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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.

Objectives: Several patient-reported outcome measures (PROMs) are available for the assessment of quality of life (QoL), anxiety and depression for testicular cancer (TCa); however, these PROMs have uncertain validation of their psychometric properties for TCa-only cohorts. This systematic review aims to critically analyse and evaluate the psychometric properties of these QoL, anxiety and depression PROMs. Methods: PubMed, EMBASE and PsycInfo were searched by two independent reviewers from inception to August 2020. Evaluative studies that assessed measurement properties of PROM(s) tools used for measuring QoL, anxiety and depression in TCa patients were included. The COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) updated criteria for good measurement properties were used in the evaluation of PROM psychometric quality. This systematic review was registered on the PROSPERO database (CRD42020160232). Results: Of 4,305 abstracts screened, a final eight full-text articles were included in this review. Five general and two TCa-specific PROMs were identified (depression, n = 1; anxiety and depression, n = 2; QoL, n = 4). All studies were incomplete in the validation of nine measurement properties and the modal methodological quality was ‘indeterminate’. The European Organisation for Research and Treatment of Cancer Quality -Testicular Cancer 26 questionnaire and CAYA-T had the highest psychometric validation with three out of nine measurement properties being ‘sufficient’. Conclusion: This systematic review identifies a paucity of PROM-validation studies assessing anxiety, depression and QoL in TCa-only cohorts. We recommend further comprehensive and standardised psychometric validation studies of QoL, anxiety and depression PROMs in TCa-only study populations.

BACKGROUND The option of semen cryopreservation following a diagnosis of testicular cancer shows a variable uptake with the option to cryopreserve before surgery often dependent on the preference of the treating clinician and the fertility laboratory resources available. OBJECTIVES To assess whether the introduction of a patient-centric pathway for managing suspected testicular cancer increases the uptake of semen cryopreservation and the impact of this on surgical waiting times. MATERIALS AND METHODS A multicentre retrospective analysis of patients treated as part of a patient-centric pathway was conducted for suspected testicular cancer at two specialist centres within a one-stop testicular clinic. Clinical information, including semen cryopreservation acceptance rate, time intervals to surgery and CT scan, TNM stage, histology and age, was recorded from an institutional database. RESULTS Eighty nine patients (median age: 34 years (range: 14-89)) underwent orchidectomy for suspected testicular cancer over a 15-month period after the introduction of a patient-centric testicular cancer pathway at two UK centres. The overall uptake of semen cryopreservation was 68.5% (n = 61) with all men under the age of 33 years accepting this option. A microdissection oncoTESE was performed in 9/61 (14.8%) patients who attempted cryopreservation but were found to be azoospermic. Pre-operative CT imaging was completed for 85.4% of patients, and the median time from initial outpatient consultation to orchidectomy was 9 days. DISCUSSION AND CONCLUSIONS A patient-centric pathway ensures that the uptake of semen cryopreservation remains high particularly for those men within the common age for paternity. It also identifies men who may benefit from microdissection oncoTESE for complex cases such as tumours in solitary testicles, bilateral tumours or an atrophic contralateral testicle as well as those diagnosed with de novo azoospermia. The additional time taken for semen cryopreservation to be performed did not significantly delay orchidectomy or influence the decisions for adjuvant treatment.

