Tag Archive for: urology

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Fellowships – a key ingredient or the ‘icing on the cake’?

What is the ultimate endpoint of a residency or speciality training program? Is it to complete 5 or 6 years of training in core urological procedures? Is it to produce safe, competent independent urologists? Is it to achieve FRSC (Urol) certification? In an ideal world it would be a marriage of all three; a safe, competent, independent, certified, practising urologist ready and eager to tackle any urological referral. In reality, we know that not to be the case.

Urology is a broad and advancing speciality encompassing patients of all ages and both sexes involving a complexity of benign and malignant pathologies. It is unrealistic to be an expert in all the sub-specialties and be able to offer the best and least invasive treatments to our patients. Furthermore, with a necessary emphasis on patient safety, transparency and proficiency, surgical training programs face significant barriers in affording trainees the opportunity to operate, specifically in the working time directive era.

Fellowships are usually undertaken at the completion of higher surgical training scheme often in a centre of excellence overseas. Fellowships offer trainees intensive experience in their niche area. On completion of a coveted fellowship, trainees hope to have acquired and polished the required skills to practice independently in their chosen field.

A recent pan European survey of 219 urological residents demonstrated laparoscopy and robotics were available in 74% and 17% of centres respectively [1]. Only 23% of trainees report their exposure as ‘satisfactory’. 68% have not completed a laparoscopic radical nephrectomy as first operator. Despite this 81% are considering fellowships in laparoscopy.

Buffi et al., have called for a validated and structured training curriculum in robotic surgery [2]. Trainees acknowledge the challenges in the acquisition of such skills but the modularisation of training is the best way to learn a procedure. Step by step trainees can piece together the operations. Hours spent on simulators and in dry and wet laboratories enhances these techniques. Furthermore, the dual consoles offer invaluable experience in robotics, however, are scarcely available.

The governing bodies have a responsibility to maintain standards of training as well as a duty towards patients. Proficiency in modern techniques such as laparoscopy and robotics are deficient in most training programs. Training programs need to encompass these techniques in a modular fashion from an early stage to develop the skills of tomorrows’ urologists [3]. Fellowships will undoubtedly foster and enhance these skills but a core knowledge and technical proficiency even in a simulator setting should be encouraged.

In truth, our learning and development never should never stop.

‘Live as if you were to die tomorrow. Learn as if you were to live forever’ Mahatma Gandhi

Mr Gregory Nason is a Specialist Registrar in Urology at the University Hospital Limerick, Ireland

References

  1. Furriel FTG, Laguna MP, Figueiredo AJ, Nunes PT, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European survey. BJU Int 2013; 112: 1223–28.
  2. Buffi N, Van Der Poel H, Guazzoni G,  Mottrie A, on behalf of the Junior European Association of Urology (EAU) Robotic Urology Section with the collaboration of the EAU Young Academic Urologists Robotic Section. Methods and Priorities of Robotic Surgery Training Program. Eur Urol 2013; epub ahead of print.
  3. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011; 185: 1191-7.

Technological Innovation in the BJUI

Time waits for no man St. Marher, 1225

Urology is arguably the leading technology driven surgical specialty. This is no accident. As surgeons we have always looked towards minimal invasion to reduce the trauma of access to our patients. One would have thought that the advent of drugs for BPH and OAB would perhaps reduce our hunger for technology.You can visit One Click Power if you are always hungry for knowing trends in technology. On the contrary, many urologists have moved on to effective alternatives to TURP such as HoLEP and having learnt the lessons from previous unproven over enthusiasm, relied on the results of high quality randomised trials before accepting the results.

The BJUI has a long history of publishing innovative manuscripts in the fields of basic science, imaging and therapeutics. We aim to bring the readership entire new paradigms in surgical diagnostics and treatment. Indeed while we enjoy #ERUS13 in sunny Stockholm, the autumn sunshine reminds us of the role played by robotics in the steady rise of technological innovation. This “sub specialty” has become so prominent that the EAU are soon accepting ERUS and its committee as an integral part of the European Association of Urology. The randomised trials, meta analysis and health technology assessments are gradually appearing in contemporary literature such that it is no longer true to say that robotics is just a fad backed up by little or poor evidence. Robotics remains one of the most highly cited parts of the BJUI and therefore together with laparoscopy has its own dedicated section. We were pleased to publish the novel method of suprapubic catheterisation as an alternative to the urethral route after robotic prostatectomy [1] which led to much conversation on the BJUI twitter page. Our readers ultimately decide whether to adopt a particular technique or technology and are now able to vote via the BJUI Poll.

Last month, Mahesh Desai demonstrated microPCNL in London. The technology is truly breathtaking. It is hard to believe that light and image transmission as well as stone disintegration can be effectively achieved via a needle so thin! We almost stopped doing robotics and were thinking of re-training to become stone surgeons. Mahesh and his team went on to back up the technology with a randomised comparison against flexible ureterorenoscopy [2]. It should come as no surprise that such an article should come from the sub-continent where stone disease is endemic.

