Importance Despite efforts to ensure equitable access to medically necessary services, disparities in care may persist in pediatric otolaryngology services. Objective To examine the relationship between socioeconomic marginalization and surgical wait times for tympanostomy tube insertion in the healthcare system of Ontario. Study design Population-based, retrospective cohort study utilizing administrative health data. Setting Ontario, Canada. Participants Patients ≤12 years who underwent bilateral tympanostomy tube insertion between 2010 and 2023 were included. Exposures Socioeconomic marginalization measured by the Ontario Marginalization Index, rurality and immigrant status. Main Outcome Measures ENT visit within 90 days of surgery, age at ENT visit, time from ENT visit to surgery, number of ENT visits during each year of follow-up, time to tympanostomy tube removal, and delayed tympanostomy tube removal (≥5 years post-surgery). Results A total of 76,574 tympanostomy tube patients were analyzed. As compared to the least marginalized patients, the most marginalized patients were significantly less likely to have an ENT visit within 90 days of surgery (75% vs 81.3%, P < .001). The number of emergency department visits (1: −15%, ≥2: −29%) was protective, decreasing age at ENT visit ( P < .001). Furthermore, rural residence significantly increased the risk of higher age at ENT visit (+7%) ( P < .001). Immigrant children were older at their final ENT visit and had longer surgical wait times compared to non-immigrant children ( P < .001). Conclusion Significant disparities exist in accessing tympanostomy tubes; socioeconomic marginalization, prior emergency department visits, sex, immigrant and rural status delaying the age at final ENT visit before surgery. Relevance These findings underscore the need for targeted strategies to improve equitable access to pediatric ENT services.

PURPOSE:Pediatric dismembered pyeloplasty (PP) is the gold standard surgery for uretero-pelvic junction obstruction (UPJO) in children. However, there is no consensus regarding the duration and methods of providing follow-up care after PP. This study aims to assess the rate of redo-interventions following PP and to define the ideal follow-up care following PP. MATERIALS AND METHODS:This is a retrospective population-based cohort study including all PP patients in Ontario between April 2002 and March 2016 using routinely collected data, with a minimum 5-year follow-up. Baseline variables included demographics, surgical approach, laterality and surgeon experience. The primary outcome was time to secondary surgical intervention, including redo PP. Secondary outcomes included costs of follow-up care and rates of early ER visits. Regression analyses were preformed to predict need for secondary intervention 2-years post PP, including independent variables: age, sex, surgical approach and early complication. RESULTS:The study included 1049 patients with a median age of 2 (IQR 0-7) years. Of the 13.6% of patients who had at least one secondary intervention following PP (including 3.8% who underwent a redo PP), 90.2% occurred within 3-years of PP. The median cost/patient of follow up care was $1472 CAD (IQR $292-$31,133). Regression analysis did not reveal any predictors of delayed secondary intervention. CONCLUSIONS:This study demonstrates that over 86% of PP are completed successfully, with a 3.8% rate of redo-PP. The majority of secondary interventions for post-PP complications occur within 3 years post-PP. Variability in duration and cost of follow-up care post- PP should be addressed to minimize costs, and a minimum 3-years follow-up after PP is recommended.

