Is there a place for virtual reality simulators in assessment of competency in percutaneous renal access?

Objective

To assess competency of urology post-graduate trainees (PGTs) in percutaneous renal access (PCA).

Methods

Upon obtaining ethics approval and informed consents, PGTs between post-graduate years (PGY-3 to PGY-5) from all four urology programs in Québec were recruited. PCA competency of each participant was assessed objectively by performing task 4 on the PERC Mentor? simulator, where they had to correctly access and pop 7 balloons in 7 different renal calyces and subjectively by the validated Percutaneous Nephrolithotomy—Global Rating Scale (PCNL-GRS).

Results

A total of 26 PGTs with a mean age of 29.2 ± 0.7 years participated in this study. When compared with the 21 PGTs without practice, all 5 PGTs who had practiced on the simulator were competent (p = 0.03), performed the task with significantly shorter operative time (13.9 ± 0.7 vs. 4.4 ± 0.4 min; p < 0.001) and fluoroscopy time (9.3 ± 0.6 vs. 3.4 ± 0.4 min; p < 0.001), and had significantly higher PCNL-GRS scores (13 ± 0.6 vs. 20.6 ± 1; p < 0.001) and successful attempts to access renal calyces (23 ± 5 vs. 68.7 ± 11; p = 0.001). According to a pass score of 13/25, thirteen PGTs were competent. Competent PGTs performed the task with significantly shorter fluoroscopy time (9.8 vs. 6.5 min; p = 0.01) and higher percentage of successful attempts to access renal calyces (p < 0.001), higher PCNL-GRS scores (p < 0.001), and lower complications (p = 0.01).

Conclusion

The PCNL-GRS in combination with the PERC Mentor? simulator was able to differentiate between competent and non-competent PGTs.

     

Impact of an autotransfusion system during endoluminal repair of abdominal aortic aneurysms: does it decrease the use of allogeneic blood?

Endoluminal repair of abdominal aortic aneurysms (AAA) is associated with decreased blood loss and transfusion requirements when compared to open AAA repair. We evaluated the use of an intraoperative autotransfusion system during endoluminal exclusion of AAAs. Fifty endoluminal AAA procedures selected at random were reviewed retrospectively. Patients were divided into 4 groups according to their estimated blood loss: Group I, 20 patients (0-500 cc); Group II, 18 patients (501-1,000 cc); Group III, 7 patients (1,001-1,500 cc); and Group IV, 5 patients (1,501-3,400 cc). The average blood loss was 327 cc for Group I, 728 cc for Group II, 1,217 for Group III, and 2,125, for Group IV. The overall blood loss was 834 cc, but 75 per cent was recovered. Hematuria was always present when greater than 1,000 cc of blood was retransfused, but renal function was not affected even with the concomitant administration of radiographic contrast. Only one patient required an autologous blood transfusion. The use of an autotransfusion device is safe, efficacious, and appears to further limit the need for homologous blood transfusion in patients undergoing endoluminal AAA repair.     

Novel everting urologic access sheath: decreased axial forces during insertion

BACKGROUND: Advancement of urologic instruments through the genitourinary tract is associated with significant axial forces that likely contribute to patient discomfort, even after injection of a local anesthetic, and may lead to mucosal trauma, postprocedural dysuria and hematuria, and increased susceptibility to infection and strictures. Placing an everting urethral sheath prior to instrumentation may decrease these problems. Materials and METHODS: Two 7-cm-long, 5-mm diameter urethral luminal models were created, one with and one without an artificial stricture. We measured the forces generated during advancement of a novel everting access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) through the models in comparison with a representative cystoscope and a urologic dilator simulating a traditional access sheath. RESULTS: The mean force generated during advancement of the everting sheath was significantly less than that of both the representative cystoscope (P<0.01) and the traditional access sheath (P<0.01). This held true for the urethral models both with and without an artificial stricture (P<0.01) and with and without lubrication (P<0.01). CONCLUSIONS: This novel introduction sheath markedly decreased the axial forces applied to an artificial urethral luminal wall. It is possible that the clinical use of this technology will decrease the discomfort and potential complications associated with lower urinary-tract endoscopy.     

The results of superficial femoral, popliteal, and tibial artery stenting for peripheral vascular occlusive disease

The purpose of this study was to evaluate the patentcy rates and physiological effectiveness of angioplasty and stenting as a primary therapy for superficial femoral (SFA), popliteal (POP), and tibial (TIB) arterial occlusive disease. Seventy-eight patients had stents placed in the infra-inguinal vessels between January 1, 2001, and July 31, 2004. We collected data on patient demographics, symptoms, as well as pre- and postprocedure ankle-brachial index (ABI) and angiographic findings. Patency rates at 6 months, 12 months, and 24 months were analyzed by life table methods. Thirty-one men and 47 women had a mean age of 68 years (range 36-94 years). Risk factors included diabetes in 50 per cent, hypertension in 79 per cent, smoking in 41 per cent, and end-stage renal disease in 10 per cent. The indications for intervention were claudication in 52 per cent and limb salvage in 48 per cent of patients. Stents were placed in the SFA in 54 patients (69%), in the POP in 15 patients (18%), and in the TIB artery in 6 patients (8%). Average follow-up was 11.2 months. The mean postprocedural increase in ABI was 0.29. The 6-month, 1-year, and 2-year primary patency rates were 83 per cent, 58 per cent, and 47 per cent, respectively. Limb salvage was achieved in 66 per cent of patients treated for limb-threatening ischemia. There was one major and three minor complications. Stenting of the infra-inguinal vessels has a low morbidity, high success rate, and acceptable patency and limb-salvage rates.     

