Interdisciplinary planning improves radiologist obtained access for percutaneous nephrolithotomy.

INTRODUCTION: Proper antegrade access for percutaneous nephrolithotomy (PCNL) is essential for success but can be challenging. Previous work evaluating access obtained by interventional radiology (IR), largely in the emergent setting, has shown high rates of additional access at the time of PCNL. We hypothesize that efforts to improve pre-procedural communication between urology and IR can impact the utility of the access for subsequent PCNL. MATERIAL AND METHODS: We conducted a retrospective review of patients undergoing PCNL at a single hospital from January 2011 to December 2022. Adult patients undergoing PCNL with established preoperative access were included. RESULTS: A total of 141 cases were identified with preoperative access. A total of 111 patients had evidence of planning with IR prior to antegrade access. There were high rates of anatomic abnormality (50%) and staghorn calculus (53%). Patients with planned access had higher body mass index (BMI). While preoperative access was initially utilized in 97% of cases, 6% required additional access to be obtained intraoperatively; this included a low rate of new access in those that were previously discussed with IR (4% vs. 17%, p = 0.02). Overall stone free rates (91%), rates of second stage procedures (55%) and complications (14%) were similar between planned and unplanned groups. CONCLUSION: In this retrospective study of complex patients with large stone burden presenting for PCNL with preoperative antegrade access obtained by IR, the rate of new access was far lower than prior reports. This was likely influenced by urologist involvement in planning access.

The impact of intraoperative fluid management during laparoscopic donor nephrectomy on donor and recipient outcomes.

BACKGROUND: Intraoperative fluid management during laparoscopic donor nephrectomy (LDN) may have a significant effect on donor and recipient outcomes. We sought to quantify variability in fluid management and investigate its impact on donor and recipient outcomes. METHODS: A retrospective review of patients who underwent LDN from July 2011 to January 2016 with paired kidney recipients at a single center was performed. Patients were divided into tertiles of intraoperative fluid management (standard, high, and aggressive). Donor and recipient demographics, intraoperative data, and postoperative outcomes were analyzed. RESULTS: Overall, 413 paired kidney donors and recipients were identified. Intraoperative fluid management (mL/h) was highly variable with no correlation to donor weight (kg) (R = 0.017). The aggressive fluid management group had significantly lower recipient creatinine levels on postoperative day 1. However, no significant differences were noted in creatinine levels out to 6 months between groups. No significant differences were noted in recipient postoperative complications, graft loss, and death. There was a significant increase (P < 0.01) in the number of total donor complications in the aggressive fluid management group. CONCLUSIONS: Aggressive fluid management during LDN does not improve recipient outcomes and may worsen donor outcomes compared to standard fluid management.

A Video-Based Coaching Intervention to Improve Surgical Skill in Fourth-Year Medical Students.

OBJECTIVE: For senior medical students pursuing careers in surgery, specific technical feedback is critical for developing foundational skills in preparation for residency. This pilot study seeks to assess the feasibility of a video-based coaching intervention to improve the suturing skills of fourth-year medical students. DESIGN: Fourth-year medical students pursuing careers in surgery were randomized to intervention vs. control groups and completed 2 video recorded suture tasks. Students in the intervention group received a structured coaching session between consecutive suturing tasks, whereas students in the control group did not. Each coaching session consisted of a video review of the students' first suture task with a faculty member that provided directed feedback regarding technique. Following each suturing task, students were asked to self-assess their performance and provide feedback regarding the utility of the coaching session. All videos were deidentified and graded by independent faculty members for evaluation of suture technique. SETTING: The University of Michigan Medical School in Ann Arbor, Michigan. PARTICIPANTS: All fourth-year medical students pursuing careers in surgical specialties were contacted via e-mail for voluntary participation. In all, 16 students completed both baseline and follow up suture tasks. RESULTS: All students who completed the coaching session would definitely recommend the session for other students. A total of 94% of the students strongly agreed that the exercise was a beneficial experience, and 75% strongly agreed that it improved their technical skills. Based on faculty grading, students in the intervention group demonstrated greater average improvements in bimanual dexterity compared to students in the control group; whereas students in the control group demonstrated greater average improvements in domains of efficiency and tissue handling compared to the intervention group. Based on student self-assessments, those in the intervention group had greater subjective improvements in all scored domains of bimanual dexterity, efficiency, tissue handling, and consistency compared to the control group. Subjective, free-response comments centered on themes of becoming more aware of hand movements when viewing their suturing from a new perspective, and the usefulness of the coaching advice. CONCLUSIONS: This pilot study demonstrates the feasibility of a video-based coaching intervention for senior medical students. Students who participated in the coaching arm of the intervention noticed improvements in all domains of technical skill and noted that the experience was overwhelmingly positive. In summary, video-based review shows promise as an educational tool in medical education as a means to provide specific technical feedback.

