Comparative effectiveness of telesimulation versus standard simulation for pediatric Minimally Invasive Surgery (MIS) essential skills training.

BACKGROUND: Proctored on site simulation-based surgical education has been integrated in our residents curricula since 2012. Due to COVID-19 pandemic and social distance protocols, we developed a Tele-assisted Essential Skills Training Module (T-ESTM). The aim of this study is to evaluate comparative effectiveness between Telesimulation (T) versus Standard Simulation (S) for minimally invasive surgery (MIS) essential skills training. METHODS: ESTM includes academic lectures, tutorials for ergonomics and 7 hands-on tasks scheduled into 2 sessions of 3 hours. Initial and final assessment scoring (adapted from GOALS) as well as timing for 3 of the tasks were registered. Telesimulation (T) group accessed the content online and completed their Hands-On practice through a digital communication platform. Standard Simulation (S) group attended conferences and Hands-On practice at the simulation center. Both groups were proctored by the same educators with summative and formative feedback and debriefing. Data was analyzed with the R-studio software program. RESULTS: Each group had 20 participants with a mean age of 28 ± 5 years. 67.5% were surgeons in training, 47.5% had performed low complexity procedures and 40% had previous experience with simulation training. We observed a significant improvement in scoring and time reduction for all assessed tasks in S and T groups (p < 0.001), with no statistically significant differences when comparing both groups. Similar performance could be achieved with both strategies. CONCLUSION: Telesimulation is a reproducible and effective educational tool for remote MIS essential skills training, and should be considered as an alternative to on-site simulation programs. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Clinical Research.

Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? - A preliminary report.

OBJECTIVE: Androgens have a positive effect on penile growth in children, but they may also have a repressive effect on the healing process. The aim of this prospective study was to compare the outcomes of onlay urethroplasty with and without preoperative androgen stimulation in patients with severe hypospadias. PATIENTS AND METHOD: Of 300 severe hypospadias cases treated at a single institution, 126 operated on by the same surgeon had complete follow-up data, and 30 of these received preoperative androgen treatment (human chorionic gonadotrophin and/or systemic testosterone) 1-24 months before surgery. RESULTS: Thirty-five patients presented with a complication (27.7%) of whom 26 (20.6%) had a fistula or dehiscence. Among patients on androgen stimulation there was a 30% healing complication rate (9/30) whereas for those without this was 17.7% (17/96). When androgenic treatment was given > 3 months prior to surgery the healing complication rate was 21.7% (5/23), and when < 3 months prior to surgery the rate reached 57% (4/7). Mean follow up was 41 months (10-97). CONCLUSION: Although the numbers were too small in this series to reach statistical significance, the tissular interactions of androgens in the healing process reported by dermatologists should alert the hypospadiologists and lead to a further prospective study to define the optimal protocol for stimulation of the penis in specific cases without affecting outcome.

Outcome of severe hypospadias repair using three different techniques.

OBJECTIVE: To compare the outcomes of three different urethroplasty techniques (onlay, buccal mucosa, Koyanagi type I) used in the reconstruction of severe hypospadias. PATIENTS AND METHODS: Over 10 years (1997-2007), 300 severe hypospadias cases were treated with a mean follow up of 2 years (1-105 months); 203 were operated by the same surgeon of whom 184 completed follow up. Three main techniques were used according to the quality of the urethral plate: onlay urethroplasty (133), buccal graft urethroplasty (25) and Koyanagi type I (26). The mean age at surgery was 36 months (8-298); 76 required preoperative androgen stimulation (onlay 37, buccal 11, Koyanagi 26); 18 required a corporoplasty to straighten the penis (onlay 13, buccal 3, Koyanagi 2). RESULTS: Thirty-eight onlay (28.5%); 14 buccal (56%); 16 Koyanagi (61.5%) urethroplasties had a complication. The fistula rate was 15% for the onlay group; 32% for the buccal mucosa group; 19.2% for the Koyanagi cases. The dehiscence rate was, respectively, 11.3%, 20% and 42.3%. The stricture rate was, respectively, 1.5%, 20% and 34.6%. Urethrocele was found in seven Koyanagi patients. Final functional and cosmetic results were satisfactory in 126/133 (94.7%) onlay, 20/25 (80%) buccal and 14/26 Koyanagi (53.8%) urethroplasties. Primary cases had better results (89%) than redo cases (75.9%). Patients submitted to preoperative androgen therapy developed more complications (onlay: 40.5% vs 23.9%; buccal: 70% vs 43.7%). CONCLUSION: Two striking results are the low number of severe hypospadias cases requiring an additional corporoplasty, and the increased complication rate found in androgen-stimulated patients. The excellent results of the onlay procedure could be related to the use of dorsal preputial tissue, which in hypospadias is characterized by a well-balanced protein platform compared to the ventral tissues.

