Cuaj-Canadian Urological Association Journal最新文献

Introduction: The integration of artificial intelligence (AI) into surgical training is rapidly evolving, driven by advancements in machine learning. This review aims to map the current landscape of AI's educational applications in urology.

Methods: A systematic search of MEDLINE, PubMed, Embase, Cochrane, Scopus, and Engineering Village identified studies exploring AI applications in video-based surgical education and assessment. Search terms included AI, urologic procedures, and training/assessment components, and results were screened in Covidence^®. AI applications involving urological procedures were included. For every study, two reviewers independently conducted screening. Data were synthesized thematically to evaluate AI's application in urology training.

Results: Our search yielded 2767, of which 59 relevant studies were identified. AI was most frequently applied with robotic-assisted radical prostatectomy (RARP), followed by robotic-assisted partial nephrectomy (RAPN). AI applications were broadly categorized into three domains: 1) annotation, where key anatomy and instruments from procedural videos are labelled; 2) feedback, such as recognizing surgical phases or monitoring surgical events; and 3) evaluation, where the surgical gestures are recognized or evaluated to stratify skill level and predict patient outcomes.

Conclusions: The emergence of AI use in urologic procedures underscores its transformative potential in procedural education and training. AI has wide applications in annotation, feedback, and assessment across different procedures. While prostatectomy dominates in the literature, the adaptability of AI frameworks exists across other urologic procedures. New commercially available tools demonstrate promising results, making them potentially beneficial additions to urology training programs. Future efforts should focus on multicentric collaboration and longitudinal skill assessments.

Introduction: Pediatric and adult reconstructive urology remain underrepresented in global surgical efforts, despite their critical role in restoring genitourinary function. This global surgery initiative aimed to address the gap in specialized urologic care in low- to middle-income countries (LMICs) through a longitudinal, mentorship-based approach integrating augmented reality (AR) telementoring.

Methods: This report describes an approach used to enhance global surgical expertise in LMICs and summarizes data documenting impact. A Global Surgery Partnership Initiative was launched by an academic surgeon from the University of Toronto to address the lack of specialized pediatric and reconstructive urologic training. Through collaboration with local institutions in the Philippines and Vietnam, the program employed a mixed-method approach that delivered longitudinal mentorship, combining virtual case conferences, in-person surgical mentoring, pilot of AR-supported telementoring, and continuous postoperative coaching. Patient outcomes were assessed and mentees self-reported pre- and post-intervention surveys evaluating comfort and technical understanding. Descriptive statistics and paired t-tests were used to analyze outcomes.

Results: Thirty-eight pediatric and adult reconstructive urology cases were performed. Over time, operative times and length of stay decreased, with low complication rates (6/38, 12.7%) and Clavien-Dindo ≥3 complications (3/38, 8%). Mentee comfort and understanding significantly improved (mean comfort score: 3.06 to 6.77; technical understanding: 4.77 to 8.43; p<0.001). AR-assisted mentoring, introduced in 2022 and expanded in 2024, showed feasibility, with further enhanced intraoperative feedback and sustainability.

Conclusions: This structured, mixed-method model effectively improved surgical competencies and system-level capacity in LMICs. Unlike short-term missions, this initiative emphasized continuity, adaptability, and sustainability. It presents a scalable framework for integrating reconstructive urology into global health programs while leveraging AR to overcome geographic and resource limitations.

Introduction: Extracorporeal magnetic stimulation (EMS) is a non-invasive treatment for urinary incontinence (UI) in women, but its effectiveness in men is not well known. This review identifies and evaluates the evidence supporting EMS for treating UI in adult men.

Methods: We systematically searched the MEDLINE, CINAHL, and PEDro databases up to November 2024. Studies included EMS alone or compared to other treatments in men with UI. A qualitative assessment of the evidence was carried out. Study quality was assessed using the Downs and Black checklist for randomized and non-randomized studies and the Cochrane Risk of Bias 2 tool for randomized controlled trials (RCTs).

Results: Of 285 studies screened, nine met the inclusion criteria, encompassing 181 men treated with EMS, mostly post-prostatectomy. Four RCTs, with qualities ranging from fair to good, and small sample sizes (n=16-36), found EMS led to earlier continence compared to pelvic floor muscle therapy (PFMT) and was superior to sham treatment. One study reported significant improvements in urodynamic measures after EMS, and another showed a 48% reduction in 24-hour pad usage, sustained at 12.5 months. Several studies indicated that EMS accelerated symptom improvement compared to PFMT but had similar long-term outcomes. All studies using validated quality-of-life measures reported significant improvements after EMS.

Conclusions: Evidence for EMS in treating male UI is limited but generally positive. EMS may promote faster continence recovery than PFMT, with similar long-term outcomes. Larger, high-quality studies are needed to confirm these findings and guide clinical practice and recommendations for different subgroups.

Introduction: Electives strongly influence residency selection. While the CanMEDS framework outlines core competencies, the specific traits most valued by urology programs during electives remain unclear.

Methods: We surveyed selection committee members in Canadian urology residency programs. Using the CanMEDS framework, we developed 21 competencies and designed a best-worst scaling survey, where respondents selected the most and least important items from 21-question sets. A hierarchical Bayes model was used to calculate probability scores to rank each item and CanMEDS role. Scores reflect the likelihood of being chosen as most important.