And the technological innovations in the BJUI continue. This month we present three rather different articles for your reading pleasure. The first is an international collaboration demonstrating the ideal dose and safety of photodynamic TOOKAD therapy (a light-activated vascular occluding agent) in localised prostate cancer. Nearly 80% of patients had negative biopsies at 6 months [3]. Next we evaluate the role of PET CT in bladder cancer patients undergoing cystectomy. With almost a 20% greater pickup than standard imaging, we may be able to save a number of patients a morbid operation in the presence of metastasis. Advanced imaging may also allow better stratification of patients for neo-adjuvant chemotherapy [4]. Finally, we have an exciting paper from Iran on the use of endometrial derived stem cells for creating bladder replacements and alternatives to meshes in prolapse surgery. The immuno and scanning electron micrographic images in this paper are just stunning [5].

The BJUI intends to continue leading technological innovation in urology. We will bring our readers early phase safety data on new technologies in addition to long-term results to truly judge their efficacy and durability. We hope you enjoy reading, citing and interacting with these articles online at bjui.org and ultimately translate them to your own clinical practice.

Prokar Dasgupta, Editor in Chief, BJUI
Ben Challacombe, Associate Editor, BJUI
King’s Health Partners

References

  1. Ghani KR, Trinh Q-D, Sammon JD et al. Percutaneous suprapubic tube bladder drainage after robot-assisted radical prostatectomy: a step-by-step guide. BJU Int 2013; 112: 703–705
  2. Sabnis RB, Ganesamoni R, Doshi A, Ganpule AP, Jagtap J, Desai MR. Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013; 112: 355–361
  3. Azzouzi A-R, Barret E, Moore CM. TOOKAD® Soluble vascular-targeted photodynamic (VTP) therapy: determination of optimal treatment conditions and assessment of effects in patients with localised prostate cancer. BJU Int 2013; 112: 766–774
  4. Mertens LS, Fioole-Bruining A, Vegt E, Vogel WV, van Rhijn BW, Horenblas S. Impact of 18F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle. BJU Int 2013; 112: 729–734
  5. Shoae-Hassani A, Sharif S, Seifalian AM, Mortazavi-Tabatabaei SA, Rezaie S, Verdi J. Endometrial stem cell differentiation into smooth muscle cell: a novel approach for bladder tissue engineering in women. BJU Int 2013; 112: 854–863
Original publication of this editorial can be found at: doi 10.1111/bju.12431BJUI 2013; 112: 707.

 

Heroes

Being an Irishman, and enthusiastic rugby supporter, I, like many other rugby fans, was much vexed when our Irish rugby hero, Brian O’Driscoll, was dropped for the deciding Test for the British and Irish Lions versus Australia this summer.  This vexation was due somewhat to national pride, but more importantly, because he is one of my sporting heroes. This outpouring of emotion on the demotion of someone I’ve never met led me to contemplate the nature of heroism and heroes, how they affect us, and specifically how heroes can have a positive impact on urologists in this day and age of constant cynicism towards the noble deeds of others.

Heroism is defined as conduct as exhibited in fulfilling a high purpose or attaining a noble end. To this end, how does my rugby hero qualify? Is it his display of innate skills that thrill the crowd? Is it his professional attitude to the institution of his sport/profession? Is it his ability to overcome adversity for the good of his team?  (These are all attributes I see in my Urological heroes.)  Personally, I think back to moments where I realised that he had done things that I couldn’t even imagine being able to do, and just marvel at them.  Passing the ball to himself and ghosting past the opposition, scoring a length of the field try and being physically ill afterwards due to a pre-existing virus, being listed as ‘likely to play’ for the following week with a personal injury list of ‘concussion, torn hamstring and lacerated ear’. These are levels of physical and athletic prowess unattainable by most people.

 

But what of others that I would class as heroes? It is 50 years this June since the late John F. Kennedy made his famous speech in Berlin, immortalised by the phrase “Ich bin ein Berliner’.  However, his greatest segment is when he lists some of the positives that people were attributing to Communism at the time, and extolling his own personal opposition with the repeated statement ‘Let them come to Berlin!’  Watching the reaction of a group of Berliners to this speech 40 years after its occurrence, seeing them moved to tears by his reiteration of the support of the free world to the citizens of Berlin, this alone is enough to convince me of the heroism of this amazing, somewhat flawed, ever impressive man.

Heroism can also be displayed by people using their professional experience to reach extraordinary outcomes in the face of enormous adversity. Captain Chesley ‘Sully’ Sullenberg, who, after a complete engine failure on his commercial jet, in the space of 180 seconds, managed to control and ditch his plane on the Hudson River in New York, saving 155 souls. His wife, on being told that her husband had landed a multi-ton commercial jet in a river, with no harm to anyone, apparently replied laconically “Oh that sounds like Sully, alright”.