Thulium:yttrium‐aluminium‐garnet laser prostatectomy in men with refractory urinary retention

OBJECTIVE

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

PATIENTS AND METHODS

Preoperative data and postoperative outcome, as well as complications, were recorded in 65 patients with a history of recurrent urinary retention before surgery (group A), who were compared with a group of 143 men with no recurrent urinary retention (group B).

RESULTS

The mean (sd ) volume of the prostate was 45.6 (22.5) and 43.1 (24.5) mL in groups A and B, respectively. The respective preoperative prostate‐specific antigen levels were 3.6 (7.8) and 2.8 (6.4) ng/mL, the surgical duration 72.4 (28.9) and 65.6 (28.6) min, the mean laser time and energy 32.5 (11.8) min/140.7 (42.1) kJ and 29.4 (11.6) min/117.6 (11.6) kJ, the maximum urinary flow rate after surgery 19.6 (11.2) and 19.1 (9.6) mL/s, and the postvoid residual urine volume 26.7 (36.3) and 20.6 (27.3) mL. Recorded complications were: bleeding, at 3% in group A and 1.4% in group B; urinary tract infection 15.4% and 4.2%; and a second procedure, 3% and 2.3%. Overall, complications were more frequent in group A (P = 0.02).

CONCLUSION

Thulium:YAG prostatectomy is feasible and effective, even in patients with potentially impaired detrusor function. The long‐term durability of these promising results has yet to be confirmed.     

Bilateral intrathoracic kidneys and adrenal glands associated with posterior congenital diaphragmatic hernias

We present a case of bilateral intrathoracic kidneys and adrenal glands associated with bilateral posterior diaphragmatic defects in a symptomatic 18-month-old baby boy. The diaphragmatic defect did not appear to be the typical posterolateral diaphragmatic hernia of Bochdalek. The patient underwent primary surgical correction through an abdominal approach. Postoperatively, the patient enjoyed an uneventful course and was discharged home without any further events. We discuss this report of bilateral intrathoracic kidneys associated with bilateral diaphragmatic hernias, we describe the operative management, and we analyze the possible embryological development of this defect.     

Three-Dimensional Reconstruction of Basal Cell Carcinomas

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer. One of the main problems with BCC is the risk of local recurrence of the tumor after treatment. This is mainly due to its irregular outgrowths, which cannot be detected clinically. OBJECTIVE: To better understand the tumor morphology and growth pattern of BCC, we tried to develop a method that provides a precise three-dimensional model of the tumor. METHODS: Because Mohs surgery provides the best overview of the tumor and the tumor margins (both lateral and in depth), the reconstruction was based on slides from Mohs surgery. After digitization and processing of the slides, the tumor was then surrounded by a Mohs surgeon on a computer screen. These selections (lines) were used for a three-dimensional reconstruction of the tumor using MedSurf3D software. RESULTS: This method allows three-dimensional reconstruction of any given BCC. The MedSurf3D software enables visualization of a three-dimensional model of the tissue, which is removed during the surgical procedure. CONCLUSIONS: Three-dimensional reconstruction is a fascinating tool that might improve our understanding of the behavior, growth pattern, and tumor morphology of BCCs. This technique might also be useful in other fields of cutaneous oncology, such as the calculation of the tumor volume of melanomas.     

Benign breast papilloma: Is surgical excision necessary?

In many centers internationally, current standard of care is to excise all papillomas of the breast, despite recently reported low rates of upgrade to malignancy on final excision. The objective of this study was to determine the upgrade rate to malignancy in patients with papilloma without atypia. A retrospective review of a prospectively maintained database of all cases of benign intraductal papilloma in a tertiary referral symptomatic breast unit between July 2008 and July 2018 was performed. Patients with evidence of malignancy or atypia on core biopsy and those with a history of breast cancer or genetic mutations predisposing to breast cancer were excluded. One hundred and seventy‐three cases of benign papilloma diagnosed on core biopsy were identified. Following exclusions, the final cohort comprised of 138 patients. Mean age at presentation was 51. Mean follow‐up time was 9.6 months. The most common symptom was a lump (40%). Of the 124 patients who underwent excision, three had ductal carcinoma in situ and there were no cases of invasive disease, giving an upgrade rate to malignancy of 2.4%. Upgrade to other high‐risk lesions (atypical lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15 cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had no residual papilloma found on final excision. Twelve patients (8.7%) were managed conservatively. Of those, one later went on to develop malignancy. Patients with a diagnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade to malignancy on final pathology, suggesting that observation may be a safe alternative to surgical excision. Further research is warranted to determine which patients can be safely managed conservatively.