The penile microbiota has been implicated in genital inflammation and increased risk of HIV, HPV, HSV-2, and female-partner bacterial vaginosis in adult males, yet its development during childhood and potential role in pediatric foreskin pathologies remain unknown. We characterized the coronal sulcus microbiota of 75 pediatric males (median age 8.5 years; 43% with pathological phimosis) before and after circumcision and compared these profiles to 56 uncircumcised adult men. Pediatric penile microbiota were highly diverse, dominated by strict and facultative anaerobes, and loosely structured compared to adults, who exhibited two distinct, ecologically organized communities. Circumcision markedly reduced anaerobic taxa and increased Corynebacterium and Staphylococcus. Pathological phimosis (the inability to retract the foreskin due to scarring) was associated with increased densities of CD3+ T cells, CD4+ cells, and CD11c+ dendritic cells, suggesting an adaptive immune mechanism; however, pathological phimosis was not associated with microbiota composition. Nonetheless, Mobiluncus was negatively correlated with CD11c+ dendritic cells, while Campylobacter and Peptoniphilus were negatively correlated with CD56+ NK cells, suggesting microbe-immune interactions. Our data suggest pathologic phimosis is driven by adaptive immune responses but not by specific bacteria; the pathology may be driven by differences in host responses to bacteria or by other stimuli, such as fungal antigens. Our data also demonstrate that the transition to adulthood is accompanied by reorganization of penile communities into structured types previously linked to infection risk, highlighting puberty as a potential window for interventions that promote protective adult microbiota and improve lifelong sexual and reproductive health.IMPORTANCEThe human penis hosts complex bacterial communities that can influence inflammation, infection risk, and sexual health, but little is known about how these communities form early in life or whether they contribute to childhood foreskin inflammatory disorders. We combined 16S rRNA sequencing with quantitative microscopy to investigate the penile microbiota in boys and its relationship to pathological phimosis, a common condition marked by foreskin scarring. We found that phimosis is associated with infiltration of T cells and dendritic cells, indicating an adaptive immune process, but with no associations with specific bacteria. We also show that penile microbiota reorganize during puberty into structured community types previously linked to HIV and sexually transmitted infection risk. These findings suggest that childhood pathologic phimosis is mediated by adaptive immune responses rather than driven by specific bacterial communities and identify puberty as a critical period for shaping adult penile microbiota, with implications for lifelong genital health.

Chronic kidney disease (CKD) affects up to 40

INTRODUCTION:Congenital lower urinary tract obstruction due to posterior urethral valves (PUV) often results in chronic kidney disease (CKD) and renal replacement therapy (RRT). The Posterior Urethral Valve Risk of Chronic Kidney Disease (PURK) score, a validated prognostic tool, uses clinical variables at presentation to predict development of CKD stage 3 or higher. However, its role in predicting progression to RRT remains unexplored. OBJECTIVE:This study evaluates the utility of the PURK score for RRT risk stratification internationally, aiming to facilitate early counseling and management for affected families. STUDY DESIGN:Patients with posterior urethral valves (PUV) presenting before age 1 were analyzed from internal and external databases (9 institutions), excluding early RRT events (<14 days). PURK scores were calculated. ROC curves assessed predictive accuracy and Kaplan-Meier survival analysis stratified risk groups. External validation involved data from eight international centers. RESULTS:Internal validation from 183 PUV patients at a single center, with a median follow-up of 8.1 years, was analyzed. This showed significant differences in PURK score distribution between patients who progressed to RRT (15.1 %) and those who did not. Kaplan-Meier curves identified low- (0-1, 0 %), intermediate- (2-3, 9.6 %), and high-risk groups (≥4, 37.5 %) for RRT progression. AUROC values demonstrated good predictive ability for 1-, 5-, and 10-year RRT events (0.798-0.839). External validation of 265 patients confirmed these findings, with excellent AUROC values for 1-, 5-, and 10-year RRT events (0.868-0.885) and consistent survival stratification. DISCUSSION:We identified clear risk groups for progression to RRT using survival analysis, with those with high PURK score being much more likely to progress to RRT compared to lower scores. Being able to prognosticate patients into different risk groups is important as it can guide frequency of follow up and early interventions including alpha-blockers, anticholinergics, or clean intermittent catheterization for children with higher risk profiles. CONCLUSION:The PURK score is a reliable tool for early prediction and risk stratification of progression to RRT in PUV patients.