Background It has been suggested that, in comparison with open radical cystectomy (ORC), robot-assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. Objectives To assess the effects of RARC vs ORC in adults with bladder cancer. Search methods We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk-of-bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. Results We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very-low-certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference -0.67, 95% CI -1.22 to -0.12; five trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low-certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. Conclusions We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very-low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Objectives To report the study protocol for the first international multicentre randomized controlled trial investigating the effectiveness of simulation-based surgical training and the development process for an evidence-based training curriculum, to be delivered as an educational intervention. Participants and methods This prospective, international, multicentre randomized controlled clinical and educational trial will recruit urology surgical trainees who must not have performed ≥10 of the selected index procedure, ureterorenoscopy (URS). Participants will be randomized to simulation-based training (SBT) or non-simulation-based training (NSBT), the latter of which is the current sole standard of training globally. The primary outcome is the number of procedures required to achieve proficiency, where proficiency is defined as achieving a learning curve plateau of 28 or more on an Objective Structured Assessment of Technical Skills (OSATS) assessment scale, for three consecutive operations, without any complications. All participants will be followed up either until they complete 25 procedures or for 18 months. Development of the URS SBT curriculum took place through a two-round Delphi process. Results A total of 47 respondents, consisting of trainees (n = 24) with URS experience and urolithiasis specialists (n = 23), participated in round 1 of the Delphi process. Specialists (n = 10) finalized the content of the curriculum in round 2. The developed interventional curriculum consists of initial theoretic knowledge through didactic lectures followed by select tasks and cases on the URO-Mentor (Simbionix, Lod, Israel) VR Simulator, Uro-Scopic Trainer (Limbs & Things, Bristol, UK) and Scope Trainer (Mediskills, Manchester, UK) models for both semi-rigid and flexible URS. Respondents also selected relevant non-technical skills scenarios and cadaveric simulation tasks as additional components, with delivery subject to local availability. Conclusions SIMULATE is the first multicentre trial investigating the effect and transferability of supplementary SBT on operating performance and patient outcomes. An evidence-based training curriculum is presented, developed with expert and trainee input. Participants will be followed and the primary outcome, number of procedures required to proficiency, will be reported alongside key clinical secondary outcomes, (ISCRTN 12260261).

Objectives To develop and validate the Urethroplasty Training and Assessment Tool (UTAT) using Healthcare Failure Mode and Effect Analysis (HFMEA) for training and assessment of urology trainees learning this urethral reconstruction technique, as urethroplasty is the 'gold standard' treatment for long and recurrent urethral strictures and with a variety of techniques and a lack of standardised reconstructive curricula, there is a need for procedure-specific training tools to improve surgeon training and patient safety. Materials and methods This international observational study was performed over an 11-month period. The HFMEA was used to identify and evaluate hazardous stages of urethroplasty to develop the UTAT. Hazard scores were calculated for the included steps of urethroplasty. Content validation was performed by 12 expert surgeons and multidisciplinary teams from international tertiary centres. Results The HFMEA process resulted in an internationally validated UTAT. Hazard scores ≥4 and single point weaknesses were included to implement actions and outcome measures. Content validation was achieved by circulating the process map, hazard analysis table, and developed tools. Changes were implemented based on the feedback received from expert surgeons. The content validated dorsal onlay buccal mucosa graft bulbar UTAT contained five phases, 10 processes and 23 sub-processes. Conclusions The modular UTAT offers a comprehensive validated training tool developed via a detailed HFMEA protocol. This may be utilised to standardise the training and assessment of urology trainees.

BACKGROUND: Radiotherapy (RT) is an integral component in the treatment of head and neck cancer (HNC).We hypothesized there would be alterations in gene-expression and pathway activity in HNC samples obtained in recurrent HNC that were previously treated with RT, when compared to RT-naïve disease. METHODS: Patient data was abstracted from a prospectively maintained database. Linear-microarray analysis and supervised gene-set enrichment-analysis were employed to compare RT-naive and recurrent disease after prior-RT. RESULTS: A total of 157 patients were analyzed, 96 (61%) were RT-naive and 61 (39%) had RT.After radiation, there was upregulation of genes associated with angiogenesis, protein-translation-machinery, cell-cycle regulation, and growth factors, and downregulation associated with Myc activity, and hypoxic response (all P < .001).Previously irradiated HNC was associated with down-regulation in 19/42 genes in the Wnt/B-catenin-pathway (P = .045)and 119/199 genes involved in the MYC target pathway (P = .024). CONCLUSION: Patients with recurrences salvaged surgically post-RT had significant alterations in gene-expression and in Wnt/B-catenin and MYC-target pathways. These pathways may represent potential targets to prevent development of resistance to RT.

With the prolific uptake of simulation-based training courses, this systematic review aims to identify the available microsurgical simulation and training models, their status of validation, associated studies, and levels of evidence (LoE) for each training model, thereby establishing a level of recommendation (LoR). MEDLINE, Embase, and the Cochrane Library databases were searched for English language articles, describing microsurgery simulators and/or validation studies. All studies were assessed for LoE, and each model was subsequently awarded a LoR using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education, with 1 being the highest and 4 the lowest score. A total of 86 studies were identified describing 64 models and simulators ranging from bench models, cadaveric animal tissue, cadaveric human tissue, live animal models, virtual reality simulators, and training curricula. Of these, 49 simulators had at least one validation study. Models were assessed for face (n = 42), content (n = 31), construct (n = 25), transfer (n = 10), and concurrent validity (n = 1) by these studies. The most commonly identified modality was bench models (n = 28) followed by cadaveric animal tissue (n = 24). The cryopreserved rat aorta model received the highest LoR followed by chicken wing, chicken thigh and practice cardboard models. Microsurgery simulation is a growing field and increasing numbers of models are being produced. However, there are still only a few validation studies with a high LoE. It is therefore imperative that training models and/or programs are evaluated for validity and efficacy in order to allow utilization in microsurgical skills acquisition.

