In all, 223 participants ranging from novice to expert robotic surgeons completed 1565 exercises. Competency was set at 75% of the mean expert score. Benchmark scores for all general performance metrics generated by the simulator were calculated. Assessment exercises were selected by expert consensus and through learning-curve analysis. Three basic skill and two advanced skill exercises were identified. Results Benchmark scores based on expert performance offered viable targets for novice and intermediate trainees in robotic surgery. Novice participants met the competency standards for most basic skill exercises; however, advanced exercises were significantly more challenging. Intermediate participants performed better across the seven metrics but still did not achieve the benchmark standard in the more difficult exercises. Conclusion Benchmark scores derived from expert performances offer relevant and challenging scores for trainees to achieve during VR simulation training. Objective feedback allows both participants and trainers to monitor educational progress and ensures that training remains effective. Furthermore, the well-defined goals set through benchmarking offer clear targets for trainees and enable training to move to a more efficient competency based curriculum. [ABSTRACT FROM AUTHOR]

We are grateful to Petros et al. for taking an interest in our systematic review and meta-analysis and for providing interesting commentary regarding uterosacral ligament laxity (USL) as a treatable cause chronic pelvic pain (CPP). DATA AVAILABILITY STATEMENT Data sharing is not applicable - no new data is generated. CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest. [Extracted from the article]

Copyright of Turkish Journal of Urology is the property of Turkish Association of Urology and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Effective medical expulsion for ureteric stones with α-blockers offers numerous advantages over surgical alternatives. However, its effectiveness remains uncertain and with the publication of new trial data, the available evidence requires reappraisal.Objective: The aim of this study was to assess the efficacy of α-blockers the management of ureteric lithiasis.Methods: A systematic review of the literature, with predefined search criteria, was conducted using PubMed and Embase. All randomised trials comparing α-blocker monotherapy to placebo or standard therapy were included. Stone expulsion rate was the primary outcome measure. Secondary outcome measures were time to stone expulsion, analgesic usage and pain scores. Subgroup analyses assessed individual adrenergic antagonists and variations in standard therapy. Sensitivity analysis was based on stone location, stone size, Cochrane Risk of Bias score and study protocol. Summary effects were calculated using a random-effect model and presented as Relative risks (RR) and mean differences (MD) for dichotomous and continuous outcome measures, respectively.Results: Sixty-seven studies randomising 6654 patients were included in the meta-analysis. Stone expulsion rates improved with α-blockers (RR, 1.49; 95% CI 1.38-1.61). Contrast enhanced funnel showed evidence of publication bias. Stone expulsion time was 3.99 days (CI -4.75 to -3.23) shorter with α-blockers. Similarly, patients required 106.53 mg [CI -148.20 to -64.86] less diclofenac compared with control/placebo, and had 0.80 [CI -1.07 to -0.54] fewer pain episodes. Visual Analogue Scores were also reduced, -2.43 [CI -3.87 to -0.99]. All formulations of α-antagonists all demonstrated beneficial effects over conservative treatment/placebo. Sensitivity analysis demonstrated significant effects of stone location, stone size and study design.Conclusions and Relevance: Despite the opposing results of recently published trial, current evidence continues to demonstrate a potential benefit of α-blocker treatment particularly for distal stones over 5 mm. [ABSTRACT FROM AUTHOR]

Objective: Pelvic lymph node dissection (PLND) is performed alongside radical prostatectomy as the most accurate method of staging prostate cancer. Yet the potential therapeutic benefits of lymphadenectomy are yet to be confirmed. Material and methods: A PubMed database search was performed to identify all papers comparing techniques for PLND or none. The primary outcome measure was long term oncological outcomes. Studies looking at men with clinically localized prostate cancer at the time of radical prostatectomy who received no adjuvant treatment were included. Previous reviews and single case reports were excluded. The subsequent available papers were then systematically reviewed. Results: Limited PLND provides no benefit in low risk prostate cancer and is unlikely to provide a therapeutic benefit in higher risk groups either when compared with no PLND. Extended PLND may provide some therapeutic benefit, particularly in patients with occult metastases; however, the evidence base for this is not particularly strong and may be down to statistical phenomena. Conclusion: When performed in prostate cancer patients, PLND should be extended, as it is a more accurate staging tool and may provide therapeutic benefit to some patients. However, to properly assess this, randomised controlled studies need to be performed in this area. [ABSTRACT FROM AUTHOR]