INTRODUCTION:Surgical management of pediatric neurogenic bladder (NB) and bowel aims to achieve safe filling pressures and achieve dryness, simultaneously allowing independence to manage voiding functions. The surgical armamentarium includes; augmentation cystoplasty (AC), bladder neck reconstruction (BNR), Mitrofanoff procedure (MP) and cecostomy (MACE). Often, patients undergo these procedures concomitantly, based on urodynamic and clinical findings. OBJECTIVE:This study aims to determine the 30-day outcomes of pediatric NB reconstructive surgery, and identify independent risk factors for an early adverse outcome. STUDY DESIGN:This study is a secondary analysis of prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) Pediatric database between 2015 and 2020. Patients <18 years of age with an International Classification of Disease, Ninth and Tenth Revision (ICD-9/10) diagnosis of Spina Bifida (SB) undergoing a urological reconstruction defined with specific Current Procedural Terminology (CPT) codes were included. Patient demographics, perioperative variables, operative timing, length of stay, 30-day readmission/reoperation data and surgical complications were assessed. Patients were categorized into four surgical groups: 1: MP only; 2: isolated BNR; 3: AC ± MP; 4: AC + BNR + MP ± MACE. A multivariable logistic regression analysis was conducted to identify risk factors for 30-day readmission and re-operation using age, body mass index (BMI), operative time and surgical groups as independent variables. RESULTS:We identified a cohort of 700 patient encounters involving at least one of these procedures, with a median age at surgery of 10.3 years (Interquartile Range [IQR] 6.6-13.6). The majority were females (58.3 %) and 53.6 % had a normal BMI, 18.3 % were overweight and 28.1 % were obese. The overall early complication rate ranged from 14.8 % to 27.2 %, with a 15.1 % readmission rate and reoperation rate was 7.9 % following pediatric NB reconstruction. Multivariable logistic regression analysis indicated that those in surgical group 4 were 2.78 times (95 % CI-1.03 - 7.49) more likely for 30-day readmission, compared to Group 1 (p = .04). Multivariable analysis revealed no significant predictors of 30-day reoperation. DISCUSSION:Age at surgery, BMI and operative time do not predict the risk of surgical complications following NB reconstruction. We validated that increasing procedure count was associated with increased risk of 30-day readmission. CONCLUSION:Increasing the number of surgical interventions for NB reconstruction is associated with higher 30-day readmission rates, while increasing age at surgery and BMI did not predict readmission or reoperation. The results of this study are generalizable, given the cohort, and can help pediatric urologists prognosticate early patient outcomes following major NB reconstructive surgeries.

OBJECTIVE:To compare trends and incidence of surgical intervention among adults with urolithiasis in Ontario, Canada, and Israel. PATIENTS AND METHODS:A retrospective analysis was conducted using administrative databases from Clalit Health Service in Israel and IC/ES in Canada. The study included adults who underwent their initial surgical treatment for urolithiasis. Descriptive statistics summarized baseline patient demographics, while comparisons were analyzed with a t-test. RESULTS:Between 2003 and 2018, 31,034 and 105,013 patients who underwent surgical intervention for upper urinary tract stones for the first time in their clinical history, excluding those with prior surgical treatments for the same condition, in Israel and Ontario, respectively. The number of insured at Clalit Health Services increased by 21.3%, while the population in Ontario grew by 18.5%. The total number of treated cases rose by 82% and 64.4% in Israel and Ontario, respectively. The procedures per 100,000 people increased by 51% in Israel and 34.6% in Ontario. In Israel, the proportion of females undergoing surgery decreased from 33.5% to 32%, while in Ontario, it increased from 36.3% to 49.8%. Ureteroscopy (URS) was more commonly used in Ontario, while shock wave lithotripsy (SWL) was more common in Israel. URS utilization surged by 281% in Israel and 145.5% in Ontario. Percutaneous nephrolithotripsy (PCNL) increased by 52% in Israel and 8.6% in Ontario, while SWL procedures declined by 57% in Israel and 32.5% in Ontario. CONCLUSIONS:A significant rise in the number of patients undergoing their first stone-related procedure in both regions, particularly in Israel. There was a difference in the proportion of female patients requiring surgical intervention, with an increase in Ontario and a decrease in Israel.

INTRODUCTION:Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness. MATERIALS AND METHODS:This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N = 21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use. RESULTS:The mean age at surgery was 11.6 years (SD = 6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2. DISCUSSION:Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure. CONCLUSIONS:Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.

BackgroundUrinary stone disease (USD) historically has affected older men, but studies suggest recent increases in women, leading to a near identical sex incidence ratio. USD incidence has doubled every 10 years, with disproportionate increases amongst children, adolescent, and young adult (AYA) women. USD stone composition in women is frequently apatite (calcium phosphate), which forms in a higher urine pH, low urinary citrate, and an abundance of urinary uric acid, while men produce more calcium oxalate stones. The reasons for this epidemiological trend are unknown.MethodsThis perspective presents the extent of USD with data from a Canadian Province and a North American institution, explanations for these findings and offers potential solutions to decrease this trend. We describe the economic impact of USD.FindingsThere was a significant increase of 46% in overall surgical interventions for USD in Ontario. The incidence rose from 47.0/100,000 in 2002 to 68.7/100,000 population in 2016. In a single United States institution, the overall USD annual unique patient count rose from 10,612 to 17,706 from 2015 to 2019, and the proportion of women with USD was much higher than expected. In the 10–17-year-old patients, 50.1% were girls; with 57.5% in the 18–34 age group and 53.6% in the 35–44 age group. The roles of obesity, diet, hormones, environmental factors, infections, and antibiotics, as well as the economic impact, are discussed.InterpretationWe confirm the significant increase in USD among women. We offer potential explanations for this sex disparity, including microbiological and pathophysiological aspects. We also outline innovative solutions – that may require steps beyond typical preventive and treatment recommendations.

