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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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

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.

Introduction: Urological cancers can be challenging in the diagnosis and treatment of patients with neurological diseases. As a result, there are still uncertainties regarding the incidence and risk factors favouring the development of urological cancers in these patients. The aim of this study was to review the available evidence regarding the incidence for the development of urological cancers in neurological patients to provide a basis for future recommendations and research., Evidence Acquisition: A narrative review of the literature in Medline and Scopus up to June 2019 was performed., Evidence Synthesis: After screening 1729 records, 30 retrospective studies were retained. For bladder cancer (BC), 21 articles were identified, including a total of 673,663 patients. Among these patients, 4744 had a diagnosis of BC (1265 females, 3214 males, gender not reported in 265). In this group, 2514 were diagnosed with BC associated with a neurological disease. For prostate cancer (PC), 14 articles were identified, including a total of 831,889 men. Among these patients, 67,543 had a diagnosis of PC and 1457 had PC and a neurological disease. Two articles reported kidney cancer (KC), one reported testicular cancer (TC) and none described penile cancer or urothelial carcinomas of the upper urinary tract in neurological patients., Conclusions: The incidence of urological cancers, especially BC and PC, in patients with neurological diseases appears comparable to the general population. However due to the paucity of studies, specific recommendations for the management are lacking in neurologically disabled patients. In this report we investigated the frequency of urinary tract cancers in patients with neurological diseases. We conclude that urological cancers, especially bladder and prostate cancer, in patients with neurological diseases occur with similar frequency as in the general population.

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., (© 2023 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

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., (© 2022. The Author(s).)

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., (© 2022 John Wiley & Sons Australia, Ltd.)

Background: It is hypothesised that simulation enhances progression along the initial phase of the surgical learning curve., Objective: To evaluate whether residents undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes., Design, Setting, and Participants: This international, multicentre, randomised controlled trial recruited 94 urology residents with experience of zero to ten procedures and no prior exposure to simulation in ureterorenoscopy, selected as an index procedure., Intervention: Participants were randomised to simulation or conventional operating room training, as is the current standard globally, and followed for 25 procedures or over 18 mo., Outcome Measurements and Statistical Analysis: The number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on the Objective Structured Assessment of Technical Skill (OSATS) scale over three consecutive operations, was measured. Surgical complications were evaluated as a key secondary outcome. This trial is registered at www.isrctn.com as ISCRTN 12260261., Results and Limitations: A total of 1140 cases were performed by 65 participants, with proficiency achieved by 21 simulation and 18 conventional participants over a median of eight and nine procedures, respectively (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.72-2.75). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring a lower number of procedures (HR 0.89, 95% CI 0.39-2.02). Significant differences were observed in overall comparison of OSATS scores between the groups (mean difference 1.42, 95% CI 0.91-1.92; p < 0.001), with fewer total complications (15 vs 37; p = 0.003) and ureteric injuries (3 vs 9; p < 0.001) in the simulation group., Conclusions: Although the number of procedures required to reach proficiency was similar, simulation-based training led to higher overall proficiency scores than for conventional training. Fewer procedures were required to achieve proficiency in the complex form of the index procedure, with fewer serious complications overall., Patient Summary: This study investigated the effect of simulation training in junior surgeons and found that it may improve performance in real operating settings and reduce surgical complications for complex procedures., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

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., (© 2020. The Author(s).)

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.

To evaluate all simulation models for ophthalmology technical and non-technical skills training and the strength of evidence to support their validity and effectiveness. A systematic search was performed using PubMed and Embase for studies published from inception to 01/07/2019. Studies were analysed according to the training modality: virtual reality; wet-lab; dry-lab models; e-learning. The educational impact of studies was evaluated using Messick's validity framework and McGaghie's model of translational outcomes for evaluating effectiveness. One hundred and thirty-one studies were included in this review, with 93 different simulators described. Fifty-three studies were based on virtual reality tools; 47 on wet-lab models; 26 on dry-lab models; 5 on e-learning. Only two studies provided evidence for all five sources of validity assessment. Models with the strongest validity evidence were the Eyesi Surgical, Eyesi Direct Ophthalmoscope and Eye Surgical Skills Assessment Test. Effectiveness ratings for simulator models were mostly limited to level 2 (contained effects) with the exception of the Sophocle vitreoretinal surgery simulator, which was shown at level 3 (downstream effects), and the Eyesi at level 5 (target effects) for cataract surgery. A wide range of models have been described but only the Eyesi has undergone comprehensive investigation. The main weakness is in the poor quality of study design, with a predominance of descriptive reports showing limited validity evidence and few studies investigating the effects of simulation training on patient outcomes. More robust research is needed to enable effective implementation of simulation tools into current training curriculums.