From a survey of the papers published in leading accounting journals in 2014, we find that accounting researchers conduct significance testing almost exclusively at a conventional level of significance, without considering key factors such as the sample size or power of a test. We present evidence that a vast majority of the accounting studies favour large or massive sample sizes and conduct significance tests with the power extremely close to or equal to one. As a result, statistical inference is severely biased towards Type I error, frequently rejecting the true null hypotheses. Under the 'p‐value less than 0.05' criterion for statistical significance, more than 90% of the surveyed papers report statistical significance. However, under alternative criteria, only 40% of the results are statistically significant. We propose that substantial changes be made to the current practice of significance testing for more credible empirical research in accounting. [ABSTRACT FROM AUTHOR]

Background Studies suggest treatment outcomes may vary between high (HVC)‐ and low‐volume centers (LVC). Radiation therapy (RT) for head and neck cancer (HNC) requires weeks of treatment, the inconvenience of which may influence a patient's choice for treatment location. We hypothesized that receipt of RT for HNC at a HVC would influence outcomes compared to patients evaluated at a HVC, but who chose to receive RT at a LVC. Methods From 1998 to 2011, 1930 HNC patients were evaluated at a HVC and then treated with RT at either a HVC or LVC. Time‐to‐event outcomes and treatment factors were compared. Results Median follow‐up was 34 months. RT was delivered at a HVC for 1368 (71%) patients and at a LVC in 562 (29%). Patients were more likely to choose HVC‐RT if they resided in the HVC's county or required definitive RT (all P

We examine the investor reaction to misstatement news for Australian listed firms from 2006 to 2013. We find 4.1% of firm-years have a misstatement and 79% of misstatements are disclosed initially only in the periodic filings (stealth misstatements). We find no investor reaction for the average misstatement, reactions of between -2.3% and -2.8% (- 1.5% and -1.7%) for misstatements that reduce prior-period earnings or equity (affect revenue), and reactions of between -1.3% and -2.7% for non-stealth misstatements. Investor reactions are more negative for non-stealth misstatements that reduce prior period earnings or equity than to stealth misstatements.

We examine the role of board characteristics on the performance of Australian credit unions during the period 2004–2012. Credit unions are unique as they are member‐owned institutions, and their directors are democratically elected by their members – an unusual governance structure that poses challenges for board effectiveness. We find that board remuneration, board expertise and attendance at meetings are associated with increased credit‐union performance and are consistent with the goal of maximising member benefits. While the unique features of credit unions limit the presence of external monitoring mechanisms, we provide evidence that these board characteristics are relevant for credit unions.

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.

This study investigates the effect of extreme uncertainty on disclosure behaviour by analyzing the quality and quantity of forward-looking disclosures during the global financial crisis and pre-crisis periods, controlling for other determinants of disclosure behaviour. Prior research has struggled to distinguish between the quality and quantity dimensions of forward-looking disclosures. Also, the impact of the recent financial crisis on these forward-looking disclosure attributes has not yet been examined systematically. We address this gap by exploiting the unique setting of German publicly traded firms. These firms must provide forward-looking information within their audited financial statements, although relevant regulation is sufficiently vague to allow great variation in the quality, scope and quantity of forward-looking disclosures actually observed. Using hand-collected data from 2005 to 2009, we provide evidence of a significantly negative association between crisis and disclosure quality. This finding is robust to several different disclosure quality proxies and regression specifications. In contrast, we find no negative significant relation between crisis and disclosure quantity; rather, there is evidence that reported volume increases during the crisis. Our results are consistent with extreme uncertainty, as occurring during times of crisis, negatively affecting the quality of voluntary disclosures, while firms maintain or increase disclosure quantity, ultimately diluting the information density of forward-looking disclosures.

