Evaluation of Urology Residency Training and Perceived Resident Abilities in the United States.

OBJECTIVE: To identify differences and potential deficiencies in urology residency training programs in the United States as they are perceived by residents/recent graduates and program directors. MATERIALS AND METHODS: A 45-question and 38-question survey was sent to chief residents/recent graduates and program directors, respectively, at all 120 US urology programs regarding prior medical education, urologic training curricula, and perceived surgical proficiency, among other topics. RESULTS: Survey response rate was 58% and 52% for residents and program directors, respectively. Responses regarding program characteristics (e.g., salary, vacation) and research training were similar between program directors and residents. However, their responses regarding skills training and subspecialty training (e.g., robotics and pediatrics) differed substantially. Program directors reported the availability of advanced skills trainers (robot-88%, laparoscopic-86%), whereas fewer residents felt they were available (robot 54% and laparoscopic 72%). The same discrepancies persisted with questions about subspecialty exposure (e.g., program directors reported 48% renal transplant experience vs. 13% reported by residents). Most residents felt comfortable performing essential urology procedures (e.g., cystoscopy/ureteroscopy, open nephrectomy). In contrast, the majority expressed a lack of confidence in performing unsupervised advanced minimally invasive procedures (e.g., laparoscopic and robotic partial nephrectomy, endopyelotomy). Among the responding residents, 72% pursued fellowship training; nearly two-thirds of these residents chose to enter fellowship in order to overcome perceived training deficiencies. CONCLUSIONS: Program directors and residents have differing perceptions regarding the education and resources associated with US urology residency training programs. US graduates of urology residency programs express a perceived lack of confidence in several procedures that are commonly encountered in a general urologic practice.

Clinical outcomes of patients with nondiagnostic biopsy during cryoablation of small renal masses.

OBJECTIVE: To compare the outcomes of patients with biopsy-proven renal cell carcinoma (RCC), benign tumors (BTs), and nondiagnostic (ND) biopsies after renal cryoablation (RC). METHODS: We retrospectively reviewed medical records of 114 patients who underwent RC between 2003 and 2013. Patients were stratified according to biopsy histopathology results-RCC, BT, and ND biopsy. We recorded patient demographics and tumor features and examined oncologic outcomes among the 3 groups. RESULTS: RC was performed in 114 patients with 117 tumors. Seventy-two tumors (61.5%) were RCC, 18 (15.4%) were BTs (oncocytoma or angiomyolipoma), and 27 (23.1%) were ND. Patient characteristics and tumor features were similar among the 3 groups. The median follow-up was 26.5, 26.0, and 22.0 months in the RCC, BT, and ND biopsy groups, respectively (P = .18). Residual disease occurred in the RCC (1.4%) and ND biopsy (7.4%) groups, but not in the BT group (P = .19). All 9 patients (12.5%) who developed recurrent disease had biopsy-proven RCC. The 2- and 5-year recurrence-free survival rates (RFS) for patients with biopsy-proven RCC were 90.2% and 81.2%, respectively. Because no patient in the BT and ND biopsy groups had a recurrence, their RFS was 100%. CONCLUSION: No patient with a BT or ND biopsy developed a local recurrence with short-term follow-up, whereas a recurrence developed in 12.5% of biopsy-proven RCC tumors. RFS for patients with biopsy-proven RCC was worse than the other 2 biopsy groups, although not statistically significant. Long-term follow-up in a larger cohort of patients is needed to further evaluate these preliminary findings.

Comparison of outcomes in patients undergoing percutaneous renal cryoablation with sedation vs general anesthesia.

OBJECTIVE: To compare the efficacy and safety of local anesthesia with conscious sedation (LACS) with general anesthesia (GA) in patients undergoing percutaneous renal cryoablation (PRC) for renal cortical neoplasms. METHODS: We performed a retrospective review of patients undergoing PRC between 2003 and 2013. Patient demographics, tumor characteristics, and perioperative and postoperative follow-up data were recorded and analyzed. We compared 3 principal outcomes across the GA and LACS groups: anesthesia-related outcomes, treatment failure, and complications. RESULTS: A total of 235 patients with available data were included. Of these, 82 underwent PRC under GA and 153 patients under LACS. The 2 groups were similar with regard to age, gender, body mass index, American Society of Anesthesiologists score, tumor features, preoperative serum creatinine level, and hematocrit value. The GA and LACS groups had a similar percentage of patients with biopsy-proven renal cell carcinoma (68.5% and 64.2%, respectively; P = .62). The mean follow-up time for GA and LACS was 37 and 21 months, respectively (P <.0001). The mean procedure time for GA was significantly longer compared with LACS (133 vs 102 minutes; P <.001), and the mean hospital stay was shorter under LACS (1.08 vs 1.95 days; P <.0001). There was no difference in immediate failure (0% and 1.9%; P = .051) or recurrences (11% and 3.9%, respectively; P = .051) between GA and LACS groups. There was no difference in intraoperative and postoperative treatment-related complications between the 2 groups. CONCLUSION: PRC for small renal masses under LACS is effective and safe. PRC with LACS has the advantage of decreased procedure time and a shorter hospital stay.