PurposeTo review the urological outcomes of proactive versus delayed management of children with a neurogenic bladder (NB).MethodsWe performed a literature search on EMBASE, MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials between January 1, 2000 to August 21, 2023 for studies investigating the management of spina bifida-associated NB in pediatric patients (0-18 years of age). Proactive management was defined as use of clean intermittent catheterization, and/or anticholinergics at presentation, or based on initial high-risk urodynamic findings by 1 year of age. Delayed management was defined as beginning management after 1 year of age or no intervention. Outcomes included incidence or diagnosis of secondary vesicoureteral reflux (VUR), urinary tract infection (UTI), and renal deterioration, which included renal scarring, loss of differential renal function on a nuclear scan, or a decrease in renal function defined by glomerular filtration rate or serum creatinine estimation. Forest plots were synthesized using the Inverse Variance method with random-effect model. The Risk of Bias was assessed using the ROBINS-I tool.ResultsWe included 8 observational studies on 652 pediatric patients with spina bifida-associated NB (mean follow-up - 7 years). Proactive management following initial assessment was associated with significantly lower risks of secondary VUR (OR 0.37 [0.19, 0.74], p = 0.004), non-febrile UTI (OR 0.35 [0.19, 0.62], p = 0.0004), and renal deterioration (OR 0.31 [0.20, 0.47], p < 0.00001).DiscussionDelayed management of NB potentially has 3 times higher risks of secondary VUR, non-febrile UTI, and renal deterioration. However, the evidence is limited by the high risk of bias due to lack of randomization and standardized reporting in observational studies.ConclusionWhile further well-defined prospective studies with long-term follow-up should be conducted to confirm this finding, this study supports the EAU/ESPU recommendations for early intervention in children with NB.

IntroductionThe worldwide incidence of pediatric urinary stone disease (PUSD) is increasing. However, there is no commensurate data on whether this translates to an increasing need for surgical intervention for PUSD, given the role of conservative management.ObjectiveWe aimed to evaluate the trends and outcomes of clinically significant PUSD, using administrative databases to identify patients surgically treated for PUSD.Study designThis retrospective population-based cohort study assessed the incidence and trends of surgically treated PUSD and outcomes in Ontario, Canada in patients <18 years of age who underwent their first PUSD procedure between 2002 and 2019 utilizing administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). We assessed the incidence of surgically treated PUSD, demographics, initial surgical treatment and imaging modality, and risk factors for repeat intervention within 5 years. Statistical analyses summarized demographics, surgical trends, and logistic regression was used to identify risk factors for repeat surgical intervention.ResultsWe identified 1149 patients (mean age 11.3 years), with 59.6% older than 12 years. There was a decrease in the number of PUSD procedures per-formed per year that was close to statistical significance (p = 0.059) and a trend towards increased utilization of ureteroscopy (URS) compared with Shockwave Lithotripsy (SWL). In addition, there was a significant increase in the proportion of females surgically treated with PUSD (p = 0.001). In the 706 patients followed for 5 years, 17.7% underwent a repeat procedure within 6 months, while 20.4% underwent a repeat procedure from 6-months to 5 years. Renal stone location (OR 2.79, 95% confidence interval (CI) 1.62-4.80, p = 0.0002) and index SWL (OR 1.66, 95% CI 1.20-2.31, p = 0.0025) were risk factors for repeat surgical intervention within the first 6-months. There was an increasing utilization of ultrasound (US) compared to computerized tomography (CT) (p = 0.0008).DiscussionDespite the literature reporting increasing PUSD incidence, we observed a non-significant decrease in the number of surgical PUSD procedures performed. Exclusion of those treated conservatively may explain our results. The increase in the proportion of females treated reflects the narrowing gender gap in stone disease. A trend towards increased URS utilization was observed and re-intervention rates were similar to previous studies.ConclusionThe overall rate of surgically treated PUSD did not show an increasing trend in Ontario, Canada from 2002 to 2019. URS was the most common surgical treatment modality, with a corresponding decline in SWL rates. PUSD was associated with a high surgical re-intervention rate within 6 months.

