Publications by authors named "Domenico Veneziano"

50 Publications

Development methodology of the novel Endoscopic Stone Treatment step 2/A (EST s2/A) training/assessment curriculum and a roadmap on developing hands on training curriculums in future: An international collaborative work by EAU sections.

J Endourol 2021 May 18. Epub 2021 May 18.

University Hospitals Southampton NHS Trust, Urology, Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland, SO16 6YD.

Background: Basic simulation training in endourology was established with the endoscopic stone treatment step 1(EST s1), which is now recognised worldwide for training and examination. Following on from EST s1, the EST s2 was started by the EAU sections.

Objective: We describe the methodology used in the development of Endoscopic Stone treatment step 2(EST s2) assessment curriculum.

Material And Methods: The "full-life cycle curriculum development" template was followed for curriculum development, focussing on intermediate training of EST protocol with complex endourological tasks. A cognitive task analysis(CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EULIS(EAU Urolithiasis Section) experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in EUREP 2019 and in phase five the protocol was finalised with full tutor instruction sheet.

Results: The EST-s2/A curriculum development, took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology (ESU) training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees respectively. While the experts agreed that EST s2/A protocol was well structured (96%), covered the complex endourological manoeuvres (92%) and was useful to optimise and improve hands-on-training sessions (92%), the overall evaluation was scored 4.25/5 by trainees.

Conclusion: We describe the development methodology for intermediate endoscopic stone treatment curriculum, which also provides a roadmap on developing other hands-on training protocols in future.
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http://dx.doi.org/10.1089/end.2021.0040DOI Listing
May 2021

A systematic review of nerve-sparing surgery for high-risk prostate cancer.

Minerva Urol Nephrol 2021 Jun 13;73(3):283-291. Epub 2021 Jan 13.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Introduction: We provide a systematic analysis of nerve-sparing surgery (NSS) to assess and summarize the risks and benefits of NSS in high-risk prostate cancer (PCa).

Evidence Acquisition: We have undertaken a systematic search of original articles using 3 databases: Medline/PubMed, Scopus, and Web of Science. Original articles in English containing outcomes of nerve-sparing radical prostatectomy (RP) for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: erectile function (EF) and urinary continence.

Evidence Synthesis: The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on odds ratio (OR) for positive margin and biochemical relapse. The presented results showed no effect of nerve sparing (NS) on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (hazard ratio [HR]=0.93, 0.52-1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with and without NSS.

Conclusions: NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.
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http://dx.doi.org/10.23736/S0393-2249.20.04178-8DOI Listing
June 2021

Reply by Authors.

J Urol 2021 03 23;205(3):685. Epub 2020 Dec 23.

Unit of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy.

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http://dx.doi.org/10.1097/JU.0000000000001417.02DOI Listing
March 2021

Deviation from the Protocol of a Randomized Clinical Trial Comparing On-Clamp versus Off-Clamp Laparoscopic Partial Nephrectomy (CLOCK II Laparoscopic Study): A Real-Life Analysis.

J Urol 2021 Mar 9;205(3):678-685. Epub 2020 Oct 9.

Unit of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy.

Purpose: We assess factors/additional morbidities related to the conversion of clamping approach during off-clamp vs on-clamp laparoscopic partial nephrectomy in the setting of a randomized study.

Materials And Methods: Consecutive candidates for laparoscopic partial nephrectomy from 6 institutions were randomized to on-clamp or off-clamp surgery. The present study analyzed 1) off-clamp arm patients, comparing the procedures finalized per protocol without artery clamping (off-clamp) to those needing renal artery clamping (shift-on-clamp) and 2) on-clamp arm patients, comparing the procedures finalized with artery clamping (on-clamp) to those completed without clamping (shift-off-clamp).

Results: A total of 123 patients were randomized to on-clamp and 126 to off-clamp surgery. Of the off-clamp patients 41 (32.5%) converted to on-clamp. Of the on-clamp patients 70 (56.9%) completed surgery without clamping the renal artery due to subjective intraoperative decision of the surgeon. Tumor size was greater in shift-on-clamp vs off-clamp cases (4 vs 3, p=0.002). Conversely, tumor size (3.7 vs 3 cm, p=0.002) and R.E.N.A.L. nephrometry score (6 vs 5, p=0.038) were lower in shift-off-clamp cases. Shift-on-clamp cases had longer operative times and greater changes in estimated glomerular filtration rate on postoperative day 1. Shift-off-clamp cases had shorter operative times. A higher proportion of patients who completed on-clamp surgery per protocol had a greater than 25% drop in estimated glomerular filtration rate on postoperative day 1 (29.4%) compared to smaller changes (10.3%, p=0.009) in estimated glomerular filtration rate. Increasing tumor size and complete endophytic growth pattern predicted shift-on-clamp while preventing shift-off-clamp. Body mass index above 28 predicted shift-off-clamp.