This study examines the effect of audit quality on earnings management and cost of equity capital of listed companies in India. Our results show that companies employing a high-quality auditor have a lower degree of earnings management and lower cost of equity capital. The results also show that companies belonging to business groups have a lower degree of earnings management and lower cost of equity capital than do stand-alone companies but that they benefit less from employing a high-quality auditor. Our results are based on a large sample of 7,303 firm-year observations on listed companies in India and are robust to alternative measures for our main variables – audit quality, earnings management, and cost of capital – and to tests for endogeneity and the impact of the global financial crisis (GFC). Given the distinctive and unique institutional features of the Indian market such as the dominant role of family business groups in the national economy, large market share of domestic audit firms, less litigious environment, and less effective professional accounting bodies in checking audit failure, our findings make a significant contribution to the literature on the role of audit quality as a corporate governance monitoring mechanism as reflected in the impact on earnings management and cost of equity capital.

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.

BACKGROUND Patients covered by Medicaid insurance appear to have poorer cancer outcomes. Herein, the authors sought to test whether Medicaid was associated with worse outcomes among patients with head and neck cancer (HNC). METHODS The records of 1698 patients with squamous cell HNC without distant metastatic disease were retrospectively reviewed from an institutional database between 1998 and 2011. At the time of diagnosis, insurance status was categorized as Medicaid, Medicare/other government insurance, or private insurance. Outcomes including locoregional control (LRC) and overall survival (OS) were estimated using the Kaplan-Meier method and Cox regression multivariate analysis (MVA). RESULTS The median follow-up for all patients was 35 months. Medicaid patients comprised 11% of the population; the remaining patients were privately insured (56%) or had Medicare/government insurance (34%). On MVA, Medicaid patients were younger, were current smokers, had higher tumor T and N classifications, and experienced a longer time from diagnosis to treatment initiation (all P 45 days was found to be associated with worse 3-year LRC (77% vs 83%; P = .009) and OS (68% vs 71%; P = .008). On MVA, Medicaid remained associated with a deficit in LRC (P = .002) and OS (P

type="main"> Recent regulatory changes in Australia require listed companies to implement policies for increasing board diversity and to report thereon. In this paper we examine the association between gender diversity on corporate boards and the financial performance of a large sample of the top 500 listed companies in Australia during the period 2005–2011, addressing many of the methodological weaknesses in prior studies. Our descriptive statistics show that the proportion of female directors on boards increased markedly between 2010, when ASX amended principles came into effect, and 2011. The results also show that board diversity is positively associated with financial performance after controlling for a number of firm-specific, ownership and governance characteristics and potential endogeneity with the two-stage least square tests. Thus, we inform the policy debate by providing empirical evidence supporting the business case for board diversity.

We examine the investor reaction to misstatement news for Australian listed firms from 2006 to 2013. We find 4.1% of firm-years have a misstatement and 79% of misstatements are disclosed initially only in the periodic filings (stealth misstatements). We find no investor reaction for the average misstatement, reactions of between -2.3% and -2.8% (- 1.5% and -1.7%) for misstatements that reduce prior-period earnings or equity (affect revenue), and reactions of between -1.3% and -2.7% for non-stealth misstatements. Investor reactions are more negative for non-stealth misstatements that reduce prior period earnings or equity than to stealth misstatements.

Objectives To describe the progress being made in training for minimally invasive surgery (MIS) in urology. Methods A group of experts in the field provided input to agree on recommendations for MIS training. A literature search was carried out to identify studies on MIS training, both in general and specifically for urological procedures. Results The literature search showed the rapidly developing options for e-learning, box and virtual training, and suggested that box training is a relatively cheap and effective means of improving laparoscopic skills. Development of non-technical skills is an integral part of surgical skills training and should be included in training curricula. The application of modular training in surgical procedures showed more rapid skills acquisition. Training curricula for MIS in urology are being developed in both the USA and Europe. Conclusion Training in MIS has shifted from ‘see-one-do-one-teach-one’ to a structured learning, from e-learning to skills laboratory and modular training settings.