Introduction Transition from multidisciplinary paediatric to adult care results in a significant change in the intensity of care provided to patients with spina bifida (SB). Objective To compare planned and unplanned health care utilization and costs of care of transitioning SB patients. Study Design Through a retrospective population-based cohort study, patients with SB born in Ontario between 1988 and 1999 were studied using routinely collected data analysed at ICES. Patients were followed longitudinally from age 16 to 22 years with comparisons made between the paediatric baseline year (age 16) to the first 3 years of adulthood (ages 19 to 21). A composite primary outcome of unplanned emergency room (ER) visits, hospitalizations and emergency surgical procedures, was compared before and after transition. Secondary outcomes included these variables individually and estimated health care costs. Results In the 299 patients, no significant differences were identified in the composite primary outcome between periods (P = 0.09). Unplanned ER visits (P = 0.004) and emergency surgical procedures (P = 0.02) increased after transition. Despite this, the estimated individual total cost of care declined after transition (P = 0.03). Further, multivariable analysis identified rural residence (RR 1.78, confidence interval [CI] 1.30 to 2.44) and previous urologic surgery (RR 1.91, CI 1.41 to 2.57) as significant predictors of increased need for emergent care and health care costs, respectively. Conclusion Patients with SB in Ontario have higher rates of ER usage and unplanned surgery after the transition to adult care. While this does not drive an increase in health care costs, improvements in the care of transitioned SB patients, particularly rural patients and those with prior urologic surgery, may decrease the requirement for acute care.

BACKGROUND:Delays in performing orchidopexy (OP) for undescended testis (UDT) result in loss of germ cells. Despite practice guidelines recommending OP by 18 months of age, significant delays in OP occur. This delay may impact fertility and increase the risk of testicular malignancy in boys with UDT.OBJECTIVE:The objective of this study is to identify factors associated with delayed OP with the goal of identifying modifiable risk factors.STUDY DESIGN:A population-based, retrospective cohort study was conducted using linked databases held at ICES to evaluate factors associated with timing of OP in Ontario for 4339 male newborns undergoing their first OP between 2006 and 2012. Primary outcome was delayed OP (>18 months). Multivariable logistic regression analysis was performed to identify patient, physician, and hospital risk factors for delayed OP.RESULTS:Median age at OP was 24 months, while median age at first surgical consult was 20 months (IQR 10-60 months). Older age at first surgical consult (>12 months vs. <9 months, OR 17.83) was identified as the primary risk factor for delayed OP, besides ICU hospitalization (OR 3.42), associated hypospadias (OR 2.30), higher hospital OP volume (OR 1.91), more healthcare visits in first year of life (OR 1.05), and older surgeon age (OR 1.02).DISCUSSION:Our findings support reports that OP is often performed past guideline recommendations. Interventions that result in earlier referral for UDT (<6 months) may result in timely OP. Limitations for this study include potential misclassification or missing data within the utilized databases.CONCLUSION:The most important barrier to timely OP is delay in first surgical consultation. Aiming for an earlier referral through guideline modifications or education to referring providers may help achieve the goal of timely OP.

Mastering a surgical skill requires experience and repetition, yet opportunities for surgical trainees to gain real experience are variable and limited by case load. Surgical simulators have emerged in an attempt to overcome these limitations. However, the few currently available skills simulators for flexible endoscopy are costly, have limited accessibility and versatility, lack portability, and require dedicated time for practice. The use of a portable skills simulator to teach flexible endoscopy may provide a feasible alternative. This study introduces a novel, low-cost, portable, endoscopic simulation system for training basic endoscopic skills. Using custom software, the simulator presents a virtual environment featuring 3D models of anatomy, endoscopes, and endoscopic tools. The virtual endoscope and its tools are directly controlled in the simulation by motion input from a custom-manufactured portable endoscopic controller that communicates data via a Bluetooth interface. This two-part study presents proof of concept and initial pilot data examining the face/content validity and preliminary construct validity of the portable endoscopic simulator. In part 1, experts (n = 2) and novices (n = 6) provided ratings of fidelity and utility as a training tool. In part 2, experts (n = 4) and novices (n = 4) completed 10 simulated sequential basic endoscopic tasks, and time to completion was assessed. Findings indicate that the simulator has good utility as a training tool, but some features require modification to be more realistic. Furthermore, both novices and experts improved on the task with repeated measurements (p < 0.001), but there were no significant differences between experts and novices in time to completion. Although more robust validation is required, this simulator appears promising as a feasible and cost-effective tool for providing simulation training on basic endoscopic skills.

