Naji J. Touma

Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta- analysis of case series studies

Study Type – Therapy (systematic review)

Spontaneous regression of metastatic pulmonary renal cell carcinoma in the setting of sarcomatoid differentiation of the primary tumour

We present a case of spontaneous regression of pulmonary metastases from renal cell carcinoma (RCC) with sarcomatoid differentiation, prior to intervention. The patient presented with conventional type RCC with Furhman Grade 4/4 and sarcomatoid differentiation, complicated by pulmonary metastases. Palliative systemic therapy was planned, but prior to the onset of treatment, serial computed tomography scans demonstrated regression of metastatic disease. Spontaneous regression of metastases is rare, but well-documented in conventional clear cell RCC. To the best of our knowledge, this has not previously been described in the setting of sarcomatoid differentiation of the primary tumour.

Response of renal cell carcinoma to ibrutinib, a bruton tyrosine kinase inhibitor, in a patient treated for chronic lymphocytic leukemia

Ibrutinib is a bruton tyrosine kinase (BTK) inhibitor approved for B cell malignancies. Although there are currently two clinical trials evaluating ibrutinib in combination with nivolumab (programmed cell death protein 1, PD-1, inhibitor) or everolimus (mammalian target of rapamycin, mTOR, inhibitor) for metastatic renal cell carcinoma (RCC), there are no reports of RCC (metastatic or non-metastatic) showing response to a BTK inhibitor in humans. Here we report a 22-month clinical response of biopsy-proven RCC to ibrutinib. This is unexpected, given that BTK is not wellimplicated in RCC pathophysiology. We explore a possible mechanism for the response of RCC to ibrutinib through inhibition of interleukin-2-inducible T-cell kinase (ITK) leading to enhanced antitumour immune responses.

The Face of Testicular Pain: A Surprising Ultrasound Finding

A scrotal ultrasound scan of a patient with a painful inflammatory mass surprisingly revealed a face in the image, which looked like a man experiencing painful stimuli.

Impact of a training program on the performance of graduating Canadian residents on a national urology exam: Results of the last 20 years

INTRODUCTION Many factors impact the performance of graduating residents on certification exams. It is thought that most factors are related to the individual candidates ability, motivation, and work ethic. Less understood, however, is whether a training program has any impact on the preparation and performance of its graduates on certification exams. We present 20 years of results of a national preparatory exam that all graduating residents complete about three months before the Royal College of Physicians and Surgeons of Canada (RCPSC) qualifying urology exam. This exam, known colloquially as QUEST, aims to simulate the RCPSC exam with written and oral components. We aimed to analyze the impact of a training program on the performance of its residents. METHODS A retrospective review of exam results from 1997-2016 was conducted. During that time, 495 candidates from all 12 Canadian urology training programs undertook the exam. The performance of graduating residents from each individual program was grouped together for any given year. The different programs were anonymized, as the aim of this study is to assess the impact of a training program and not to rate the different programs. Statistical analysis using one-way ANOVA was conducted. RESULTS All training programs fall within one standard deviation of the mean for the written component, the oral component, and the overall score. The residents of four training programs had statistically better scores than the overall mean of the written component. The residents of three out of these four training programs also had statistically better scores than the overall mean of the oral component and the overall results of the exam. CONCLUSIONS Most Canadian training programs prepare their residents adequately for this simulated certification exam in urology. However, there are some training programs that consistently prepare graduating residents to outperform their peers.