But how does this relate to urologists?  It is my personal belief that the ‘heroes’ we have in society today are not fit for purpose, vacuous celebrities of little consequence in general, and that we would all gain much by having a number of personal and professional heroes that we can use as an example when adversity, conflict, or difficult decisions face us as surgeons. Surgeons should, and often do, aim to attain a noble end. I have many heroes in Urology in particular, and often use their example, and sage-like advice in times of difficulty,

It is extremely easy to live life these days in a manner that loses sight of the wonder and awe with which we held medicine when young. It is easy to live life in a manner where much of it seems jaded and worn. It is easy to believe that there are things we cannot do, goals we cannot reach, achievements we cannot achieve. In these situations, having a hero, whose deeds seem somehow beyond what the rest of us can do, can give us a guide, an example to strive to emulate, attempt to equal, maybe even to surpass.  It is this aspect of heroism which can be utilised as something to be aspired to, for the betterment of all.

On a final note, I am often astounded by the heroism of my patients.  For these people to be able to face ill health, their own frailties and mortality and put their trust in us as surgeons, especially if we are recommending a new or unique form of treatment, is to display a level of trust that definitely puts them in the pantheon of heroes for me.  I believe we owe it to them to remain interested, invigorated and willing to sacrifice ourselves to emulate our heroes, for their benefit.  Heroes are great, everyone should have one!

 

David Bouchier-Hayes is Consultant Urologist and Robotic Surgeon Honoray Clinical Lecturer at the Galway Clinic, Doughiska, Co. Galway, Ireland. Follow him on Twitter @dbh44

Urologists up in arms? ….Diclofenac no longer indicated in high risk groups

This blog is an update form the originally published comment article in BJU International, 110: 607608.
DOI: 10.1111/j.1464-410X.2012.11330.x

On the 23rd June 2013 the MHRA (The Medicines and Healthcare products Regulatory Agency) issued a press release stating that ‘patients with serious underlying heart conditions, such as heart failure, heart disease, circulatory problems or a previous heart attack or stroke should no longer use diclofenac’. The MHRA is responsible for regulating all medicines and medical devices in the United Kingdom (UK) by ensuring they work and are acceptably safe.

 

 

The new guidelines in the UK state:

  • Diclofenac is now contraindicated in patients with established:
     ischaemic heart disease
     peripheral arterial disease
     cerebrovascular disease
    – congestive heart failure (New York Heart Association [NYHA] classification II–IV)

Patients with these conditions should be switched to an alternative treatment at their next routine appointment

  • Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g., hypertension, hyperlipidaemia, diabetes mellitus, smoking).

Now for urologists in the UK this has wider implications. What else are we to use for acute renal colic, chronic pelvic pain, prostatitis, urethritis and any other type of..-itis?

We are treating an ever aging population and the use of non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, will increase. NSAIDs have been the cornerstone of pain relief in patients with first presentation of renal and ureteric lithiasis. The British Association of Urological Surgeons (BAUS) and the European Association of Urology (EAU) guidelines for the acute management of renal and ureteric lithiasis state the first line analgesia is an NSAID e.g. diclofenac [1][2]. There have been a number of clinical trials which have clearly shown that NSAIDs provide effective relief in patients who have acute stone colic [3][4][5].

Controversies of NSAID use

Rofecoxib (trade name Vioxx ®), was approved by the Food and Drug Administration (FDA) in May 1999. The drug was heavily promoted by the global pharmaceutical and chemical company Merck as safer than older generation NSAIDs. The increased risk of stroke was highlighted in a large study, the Vioxx gastrointestinal outcomes research (VIGOR) study, published in the New England Journal of Medicine in 2000. Merck voluntarily took rofecoxib off of the market on 30 September 2004 after research showed that it almost doubled the risk of myocardial infarction and stroke when taken for 18 months or longer. In 2007 Merck paid $4.85bn to settle about 26 000 lawsuits in the United States relating to the drug in state and federal courts.

What are the alternatives suggested?

Naproxen and low-dose ibuprofen are considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAIDs. There is limited evidence for the use of naproxen and low-dose ibuprofen in the management of acute renal colic. We do not know if the efficacy is equivalent to diclofenac. There are a lot of unanswered questions since the press release, but the key questions remain: Is this guidance applicable to us as urologists? And will this change my practice?

This topic is an important area for urologists to be aware of as NSAIDs are prescribed daily in urological practise to a wide range of patients. There is some caution that has to be exercised when reviewing the published data. In a recently published meta-analysis by the Coxib and traditional NSAID Trialists’ (CNT) Collaboration group their data provides further evidence that the vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs.

