Abstract
Objectives: To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1–F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively. Conclusions: Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competency-based medical education model in learning US for identifying the ureters.
| Original language | English |
|---|---|
| Pages (from-to) | 2365-2372 |
| Number of pages | 8 |
| Journal | Journal of Ultrasound in Medicine |
| Volume | 39 |
| Issue number | 12 |
| DOIs | |
| Publication status | Published - Dec 2020 |
| Externally published | Yes |
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In: Journal of Ultrasound in Medicine, Vol. 39, No. 12, 12.2020, p. 2365-2372.
Research output: Contribution to journal › Article › peer-review
TY - JOUR
T1 - Ureter Visualization With Transvaginal Ultrasound
AU - Ong, Jozarino
AU - Leonardi,, Mathew
AU - Espada, Mercedes
AU - Stamatopoulos, Nicole
AU - Georgousopoulou, Ekavi
AU - Condous, George
N1 - Funding Information: Dr Leonardi reports grants from the Australian Women and Children's Research Foundation outside the submitted work. Dr Condous reports personal fees from Roche, personal fees from GE Healthcare, and grants from the Australian Women and Children's Research Foundation outside the submitted work. All of the other authors of this article have reported no disclosures. Funding Information: All patients underwent an expert-guided TVUS examination of the pelvis using a Voluson E8 system (GE Healthcare, Milwaukee, WI) with volumetric intravaginal transducers (GE RIC 5?9 MHz) by the expert sonologist (ES; G.C.) as a reference standard scan. No bowel preparation, intravaginal saline solution, or intrarectal contrast was used in this study. All women emptied their bladder before the examination. The TVUS examinations were performed per the recommendations of the International Deep Endometriosis Analysis group.15 Specific to the urinary tract, the bladder is examined in the transverse plane to evaluate for deep endometriosis within the detrusor muscle. A longitudinal view in the midline, guided by the urethra, is then obtained. From here, the transducer is swept toward the lateral pelvic side wall to identify the distal part of the ureter. Ureters typically appear as long tubular hypoechoic structures with thick hyperechoic walls extending from the lateral aspect of the bladder base toward the common iliac vessels (Figure 1).13 Methods to determine the identity of the ureter beyond the course and appearance include the use of color Doppler imaging to ensure that the ureter was not mistaken for a vessel and observing for vermiculation (Video 1). Once one side is visualized, the same is repeated on the contralateral side. Video documentation showing vermiculation is valuable both for identification of the ureter and for assessment of asymmetry, hydroureter, or both. The ES is considered an EFSUMB level 3 practitioner22 with expertise in endometriosis US.15,23 The ES was aware of the clinical and surgical history, including any previous imaging results, of the study patients. We performed a prospective learning curve study on women attending an outpatient gynecologic clinic in a tertiary referral center for endometriosis (Nepean Hospital) over a 12-month period between December 2017 and December 2018. The learning curves to identify bilateral ureters with TVUS of 3 enrolled minimally invasive gynecologic (MIG) surgery fellows were evaluated. This study received ethical approval from the Nepean Blue Mountains Local Health District Human Research Ethics Committee (HREC/16/NEPEAN/30), and written informed consent was obtained from all study patients. The same fellows and patient population were used to perform a simultaneous although different learning curve study on pouch of Douglas obliteration and bowel deep endometriosis.21 Consecutive patients with pelvic pain were recruited for the study. Inclusion criteria included the following: postmenarchal and premenopausal status and clinical suspicion or confirmed current endometriosis (either based on signs/symptoms, including dysmenorrhea, dyspareunia, dyschezia, noncyclic chronic pelvic pain, and infertility, or confirmed by imaging or surgery). Exclusion criteria included premenarchal or postmenopausal status, a surgical history of hysterectomy, bilateral oophorectomy, or both, pregnancy, known M?llerian anomalies, and an inability to undergo a TVUS examination (eg, virginal status). Participants included 3 (MIG) surgery fellows (F1?F3) of varying prestudy US experience, including core obstetrics and gynecology training. All were undergoing the same subspecialty training program in gynecologic US and MIG surgery at the time of the study. All fellows enrolled in the fellowship program participated in the study. At the initiation of the study, F1, F2, and F3 had performed approximately 500, 1000, and 100 basic TVUS examinations, respectively. No fellow had formal training or experience in advanced TVUS for endometriosis or ureter identification. Fellow 1's prestudy scan experience focused on early pregnancy complications and general gynecologic conditions under supervision by a senior gynecologic sonologist. At the onset of the study, F1 would not have yet been considered level 1 competent by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) minimum training requirements.22 Before the study, F2 had moderate experience in formal diagnostic gynecologic US, in a general gynecology outpatient clinic, performing and reporting independently. Fellow 2 would have been considered EFSUMB level 1 at the onset of the study. Fellow 3's prestudy scan experience was obtained from a general radiology practice under supervision by a senior sonographer/radiologist. At the onset of the study, F3 would not have yet been considered level 1 competent by the EFSUMB. All 3 fellows had prestudy MIG surgery exposure, including exposure to retroperitoneal dissection and ureterolysis. All patients underwent an expert-guided TVUS examination of the pelvis using a Voluson E8 system (GE Healthcare, Milwaukee, WI) with volumetric intravaginal transducers (GE RIC 5?9 MHz) by the expert sonologist (ES; G.C.) as a reference standard scan. No bowel preparation, intravaginal saline solution, or intrarectal contrast was used