Conclusions: The likelihood of shift-on/off-clamp relies on tumor size/complexity. The intraoperative need to convert the planned strategy seemed harmless on postoperative course. An advantage in terms of early functional outcomes does exist when avoiding artery clamping.
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http://dx.doi.org/10.1097/JU.0000000000001417DOI Listing
March 2021

VR and machine learning: novel pathways in surgical hands-on training.

Curr Opin Urol 2020 11;30(6):817-822

University Hospital Southampton NHS Trust, Southampton, UK.

Purpose Of Review: Surgical training has dramatically changed over the last decade. It has become not only the way to prepare surgeons for their everyday work, but also a way to certify their skills thus increasing patient safety. This article reviews advances in the use of machine learning and artificial intelligence applied to virtual reality based surgical training over the last 5 years.

Recent Findings: Eight articles have been published which met the inclusion criteria. This included six articles about the use of machine learning and artificial intelligence for assessment purposes and two articles about the possibility of teaching applications, including one review and one original research article. All the research articles pointed out the importance of machine learning and artificial intelligence for the stratification of trainees, based on their performance on basic tasks or procedures simulated in a virtual reality environment.

Summary: Machine learning and artificial intelligence are designed to analyse data and use them to take decisions that typically require human intelligence. Evidence in literature is still scarce about this technology applied to virtual reality and existing manuscripts are mainly focused on its potential to stratify surgical performance and provide synthetic feedbacks about it. In consideration of the exponential growth of computer calculation capabilities, it is possible to expect a parallel increase of research about this topic within the next few years.
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http://dx.doi.org/10.1097/MOU.0000000000000824DOI Listing
November 2020

Artificial intelligence in the diagnosis, treatment and prevention of urinary stones.

Curr Opin Urol 2020 11;30(6):782-787

University Hospital Southampton NHS Trust, UK.

Purpose Of Review: There has a been rapid progress in the use of artificial intelligence in all aspects of healthcare, and in urology, this is particularly astute in the overall management of urolithiasis. This article reviews advances in the use of artificial intelligence for the diagnosis, treatment and prevention of urinary stone disease over the last 2 years. Pertinent studies were identified via a nonsystematic review of the literature performed using MEDLINE and the Cochrane database.

Recent Findings: Twelve articles have been published, which met the inclusion criteria. This included three articles in the detection and diagnosis of stones, six in the prediction of postprocedural outcomes including percutaneous nephrolithotomy and shock wave lithotripsy, and three in the use of artificial intelligence in prevention of stone disease by predicting patients at risk of stones, detecting the stone type via digital photographs and detecting risk factors in patients most at risk of not attending outpatient appointments.

Summary: Our knowledge of artificial intelligence in urology has greatly advanced in the last 2 years. Its role currently is to aid the endourologist as opposed to replacing them. However, the ability of artificial intelligence to efficiently process vast quantities of data, in combination with the shift towards electronic patient records provides increasingly more 'big data' sets. This will allow artificial intelligence to analyse and detect novel diagnostic and treatment patterns in the future.
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http://dx.doi.org/10.1097/MOU.0000000000000820DOI Listing
November 2020

Editorial: Artificial intelligence and simulation in urology.

Curr Opin Urol 2020 11;30(6):747

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy.

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http://dx.doi.org/10.1097/MOU.0000000000000818DOI Listing
November 2020

Role of immersive technologies in healthcare education during the COVID-19 epidemic.

Scott Med J 2020 Nov 2;65(4):112-119. Epub 2020 Sep 2.

Consultant Urologist, Department of Urology, St James's University Hospital, Leeds, UK.

The unparalleled epidemic of the novel coronavirus (COVID-19), during early December 2019 in Wuhan, China, has rapidly evolved into a global pandemic, became a matter of grave concern. The pandemic presented a unique challenge to government agencies worldwide. The paucity of resources and lack of knowledges to manage the pandemic, coupled with the fear of future consequences has established the need for adoption of emerging and future technologies to address the upcoming challenges. With introduction of measures to control the pandemic, trainees will see a dramatic decline in their in-person exposure to all aspects of their education, with no clear endpoint. This presents an extreme challenge for educators and, given the rapidly evolving situation, there have not yet been training authorities recommendations. We propose several innovative solutions to deliver medical education while maintaining the safety of residents and educators.
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http://dx.doi.org/10.1177/0036933020956317DOI Listing
November 2020

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial.