The majority of trials evaluating the cardiovascular risk of NSAIDs have looked at a group of patients with predominately arthritis or Alzheimer’s disease; not a typical urological cohort of patients. None of the studies in the meta-analysis looked at the short term use of NSAIDs, in particular diclofenac. Some may argue that absolute rates of events were low and clinically irrelevant as the event rates in the included trials are considerably lower than in routine clinical settings.

The options for the treatment of acute urological pain have not changed in the past 15 years. COX-2 selective inhibitors and diclofenac are associated with an increased risk of thrombotic events. Naproxen is associated with a lower thrombotic risk and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. The lowest effective dose of NSAIDs should be prescribed for the shortest period of time to control the symptoms and the need for long term treatment should be reviewed periodically. As we treat an ever aging population with increasing medical co-morbidities the widespread use of NSAIDs has to be evaluated and urologists need to keep up to date with current prescribing guidelines and long term cardiovascular risk factors. 

 

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

References

  1. EAU guidelines on urolithasis. European Association of Urology; 2011. https://www.uroweb.org/gls/pdf/18_Urolithiasis.pdf. Accessed 12 December 2011.
  2. Guidelines for acute management of first presentation of renal/ ureteric lithiasis (excluding pregnancy). British Association of Urological Surgeons; 2008. https://www.baus.org.uk/AboutBAUS/publications/stones-guidelines. Accessed 12 December 2011.
  3. Phillips E, Kieley S, Johnson EB, et al. Emergency room management of ureteral calculi: current practices. J Endourol 2009; 23: 1021–1024.
  4. Micali S, Grande M, Sighinolfi MC, et al. Medical therapy of urolithiasis. J Endourol 2006; 20: 841847.
  5. Engeler DS, Schmid S, Schmid HP. The ideal analgesic treatment for acute renal colic–theory and practice. Scand J Urol Nephrol 2008; 42: 137–142.

 

 

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Early Prostate Cancer Detection. One Canadian Urologist’s Perspective

After seventeen years as a practicing urologist and a further six in training, it amazes me that we still regard prostate cancer as a mystical science and view the issue of screening through the opaque prism of controversy. For so long it seems that the advanced stage disease that I learned about in the mid 1980s in medical school was irreversibly altered by early detection and treatment. Of course we now know that much of this early detection was simply a lead-time bias and that many men who were treated required only observation and were left with many potential compromises to quality of life. “Doctor, my cancer is gone, why am I so miserable?”

At the recent annual meeting of the American Urological Association in San Diego, new guidelines on prostate cancer screening were unveiled. In the past, routine testing at age 50 was recommended with age 40 being the threshold for those at risk. Essentially they can be summarized as:

  • Avoid screening under 40
     
  • Do not routinely screen between 40 and 54 for average risk men. For those at risk screening should be individualized.
     
  • For those between age 55 and 69 there is possibly some benefit and shared decision-making with a patient should be the rule.
     
  • Finally no routine screening after 70.
     
  • PSA should be considered every two years

The motivation for this more cautious recommendation stems for the fact that many men have indolent disease. Many of these men don’t require treatment. Treatment brings with it the potential to harm and therefore casts into doubt the value of any treatment.

The problem of course is while that may represent a possible, cost-effective strategy across the wider population, there is little doubt in my mind that this will lead to many younger and even older men falling through the cracks. It will be justified as too high a number needed to treat to make sense to find these men. Policy makers and health economists may shrug. My own experience is that we have much to learn about risk factors and that many men present seemingly without warning with significant disease.

 

This email from a patient illustrates the concern. Identifiers of course are removed. Both men had disease beyond the capsule of the prostate. Neither man had risk factors. Our patients are very wise and quickly become experts in the disease.

In Canada, the Canadian Urological Association has taken the view for some time that we should look at multiple factors as we “build a case” for prostate biopsy. Its own guidelines reflect this. This paper that we published speaks to the use of nomograms to make better biopsy decisions. Many calculators are available on the web.

So what is shared, informed decision-making? The assumption after the AUA meeting is that somehow patients and their primary care doctors will somehow know. What sort of conversation is happening if urologists themselves don’t seem to provide clear guidance? I suspect it will go something like “PSA doesn’t work, prostate cancer is not lethal and you will likely die from something else” Many family doctors have much of their time rightfully diverted to treating important disease entities such as hypertension, depression and diabetes. A not insignificant number of primary care doctors don’t necessarily even do a DRE anymore. If the urological community conveys the message that prostate cancer is not worth the effort it will further fall down the priority list.

In my view I am a little dismayed by the rhetoric that has started since these guidelines were presented. Much of this is well intentioned and a reaction to years of potential over-treatment. This earlier 2012 piece from the highly respected @OtisBrawley of the American Cancer Society illustrates the false promise of screening message that is being told. It will only be amplified after San Diego. In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.