Study habits of Canadian urology residents: Implications for development of a competence by design curriculum

INTRODUCTION The purpose of this study was to evaluate the study habits of Canadian urology residents throughout their residency training. METHODS A survey was administered to all final-year Canadian urology residents over a two-year period. Sixty-seven respondents answered a survey consisting of 54 questions scored on a 10-point Likert score. The survey addressed study habits throughout training, motivations for studying, and preferred resources used. RESULTS Dedication to studying was directly correlated with proximity to the Royal College of Physicians and Surgeons of Canada (RCPSC) exam. Ninety-six percent of residents reported studying over 10 hours per week during their chief year compared to 0% during their junior year. As residents progressed in their training, preparation for the Royal College exam became the greatest motivator for studying. There was considerable variability in study methods and study resources used throughout training. In their chief year, residents found such resources as the textbook Campbell-Walsh, AUA updates, CUA and AUA guidelines, and the study notes of former trainees to be valuable for their preparation. Teaching rounds, journal clubs, and reading current urological literature were found to be les helpful. Forty-six percent of all residents surveyed indicated that they would prefer writing their RCPSC exam one year earlier than the current timing. CONCLUSIONS This study provides insight into study habits of Canadian urology residents. This data may be helpful in shaping the future of urology training programs and examinations within Canada and elsewhere.

Urology residency training: Time to enter the 21st century.

Prior to the last century, surgeons perfected their craft through preceptorships. Early in the last century, Halsted introduced the German residency system of graded responsibility to North America.1 This system remains the cornerstone of surgical education. However, there has been tremendous change in surgical techniques, especially related to the practice of urology. We have witnessed the introduction of flexible ureteroscopy with laser lithotripsy and percutaneous nephrolithomy for the treatment of renal calculi. In addition, with the advent of laparoscopy and robotics, the surgical treatment of many urological diseases has changed dramatically. Despite this rapid evolution in urological practice, changes in surgical education and evaluation have lagged behind. The authors highlight the disparity in the use of novel teaching adjuncts among various programs.2 In addition, the incorporation of such adjuncts into formal assessments seems to be applied in a heterogeneous manner. Although many believe surgical expertise is a reflection of an individual’s intrinsic ability, empiric research has con-firmed the importance of practice.3,4 Simulators are instruments that reproduce, under artificial conditions, components of surgical tasks.5 Types of models include cadaver, animal, bench and computer software-based simulators. Cadaver models provide true anatomic representation, but the tissue quality might not be as realistic as living tissue. Live animals provide a model with appropriate tissue texture; however, anatomy may not be entirely representative of its human counterparts. Additionally, the use of human cadavers and live animals tends to be expensive and raises ethical issues. Bench models sacrifice fidelity for safety, availability, portability and lower overall cost.1,6 With advances in material technology and computer hardware and software, simulators have become more advanced, with higher fidelity and more capacity for assessment and feedback. Fidelity of a model refers to its realistic features. A simulator does not need to look realistic as long as the pertinent steps of the procedure are performed. That is, a low-fidelity simulator can provide the same benefit as a high-fidelity model.7 The most important outcome of simulators is the ability for skills learned on a model to be translated into improved performance in the clinical setting. This concept is referred to as transferability.3 Many bench and virtual reality simulators have been developed to reproduce many urological procedures.8 Some of these simulators are currently commercially available. While simulators can act as adjuncts for the acquisition of technical skills, they are no substitution to practice in real-life surgical conditions. The second aspect highlighted in this study is the lack of uniformity in assessing surgical skills across programs.2 The ideal components of a sound assessment test are reliability and validity. Reliability refers to the reproducibility of the results produced by the assessment; validity refers to whether a test measures what it purports to measure. Competency-based medical education (CBME) is an emerging concept in training that is being advocated as a substitute or, at least, a complement to the traditional time-based residencies. A white paper has been submitted to the Royal College of Physicians and Surgeons of Canada advocating a shift towards a CBME approach.9 In the United States, the Accreditation Council for Graduate Medical Education began an initiative in 1998 known as the outcome project; the program focuses on the competency domains.10 The Division of Orthopaedics at the University of Toronto and the Royal Australasian College of Psychiatry pilot projects are current examples of CBME.9 A successful shift towards a CBME approach requires three critical components: (1) identifying the required abilities; (2) identifying ways to teach the required abilities; and (3) identifying ways to assess these abilities. It is obvious that, as a specialty, we have a lot of work on these three fronts to move into a 21st century model of training.