Surg Endosc 2021 Aug 26;35(8):4183-4191. Epub 2020 Aug 26.

MRC Centre for Transplantation, King's College London, Guy's Hospital, King's Health Partners, London, SE1 9RT, UK.

Background: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH.

Methods: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants.

Results: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047).

Conclusions: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice.

Trial Registration: ISRCTN 83733979.
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http://dx.doi.org/10.1007/s00464-020-07899-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263395PMC
August 2021

Simulator Availability Index: a novel easy indicator to track training trends. Is Europe currently at a urological training recession risk?

Cent European J Urol 2020 6;73(2):231-233. Epub 2020 Apr 6.

ESUT-YAU Working Party.

Introduction: To evaluate the European trend regarding the availability of surgical simulators and to propose a novel index to easily track this trend.

Material And Methods: During European Urology Residents Education Program, from 2014 to 2018, residents were asked through an anonymous survey about the availability of specific simulator training boxes at their department. The Simulator Availability Index (SAI) was made by the ratio between the number of departments with at least one box trainer and the total number of departments evaluated.

Results: The SAI decreased in five years from 0.47 to 0.41 for laparoscopic trainers, while the already low initial SAI (0.17) decreased by up to 0.05 in four years for both ureteroscopy (URS) and transurethral resection (TUR) trainers.

Conclusions: A self-analysis may be advisable in order to improve the spread of information and investigate whether any specific reasons may be responsible for this trend. The SAI might be a simple but useful tool to monitor and evaluate this trend in the context of national training plans.
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http://dx.doi.org/10.5173/ceju.2020.0048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407789PMC
April 2020

The performance improvement-score algorithm applied to endoscopic stone. Treatment step 1 protocol.

Minerva Urol Nefrol 2020 Aug 4. Epub 2020 Aug 4.

Department of Urology, University of Southampton, Southampton, UK.

Background: Pi-score (Performance Improvement score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training.

Methods: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during 4 courses in Barcelona and Milan. Collected data were independently analysed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa Statistics was used for comparison analysis.

Results: 16 Hands-on Training expert tutors and 47 3rd year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task1=0.30 ("fair"); Task2=0.18 ("slight"); Task3=0.10 ("slight"); Task4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task1=0.74 ("substantial"); Task2=0.71 ("substantial"); Task3=0.46 ("moderate"); Task4=0.49 ("moderate").

Conclusions: Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.
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http://dx.doi.org/10.23736/S0393-2249.20.03747-9DOI Listing
August 2020

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

BJU Int 2021 01 19;127(1):56-63. Epub 2020 Oct 19.

Urology Unit, San Carlo di Potenza, Potenza, Italy.

Objective: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19.

Methods: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month.

Results: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions.

Conclusion: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.
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http://dx.doi.org/10.1111/bju.15149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322984PMC
January 2021

Do prostate cancer-related mobile phone apps have a role in contemporary prostate cancer management? A systematic review by EAU young academic urologists (YAU) urotechnology group.

World J Urol 2020 Oct 22;38(10):2411-2431. Epub 2020 Apr 22.

University Hospital Southampton NHS Trust, Southampton, UK.

Aims And Objectives: To review the available literature regarding the use of prostate cancer-related mobile phone applications (PCA).

Materials And Methods: The search was for English language articles between inceptions of databases to June 2019. Medline, EMBASE, Cochrane Library, CINAHL and Web of Science were searched. Full-text articles were reviewed, and the following data were extracted to aid with app analysis: name of application, developer, platform (Apple App Store or Google Play Store) and factors assessed by the article.

Results: The search yielded 1825 results of which 13 studies were included in the final review. 44 PCAs were identified from the data collected of which 59% of the PCAs had an educational focus. 11 apps were inactive and 5 weren't updated within the last year. Five studies focused on the development and testing of apps (MyHealthAvatar, CPC, Rotterdam, Interaktor, NED). Two studies evaluated the readability of PCAs. Most PCAs had a reading level greater than that of the average patient. Two studies evaluated the quality and accuracy of apps. Majority of PCAs were accurate with a wide range of information. The study reported most PCAs to have deficient or insufficient scores for data protection. Two studies evaluated the accuracy of Rotterdam, CORAL and CPC risk calculators. Rotterdam was the best performer.