To many, prostate cancer is simply a benign disease in aging males along the lines of male pattern baldness. This would be a disaster in my view. We have definitely shifted the curve to the left but in addition to lowering overall mortality have greatly lessened the burden of disease complications. Men presenting with hematuria, urinary retention and renal failure has significantly diminished. It is rare that we get asked to insert nephrostomy tubes for advanced disease. This was a common clinical scenario when I was a resident in the early 1990s. I think we will see much more of that if we massively abandon screening.

I think as urologists we have a big responsibility to lead within our local communities. This comment from Dr. A Partin speaks to this very well. In the absence of the perfect pre-test conditions that predict meaningful disease my view is that we have to cast a wide net. In doing so we will uncover disease that does not need to be treated. We must then be prepared to separate diagnosis from treatment and carefully counsel our patients in a way that takes much detail and effort. It is not a five-minute discussion you can have in the middle of a busy clinic. Active Surveillance does work for low-risk disease. Our patients are sophisticated and will not blindly ask for treatment out of overwhelming anxiety. In parallel, we must continue to improve. The risk of biopsy, which has greatly increased over fifteen years, must be modified. Biopsy accuracy to find “real” disease can perhaps be improved with technology such as MRI. Techniques that lessen quality of life issues need to be modified. Robotic surgery can’t be a marketing free-for-all. In other words the onus is on us experts to get it right and do better.

Prostate cancer is a very significant disease and the source of pain and suffering for men and their families. We must continue to be vigilant of its implications, respectful of patient desires and hopeful ultimately of a cure. A benign disease it most certainly is not.

Dr. Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.

Follow him on Twitter at @DrRKSingal

 

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Article of the week: Surgical safety checklist for robotic surgery

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development and content validation of a surgical safety checklist for operating theatres that use robotic technology

Kamran Ahmed, Nuzhath Khan, Mohammed Shamim Khan and Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, UK

Read the full article
OBJECTIVES

• To identify and assess potential hazards in robot-assisted urological surgery.

• To develop a comprehensive checklist to be used in operating theatres with robotic technology.

METHODS

• Healthcare Failure Mode and Effects Analysis (HFMEA), a risk assessment tool, was used in a urology operating theatre with innovative robotic technology in a UK teaching hospital between June and December 2011.

• A 15-member multidisciplinary team identified ‘failure modes’ through process mapping and flow diagrams.

• Potential hazards were rated according to severity and frequency and scored using a ‘hazard score matrix’.

• All hazards scoring ≥8 were considered for ‘decision tree’ analysis, which produced a list of hazards to be included in a surgical safety checklist.

RESULTS

• Process mapping highlighted three main phases: the anaesthesia phase, the operating phase and the postoperative handover to recovery phase.

• A total of 51 failure modes were identified, 61% of which had a hazard score ≥8.

• A total of 22 hazards were finalised via decision tree analysis and were included in the checklist.

• The focus was on hazards specific to robotic urological procedures such as patient positioning (hazard score 12), port placement (hazard score 9) and robot docking/de-docking (hazard score 12).

CONCLUSIONS

• HFMEA identified hazards in an operating theatre with innovative robotic technologies which has led to the development of a surgical safety checklist.

• Further work will involve validation and implementation of the checklist.

 

Read Previous Articles of the Week

 

Editorial: Sergeant, do you copy?

In the Institute of Medicine report published in 1999, it was estimated that 44 000–98 000 patients died annually from preventable medical errors. It was further reported that the annual burden on economy due to preventable medical errors was anywhere between 17–29 billion American dollars. In the USA federal budget 2000–2001, the entire federal resources devoted to general science, space and technology was 19.2 billion American dollars: ≈10 billion less than the cost of medical errors (Fig. 1).

Figure 1. The magnitude of problem caused by medical errors. USDs, American dollars.

On root cause analysis of the errors identified in the Joint Commission on Accreditation and Certification database (2011), it was reported that most of these errors are non-technical, i.e. human factors (72%), leadership (65%), communication breakdown (61%), etc. Furthermore, Greenberg et al. studied the patterns of communication breakdown on the Malpractice Insurers’ Medical Error Prevention Study (MIMEPS) database and concluded that breakdown patterns were similar preoperatively (38%), intraoperatively (30%) and postoperatively (32%). Most errors were due to miscommunication within a single department (78%), as compared with across departments (19%) or institutions (3%). In 49% of the cases, the information was never relayed and in 44% the information relayed was not comprehended appropriately. In all, 29% of these errors involved a surgery attending at transmitting end and 56% at the receiving end of information. In all, 85% of these communications were verbal.