Objectives To assess face, content and construct validity, and feasibility and acceptability of the GreenLight™ Simulator as a training tool for photoselective vaporisation of the prostate (PVP), and to establish learning curves and develop an evidence-based training curriculum. Subjects and Methods This prospective, observational and comparative study, recruited novice (25 participants), intermediate (14) and expert-level urologists (seven) from the UK and Europe at the 28th European Association of Urological Surgeons Annual Meeting 2013. A group of novices (12 participants) performed 10 sessions of subtask training modules followed by a long operative case, whereas a second group (13) performed five sessions of a given case module. Intermediate and expert groups performed all training modules once, followed by one operative case. The outcome measures for learning curves and construct validity were time to task, coagulation time, vaporisation time, average sweep speed, average laser distance, blood loss, operative errors, and instrument cost. Face and content validity, feasibility and acceptability were addressed through a quantitative survey. Results Construct validity was demonstrated in two of five training modules (P = 0.038; P = 0.018) and in a considerable number of case metrics (P = 0.034). Learning curves were seen in all five training modules (P < 0.001) and significant reduction in case operative time (P < 0.001) and error (P = 0.017) were seen. An evidence-based training curriculum, to help trainees acquire transferable skills, was produced using the results. Conclusion This study has shown the GreenLight Simulator to be a valid and useful training tool for PVP. It is hoped that by using the training curriculum for the GreenLight Simulator, novice trainees can acquire skills and knowledge to a predetermined level of proficiency.

Objective To evaluate the experience and views regarding live surgical broadcasts (LSB) among European urologists attending the European Association of Urology Robotic Urology Society (ERUS) congress in September 2012. Materials and Methods An anonymous survey was distributed via email inviting the participants of the ERUS congress with experience of LSB to share their opinions about LSB. The outcomes measured included; personal experience of LSB, levels of anxiety faced and the perceived surgical quality. The impact of factors, such as communication/team-working, travel fatigue and lack of specific equipment were also evaluated. Results In all, 106 surgeons responded with 98 (92.5%) reporting personal experience of LSB; 6.5% respondents noted ‘significant anxiety’ increasing to 19.4% when performing surgery away from home (P < 0.001). Surgical quality was perceived as ‘slightly worse’ and ‘significantly worse’ by 16.1% and 2.2%, which deteriorated further to 23.9% and 3.3% respectively in a ‘foreign’ environment (P = 0.005). In all, 10.9% of surgeons ‘always’ brought their own surgical team compared with 37% relying on their host institution; 2.4% raised significant concerns with their team and 18.8% encountered significantly more technical difficulties. Lack of specific equipment (10.3%), language difficulties (6.2%) and jet lag (7.3%) were other significant factors reported. In all, 75% of surgeons perceived the audience wanted a slick demonstration; however, 52.2% and 42.4% respectively also reported the audience wished the surgeon to struggle or manage a complication during a LSB. Conclusions A small proportion of surgeons had significantly heightened anxiety levels and lower perceived performance during LSB, which in a ‘foreign’ environment seemed to affect a greater proportion of surgeons. Various factors appear to impact surgical performance raising concerns about the appropriateness of unregulated LSB as a teaching method. To mitigate these concerns, surgeons' performing live surgery feel that the operation needs to be well planned using appropriate equipment; with many considering bringing their own team or operating from home on a video link.

Objective To determine the number of cases a urological surgeon must complete to achieve proficiency for various urological procedures. Patient and Methods The MEDLINE, EMBASE and PsycINFO databases were systematically searched for studies published up to December 2011. Studies pertaining to learning curves of urological procedures were included. Two reviewers independently identified potentially relevant articles. Procedure name, statistical analysis, procedure setting, number of participants, outcomes and learning curves were analysed. Results Forty-four studies described the learning curve for different urological procedures. The learning curve for open radical prostatectomy ranged from 250 to 1000 cases and for laparoscopic radical prostatectomy from 200 to 750 cases. The learning curve for robot-assisted laparoscopic prostatectomy (RALP) has been reported to be 40 procedures as a minimum number. Robot-assisted radical cystectomy has a documented learning curve of 16–30 cases, depending on which outcome variable is measured. Irrespective of previous laparoscopic experience, there is a significant reduction in operating time (P = 0.008), estimated blood loss (P = 0.008) and complication rates (P = 0.042) after 100 RALPs. Conclusions The available literature can act as a guide to the learning curves of trainee urologists. Although the learning curve may vary among individual surgeons, a consensus should exist for the minimum number of cases to achieve proficiency. The complexities associated with defining procedural competence are vast. The majority of learning curve trials have focused on the latest surgical techniques and there is a paucity of data pertaining to basic urological procedures.