Conclusions: PCAs are currently in its infancy and do require further development before widespread integration into existing clinical practise. There are concerns with data protection, high readability standards and lack of information update in current PCAs. If developed appropriately with responsible governance, they do have the potential to play important roles in modern-day prostate cancer management.
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http://dx.doi.org/10.1007/s00345-020-03197-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508932PMC
October 2020

Evaluation of the "Teaching Guide for Basic Laparoscopic Skills" as a stand-alone educational tool for hands-on training sessions: a pilot study.

World J Urol 2021 Jan 21;39(1):281-287. Epub 2020 Mar 21.

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy.

Introduction And Objectives: Standardization of hands-on training (HoT) has profoundly impacted the educational field in the last decade. To provide quality training sessions on a global scale, the European School of Urology Training group developed a teaching guide for tutors in 2015. Our study aims to understand whether this guide alone can provide information enough to match the performance improvement guaranteed by an expert tutor.

Material And Methods: 4 randomized groups of participants underwent HoT sessions with different teaching modalities: an expert surgeon (group 1), an expert E-BLUS tutor (group 2), E-BLUS guide alone (group 3), no tutor (group 4). Groups 1 and 2 were respectively provided with two different tutors to avoid biases related to personal tutor ability. Along the training session, each participant could perform five trials on two E-BLUS tasks: Peg transfer and Knot tying. During trials 1 and 5, completion time and number of errors were recorded for analysis with Pi-score algorithm. The average per-group Pi-scores were then compared to measure different performance improvement results.

Results: 60 participants from Italy were enrolled and randomized into four groups of 15. Pi-scores recorded on Peg transfer task were 24,6 (group 1), 26,4 (group 2), 42,2 (group 3), 11,7 (group 4). Pi-scores recorded on Knot tying task were 33,2 (group 1), 31,3 (group 2), 37,5 (group 3), 18,6 (group 4).

Conclusion: Compared to a human tutor, standardized teaching with the EBLUS guide may produce similar performance improvement. This evidence opens doors to automated teaching and to several novelties in hands-on training.
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http://dx.doi.org/10.1007/s00345-020-03161-8DOI Listing
January 2021

Artificial intelligence and neural networks in urology: current clinical applications.

Minerva Urol Nefrol 2020 Feb 12;72(1):49-57. Epub 2019 Dec 12.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

Introduction: As we enter the era of "big data," an increasing amount of complex health-care data will become available. These data are often redundant, "noisy," and characterized by wide variability. In order to offer a precise and transversal view of a clinical scenario the artificial intelligence (AI) with machine learning (ML) algorithms and Artificial neuron networks (ANNs) process were adopted, with a promising wide diffusion in the near future. The present work aims to provide a comprehensive and critical overview of the current and potential applications of AI and ANNs in urology.

Evidence Acquisition: A non-systematic review of the literature was performed by screening Medline, PubMed, the Cochrane Database, and Embase to detect pertinent studies regarding the application of AI and ANN in Urology.

Evidence Synthesis: The main application of AI in urology is the field of genitourinary cancers. Focusing on prostate cancer, AI was applied for the prediction of prostate biopsy results. For bladder cancer, the prediction of recurrence-free probability and diagnostic evaluation were analysed with ML algorithms. For kidney and testis cancer, anecdotal experiences were reported for staging and prediction of diseases recurrence. More recently, AI has been applied in non-oncological diseases like stones and functional urology.

Conclusions: AI technologies are growing their role in health care; but, up to now, their "real-life" implementation remains limited. However, in the near future, the potential of AI-driven era could change the clinical practice in Urology, improving overall patient outcomes.
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http://dx.doi.org/10.23736/S0393-2249.19.03613-0DOI Listing
February 2020

Is remote live urologic surgery a reality? Evidences from a systematic review of the literature.

World J Urol 2020 Oct 7;38(10):2367-2376. Epub 2019 Nov 7.

USC Institute of Urology and Catherine and Joseph, University of Southern California, Los Angeles, CA, USA.

Introduction And Objectives: The possibility of performing remote-surgery has been the goal to achieve, since the early development of the first surgical robotic platforms. This systematic review aims to analyse the state of the art in the field and to provide an overview of the possible growth of this technology.

Methods: All English language publications on Telementoring and Telesurgery for minimally invasive urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed, Scopus, and Web of Science™ databases (up to June 2019).

Results: Our electronic search identified a total of 124 papers in PubMed, Scopus, and Web of Science. Of these, 81 publications were identified for detailed review, which yielded 22 included in the present systematic review. Our results showed that remote surgery has been under-utilised until today, mostly due to the lack of appropriate telecommunication technologies.