In this issue of BJUI, Ahmed et al. have used the Healthcare Failure Mode and Effect Analysis (HFMEA) model to design a safety checklist specifically for robotic procedures. Checklists have been heavily used in high-risk environments that involve complex technology, e.g. aerospace and nuclear engineering. Robotic surgery is another such high-risk environment, where intraoperative communication is critical. When a surgeon performs a robotic surgery, (s)he is not standing next to the patient (and occasionally not even in the same room!) and relies heavily on his/her assistant. Additionally, the bulky robot takes most of the space around the patient. Small movements of the instruments can cause abrupt and exaggerated movements of the robotic arms, which might injure the bedside assistant, anaesthesiologist, or the patient himself. Last, but not the least, there is a memory clutch on the robotic arms, and its purpose is to ‘remember’ the position of the arms while exchanging the instruments. However, if this clutch is pressed by mistake, all memory is lost and careless insertion of an instrument at this time, making an assumption of memory, can be dangerous and can cause serious injury. The safety checklist described by Ahmed et al. is one of the first checklists specific to robotic surgery. In parallel to this, the Fundamentals of Robotic Surgery (FRS) inter-disciplinary consortium led by Dr Richard Satava has also developed a checklist, specifically for robotic surgery. It will be interesting to study the actual impact of these checklists on prevention of medical errors in robotic surgery. Similar checklists have been validated showing significant clinical correlation using in situ simulation for obstetric emergencies.

Although checklists do help to a certain extent to prevent serious errors, the basics of communications must not be forgotten while communicating to a colleague about patient care. There should be no ambiguity about who is the ‘transmitter’ and who is the ‘receiver’ of information. Both the ‘transmitter’ and ‘receiver’ should have a shared mental model about the purpose of communication (‘transmitter’ is seeking guidance, giving orders, asking for an opinion, referring a case, etc.). Finally, closed-loop communication should be a part of protocol where both the ‘receiver’ and ‘transmitter’ acknowledge the receipt of information, e.g.

Console Surgeon: ‘Please replace the scissors in the right arm with the needle driver’.

Assistant: ‘OK, I am replacing the scissors in your right arm with a needle driver’.

Console Surgeon: ‘Go ahead’.

Assistant: ‘Needle driver coming in’.

Console Surgeon: ‘Perfect. Thank you’.

 

Sanket Chauhan and Robert M. Sweet
Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA

Read the full article

The Perfect Storm: How Hurricane Sandy Took Down Manhattan

Nobody could have really predicted the impact of Hurricane Sandy, which struck Manhattan on October 29, 2012. If you told us a year ago that a hurricane would shut down all of New York City for weeks and that the hospital would be closed for months, we never would have believed it. Six months later, things still have not completely returned to normal.

It all began on what seemed like an ordinary Friday afternoon, as we hurried between clinical duties and research meetings to get some semblance of order before the Halloween weekend. In the midst of the daily hubbub, emails and texts began pouring in about Hurricane Sandy, a massive tropical storm that was projected to hit New York City directly. All 3 hospitals served by the New York University (NYU) are located right along the water in Manhattan and many of the employees live nearby, causing significant concern.

As the storm approached, the lines at the local grocery and convenience stores grew exponentially, wrapping around aisles and often out the door and down the street. Shoppers filled carts with everything from toilet paper and toothpaste, to bottled water and batteries. As soon as their inventory was sold out, shop owners locked their doors and boarded up their windows in preparation for the storm.

When the meteorologists’ worst predictions appeared to be imminent, a mandatory evacuation order was issued for parts of east and southeast Manhattan. The inhabitants of these neighborhoods, many of which included the faculty, staff, residents, and medical students of NYU, migrated to the homes of friends and family. Others, whose apartments were just outside the evacuation zone, hunkered down for what was going to be a long, dark, cold, and wet night.

A few hours after the storm began to hit Manhattan, a massive explosion rocked the electric plant that supplies power to the lower half of Manhattan. Suddenly the skyline was transformed as half of New York City went completely dark, from 39th Street all the way to the southern tip of Battery Park. Without power, there was no electricity, no heat, and no hot water. The winds howled, uprooting trees and tearing down street signs, all while the rain flew sideways. The streets lining the East River flooded early and slowly rescinded overnight, leaving a wake of debris. When morning came, the residents of Manhattan peered out their windows to investigate the damage of the storm, not knowing what to expect.

The New York University (NYU) Department of Urology covers 3 hospitals. The Manhattan VA Hospital was evacuated in advance of the storm, with all of the patients transferred to other veterans’ hospitals in neighboring cities. Bellevue Hospital and NYU Langone Medical Center initially continued to operate during the storm, but were ultimately evacuated when the emergency power supply failed. Many of you may have seen the dramatic TV footage of babies from the ICU being ventilated while carried by nurses down the dark staircases to evacuate the hospital. The efforts made by the clinical staff to ensure patient safety during that time were truly heroic.