Introduction: Prostate specific antigen is a marker for prostate cancer and a key diagnostic tool, yet when to refer patients with a borderline PSA is currently unclear. This review describes how to assess a patient with borderline PSA and provides an algorithm for management.Methods: Current literature on reference values, factors affecting PSA, indications for referral, non-invasive investigations and the role of MRI were reviewed. Medline and EMBASE were searched using MeSH terms.Results: The literature suggests that a PSA of over 1.5 ng/mL should be used as a cut-off to consider further testing for all age groups. There is strong evidence to show that adjuncts are useful when interpreting PSA results, most notably percentage free PSA and proPSA. Considerable weighting should also be given to the ERSPC risk calculator when deciding when to refer. Multi-parametric MRI is valuable in closely examining suspicious lesions to reduce the number of negative biopsies. MRI fusion biopsy (TRUS, transrectal ultrasonography or transperineal) should be considered over standard TRUS biopsy to detect more clinically significant disease.Conclusions: Management of borderline PSA is not straightforward. A cut-off of 1.5 ng/mL should be used in conjunction with digital rectal exam, risk calculation and PSA adjuncts. Imaging and biopsy should utilise mpMRI to achieve improved diagnosis of clinically significant prostate cancer, with fewer unnecessary investigations. [ABSTRACT FROM AUTHOR]

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumour found predominantly in the gastrointestinal tract. Comprising adenocarcinomatous and neuroendocrine components, MANEC have been reported in the bladder. We report the first case to our knowledge of a MANEC arising in the urethra. A 62-year-old woman presented with a suburethral mass. Initial excision of the mass revealed it to be a MANEC. Immunohistochemistry staining was positive for CK20 and synaptophysin associated with neuroendocrine tumours. Cross-sectional imaging ruled out metastases and the patient underwent radical urethrectomy, vaginal reconstruction and Mitrofanoff urinary diversion. The patient declined adjuvant chemotherapy and remained under regular surveillance. MANECs are uncommon tumours and treatment was therefore guided by expert opinion. A multidisciplinary approach is essential with the early involvement of surgeons, oncologists, histopathologist, radiologist and neuroendocrine specialists. [ABSTRACT FROM AUTHOR]

Objectives: To assess face, content, and construct validity of the RobotiX Mentor virtual reality simulator, to assess its acceptability as a robotic surgery training tool and feasibility of its use, and to develop a supplementary training curriculum. Subjects and Methods: This prospective, observational, and comparative study recruited novice ( n = 20), intermediate ( n = 15), and expert ( n = 11) robotic surgeons as participants from institutions across the United Kingdom and at the 30th European Association of Urology Annual Meeting. Each participant completed nine surgical tasks across two modules on the simulator, followed by a questionnaire to evaluate subjective realism (face validity), task importance (content validity), feasibility, and acceptability. Outcome measures of novice, intermediate, and expert groups were compared using Mann-Whitney U-tests to assess construct validity. Results: Construct validity was demonstrated in a total of 17/25 performance evaluation metrics ( p < 0.001). Experts performed better than intermediates with regard to time taken to complete the first ( p = 0.002) and second ( p = 0.043) module, number of instrument collisions ( p = 0.040), path length ( p = 0.049), number of cuts >2 mm deep ( p = 0.033), average distance from suture target ( p = 0.015), and number of suture breakages ( p = 0.038). Participants determined both the simulator console and psychomotor tasks as highly realistic (mean: 3.7/5) and important for surgical training (4.5/5), with system pedals (4.2/5) and knot tying task (4.6/5) scoring highest, respectively. The simulator was also rated as an acceptable (4.3/5) tool for training and its use highly feasible (4.3/5). Conclusion: Construct, face, and content validity was established for the RobotiX Mentor, and feasibility and acceptability of incorporation into surgical training were ascertained. The RobotiX Mentor shows potential as a valuable tool for training and assessment of trainees in robotic skills. Investigation of concurrent and predictive validity is necessary to complete validation, and evaluation of learning curves would provide insight into its value for training. [ABSTRACT FROM AUTHOR]

Since the first telegraphic transmission of an electrocardiogram in 1906, technological developments have allowed telemedicine to flourish. It has become a multi-billion pound industry encompassing many areas of medical practice and education. Telemedicine is now widely used in surgery from performing operations to teaching and can be divided into three main components; telesurgery, telementoring and teleconsultation. Developments across these fields have led to remarkable achievements such as intercontinental telesurgery and telementoring. However, barriers to the further implementation of telemedicine remain. In this review, the developments and recent advances of telemedicine across the three domains are discussed together with the challenges and limitations that need to be overcome. [ABSTRACT FROM AUTHOR]