Objectives To describe how learning curves are measured and what procedural variables are used to establish a ‘learning curve’ (LC). To assess whether LCs are a valuable measure of competency. Patients and Methods A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases. Results Variables should be fully defined and when possible, patient-specific variables should be used. Trainee's prior experience and level of supervision should be quantified; the case mix and complexity should ideally be constant. Logistic regression may be used to control for confounding variables. Ideally, a learning plateau should reach a predefined/expert-derived competency level, which should be fully defined. When the group splitting method is used, smaller cohorts should be used in order to narrow the range of the LC. Simulation technology and competence-based objective assessments may be used in training and assessment in LC studies. Conclusions Measuring the surgical LC has potential benefits for patient safety and surgical education. However, standardisation in the methods and variables used to measure LCs is required. Confounding variables, such as participant's prior experience, case mix, difficulty of procedures and level of supervision, should be controlled. Competency and expert performance should be fully defined.

Objectives To identify and assess potential hazards in robot-assisted urological surgery. To develop a comprehensive checklist to be used in operating theatres with robotic technology. Methods Healthcare Failure Mode and Effects Analysis (HFMEA), a risk assessment tool, was used in a urology operating theatre with innovative robotic technology in a UK teaching hospital between June and December 2011. A 15-member multidisciplinary team identified ‘failure modes’ through process mapping and flow diagrams. Potential hazards were rated according to severity and frequency and scored using a ‘hazard score matrix’. All hazards scoring ≥8 were considered for ‘decision tree’ analysis, which produced a list of hazards to be included in a surgical safety checklist. Results Process mapping highlighted three main phases: the anaesthesia phase, the operating phase and the postoperative handover to recovery phase. A total of 51 failure modes were identified, 61% of which had a hazard score ≥8. A total of 22 hazards were finalised via decision tree analysis and were included in the checklist. The focus was on hazards specific to robotic urological procedures such as patient positioning (hazard score 12), port placement (hazard score 9) and robot docking/de-docking (hazard score 12). Conclusions HFMEA identified hazards in an operating theatre with innovative robotic technologies which has led to the development of a surgical safety checklist. Further work will involve validation and implementation of the checklist.

The authors outline the evidence that robotic-assisted laparoscopic surgery has equivalent or better outcomes compared with laparoscopic or open surgery. With reduced hospital stay, faster recovery, reduction in blood product use and equivalent quality-of-life measures to laparoscopic techniques, this modern age of surgical technology is here to stay. Copyright © 2013 John Wiley & Sons

What's known on the subject? and What does the study add? It has long been acknowledged that clinical expertise alone may not equip a surgeon to become a successful educator, and that medical educators may require additional teacher training to be able to teach effectively. To this end, many different faculty development training courses have arisen over the years including workshops, seminar series, longitudinal programmes, and fellowships. However, there is a lack of research into the effectiveness of these training programmes on long-term sustainable changes in teaching and learning, especially in the field of surgical education. This article discusses the importance of faculty training within surgery and evaluates the existing faculty development programmes in terms of long- and short-term outcomes. Recommendations are provided that highlight the need for additional teacher training opportunities in surgery, the vigorous evaluation of the methodology and long-term outcomes of existing training programmes, and the need for better recognition and reward for teaching excellence within organisations. Objective To explore faculty training in the field of surgical specialities with a focus on the educational aspect of faculty training. Teaching is an important commitment for academic surgeons alongside duties of patient care, research and continuing professional development. Educating surgical faculty in the skills of teaching is becoming increasingly important and the realisation that clinical expertise does not necessarily translate to teaching expertise has led to the notion that faculty members require formal training in teaching methods and educational theory to teach effectively. The aim of faculty training or development is to increase knowledge and skills in teaching, research and administration of faculty members. Materials and Methods A range of resources, e.g. journal articles, books and online literature was reviewed to investigate faculty development programmes in surgery. Various issues were addressed, e.g. the need for faculty development, evaluating the various types of training programmes and their outcomes, and exploring barriers to faculty training. Recommendations were provided based on the findings. Results There is increased recognition that faculty members require basic training in educational theory and teaching skills to teach effectively. Most faculty training programmes are workshops and short courses, which use participant satisfaction as an outcome measure. However, there is growing consensus that longer term interventions, e.g. seminar series, longitudinal programmes and fellowships, produce more sustainable change in learning, behaviour and organisational culture. Barriers to faculty development include lack of protected time, reward and recognition for teaching. Conclusion Recommendations are made including better documentation of faculty training interventions within surgery, further investigation into the effectiveness of long- vs short-term interventions, improved methodology, and increased recognition and reward for educational accomplishments.