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.

A systematic review and meta-analysis were performed to determine the relationship between testosterone therapy and the risk of recurrence in testosterone-deficient survivors of curatively treated high-risk prostate cancer. Primary outcome was the risk of biochemical recurrence (BCR) in 109 high-risk patients in 13 included studies (1997-2017). Biochemical and symptomatic effects of therapy were also reviewed. The BCR rate was 0.00 (0.00-0.05), lower than the expected rate for high-risk prostate cancer survivors, suggesting that testosterone therapy may not increase their BCR risk. However, this is uncertain as the available evidence is of very low quality. Testosterone therapy remains investigational in this group., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

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 (r s  = 0.613, p < 0.005), but the correlation for knot tying was insignificant (r s  = 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.

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.

Objective: To perform the first validation of a full procedural virtual reality robotic training module and analysis of novice surgeon's learning curves., Design: Participants completed the bladder neck dissection task and urethrovesical anastomosis task (UVA) as part of the prostatectomy module. Surgeons completed feedback questionnaires assessing the realism, content, acceptability and feasibility of the module. Novice surgeons completed a 5.5-hour training programme using both tasks., Setting: King's College London, London., Participants: 13 novice, 24 intermediate and 8 expert surgeons completed the validation study., Results: Realism was scored highly for BDN (mean 3.4/5) and UVA (3.74/5), as was importance of BDN (4.32/5) and UVA (4.6/5) for training. It was rated as a feasible (3.95/5) and acceptable (4/5) tool for training. Experts performed significantly better than novice group in 6 metrics in the UVA including time (p = 0.0005), distance by camera (p = 0.0010) and instrument collisions (p = 0.0033), as well as task-specific metrics such as number of unnecessary needle piercing points (p = 0.0463). In novice surgeons, a significant improvement in performance after training was seen in many metrics for both tasks. For bladder neck dissection task, this included time (p < 0.0001), instrument collisions (p = 0.0013) and total time instruments are out of view (p = 0.0251). For UVA, this included time (p = 0.0135), instrument collisions (p = 0.0066) and task-specific metrics such as injury to the urethra (p = 0.0032) and bladder (p = 0.0189)., Conclusions: Surgeons found this full procedural VR training module to be a realistic, feasible and acceptable component for a robotic surgical training programme. Construct validity was proven between expert and novice surgeons. Novice surgeons have shown a significant learning curve over 5.5 hours of training, suggesting this module could be used in a surgical curriculum for acquisition of technical skills. Further implementation of this module into the curriculum and continued analysis would be beneficial to gauge how it can be fully utilised., (Copyright © 2017. Published by Elsevier Inc.)

Background: The aim of this study was to determine the correlation of visual-spatial ability with progression along the learning curve for robotic surgical skills training., Methods: A total of 21 novice participants were recruited. All participants completed a training program consisting of 5 training sessions of 30 minutes of virtual reality (VR) simulation and 30 minutes of dry laboratory training. The VR simulation part was the subject of the present study. During VR simulation training, participants performed the basic skill exercises of Camera Targeting 1, Pick and Place, and Peg Board 1 followed by advanced skill exercises of Suture Sponge 1 and Thread the Rings. The visual-spatial ability was assessed using a mental rotation test (MRT). Pearson correlation coefficients were used to assess the relationship between the MRT score and simulator score for the aforementioned 5 tasks. Student t test was used to compare the simulator score between high- and low-MRT score groups., Results: A median MRT score of 26/40 (range: 13-38) was observed. Approximately 19 participants completed the full curriculum but 2 did not complete "Thread the Rings" during the study period. A significant correlation was observed between the MRT score and simulator score only in "Suture Sponge 1" over the first 3 attempts (first: r = 0.584, p = 0.0054; second: r = 0.443, p = 0.0443; third: r = 0.4458, p = 0.0428). After the third attempt, this significant correlation was lost. Comparison of the score for "Suture Sponge 1" between the high-MRT and low-MRT scoring participants divided by a median MRT score of 26 also showed a significant difference in the score until the third trial., Conclusion: Our observations suggest that the spatial cognitive ability influences the initial learning of robotic suturing skills. Further studies are necessary to verify the usefulness of an individual's spatial ability to tailor the surgical training program., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

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.