Conclusion: Remote live surgery is a growing technology that is catalyzing incremental interest. Despite not being yet reliable today on a regular basis in its most advanced applications, thanks to the advent of novel data-transmission technologies, telepresence might become a critical educational methodology, highly impacting the global healthcare system.
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http://dx.doi.org/10.1007/s00345-019-02996-0DOI Listing
October 2020

Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience.

Turk J Urol 2020 01 21;46(1):37-43. Epub 2019 Oct 21.

SLK-Kliniken Urology Department, Heidelberg University, Heilbronn, Germany.

Objective: The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management.

Material And Methods: A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed.

Results: The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages.

Conclusion: A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.
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http://dx.doi.org/10.5152/tud.2019.19008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944418PMC
January 2020

What is the standard surgical approach to large volume BPE? Systematic review of existing randomized clinical trials.

Minerva Urol Nefrol 2020 Feb 10;72(1):22-29. Epub 2019 Oct 10.

Department of Urology, University of Florence, Florence, Italy.

Introduction: In the past years several reviews have analysed different aspects of surgical techniques for patients with LUTS due to BPE however none of them have concentrated on large prostates treatment exclusively. Moreover, none of the reviews have focused on level 1 evidence which is essential to avoid bias and wrong conclusions. With this knowledge in mind, aim of the present review is to analyze the available randomized clinical trials assessing the management of patients with big prostates (>80 cc).

Evidence Acquisition: A systematic review of the literature using the Medline, Scopus and Web of Science databases for relevant articles published until January 2019 was performed using both the Medical Subjects Heading and free test protocols. The search was conducted by combining the following terms: "Enucleation," "Prostate," "Benign Prostatic Hyperplasia," "Holmium," "laser," "adenomectomy," "Randomized clinical trial," "Big" "large" "prostate," ">80," "≥80," "transurethral resection of prostate," "Thulium," "Diode," "laparoscopy," "robotic," "Plasmakinetic," "green light" "532 nm" "YAG" "Lower Urinary tract symptoms". Only randomized clinical trials were included in the analysis.

Evidence Synthesis: Overall 9 RCTs were retrieved with most of them reporting data at 1 year. The present trials compared enucleation, vaporization and open techniques between each other. In terms of perioperative outcomes all the techniques had similar operative times and resected weight however catheterization time and hospital stay were better in endoscopic techniques when compared to open surgery. In terms of functional outcomes (IPSS, QMAX and PVR) none of the techniques was proven superior to the other. When considering complications open procedures carried a higher risk of transfusions while no technique was proven superior to the others in terms of transient urge urinary incontinence, bladder neck contracture and reintervention. Only one trial was retrieved reporting five years data confirming the safety, efficacy and durability of simple prostatectomy SP and holmium laser enucleation of the prostate at five years.

Conclusions: According to our review no technique may be considered better than the other when treating large adenomas. Studies are still lacking to prove long term efficacy and future studies should clarify the role of prostatic artery embolization and minimally invasive simple prostatectomy in the management of prostates larger than 80 mL.
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http://dx.doi.org/10.23736/S0393-2249.19.03589-6DOI Listing
February 2020

Climbing over the Barriers of Current Imaging Technology in Urology.

Eur Urol 2020 02 12;77(2):142-143. Epub 2019 Oct 12.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy.

We are facing an era of disruption in the field of anatomic visualisation. The future standard in urology will probably emerge from among several possibilities that are outlined here.
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http://dx.doi.org/10.1016/j.eururo.2019.09.016DOI Listing
February 2020

Anterograde ejaculation preservation after endoscopic treatments in patients with bladder outlet obstruction: systematic review and pooled-analysis of randomized clinical trials.

Minerva Urol Nefrol 2019 Oct 4;71(5):427-434. Epub 2019 Sep 4.

Department of Urology, University of Catania, Catania, Italy.

Introduction: Despite the high rate of resolution, ejaculatory dysfunction still is the most common side effect related to surgical treatment of bladder outlet obstruction (BOO). The aim of the present systematic review was to compare several technological treatment modalities for the management of lower urinary tract symptoms/BOO in terms of functional and sexual outcomes.

Evidence Acquisition: All English language randomized controlled trials assessing the impact of different endoscopic treatments for BOO were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus®, and Web of Science™ databases (up to June 2019).

Evidence Synthesis: Our electronic search identified a total of 2221 papers in PubMed, Scopus, and Web of Science. Of these, 142 publications were identified for detailed review, which yielded 21 included in the present systematic review. All groups appeared similar with regards to preoperative IPSS/AUA Score, Qmax, and prostate volume (cc). Patients undergoing endoscopic treatments using ThuLEP, Greenlight or Prostate Artery Embolization techniques had lower-but not statistically significant- relative risk (RR) of retrograde ejaculation compared with conventional transurethral resection of the prostate (TURP) (RR: 0.90; P=0.35; RR: 0.71; P=0.1; RR0.73; P=0.11). Efficacy of those techniques was equal to TURP.