Background: Acute low back pain is a common cause for presentation to the emergency department (ED). Since benign etiologies account for 95% of cases, red flags are used to identify sinister causes that require prompt management. Objectives: We assessed the effectiveness of red flag signs used in the ED to identify spinal cord and cauda equine compression. Patients and Methods: It was a retrospective cohort study of 206 patients with acute back pain admitted from the ED. The presence or absence of the red flag symptoms was assessed against evidence of spinal cord or cauda equina compression on magnetic resonance imaging (MRI). Results: Overall, 32 (15.5%) patients had compression on MRI. Profound lower limb neurologic examination did not demonstrate a statistically significant association with this finding. The likelihood ratio (LR) for bowel and bladder dysfunction (sensitivity of 0.65 and specificity of 0.73) was 2.45. Saddle sensory disturbance (sensitivity of 0.27 and specificity of 0.87) had a LR of 2.11. When both symptoms were taken together (sensitivity of 0.27 and specificity of 0.92), they gave a LR of 3.46. Conclusions: The predictive value of the two statistically significant red flags only marginally raises the clinical suspicion of spinal cord or cauda equina compression. Effective risk stratification of patients presenting to the ED with acute back pain is crucial; however, this study did not support the use of these red flags in their current form. [ABSTRACT FROM AUTHOR]

The article discusses the use of social media at conferences that helped stoke academic discussion and transformed conferences through virtual mass dissemination of information. According to Symplur.com that social networking sites such as Twitter serves as a platform for discussion and debate of conference topics and policy. It notes the social media controversy wherein the American Diabetes Association (ADA) banned delegates from tweeting photographs of slides presented at its conference.

Background: Difficult surgical procedures may result in a higher mental workload, leading to increased fatigue and subsequent errors. This study was aimed to investigate the effect of repeated simulation training in ureterorenoscopy in a high-fidelity setting on the performance and mental workload of novice operators. Methods: Medical students voluntarily participated in the present simulation study. After a didactic and video-based lecture, they underwent simulation training involving a renal stone case, including a rigid cystoscope component (task 1, performing a WHO checklist, assembling a scope, and insertion of a guide-wire and an access sheath after examining the bladder) and a flexible ureterorenoscope component (task 2, retrieving a stone located in the upper calyx using a basket after inspecting the upper, middle, and lower calyx). Training was performed in a mock operating theater. Technical skills were assessed by one author (an experienced urologist) onsite using an Objective Structured Assessment of Technical Skills (OSATS) score at each training session. The mental workload was subjectively evaluated by the National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire after each training session. Results: Seventeen students completed a minimum of 6 training sessions (male: female = 10: 7, median age of 22) over a median of 21 days (range, 10–32). In both tasks 1 and 2, the OSATS score improved over the 6 sessions with evidence of plateauing (MANOVA model, task 1: p < 0.0001, task 2: p < 0.0001). In contrast, the NASA-TLX score persistently decreased without plateauing (task 1: p = 0.0005, task 2: p = 0.0028). Conclusions: Under repeated simulation training in ureterorenoscopy in a high-fidelity setting, participants showed a continual decrease of the mental workload, while the improvement of technical skills reached a plateau over the 6 sessions. Our study showed the important benefit of simulation training to reduce the mental workload by repeated scenario training before actual clinical practice. [ABSTRACT FROM AUTHOR]

The author discuses an increase in the use of altmetrics to measure the real-time reach and influence of academic articles.

The article presents author's comments on DNA-repair defects and olaparibs related to metastatic prostate cancer. It mentions that the development of new agents has expanded the treatment options for metastatic castrate-resistant prostate cancer (mCRPC), with the impact on survival outcomes has been limited.

The authors discuss the state and potential benefits of robot-assisted radical cystectomy (RARC) for the treatment of non-metastatic muscle-invasive urothelial carcinoma of the bladder. The authors mention the results of various studies in which benefits of RARC are well established including improvement in blood loss, quicker return of bowel function, and other peri-operative advantage. The authors also cite studies which showed evidence for the limited benefit of the RARC approach.

The authors comments on the results of the several studies on the use of antidiabetic drug pioglitazone for treatment of cancers such as bladder cancers. Topics include the increase of risks in taking pioglitazone in bladder cancer patients, the complication brought by receiving pioglitazone type 2 diabetes mellitus in high-risk patients, and the significant increase of developing bladder cancer.

In the original version of this article, Oussama Elhage's name was spelled incorrectly. It is correct as displayed above. [ABSTRACT FROM AUTHOR]