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., (© 2017 Royal Australasian College of Surgeons.)

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., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Background: There is a need for new approaches to surgical training in order to cope with the increasing time pressures, ethical constraints, and legal limitations being placed on trainees. One of the most interesting of these new approaches is "cognitive training" or the use of psychological processes to enhance performance of skilled behaviour. Its ability to effectively improve motor skills in sport has raised the question as to whether it could also be used to improve surgical performance. The aim of this review is to provide an overview of the current evidence on the use of cognitive training within surgery, and evaluate the potential role it can play in surgical education., Methods: Scientific database searches were conducted to identify studies that investigated the use of cognitive training in surgery. The key studies were selected and grouped according to the type of cognitive training they examined., Results: Available research demonstrated that cognitive training interventions resulted in greater performance benefits when compared to control training. In particular, cognitive training was found to improve surgical motor skills, as well as a number of non-technical outcomes. Unfortunately, key limitations restricting the generalizability of these findings include small sample size and conceptual issues arising from differing definitions of the term 'cognitive training'., Conclusions: When used appropriately, cognitive training can be a highly effective supplementary training tool in the development of technical skills in surgery. Although further studies are needed to refine our understanding, cognitive training should certainly play an important role in future surgical education., (Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Objective: Development of nontechnical skills for surgeons has been recognized as an important factor in surgical care. Training tools for this specific domain are being created and validated to maximize the surgeon's nontechnical ability. This systematic review aims to outline, address, and recommend these training tools., Design: A full and comprehensive literature search, using a systematic format, was performed on ScienceDirect and PubMed, with data extraction occurring in line with specified inclusion criteria., Setting: Systematic review was performed fully at King's College London., Results: A total of 84 heterogeneous articles were used in this review. Further, 23 training tools including scoring systems, training programs, and mixtures of the two for a range of specialities were identified in the literature. Most can be applied to surgery overall, although some tools target specific specialities (such as neurosurgery). Interrater reliability, construct, content, and face validation statuses were variable according to the specific tool in question., Conclusions: Study results pertaining to nontechnical skill training tools have thus far been universally positive, but further studies are required for those more recently developed and less extensively used tools. Recommendations can be made for individual training tools based on their level of validation and for their target audience. Based on the number of studies performed and their status of validity, NOTSS and Oxford NOTECHS II can be considered the gold standard for individual- and team-based nontechnical skills training, respectively, especially when used in conjunction with a training program., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

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., (© 2017 John Wiley & Sons Ltd.)

Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case. The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations. An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Innovation in recent times has accelerated due to factors such as the globalization of communication; but there are also more barriers/safeguards in place than ever before as we strive to streamline this process. From the first planned partial nephrectomy completed in 1887, it took over a century to become recommended practice for small renal tumours. At present, identified areas for improvement/innovation are 1) to preserve renal parenchyma, 2) to optimise pre-operative eGFR and 3) to reduce global warm ischaemia time. All 3 of these, are statistically significant predictors of post-operative renal function. Urologists, have a proud history of embracing innovation & have experimented with different clamping techniques of the renal vasculature, image guidance in robotics, renal hypothermia, lasers and new robots under development. The DaVinci model may soon no longer have a monopoly on this market, as it loses its stranglehold with novel technology emerging including added features, such as haptic feedback with reduced costs. As ever, our predictions of the future may well fall wide of the mark, but in order to progress, one must open the mind to the possibilities that already exist, as evolution of existing technology often appears to be a revolution in hindsight., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Ketamine-associated cystitis is a well-recognised syndrome; yet upper urinary tract involvement remains poorly understood. We present the case of a 33-year-old man who developed ketamine-associated cystitis and ureteritis. The patient's severe bladder symptoms required subtotal cystectomy and orthotopic reconstruction. However, the associated ureteritis led to bilateral ureteric obstruction and renal failure. Bilateral autotransplantation with pyelovesicostomy was performed. This first case of autotransplantation for ketamine uropathy helps to demonstrate the potentially devastating effects of ketamine on the urinary tract., (2015 BMJ Publishing Group Ltd.)