What's known on the subject? and What does the study add? A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants – South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres). Objectives To establish the feasibility and acceptability of a centralized, simulation-based training-programme. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills. Materials and Methods For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales. Results In total 33, three specialist registrars of different grades and five urological nurses participated in the present study. Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized. A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills. Conclusions A centralized simulation programme that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

Technological advances in urology have led to many beneficial outcomes for patients. Unfortunately, increasing the complexity of a procedure may make surgical interventions even more unpredictable, increasing the possibility of error, with its detrimental effect on patient safety. In this article, the authors highlight the fundamental components of the patient safety process and recommend measures to maintain and enhance safer patient care. Copyright © 2012 John Wiley & Sons

To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE(®), EMBASE(®) and PsycINFO(®) databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; 'expert' and 'novice'. Experts ranged in experience from 21-2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer(®), ProMIS(®), SimSurgery Educational Platform(®) (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial. Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

What's known on the subject? and What does the study add? The use of robotic assistance for the partial nephrectomy procedure has emerged as an alternative that may help some of the technical challenges of laparoscopic partial nephrectomy. The main concerns in laparoscopic partial nephrectomy relates to a steeper ‘learning curve’, prolonged warm ischaemia times and the potential for postoperative haemorrhage. The article delineates the dynamics of patient preparation, the surgical team, surgical technique & post-operative care to conclude that robotic-assisted partial nephrectomy is a viable alternative to both open and laparoscopic techniques. Partial nephrectomy has shown both improved overall patient survival and more effective preservation of renal function, when compared with radical nephrectomy. Robot-assisted partial nephrectomy has several potential advantages over the laparoscopic approach. Robotic assistance allows urologists to perform this complex reconstructive procedure more quickly, with improved precision and dexterity, tremor elimination and improved visualization. The present article aims to delineate the dynamics of patient preparation and surgical team, surgical technique and postoperative care. The oncological outcomes and disease-free survival of partial nephrectomy have been found to be equivalent to open partial nephrectomy [1–4].

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post-operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery. This review concludes that robotic surgery should be targeted for cost efficiency in order to fully reap the benefits of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review finds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs difficult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it difficult to accurately assess long term post-operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology. OBJECTIVES • Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery. • These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes. METHODS • A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study. RESULTS • Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1–1.76 days and 1–5.5 days, respectively) and blood loss (range 482–780 mL and 227–234 mL, respectively) when compared with the open approach (range 2–8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000–$39 215) than both laparoscopic (range US $740–$29 771) and open radical prostatectomy (range US $1870–$31 518). • This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1–1.5 days) and length of surgery (range 102–360 min) are unable to compensate for the excess costs. • Robotic surgery may require a smaller learning curve (20–40 cases) although the evidence is inconclusive. CONCLUSIONS • Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve. • Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs. • Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery.

Reuters, Australia , and † Mater Misericordiae Hospital and University College Dublin, Ireland Since the advent of Garfi eld ’ s science citation index in the 1950s [ 1 ] , bibliometrics have been formally used to assess academic productivity and performance [ 2 ] . Although the use of bibliometric studies predates Garfi eld, the need to assess mathematically and statistically the quantity and quality of published work did not arise until the 1960s. This was attributable to the exponential growth in scientifi c publications resulting from the culture of ‘ publish or perish ’ [ 3,4 ] that overwhelmed different scientifi c fi elds, and the need to identify top quality research. With the development of many performance indices over the years, bibliometrics are increasingly becoming a political tool among scientists and policymakers [ 5 ] , to the extent that they can be used in important decisions regarding appointments [ 6 ] , promotions and funding.