Conclusions: Data reporting anterograde ejaculation preservation after endoscopic treatment in patients with benign prostatic enlargement are sparse and heterogeneous. Pooled analyses suggest that new technological alternatives to conventional TURP might improve sexual outcomes, especially for non-ablative treatments.
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http://dx.doi.org/10.23736/S0393-2249.19.03588-4DOI Listing
October 2019

The industrial revolution for the management of benign prostate obstruction: worldwide publication trends for surgical and medical therapies over the past two decades.

Cent European J Urol 2019 26;72(2):149-155. Epub 2019 Apr 26.

Consultant Urological Surgeon (Endourology Lead), University Hospital Southampton, NHS Trust Southampton, United Kingdom.

Introduction: Research for management of benign prostate obstruction (BPO) for adult males remains a cornerstone of urology research. This landscape has witnessed the rise and fall of multiple therapies, both surgical and medical. Our aim was to formally evaluate the publication trends for these interventions over the past 20 years.

Material And Methods: A systematic search was performed in a Cochrane style. Data was analysed using the independent t-test and Pearson's correlation coefficient (SPSS version 24). To observe changes in trends more effectively, data was sub-divided into two time periods: 1997 to 2006 and 2007 to 2016.

Results: Over the past 20 years, 4236 papers have been published concerning for BPO (surgical, n = 2177 and medical, n = 2059). For surgical treatments, these included articles on monopolar transurethral resection of prostate (TURP) (n = 340), bipolar TURP (n = 260), HoLEP (n = 293) and Greenlight laser (n = 395). For medical therapies, these included alpha blockers (848), 5-alpha reductase inhibitors (n = 618) and PDE5I (n = 91). Between the two time periods the change was +18.8% (p = 0.108) for monopolar TURP, +497.1% (<0.001) for bipolar TURP, -54.5% (p <0.001 for prostatic stents and -81.9% (p <0.001) for transurethral microwave therapy (TUMT). There was over 290% rise in number of publications related to BPO laser surgery (p <0.001). For medical interventions, the change was +11.5% (p = 0.397) for alpha blockers, -1.9% (p = 0.867), +49.0%( 0.122) for phytotherapy, +2075% (p <0.001) for PDEI and +2375.0% (p <0.001) for combined alpha blocker and anti-muscarinics.

Conclusions: Interventions for BPO have undergone a high volume of research. In particular, minimally invasive laser surgeries and combined medical therapies have seen significant expansion.
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http://dx.doi.org/10.5173/ceju.2019.1876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715083PMC
April 2019

Impact of Three-dimensional Printing in Urology: State of the Art and Future Perspectives. A Systematic Review by ESUT-YAUWP Group.

Eur Urol 2019 08 18;76(2):209-221. Epub 2019 May 18.

Uro-technology and SoMe Working Group of the Young Academic Urologists (YAU) Working Party of the European Association of Urology (EAU), Arnhem, The Netherlands; Department of Urology and Renal Transplantation, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy.

Context: Three-dimensional (3D) printing has profoundly impacted biomedicine. It has been used to pattern cells; replicate tissues or full organs; create surgical replicas for planning, counseling, and training; and build medical device prototypes and prosthetics, and in numerous other applications.

Objective: To assess the impact of 3D printing for surgical planning, training and education, patient counseling, and costs in urology.

Evidence Acquisition: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Evidence Synthesis: After screening, 4026 publications were identified for detailed review, of which 52 were included in the present systematic review: two papers reported the use of 3D-printing modeling for adrenal cancer, two papers for urethrovesical anastomosis, 24 papers for kidney transplantation and renal cancer, 13 papers for prostate cancer, seven papers for pelvicalyceal system procedures, and three papers for ureteral stents, and three papers reported 3D-printed biological scaffold development.

Conclusions: Three-dimensional printing shows revolutionary potentials for patient counseling, pre- and intraoperative surgical planning, and education in urology. Together with the "patient-tailored" presurgical planning, it puts the basis for 3D-bioprinting technology. Although costs and "production times" remain the major concerns, this kind of technology may represent a step forward to meet patients' and surgeons' expectations.

Patient Summary: Three-dimensional printing has been used for several purposes to help the surgeon better understand anatomy, sharpen his/her skills, and guide the identification of lesions and their relationship with surrounding structures. It can be used for surgical planning, education, and patient counseling to improve the decision-making process.
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http://dx.doi.org/10.1016/j.eururo.2019.04.044DOI Listing
August 2019

Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study.