In the first few days after the storm, the lower half of Manhattan was like a war zone. With all of the skyscrapers, many people had to walk up and down 10-30 flights of stairs in the dark to look for food or supplies. Some of the elderly people in our neighborhood were unable to do this, so they literally sat in a dark apartment for >10 days eating whatever food remained in the pantry. There was also intermittent internet and cell phone service in the area, leaving people with a very eerie and disconnected feeling. The streets were mostly desolate, with many stores closed and some of them looted. Sanitation was another issue. Without any running water, many people used small amounts of their precious bottled water to flush the toilet once a day. Bags of refuse were carried up and down the dark staircases for disposal. And this is New York, what some (New Yorkers at least) would consider the “center of the universe!” With the world usually at your fingertips, many New Yorkers have never had to think about survival skills. Of course, CNN and other TV news stations featured all kinds of seemingly helpful tips during Hurricane Sandy on how to manage without electricity or running water, but most people who desperately needed this information had no way to watch these segments. Instead makeshift cell phone charging stations were set up along the street for desperate residents hoping to reconnect.

Mass confusion ensued. Many people’s homes and cars were flooded or destroyed. Military vehicles began to appear around the city to help restore order. The hospitals remained closed and patients were dispersed. There was no way to access the electronic medical record to find out the names and contact information for patients on the upcoming schedule. Even the institutional email system was down, so employees didn’t know when, where or if they needed to report to work. Insurance companies had their work cutout for them. Some even went to the extent of reducing their rates on new insurances and provided the cheapest van insurance and car insurances to the new policy holders. Collision repair technicians fix the outer body of cars. These technicians can also be trained in repairing internal components of a damaged automobile. Formal training is not always required, as many repair shops train employees on the job, but obtaining a degree or certification can assist in employment prospects. For people who owns a car, getting an insurance for it is a matter to be given a deep thought. Everyone knows that car insurance costs high, yet, important. The idea behind this gives the reason why premiums are a very dear commodity. However, in this new age of car insurances, a new type of car policy is born! This is one of the short-term insure companies introduced and termed the car insurance for one week. A car only insured for a one-week period. with this short coverage, the user or buyer of this insurance is not being prompted with so much requirements, unlike the regular or normal car policy in which many documentary, unlike the regular or normal car policy in which many documentary requisites are being asked to be prepared. Click here to find more about the author.

Over time, the city gradually started to reopen. A limited bus service began working at no charge, but the lines were several blocks long and the crowding was extreme. Most of the subway stations were flooded and it took several weeks to months for the subway and train services to be restored. There were also gas shortages leading to rationing. People had to wait for 2+ hours in line at the gas station, resulting in crazy stories like this one where a man pulled out a gun to jump the line.

Meanwhile, as soon as the airports reopened many foreigners began arriving into the midst of this scene for the New York City Marathon, which was supposed to take place the following weekend. With half of New York City flooded and in the dark, a huge controversy erupted over diverting scarce resources to allow the marathon to proceed. The New York Post ran a cover story exposing how power generators were being used to prepare the media tents for the marathon, and the race was ultimately cancelled <48 hours beforehand – too late for the many foreign runners who wasted huge sums of money and time making their way to storm-ravaged NYC unnecessarily.

On the clinical side, many NYU physicians obtained emergency privileges to practice in New Jersey. Nevertheless, this involved a long commute (>1 hour) for both patients and physicians to unfamiliar surroundings. In addition, most of these hospitals already operate at capacity. Office space was not available for the “displaced physicians” and it was often difficult just to find a free computer to use. Imagine if the entire staff from another hospital was suddenly transferred to your hospital – where would you put them and how could you accommodate their patients? Many surgeries could only be booked on nights or weekends when the OR was not in use by the local physicians, and could be bumped at the last minute. On-call coverage had to be reorganized to provide care for our patients all over the tri-state area, which was particularly challenging without the regular train and bus services to these areas. Bellevue and NYU Hospital began to partially reopen at the end of December 2012, and the Manhattan VA remained completely closed until March 2013. Even now, some of the clinical services at these hospitals have not been completely restored as the long repair process continues.

From the research standpoint, the impact was huge. Loss of the emergency generators caused many precious research experiments to be lost. Imagine if you collected special samples from around the world for your laboratory, or if you had stored tissue from patients with 20 years of follow-up data. Then one day a big storm came and it all washed away. Some of these things simply cannot be replaced. The situation was similarly bleak for clinical research since the server was also destroyed, resulting in massive data losses. Imagine that you got a grant, hired research personnel, completed several years of data collection and analysis, and even saved an extra copy of your work on the backup server, but suddenly all of that was gone. You could apply for an extension on your grant or insurance money for what was lost in the natural disaster, but it could take years to get back to where you were and this type of intellectual property loss is difficult to even quantify. The original personnel may not be available to re-do the work, the idea may no longer be timely, and what you really want to do is move forward with your research not spend months to years repeating what was already done.