Resident Surgeons Underrate Their Laparoscopic Skills and Comfort Level When Compared With the Rating by Attending Surgeons.

OBJECTIVE: The development of operative skills during general surgery residency depends largely on the resident surgeons' (residents) ability to accurately self-assess and identify areas for improvement. We compared evaluations of laparoscopic skills and comfort level of residents from both the residents' and attending surgeons' (attendings') perspectives. DESIGN: We prospectively observed 111 elective cholecystectomies at the University of Michigan as part of a larger quality improvement initiative. Immediately after the operation, both residents and attendings completed a survey in which they rated the residents' operative proficiency, comfort level, and the difficulty of the case using a previously validated instrument. Residents' and attendings' evaluations of residents' performance were compared using 2-sided t tests. SETTING: The University of Michigan Health System in Ann Arbor, MI. Large academic, tertiary care institution. PARTICIPANTS: All general surgery residents and faculty at the University of Michigan performing laparoscopic cholecystectomy between June 1 and August 31, 2013. Data were collected for 28 of the institution's 54 trainees. RESULTS: Attendings rated residents higher than what residents rated themselves on a 5-point Likert-type scale regarding depth perception (3.86 vs. 3.38, p < 0.005), bimanual dexterity (3.75 vs. 3.36, p = 0.005), efficiency (3.58 vs. 3.18, p < 0.005), tissue handling (3.69 vs. 3.23, p < 0.005), and comfort while performing a case (3.86 vs. 3.38, p < 0.005). Attendings and residents were in agreement on the level of autonomy displayed by the resident during the case (3.31 vs. 3.34, p = 0.85), the level of difficulty of the case (2.98 vs. 2.85, p = 0.443), and the degree of teaching done by the attending during the case (3.61 vs. 3.54, p = 0.701). CONCLUSIONS: A gap exists between residents' and attendings' perception of residents' laparoscopic skills and comfort level in performing laparoscopic cholecystectomy. These findings call for improved communication between residents and attendings to ensure that graduates are adequately prepared to operate independently. In the context of changing methods of resident evaluations that call for explicitly defined competencies in surgery, it is essential that residents are able to accurately self-assess and be in general agreement with attendings on their level of laparoscopic skills and comfort level while performing a case.

Paraspinous muscle as a predictor of surgical outcome.

BACKGROUND: Objective measures for preoperative risk assessment are needed to inform surgical risk stratification. Previous studies using preoperative imaging have shown that the psoas muscle is a significant predictor of postoperative outcomes. Because psoas measurements are not always available, additional trunk muscles should be identified as alternative measures of risk assessment. Our research assessed the relationship between paraspinous muscle area, psoas muscle area, and surgical outcomes. METHODS: Using the Michigan Surgical Quality Collaborative database, we retrospectively identified 1309 surgical patients who had preoperative abdominal computerized tomography scans within 90 d of operation. Analytic morphomic techniques were used to measure the cross-sectional area of the paraspinous muscle at the T12 vertebral level. The primary outcome was 1-y mortality. Analyses were stratified by sex, and logistic regression was used to assess the relationship between muscle area and postoperative outcome. RESULTS: The measurements of paraspinous muscle area at T12 were normally distributed. There was a strong correlation between paraspinous muscle area at T12 and total psoas area at L4 (r = 0.72, P <0.001). Paraspinous area was significantly associated with 1-y mortality in both females (odds ratio = 0.70 per standard deviation increase in paraspinous area, 95% confidence interval 0.50-0.99, P = 0.046) and males (odds ratio = 0.64, 95% confidence interval 0.47-0.88, P = 0.006). CONCLUSIONS: Paraspinous muscle area correlates with psoas muscle area, and larger paraspinous muscle area is associated with lower mortality rates after surgery. This suggests that the paraspinous muscle may be an alternative to the psoas muscle in the context of objective measures of risk stratification.