World J Urol 2020 Jan 13;38(1):239-246. Epub 2019 Apr 13.

Department of Urology, La Paz University Hospital, Madrid, Spain.

Purpose: To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures.

Methods: A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed.

Results: A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤  50 h per week, laparoscopic training and having laparoscopic training boxes.

Conclusions: Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.
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http://dx.doi.org/10.1007/s00345-019-02763-1DOI Listing
January 2020

Validation of the endoscopic stone treatment step 1 (EST-s1): a novel EAU training and assessment tool for basic endoscopic stone treatment skills-a collaborative work by ESU, ESUT and EULIS.

World J Urol 2020 Jan 27;38(1):193-205. Epub 2019 Mar 27.

Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Introduction: The endoscopic stone treatment step 1 (EST s1) protocol has been developed after 2 years of collaborative work between different European Association of Urology (EAU) sections.

Objectives: In this study, we added construct validity evidence to the EST s1 curriculum.

Materials And Methods: The EST-s1 curriculum includes four standardized tasks: flexible cystoscopy, rigid cystoscopy, semi-rigid URS and flexible URS. Validation was performed during the annual 2016 EUREP meeting in Prague. 124 participants provided information on their endoscopic logbook and carried out these 4 tasks during a DVD recorded session. Recordings were anonymized and blindly assessed independently by five proctors. Inter-rater reliability was checked on a sample of five videos by the calculation of intra-class correlation coefficient. Task-specific clinical background of participants was correlated with their personal performance on the simulator. Breakpoint analysis was used to define the minimum number of performed cases, to be considered "proficient". "Proficient" and "Non-proficient" groups were compared for construct validity assessment. Likert scale-based questionnaires were used to test content and to comment on when the EST-s1 exams should be undertaken within the residency program.

Results: 124 participants (105 final-year residents and 19 faculty members) took part in this study. The breakpoint analysis showed a significant change in performance curve at 36, 41, 67 and 206 s, respectively, corresponding to 30, 60, 25 and 120 clinical cases for each of the 4 tasks. EST-s1 was scored as a valid training tool, correctly representing the procedures performed in each task. Experts felt that this curriculum is best used during the third year of residency training.

Conclusion: Our validation study successfully demonstrated correlation between clinical expertise and EST-s1 tasks, adding construct validity evidence to it. Our work also demonstrates the successful collaboration established within various EAU sections.
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http://dx.doi.org/10.1007/s00345-019-02736-4DOI Listing
January 2020

Comparison between near-infrared fluorescence imaging with indocyanine green and infrared imaging: on-bench trial for kidney perfusion analysis. A project of the ESUT-YAUWP group.

Minerva Urol Nefrol 2019 Jun 18;71(3):280-285. Epub 2019 Mar 18.

Department of Urology and Kidney Transplantation, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria, Italy.

Background: Infrared thermography (IRT) imaging technology is able to measure surface temperatures in real-time. The aim of our study is to understand whether IRT imaging is a reliable technology for the assessment of kidney-parenchyma perfusion with warm fluids.

Methods: We used three porcine kidneys as a sample. IRT was compared to Near-infrared fluorescence (NIRF) technology with Indocyanine Green (ICG), X-rays with Contrast medium was used as a benchmark. Each kidney, placed inside an incubator, was perfused with contrast medium by a vascular 6-Fr catheter, to preview the perfusable parenchymal area. 100 mL of saline solution at 45 °C was then administered along a five-minutes time, followed by a second administration of 2/10 diluted ICG solution. A FLIR© C2 IR camera was used to acquire thermal data. During ICG administration, image acquisition was obtained with FireFly technology, with a 0° endoscopic camera. Quantitative variables are described using median and quartiles.

Results: Real-time evaluation by IRT showed that, after five minutes of perfusion, it was possible to highlight the same parenchymal areas as visualized by X-ray. The IR images showed that surface temperature rise was directly reflecting local perfusion with heated saline solution. Analysis of NIRF technology and ICG showed an overlap between the two technologies. In addition to the compared technology, IR provided separate temperature measurement for each pixel in real time. Our findings were replicable on all the three kidneys examined. Higher resolution IR-cameras could provide even more detailed information.

Conclusions: Although NIRF technology with ICG is providing more image detail, we demonstrated that IRT is capable of detecting kidney parenchyma perfusion with warm fluids. Further studies will show its feasibility in graft re-perfusion assessment during kidney transplant or similar applications.
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http://dx.doi.org/10.23736/S0393-2249.19.03353-8DOI Listing
June 2019

Outcomes of European Basic Laparoscopic Urological Skills (EBLUS) Examinations: Results from European School of Urology (ESU) and EAU Section of Uro-Technology (ESUT) over 6 Years (2013-2018).