What can we learn from this? Unfortunately, natural disasters happen, and many of the issues that transpired are impossible to predict or prevent, particularly at the individual level. If there are warnings about a major storm, take it very seriously. Keep a section in the closet with some basic supplies like batteries, flashlights, a radio and an emergency list of contacts. Make sure that all electronic devices are fully charged and that your data are backed up as much as possible in different locations. And hope that nothing like this ever happens again.

Dr. Stacy Loeb is an Assistant Professor of Urology and Population Health at New York University and is a Consulting Editor for BJUI. Follow her on Twitter @LoebStacy

Dr. Marc Bjurlin is a Fellow in Urologic Oncology at New York University.

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Article of the week: Centralized simulation training combines technical and non-technical skills

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity

Mohammad Shamim Khan, Kamran Ahmed, Andrea Gavazzi, Rishma Gohil, Libby Thomas*, Johan Poulsen, Munir Ahmed, Peter Jaye* and Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital , *Simulation and Interactive Learning (SaIL) Centre, Guy’s & St Thomas NHS Foundation Trust , and Department of Urology, Aalborg Denmark and King’s College Hospital, London, UK

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OBJECTIVES

• To establish the feasibility and acceptability of a centralized, simulation-based training-programme.

• Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills.

MATERIALS AND METHODS

• For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme.

• The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA] , Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills.

• The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales.

RESULTS

• In total 33, three specialist registrars of different grades and five urological nurses participated in the present study.

• Construct-validity between junior and senior trainees was signifi cant. Of the participants, 90% rated the training models as being realistic and easy to use.

• In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized.

• A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills.

CONCLUSIONS

• A centralized simulation programme that provides training in both technical and non-technical skills is feasible.

• It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

 

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Editorial: The need to devise a better means of training

There is increasing concern that current UK trainees at the end of their training are less experienced than their previous counterparts and continue to require more education, skills and support when they assume their consultant posts in the form of mentoring.

It is generally accepted that the numbers of hours required to become an ‘expert’ is 10 000–30 000 and currently in the UK our trainees experience =6000 h of training. Much of this is due to the impact of the European Working Time Directive (EWTD) and the government ‘New Deal’ initiative on junior doctors contracts introduced in 2003. The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD. Skills training has therefore been seen as the mechanism to resolve the situation, encompassing the acquisition of both technical and non-technical skills. The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them.

Contemporary urology training is moving out of clinical practice and simulation is increasingly used to provide a safe and supportive learning environment for learning and maintaining skills. However, this needs the following criteria:

• An agreed curriculum

• Agreed set of standards

• A validated form of assessment

• The availability of local and national skills centres

• Educators and trainers

The problem is that traditionally the UK has few training centres, together with a lack of trained manpower and funding. However, controversy still remains over the efficacy of simulation for training and those who are able to fund such projects comment on the paucity of available data in relation to the predictability of future outcomes and patient safety.

Projects such as the Simulation and Technology enhanced Learning Initiative (STeLI) initiative documented in this paper are important contributors to the evidence base. The programme aims to establish the feasibility and acceptability of a centralised, simulation-based system incorporating both skills and non-technical skills aspects of training. The latter involving crisis resource management using the SimMan model to teach team-working, decision-making, and communication skills in various settings between senior and junior trainees. Not surprisingly senior trainees scored significantly better on virtual reality simulators, bench-top box trainers and the European wet-lab training facility, as well as in human patient simulation training in crisis resource management (CRM) using SimMan, than junior trainees. The interesting point raised in this paper is that the trainees’ behaviour shows the value of inclusion of the CRM training and the interplay between technical and non-technical skills. Non-technical skills have often been sidelined in courses focusing on technical skills acquisition and this paper highlights the importance and added-value of incorporating such a skill set into future course content and curricula.

Thus, there is no doubt that some surgical skills can be learned in the laboratory and although this will never be a substitute for operative experience, the first steps of training can be accelerated with potential reduction of risk to patients. Increasingly data from sources such as the STeLI project underline a better appreciation of the importance of the training in non-technical skills, which equip surgeons in working under stress and more importantly working as a team player. However, the ultimate test for simulation is whether the model and content is able to reduce surgical errors, improve patient safety and reduce operative time and costs. To try and answer these questions BAUS in conjunction with the Specialist Advisory Committee (SAC) in Urology have recognised that the technology is there but there is a need to identify trainers keen to train, with the nomination of a national lead for simulation to develop a national strategy to deliver a viable programme aligned to the curriculum to try and answer the important question: ‘Does simulation enhance real-life performance of a surgical technique?’.

Adrian D. Joyce
St James’ University Hospital, Leeds LS9 7TF, UK

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