OBJECTIVE: The objective of this study was to examine the association between learner personality and capacity to be trained (i.e., performance improvement) on a surgical task, and how instructor perceptions of the learners' capacity to be trained interact with learner personality and performance during training and feedback. There is meaningful heterogeneity in the degree of learner surgical skills acquisition despite receiving the same amount of training. While learner personality may independently contribute to skill acquisition, the instructor-learner feedback process is also important to consider. To better understand this interpersonal relationship, it is necessary to also consider instructor factors (i.e., perceptions), and how this may contribute to learner variability in skills training.& nbsp;DESIGN: This exploratory study employed a prospective two-phase design. Medical and non-medical undergraduate students (N = 62) completed measures of personality and participated in two 20-minute training sessions with expert feedback 2 weeks apart, performing an end-to side anastomosis on a low-fidelity model. Learner performance and instructors' perceptions of a learner's capacity to be trained were assessed.& nbsp;PARTICIPANTS: Sixty-two medical and non-medical undergraduate students.& nbsp;RESULTS: There was a significant interaction between learner Extraversion and instructor's perceptions of learner capacity to be trained. Higher learner Extraversion was only associated with an increase in performance improvement for those who were considered trainable (OR = 4.83, p = 0.017). Post hoc analysis revealed a significant difference in the amount of feedback provided to participants who were considered trainable (M = 9.45) versus not trainable (M = 16.48).& nbsp;CONCLUSIONS: This study highlights the importance of both individual learner factors and instructor perceptions on surgical skill acquisition. ( J Surg Ed 79:686-694. (C) 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. Objective The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. Study design This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. Results Piecewise linear regression for OT identified break-points at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 +/- 46.0 min. There was a significant difference in the mean OT between Learning (203.9 +/- 35.3 min, the initial 13 cases), Proficiency (159.2 +/- 18.6 min, the middle 16 cases), and Competency (126.6 +/- 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. Discussion Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. Conclusion Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP. [GRAPHICS] .

INTRODUCTION:We aimed to review the trends and incidence of surgical intervention for adults with upper urinary tract stones in Ontario, Canada, and to hypothesize potential causes for the observed changes.METHODS:We carried out a retrospective, population-based cohort study using administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) to identify all adults (≥18 years) who underwent surgical treatment for urolithiasis, defined by records using a combination of both hospital and physician billing from 2002-2019. Descriptive statistics were used to summarize baseline patient demographics, and surgical trends were analyzed using the Cochrane-Armitage test for trend.RESULTS:From 2002-2019, 140 263 patients were treated surgically for urolithiasis. During this time period, the total number of surgically treated stone disease increased by 80.5%. By type of procedure, percutaneous nephrolithotomy (PCNL) increased by 187% and ureteroscopy (URS) increased by 158%, while the number of shockwave lithotripsy (SWL) declined by 31.4%. The adult population in Ontario in the years evaluated grew by 24.4%. The number of surgical procedures per 100 000 people over this time grew by 45.3%. For every 1% increase in the population, there was a 2.6% rise in stone-related surgical procedures.CONCLUSIONS:The number of stone-related surgical procedures performed rose significantly and cannot be accounted for by population growth alone. This rise was proportionally larger in the female population, further supporting a narrowing of the gender gap in urinary stone disease. The reasons for the increase are likely multifactorial and may imply an increasing incidence of surgically treated stone disease. The change in the proportion of URS and SWL performed may demonstrate a continued shift in surgical preference or may be reflective of resource limitations and availability. The increase in PCNL volumes may also suggest a greater complexity of cases. These findings should be considered for future resource planning and require further study.