Andrea G. Lantz

Emergency department use by CTAS Levels IV and V patients

INTRODUCTION Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use. METHODS The survey was administered to Canadian Emergency Department Triage and Acuity Scale (CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005. RESULTS Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to their family physician and 3% (6/235) used the ED because they did not have a family physician. CONCLUSIONS In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.

The association between nerve sparing and a positive surgical margin during radical prostatectomy

PURPOSE A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. METHODS We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. RESULTS Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97-2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80-1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25-2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65-1.12). CONCLUSIONS Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.

Assessing radiation exposure during endoscopic-guided percutaneous nephrolithotomy

INTRODUCTION Percutaneous nephrolithotomy (PCNL) may be associated with significant ionizing radiation exposure for patients and operating room staff. Endoscopic-guided PCNL (ePCNL) is a technique that may be associated with less radiation exposure. This study examines ePCNL-related radiation exposure (fluoroscopy time, effective dose) and investigates variables that may predict increased exposure. METHODS A retrospective review of all consecutive ePCNLs performed at our institution, by a single surgeon, was conducted between November 2011 and November 2013. Patient demographics, stone characteristics and perioperative details were recorded, including radiation exposure. Pearson and Spearman correlation were used to assess variables correlated with radiation exposure. RESULTS In total, 55 ePCNL cases were included in the study. The mean age was 60 ± 15 years, mean body mass index (BMI) 30.0 ± 6.4 kg/m(2) and mean stone size 3.2 × 2.1 cm. Seven cases (13%) involved complete staghorn stones, and 69% involved supracostal punctures. The mean fluoroscopy time was 3.4 ± 2.3 minutes, mean ED 2.4 ± 1.9 mSv. The treatment success rate, assessed 1-week postoperatively, was 87.3% and 7.3% of cases required ancillary procedures. The overall complication rate was 29%, but only 3 cases (5.5%) were Clavien ≥3. Longer fluoroscopy time correlated with increased stone size (p < 0.01), longer operative time (p < 0.01) and lower treatment success rates (p < 0.01); higher effective dose correlated with longer fluoroscopy time (p < 0.01) and increased skin-to-stone distance (p < 0.01). BMI did not correlate with fluoroscopy time or effective dose. CONCLUSIONS Outcomes of ePCNL are comparable to traditional PCNL techniques and may be associated with lower radiation exposure, particularly beneficial for patients with higher BMI.

Simulation-based flexible ureteroscopy training using a novel ureteroscopy part-task trainer

INTRODUCTION Simulation-based training (SBT) is being increasingly used for novice trainees as a means of overcoming the early learning curve associated with new surgical skills. We designed a SBT flexible ureteroscopy (fURS) course using a novel inanimate training model (Cook Medical, Bloomington, IN; URS model). We evaluated the course and validated this Cook URS model. METHODS A 2-week SBT fURS course was designed for junior level urology trainees at 2 Canadian universities. The curriculum included didactic lectures, hands-on training, independent training sessions with expert feedback, and use of the Cook URS part-task model. Baseline and post-course assessments of trainee fURS skills were conducted using a standardized test task (fURS with basket manipulation of a calyceal stone). Performances were video-recorded and reviewed by 2 blinded experts using a validated assessment device. RESULTS Fifteen residents (postgraduate years [PGY] 0-3) participated in the course. Of the participants, 80% rated the Cook URS model as realistic (mean = 4.2/5) and 5 endourology experts rated it as useful as a training device (mean = 4.9/5), providing both face and content validity. The mean overall performance scores, task completion times, and passing ratings correlated with trainee clinical fURS experience - demonstrating construct validity for the Cook URS model. The mean post-course task completion times (15.76 vs. 9.37 minutes, p = 0.001) and overall performance scores (19.20 vs. 25.25, p = 0.007) were significantly better than at baseline. Post-course performance was better in all domains assessed by the validated assessment device. CONCLUSIONS This study demonstrates that a SBT curriculum for fURS can lead to improved short-term technical skills among junior level urology residents. The Cook URS model demonstrated good face, content and construct validity.

Baseline urologic surgical skills among medical students: Differentiating trainees.

INTRODUCTION Urology training programs seek to identify ideal candidates with the potential to become competent urologic surgeons. It is unclear whether innate technical ability has a role in this selection process. We aimed to determine whether there are any innate differences in baseline urologic technical skills among medical students. METHODS Second-year medical students from the University of Toronto were recruited for this study and stratified into surgical and non-surgical cohorts based on their reported career aspirations. After a pre-test questionnaire, subjects were tested on several urologic surgical skills: laparoscopy, cystoscopy and robotic surgery. Statistical analysis was performed using chi-squared test, student t-tests and Spearmans correlation where appropriate. RESULTS A total of 29 students participated in the study and no significant baseline differences were found between cohorts with respect to demographics and prior surgical experience. For laparoscopic skills, the surgical cohort outperformed the non-surgical cohort on several exercises: Lap Beans Missed (4.9 vs. 9.3, p < 0.01), Lap Bean Rating (3.8 vs. 3.1, p = 0.01), Lap Rings Error (0.2 vs. 1.22, p < 0.01), Lap Rings Rating (3.9 vs. 2.9, p < 0.01) and LapSim Grasping Score (64.3 vs. 46.4, p = 0.01). For cystoscopic skills, there were no significant differences between cohorts on any of the performance metrics. The surgical cohort also outperformed the non-surgical cohort on all measured robotic surgery performance metrics: Task Time (50.6 vs. 76.3, p < 0.01), Task Errors (0.2 vs. 3.1, p < 0.01), and Task Score (89.5 vs. 72.6, p < 0.01). DISCUSSION Objective innate technical ability in urological skills, particularly laparoscopy and robotics, may differ between early trainees interested in a surgical career compared to those interested in a non-surgical career. Further studies are required to illicit what impact such differences have on future performance and competence.

Flank bulge following supracostal percutaneous nephrolithotomy: a report of 2 cases.

Damage to intercostal nerves during surgical procedures has been associated with a postoperative flank bulge, due to denervation of the anterolateral abdominal wall musculature. This complication has not been reported following percutaneous nephrolithotomy (PCNL). We are aware of 3 cases, but have details on 2 cases of postoperative flank bulge following supracostal PCNL which are reported here. We also suggest how this complication could potentially be minimized.

Lumbar plexopathy as a complication of percutaneous nephrolithotomy in a horseshoe kidney

Treatment of nephrolithiasis in horseshoe kidneys can be challenging due to anomalies in renal position, collecting system anatomy and vascular supply. We report on a patient who was referred after a failed percutaneous nephrolithotomy for a left moiety staghorn calculus in a horseshoe kidney. Two punctures had been performed involving upper and middle posterior calyces. Both were very medially placed and inadvertently traversed the psoas muscle, resulting in lumbar plexopathy with permanent deficit. This complication presented postoperatively with left leg weakness, paresthesia, and pain which impaired independent ambulation. The patient went on to be successfully treated for her stone disease with robotic-assisted laparoscopic pyelolithotomy.