Results: Thirteen respondents completed the survey (34% response rate). Traits related to professionalism, initiative, and reliability ranked highest. Specifically, "Demonstrating appropriate behavior through honesty, integrity, punctuality, and respect" (12.4% [95% credible interval (CI) 11.9, 13.0]) and "Seeking out responsibilities by helping with rounds, doing consults, and organizing patient handover and discharge" (9.7% [8.5, 10.9]) were top ranked. In contrast, "Incorporating evidence on health disparities in urology when presenting cases or research findings" (0.1% [0.0, 0.2]) and "Discussing barriers to care, such as cost and access, and proposing solutions during rounds when appropriate" (0.0% [0.0, 0.1]) were lowest ranked. Among CanMEDS roles, Professional (9.9%) and Leader (8.1%) ranked highest, while Health Advocate (0.2%) and Scholar (1.8%) ranked lowest.

Conclusions: Canadian urology programs prioritize professionalism, initiative, and reliability during electives. In contrast, scholarly and advocacy competencies are viewed as less critical, possibly due to the short duration and clinical focus of electives. Our findings can guide students and programs in aligning expectations during urology electives.

Introduction: Obesity is common among renal transplant recipients and increases the risk of perioperative complications. This study evaluated whether the distance from the skin to the external iliac vessels (SVD) is associated with adverse surgical outcomes in renal transplant recipients.

Methods: A retrospective cohort study of 167 consecutive patients with preoperative cross-sectional imaging who underwent renal transplantation was conducted at a single center. SVD was measured as the distance from the skin to the anterior edge of the external iliac vein at its bifurcation through the musculoaponeurotic layer of the transversus abdominis and oblique muscles. The primary outcome was the rate of postoperative complications, classified by the Clavien-Dindo system.

Results: SVD was associated with wound dehiscence (area under the curve [AUC] 0.696, 95% confidence interval [CI] 0.55-0.84, p=0.007) and wound complications (AUC 0.719, 95% CI 0.60-0.84, p<0.001). Using an SVD threshold of ≥19 cm, we observed an overall accuracy of 87.4% for predicting wound dehiscence and 85.6% for any wound complication. The retrospective, single-center design and absence of standardized criteria for CT imaging are inherent limitations that can introduce several biases.

Conclusions: SVD is associated with adverse perioperative outcomes in renal transplantation. Given the indication for preoperative imaging only in high-risk patients, prospective data with a more general renal transplant population is warranted to further evaluate SVD.

Introduction: Despite increased risk of adverse events and overdose associated with sustained-release opioids, evidence is lacking to support the short-term use of a low-dose, sustained-release opioid for acute pain control in a monitored setting. Both immediate-release and sustained-release opioids are used clinically in postoperative analgesia. We hypothesized that short-term use of low-dose, sustained-release hydromorphone combined with immediate-release hydromorphone as required would facilitate earlier ambulation after major urologic surgeries compared to immediate-release opioids alone.

Methods: Following ethics approval and patient consent, patients undergoing elective open abdominal urologic surgeries were randomized into two groups: sustained-release hydromorphone on a regular basis for two days, with immediate-release hydromorphone available on an as-required basis; or immediate-release hydromorphone on an as-required basis only. The primary outcome measure was the time to get up and walk three steps.

Results: A total of 66 participants were included in the data analysis. There was no statistically significant difference in the time to first mobilization, opioid consumption, or pain scores at any time point between the two groups. There were trends toward more nausea on postoperative days 1, 2, and 3, as well as more severe loss of sleep the first night after surgery in the immediate-release group, although the differences did not reach statistical significance.

Conclusions: Our study showed that patients receiving short-term, low-dose, sustained-release hydromorphone immediately postoperatively did not mobilize sooner compared to those only receiving immediate-release hydromorphone. There was no difference in the pain score or opioid consumption.

Introduction: Upregulation of hypoxia-inducible factors (HIF) is an important pathologic feature shared by clear-cell renal cell carcinoma (ccRCC) and obstructive sleep apnea (OSA). It is unclear whether OSA alters ccRCC pathogenesis via HIF expression. This study aimed to characterize differences in HIF expression in ccRCC tumors in patients with and without OSA. We hypothesized that a diagnosis of OSA was associated with increased HIF expression.

Methods: A cohort of adults who underwent nephrectomy for ccRCC was identified. OSA diagnosis was determined with preoperative STOP-BANG scores or polysomnography, selecting 20 individuals with and 20 without OSA. Tumor sections were immunohistochemically stained for HIF-1α & HIF-2α and assessed by an expert uropathologist.

Results: The OSA group exhibited a higher prevalence of hypertension (95% vs. 50%, p=0.001) and greater median body mass index (BMI) (34.8 vs. 29.05, p=0.006). Tumor grades were higher in the OSA group (p=0.039). No differences were noted in tumor stages. Samples of ccRCC tumors in the OSA group demonstrated a higher prevalence of HIF-1α positivity (80% vs. 50%, p=0.048), although median histoscores were not different (4 vs. 2.5, p=0.260). Neither median HIF-2α histoscores (1 vs. 2, p=0.306) nor expression (histoscore >0; 74% vs. 75%, p=0.927) was statistically significant.

Conclusions: In OSA patients, ccRCC tumors exhibited higher HIF-1α positivity and tumor grades; however, no significant differences in median HIF histoscores, HIF-2α expression, or tumor stage were found. Future studies can use our results to perform formal sample size calculations and elucidate the role of OSA in the pathogenesis of ccRCC.