Scrotal point-of-care ultrasonography: a UK cross-speciality pilot training course evaluation
A.S. and A.N. joint first authors: both authors contributed equally to the study
Abbreviations
-
- OSAUS
-
- Objective Structured Assessment of Ultrasound Skills
-
- PGY
-
- Post-Graduate Year
-
- POCUS
-
- point-of-care US
-
- US
-
- ultrasonography
Spermatic cord torsion is a time-critical surgical emergency, with suspected cases typically taken directly to theatre for scrotal exploration. However, only 20%–25% of patients who undergo scrotal exploration in this setting are found to have testicular torsion [1]. Therefore, the majority of patients undergo an unnecessary operation with associated surgical and anaesthetic risks, while increasing health resource utilisation.
The diagnostic paradigm for testicular torsion has remained unchanged for decades. Scrotal ultrasonography (US) has been shown to be an imaging modality with high specificity and sensitivity for testicular torsion [2]. However, its use is limited in the UK due to concerns about introducing a time delay to surgery and accessibility of specialists who can perform the US, particularly out of hours.
One solution is for the assessing clinician to perform a scrotal point-of-care US (POCUS) at the bedside as a clinical assessment adjunct in patients with suspected testicular torsion. A retrospective study of scrotal POCUS by emergency physicians in Canada found in 120 children presenting with an acute scrotum, the sensitivity and specificity of identifying testicular torsion were 100% and 99.1%, respectively. Results were available at a median (interquartile range) of 73 (51–112) min, faster than a formal departmental US [3]. It has been shown that urology and emergency medicine residents can be taught scrotal POCUS for this purpose with focused training [4]. However, further prospective research is required to evaluate the role of POCUS in suspected torsion [5].
Our aim was to design, deliver, and optimise an easily replicable 1-day scrotal POCUS training course for cross-speciality clinicians. This will form the basis of an ethically approved clinical trial evaluating the diagnostic accuracy of POCUS in suspected testicular torsion [6].
Delegates from the UK were recruited from urology, general surgery, paediatric surgery, or emergency medicine backgrounds. The course consisted of a pre-course online module and a 1-day practical session with an assessment of competency. The online module was designed by radiologists and outlined the basic science behind US, relevant anatomy, and key features of testicular torsion detection by US with self-assessment questions at the end [7]. The 1-day practical session was delivered by expert faculty, including radiologists and emergency physicians with a specialist interest in POCUS. The course consisted of lectures and practical sessions enabling the delegates to practise scrotal POCUS on both phantom and healthy live models with a faculty-to-delegate ratio of 1:3. The practical sessions and assessments were carried out using three different Sonosite POCUS machines (Sonosite LX, Sonosite PX and Sonosite Edge II using linear probes) to give a total of six machines.
Competency was assessed using the Objective Structured Assessment of Ultrasound Skills (OSAUS) at the end of the course (Fig. 1) [8]. This validated tool assesses applied knowledge of ultrasound equipment, image optimisation, systematic examination, interpretation of images, and documentation of examination. Competency was defined as an overall score of 80% based on expert consensus and findings in previous studies [5]. Delegates were given 8 min to perform a scrotal POCUS on a live model and 2 min to present their findings and interpret the US images. Additionally, participants completed a pre- and post-course questionnaire assessing their confidence in performing scrotal POCUS on a 5-point Likert scale (1 = ‘not confident’ to 5 = ‘very confident’). In a co-design exercise, delegates from the course participated in an anonymous focus group with qualitative researchers to explore how training materials, course design and delivery could be adapted and enhanced to meet their training needs better.
A total of 19 delegates attended the course (14 urology, one general surgery, one paediatric surgery, and three emergency medicine). In all, 89% (n = 17) had never performed scrotal POCUS before. The two delegates who had performed scrotal POCUS previously were both urologists and had performed <10 scrotal POCUS each. Delegates ranged from core surgical trainees (Post-Graduate Year [PGY]3) to higher specialist trainees (PGY5+). The confidence in performing scrotal POCUS improved from a pre-course mean of 1.2 to a post-course mean of 4.2 (P < 0.001) on the Likert scale. The mean confidence in recognising features of testicular torsion by US increased from 1.5 pre-course to 3.9 post-course (P < 0.001). The mean satisfaction for the overall course was 4.4 out of 5. Overall, 74% (n = 14, 10 urology, one general surgery and one emergency medicine) of the delegates were deemed competent to perform scrotal POCUS after training. The mean (SD) OSAUS score for all delegates was 4.0 (0.83) out of 5. The domain with the lowest mean score was systemic US examination (3.6) and the highest was the interpretation of imaging findings (4.4). The mean score for applied knowledge of the ultrasound equipment was 3.9 out of 5, image optimisation 4.0 out of 5, and documentation 4.2 out of 5.
The post-course focus group highlighted positive feedback about the course content and delivery. Some delegates thought future refresher training would be of benefit, and others suggested a local mentor to supervise initial cases would improve early confidence. The findings showed that our scrotal POCUS course was feasible, effective, and well-received by delegates across multiple specialities and different levels of training. The majority of delegates had no previous scrotal US experience and following an online learning module and a 1-day practical course, three out of four were deemed competent by expert clinicians. Delegates commented on the efficient blend of self-directed virtual learning, didactic teaching and high-fidelity practical learning with phantom and live models and a high faculty-to-delegate ratio.
Nonetheless, a minority of the participants (five) did not achieve competency following our pilot course. This is in contrast to Stringer et al. [4] where 96% were deemed competent following a shorter (2 h) training workshop. A possible reason for the difference in competency rates is the short time frame (8 min) available to our delegates to complete scrotal POCUS during the assessment. In addition, the feedback we received highlighted that the ultrasound machines in the OSAUS were different models than those used whilst practising.
The main area of course improvement will be emphasising a stepwise, systematic approach to performing POCUS, an additional training station where delegates can familiarise themselves with different machines and models, and additional training time on multiple live models. We plan to incorporate a demonstration video into the online module that will showcase a ‘gold standard’ systematic technique for scrotal POCUS and allow the delegates to refer to it in their own time before and after the course.
Limitations of the pilot course include the small sample size consisting of mainly urology trainees, lack of assessment of skill retention, the learning curve in clinical practice, and the lack of live or phantom models with findings consistent with acute testicular torsion. One suggestion made by the participants was to make a bank of torsion and non-torsion US images available on demand.
We have demonstrated an effective, feasible and replicable method of training cross-speciality doctors in scrotal POCUS. With a short training course and a high competency rate achieved, this course could support a future interventional trial assessing the diagnostic accuracy of scrotal POCUS in the assessment of suspected testicular torsion. This forms the basis of our onward work, with the aim of reducing the negative scrotal exploration rate.
Acknowledgements
We thank our funders: The Urology Foundation (TUF) and the BJUI. We would also like to thank Sonosite, MediScientific and the Royal Society of Medicine (RSM) for their support of this course.
Declaration of Interests
The BJUI have previously supported the British Urology Researchers in Surgical Training (BURST) research collaborative organisation with general funding for the purposes of conducting and disseminating research. However, they did not have any involvement in this study design or delivery, nor did they provide any direct financial contribution for this work.