What's known on the subject? and What does the study add? Provision of high-quality care necessitates the identification and measurement of relevant quality indicators. Urological surgery currently does not have a validated quality-of-care framework to guide surgical quality improvement. This article aims to delineate quality of care processes, current status of quality indicators for major urological cancers as well as recommend a provisional framework for evaluation of quality for urological procedures. Growing demands for patient safety, lower cost and quality of care have resulted in several initiatives of quality measurement across urological surgery. Although candidate indicators have been proposed in various procedures, the field still lacks a valid quality framework. Better understanding of the interplay between patient selection, surgical expertise, preoperative-, intraoperative, postoperative processes and outcomes is needed. Consensus needs to be achieved in which validated structural, process and outcomes measures to employ, how this data should be collected, which agencies to share this data with and how to use this data to effect change in health policy. Compliance with quality framework needs to be continuously audited with its outcomes frequently benchmarked against international standards. Pursuit of quality improvement schemes require significant investment and need to be weighed against current budgetary constraints.

What's known on the subject? and What does the study add? Dedicated training hours for surgeons are falling as the complexity of techniques and patient expectations are increasing. Urologists therefore need to train in more sophisticated and effective ways. This article looks at past and current urological training and suggests emerging and innovative ways to teach the next generation of urologists. Since 2004 the estimated available training time, for all doctors, has dropped from 30, 000 h to ≈ 8, 000h. By decreasing the initial stages of the learning curve, medical simulation has the potential to compensate for the reduced time available to train urologists. The current urological training pathway consists of 2 years of foundation year training, 2 years of core surgical training, followed by 5 years of specialty training. Training time pressures and the expansion of treatment techniques have led to a trend towards increased sub-specialization in urology. To optimize patient care, training programmes must evolve, taking into account several key issues and in accordance with advances in urological care.

What's known on the subject? and What does the study add? Inanimate trainers and simulators have been shown to facilitate the skill acquisition of urologists. However, there are significant challenges to integrating standalone simulation programmes into mainstream urology curricula. This study provides a framework to overcome these challenges and discusses the advantages of centralised urology simulation centres and their potential to serve as key adjuncts in the certification and validation process of urologists. Fixed performance-based outcomes of inanimate trainers and simulators have been praised as useful adjuncts in urology for reducing the learning curve associated with the acquisition of new technical and non-technical skills without compromising patient safety. Simulators are becoming an integral part of the urology training curriculum and their effectiveness is totally dependent on the structure of the programme implemented. The present paper discusses the fundamental concepts of centralized urology centres and their potential to serve as key adjuncts in the certification and validation process of urologists. In summary, proficiency-based curricula with well structured endpoints and objective tools for validating proficiency are critical in developing a simulation programme in urology. We concludes that more educational research into the outcomes of integrated urology curricula followed by trainee/trainer opinion surveys will help address some of these criteria.

What's known on the subject? and What does the study add? Revalidation encourages consolidation of clinical knowledge through active reflection on surgical practice. Current guidelines fall short of recommending structured and evidence based guidelines for specialist revalidation. This article describes the process of revalidation for urologists, highlights challenges in its practical application and suggests potential improvements to the current strategy of revalidation. The aim of revalidation (or maintenance of certification) is to reassure patients, the general public, employers and other healthcare professionals that an individual is fit to practice. It may lead to a reduction in near misses or adverse events. The process of revalidation entails a commitment to the provision of lifelong learning and assessment of clinical practice that ultimately ensure patient safety. Lifelong learning addresses knowledge and skills, whereas assessment of clinical practice ensures quality of care. Various learning and assessment tools are available in clinical practice; however, the tools for revalidation are not validated at specialist level. Further research is needed to develop and implement evidence-based structured programmes of revalidation that consider the holistic needs of modern urologists.

Background: In the past, surgical training has been based on traditional apprenticeship model of mentoring. To cope with the rapidly changing environment of modern surgery, the mentoring process may require significant modernization. Methods: Literature for this review was identified by searching for the MeSH heading ‘mentors’ in Ovid MEDLINE, EMBASE, PsycINFO and Cochrane Library databases (1950 to September 2010). The literature was reviewed to specifically identify challenges of mentoring future surgeons and to delineate a framework to establish a mentor–mentee relationship by means of a formal mentoring scheme. Results: Multidimensional approaches, models and methods of delivering mentoring are essential to meet the challenges of modern surgery. We advocate a 10-stage approach to implement a formal mentoring scheme at local, national and international levels. Conclusion: Formalizing the mentoring process, with local, national and international schemes, will initiate mentoring relationships and cultivate a mentoring culture. Ultimately, this will maintain and improve patient care.