Eur Urol Focus 2020 11 17;6(6):1190-1194. Epub 2019 Jan 17.

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy.

Background: The European School of Urology (ESU) and EAU Section of Uro-Technology (ESUT) started hands-on-training (HOT) sessions in 2007 along with structured European Basic Laparoscopic Urological Skills (EBLUS) examinations in 2013. EBLUS includes an online theoretical course, HOT by expert tutors on a set of dry-lab exercises, and finally a standardised examination for skill assessment and certification.

Objective: To analyse the results and predictors of success from the EBLUS examinations that were conducted during the European Urology Residents Education Programme (EUREP) and other international and national dedicated ESU events.

Design, Setting, And Participants: ESU has been delivering EBLUS courses and examinations over the past 6 yr (2013-2018) in more than 40 countries worldwide. Trainees were asked about their laparoscopic background (procedures assisted/performed) and about the availability of HOT or simulator/box trainer in their facility. Apart from the online theoretical course, 4 HOT tasks [(1) peg transfer, (2) pattern cutting, (3) single knot tying, and (4) clip and cut] with its quality assessment of depth perception, bimanual dexterity, and efficiency were a part of the assessment and were considered critical to pass the EBLUS examination.

Results And Limitations: A total of 875 EBLUS examinations were delivered (EUREP, n=385; other ESU events, n=490), with complete data available for 533 (61%) participants among which 295 (55%) passed the examinations. Pass rate increased on a yearly basis from 35% to 70% (p<0.001) and was similar between EUREP (56%) and other ESU/ESUT events (55%). The significant predictors of success were passing tasks 1 [odds ratio (OR): 869.9, 95% confidence interval (CI): 89.6-8449.0, p<0.001] and 2 (OR: 3045.0, 95% CI: 99.2-93 516.2, p<0.001) of the examinations. A limitation of EBLUS was its inability to provide more advanced training such as wet-lab or cadaveric training.

Conclusions: Over the past few years more trainees have passed the European Basic Laparoscopic Urological Skills (EBLUS) examinations. Trainees who spend more time on laparoscopic procedures demonstrated a better performance and pass rate. We found almost no difference between the EBLUS results collected from EUREP and other ESU/ESUT events, which confirms the robustness of the training and examinations conducted worldwide.

Patient Summary: Training in laparoscopy helps trainees pass the European Basic Laparoscopic Urological Skills (EBLUS) examinations, reflected by an increase in the pass rate over the past 6 yr. Our results also confirm the robustness of EBLUS training and examinations worldwide.
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http://dx.doi.org/10.1016/j.euf.2019.01.007DOI Listing
November 2020

Performance Improvement (Pi) score: an algorithm to score Pi objectively during E-BLUS hands-on training sessions. A European Association of Urology, Section of Uro-Technology (ESUT) project.

BJU Int 2019 04 28;123(4):726-732. Epub 2018 Dec 28.

ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.

Objective: To evaluate the variability of subjective tutor performance improvement (Pi) assessment and to compare it with a novel measurement algorithm: the Pi score.

Materials And Methods: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. We collected data during eight courses on the four European Association of Urology training in Basic Laparoscopic Urological Skills (E-BLUS) tasks. The same tutor instructed on all courses. Collected data were independently analysed by 14 hands-on training experts for Pi assessment. Their subjective Pi assessments were compared for inter-rater reliability. The average per-participant subjective scores from all 14 proctors were then compared with the objective Pi-score algorithm results. Cohen's κ statistic was used for comparison analysis.

Results: A total of 50 participants were enrolled. Concordance found between the 14 proctors' scores was the following: Task 1, κ = 0.42 (moderate); Task 2, κ = 0.27 (fair); Task 3, κ = 0.32 (fair); and Task 4, κ = 0.55 (moderate). Concordance between Pi-score results and proctor average scores per participant was the following: Task 1, κ = 0.85 (almost perfect); Task 2, κ = 0.46 (moderate); Task 3, κ = 0.92 (almost perfect); Task 4 = 0.65 (substantial).

Conclusion: The present study shows that evaluation of Pi is highly variable, even when formulated by a cohort of experts. Our algorithm successfully provided an objective score that was equal to the average Pi assessment of a cohort of experts, in relation to a small amount of training attempts.
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http://dx.doi.org/10.1111/bju.14621DOI Listing
April 2019