Development and initial porcine and cadaver experience with three-dimensional printing of endoscopic and laparoscopic equipment.

INTRODUCTION: Recent advances in three-dimensional (3D) printing technology have made it possible to print surgical devices. We report our initial experience with the printing and deployment of endoscopic and laparoscopic equipment. MATERIALS AND METHODS: We created computer-aided designs for ureteral stents and laparoscopic trocars using SolidWorks. We developed three generations of stents, which were printed with an Objet500 Connex printer, and a fourth generation was printed with an EOSINT P395 printer. The trocars were printed with an Objet30 Pro printer. We deployed the printed stents and trocars in a female cadaver and in vivo porcine model. We compared the printed trocars to two standard trocars for defect area and length using a digital caliper. Paired T-tests and ANOVA were used to test for statistical difference. RESULTS: The first two generations of stents (7F and 9F) were functional failures as their diminutive inner lumen failed to allow the passage of a 0.035 guidewire. The third generation 12F stent allowed passage of a 0.035 guidewire. The 12F diameter limited its deployment, but it was introduced in a cadaver through a ureteral access sheath. The fourth-generation 9F stents were printed and deployed in a porcine model using the standard Seldinger technique. The printed trocars were functional for the maintenance of the pneumoperitoneum and instrument passage. The printed trocars had larger superficial defect areas (p<0.001) and lengths (p=0.001) compared to Karl Storz and Ethicon trocars (29.41, 18.06, and 17.22 mm(2), respectively, and 14.29, 11.39, and 12.15 mm, respectively). CONCLUSIONS: In this pilot study, 3D printing of ureteral stents and trocars is feasible, and these devices can be deployed in the porcine and cadaver models. Three-dimensional printing is rapidly advancing and may be clinically viable in the future.

Evaluation of a novel trocar-site closure and comparison with a standard Carter-Thomason closure device.

PURPOSE: The aim of this study was to evaluate and compare a novel trocars-site closure device, the WECK EFx™ Endo Fascial Closure System (EFx) with the Carter-Thomason CloseSure System® (CT) for the closure of laparoscopic trocar site defects created by a 12-mm dilating trocar. METHODS: We created standardized laparoscopic trocars-site abdominal wall defects in cadaver models using a standard 12-mm laparoscopic dilating trocar. Trocar defects were closed in a randomized fashion using one of the two closure systems. We recorded time and number of attempts needed for complete defect closure. In addition, we recorded the ability to maintain pneumoperitoneum, endoscopic visualization, safety, security, and facility based on the surgeon's subjective evaluations. We compared outcomes for the EFx and CT closure systems. RESULTS: We created 72 standardized laparoscopic trocars-site abdominal wall defects. The mean time needed for complete defect closure was 98.53 seconds (±28.9) for the EFx compared with 133.61 seconds (±54.61) for the CT (P<0.001). The mean number of attempts needed to achieve complete defect closure were 1.19 (1-3) for the EFx and 1.19 (1-2) for the CT (P=0.50). Mean scores for safety were 2.92 for EFx vs 2.19 for CT (P<0.001). Mean scores for facility were 2.97 vs 1.83 for EFx and CT, respectively (P<0.001). Mean scores for maintenance of pneumoperitoneum were 1.97 for EFx vs 2.33 for CT (P=0.022). No significant difference was observed between the EFx and the CT systems for endoscopic visualization (2.28 vs 2.50, P=0.080). CONCLUSIONS: In this in vitro cadaver trial, the EFx was superior in terms of time needed to complete defect closure, safety, and facility. CT was superior in terms of maintenance of pneumoperitoneum. Both systems were equal in the number of attempts needed to complete the defect closure and endoscopic visualization.