in this study. All women emptied their bladder before the examination. The TVUS examinations were performed per the recommendations of the International Deep Endometriosis Analysis group.15 Specific to the urinary tract, the bladder is examined in the transverse plane to evaluate for deep endometriosis within the detrusor muscle. A longitudinal view in the midline, guided by the urethra, is then obtained. From here, the transducer is swept toward the lateral pelvic side wall to identify the distal part of the ureter. Ureters typically appear as long tubular hypoechoic structures with thick hyperechoic walls extending from the lateral aspect of the bladder base toward the common iliac vessels (Figure 1).13 Methods to determine the identity of the ureter beyond the course and appearance include the use of color Doppler imaging to ensure that the ureter was not mistaken for a vessel and observing for vermiculation (Video 1). Once one side is visualized, the same is repeated on the contralateral side. Video documentation showing vermiculation is valuable both for identification of the ureter and for assessment of asymmetry, hydroureter, or both. The ES is considered an EFSUMB level 3 practitioner22 with expertise in endometriosis US.15,23 The ES was aware of the clinical and surgical history, including any previous imaging results, of the study patients. A standardized educational program preceded study initiation. This involved theoretical learning through reading of key publications and viewing images and supplementary videos.13,15,24 In addition, fellows were present during 5 advanced TVUS examinations by the ES, during which all fellows had the opportunity to witness visualization and assessment of ureters. Additional methods to determine the identity of the ureter (use of color Doppler imaging and observation for vermiculation) were demonstrated in each case. Each fellow performed 50 predetermined study TVUS examinations. At the time of study design, previous learning curve studies on identifying abnormalities with advanced TVUS suggested that competency was attainable in fewer than 50 examinations.25,26 It was hypothesized that identifying the ureter would be more direct and uncomplicated than identifying bowel deep endometriosis, for example, and 50 TVUS examinations would suffice. This number was appropriate considering the fellowship training program duration and anticipated availability of the fellows. Throughout the study period, fellows continued to perform routine basic TVUS examinations on patients for all indications. They were instructed during this time not to attempt ureter visualization. For each patient, the fellows were blinded to the clinical and surgical history. They were aware that all patients were being evaluated for pelvic pain or endometriosis. The ES assessed the patient and visualized the ureters first as part of the advanced TVUS examination for endometriosis. This was followed by a fellow performing a focused component to assess the ureters. Fellows were blinded to the reference standard findings of the ES. During the fellow TVUS examination, the ES was present to observe performance. No verbal commentary was provided until the fellow reported identification of both ureters or the maximum allotted time was exhausted (2 minutes). When the ureters were found, the fellow captured an image depicting the ureter, which was used by the ES to score the fellow as correct or incorrect. Both ureters needed to be identified to receive an overall adequate performance score. After noting the performance of the fellows, the ES provided immediate feedback and hands-on teaching if necessary. The cumulative summation test for the learning curve (LC-CUSUM) was adopted for this study. As per Biau et al,27 it is a method to objectively define acquisition of skill competency, presumes that the fellow is not competent at the start of monitoring, and signals when the fellow has reached the acceptable predefined level of performance. We did not plan or complete a CUSUM component as part of this study to ascertain maintenance of competency. This was out of the scope of this study and limited by some factors (eg, time-limited working relationship between fellows and the ES and study design). The null hypothesis, H0, is defined as inadequate performance for the identification of bilateral ureters and is progressively tested against the alternate hypothesis, H1, defined as adequate performance by way of successive outcomes. Each of a fellow's successive outcomes contributed to an LC-CUSUM score, in which correct interventions or performance yielded progressively negative scores, and vice versa, each incorrect result led to a more positive LC-CUSUM score. When the LC-CUSUM score reaches a predefined level (h), H0 is rejected in favor of H1, signifying that adequate performance has been reached. Similar to Biau et al27 and Tammaa et al,25 we used the following parameters: for the learning curve, the hypothesis H0 was set with P0 = 0.175 (failure rate, 17.5%; process out of control), H1 with P1 = 0.1 (failure rate, 10%; process in control), and a control limit of h = 1.25 was chosen. Publisher Copyright: © 2020 American Institute of Ultrasound in Medicine
PY - 2020/12
Y1 - 2020/12
N2 - Objectives: To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1–F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively. Conclusions: Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competency-based medical education model in learning US for identifying the ureters.
AB - Objectives: To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1–F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively. Conclusions: Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competency-based medical education model in learning US for identifying the ureters.
KW - endometriosis
KW - learning curve
KW - transvaginal ultrasound
KW - ureter visualization
KW - ureteral endometriosis
KW - urinary tract endometriosis
UR - http://www.scopus.com/inward/record.url?scp=85096294314&partnerID=8YFLogxK
U2 - 10.1002/jum.15345
DO - 10.1002/jum.15345
M3 - Article
C2 - 32472967
AN - SCOPUS:85096294314
SN - 0278-4297
VL - 39
SP - 2365
EP - 2372
JO - Journal of Ultrasound in Medicine
JF - Journal of Ultrasound in Medicine
IS - 12
ER -