Background: The use of simulation-based training tools within surgery is rapidly increasing and has demonstrated promising alternative training modalities allowing for surgical skill enhancement despite workplace pressures. Whilst many simulators have been investigated for their validity, this has not been demonstrated across all domains. This review aims to identify the status of simulation-based training tools in general surgery in the current literature, assess their validity and determine their effectiveness. Methods: OVID Medline and Embase databases were searched for English language articles describing the validation of a simulator for general surgery-specific procedures between 2000 and 2020. Studies were reviewed according to Messick's validity framework and rated in each domain. A modified version of translational outcomes described by McGaghie et al. were used to determine the level of effectiveness (LoE) of each simulator. Results: A total of 9653 articles were screened and 97 articles were identified to determine the LoE of the simulators. The highest rating for each validity domain was achieved by 30 models/training courses for content validity, 48 for response processes, 5 for internal structure, 40 for relations to other variables and 10 for consequences. Two simulators gained LoE >2 showing skill transfer downstream of the simulator. Conclusion: The varying ratings across each validity domain for the simulators show that evidence of complete validity is poor. Only 2 simulators were awarded LoE >2, indicating further research is needed in order to substantiate the use of simulation in improving patient outcomes. Highlights

Background The routine clinical use of serum prostatic specific antigen (PSA) testing has allowed earlier detection of low-grade prostate cancer (PCa) with more favourable characteristics, leading to increased acceptance of management by active surveillance (AS). AS aims to avoid over treatment in men with low and intermediate-risk PCa and multiple governing bodies have described several AS protocols. This study provides a descriptive profile of the Guy’s and St Thomas NHS Foundation Trust (GSTT) AS cohort as a platform for future research in AS pathways in PCa. Methods Demographic and baseline characteristics were retrospectively collected in a database for patients at the GSTT AS clinic with prospective collection of follow-up data from 2012. Seven hundred eighty-eight men being monitored at GSTT with histologically confirmed intermediate-risk PCa, at least 1 follow-up appointment and diagnostic characteristics consistent with AS criteria were included in the profile. Descriptive statistics, Kaplan-Meier survival curves and multivariable Cox proportion hazards regression models were used to characterize the cohort. Discussion A relatively large proportion of the cohort includes men of African/Afro-Caribbean descent (22%). More frequent use of magnetic resonance imaging and trans-perineal biopsies at diagnosis was observed among patients diagnosed after 2012. Those who underwent trans-rectal ultrasound diagnostic biopsy received their first surveillance biopsy 20 months earlier than those who underwent trans-perineal diagnostic biopsy. At 3 years, 76.1% men remained treatment free. Predictors of treatment progression included Gleason score 3 + 4 (Hazard ratio (HR): 2.41, 95% Confidence interval (CI): 1.79–3.26) and more than 2 positive cores taken at biopsy (HR: 2.65, CI: 1.94–3.62). A decreased risk of progressing to treatment was seen among men diagnosed after 2012 (HR: 0.72, CI: 0.53–0.98). Conclusion An organised biopsy surveillance approach, via two different AS pathways according to the patient’s diagnostic method, can be seen within the GSTT cohort. Risk of patients progressing to treatment has decreased in the period since 2012 compared with the prior period with more than half of the cohort remaining treatment free at 5 years, highlighting that the fundamental aims of AS at GSTT are being met. Thus, this cohort is a good resource to investigate the AS treatment pathway.

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