Colite do cólon excluso: modelo experimental em ratos

In 1981 Glotzer et al. described a kind of proctocolitis, limited to a segment of colon, excluded from the fecal stream, with pathological features similar to the ulcerative colitis. The purpose of the present study was to establish a experimental model in order to evaluate the pathologic alterations of the colonic mucosa, excluded from the intestinal transit. Thirty five PUCPR Wistar male rats, with a mean age of 120 days were allocated in 4 groups. Under ether anesthesia, the animals were submitted to a 0,5cm resection of the left colon. A proximal terminal colostomy was performed and the distal rectal stump was closed. The excluded segment of the bowel was evaluated macro and microscopically a week (A group), 2 weeks (D group), 4 weeks (B group) and 8 weeks (C group) after the operation. The inflammatory reaction, collagen concentration and changes in the goblets cells were analyzed .Mo was considered the features of the excluded colon seen at the beginning of the experiment and Mf was these features seen at the end of experiment. When we compared these two different phases of the experiment, we verified that a mild acute and cronic inflammatory reaction was present in all of the groups. Ulcers were seen in 11 colons (p=0,0010) and they were not related to the exclusion phase. A significant reduction in the thickness of the colonic wall was observed in all the specimens. In Mo, the mature collagen (type I) was the predominant one (p=0.008) whereas in Mf, the immature collagen ( type III) was the predominant one (p=0.008). Reduction of total collagen, loss of collagen type I and the increase of collagen type III were constant. There was no significant change in the percentage of area occupied by the goblets cells. It was concluded that in rats, the exclusion of the distal colon by colostomy of up to 8 weeks, determines: colon atrophy and the occurrence of superficial ulcerated lesions with low-level inflammatory reaction.

Em 1981 Glotzer et al. descreveram um tipo de proctocolite, semelhante à retocolite ulcerativa, limitado ao segmento excluído do trânsito fecal, na ausência de doença intestinal inflamatória. O presente estudo tem por finalidade avaliar as alterações ocorridas no cólon após sua exclusão do trânsito, com o fim de se estabelecer um modelo em ratos que permita estudar a doença. Utilizaram-se 35 ratos Wistar-PUCPR, machos com 120 dias de idade, divididos em 4 grupos. Sob anestesia inalatória procedeu-se à laparotomia mediana, secção transversa do cólon esquerdo e colectomia de 0,5 cm par se ter o padrão inicial (Mo). Seguiu-se o fechamento do coto distal, colostomia terminal com maturação precoce do coto proximal e laparorrafia. Realizaram-se as verificações nos seguintes tempos: grupo A após uma semana, grupo D após 2 semanas, grupo B após 4 semanas e grupo C após 8 semanas. Avaliou-se o cólon excluído macro e microscópicamente (Mf) analisando-se: a reação inflamatória, a concentração de colágeno e o comportamento das células caliciformes. Comparadas os momentos Mo e Mf registrou-se a presença de úlceras em 11 cólons (p=0,0010) não relacionadas com o tempo de exclusão. Reação inflamatória agudo-crônica ou crônica discreta esteve presente em todos os tempos. Em todos os cólons observou-se diminuição significante da espessura da parede. No Mo predominou o colágeno tipo I (p=0,008) enquanto que no Mf o predomínio foi do colágeno III (p=0,008). Foi constante a diminuição do colágeno total, a perda de colágeno I e o aumento de colágeno III. Não houve mudança significante do percentual de área ocupada por células caliciformes. Conclui-se que a exclusão do cólon distal, de até 8 semanas, no rato por colostomia determina: atrofia do cólon e o aparecimento de lesões ulceradas superficiais com reação inflamatória discreta.