The new checklist to evaluate educational value of YouTube surgical videos of transurethral resection of the prostate
Highlight box
Key findings
• Most YouTube videos related to transurethral resection of the prostate (TURP) are not of high educational value, in large part because they do not demonstrate preoperative preparations or explain the steps of the surgical procedure in detail.
What is known and what is new?
• It is well known that junior clinicians tend to use online resources like YouTube to learn new techniques. However, whether these online resources can offer correct medical techniques is unclear.
• The new finding of this study is that most videos of TURP on YouTube are of low quality by performing what appears to be the first assessment of the educational quality of TURP videos on YouTube.
What is the implication, and what should change now?
• Junior clinicians need to use online resources to learn TURP critically and standard quality criteria should be developed and disseminated to ensure the production of accurate learning resources for junior clinicians.
Introduction
Benign prostatic hyperplasia (BPH) refers to the proliferation of smooth muscle and epithelial cells in the transition zone of the prostate, and it is one of the most common diseases causing urinary obstruction in middle-aged and elderly men. BPH is a benign and progressive disease, and its incidence increases with age. The incidence of BPH increases with age, with more than 50% of men over the age of 60 and as high as 83% in men over 80 (1). BPH is the leading cause of lower urinary tract symptoms (LUTS), and approximately one-fourth of men worldwide suffer from LUTS (2). LUTS mainly manifests as hesitancy, difficulty, reduced urine flow, prolonged voiding time, post-void dribbling, or incomplete emptying, often accompanied by frequency, urgency, and nocturia as LUTS. According to statistics, over 15 million men in the United States aged 30 or older are affected by BPH/LUTS (3), and 45% of men over the age of 45 will develop BPH, reaching 80% in men over 70 (4,5).
Transurethral resection of the prostate (TURP) is the standard treatment for BPH (6,7), in which adenoma in the prostate obstructs the bladder, interfering with the function of the bladder and potentially the kidney (8). Young surgeons increasingly learn their surgical skills by watching videos available online, such as those on the global portal YouTube (9), in contrast to the traditional approach of working “live” with a mentor. This poses a challenge for ensuring educational quality because YouTube video upload has low entry barriers and lacks a comprehensive supervision and evaluation system compared with the official surgical videos with strict access permission provided by some medical schools, resulting in varying quality of existing teaching videos on TURP surgery, and the overall quality level is yet to be determined. As a result, young surgeons may learn techniques and concepts incorrectly, which can have disastrous consequences for patients (10).
Therefore, this study aims to evaluate the quality of existing YouTube videos on TURP surgery teaching, select high-quality surgical teaching videos, and identify the main shortcomings of existing videos, providing references for subsequent video production for teaching purposes. Here we developed a checklist to assess the educational quality of videos related to TURP, and we applied it to videos freely available on YouTube.
Methods
We searched YouTube on August 2, 2022 for relevant videos using the following search terms: “transurethral resection of the prostate”, “benign prostatic hyperplasia”, “BPH”, “TURP”, “benign prostatic enlargement”, “bladder outlet obstruction” and “lower urinary tract symptom”. Videos were included if they met these criteria: (I) the title or video should describe the procedure. (II) Videos recorded complete main steps, not just some steps of the operation. (III) Videos were annotated with audio or text. Beyond that, other videos were excluded, such as commercial advertisements and promotional videos. During the process, if there were any disagreements or doubts between the two authors, a joint decision would be made with the help of the third author. We extracted various characteristics of the videos, such as title, duration, number of likes received, and number of views.
We developed a checklist, based on the literature (6-9), to assess the educational quality of the videos (Table 1). The checklist included information about the video uploaders as well as information related to the following five items: introduction, case presentation, anatomical demonstration, outcomes of the procedure, and associated educational content. Each of these items was further divided into sub-items. Each sub-item was assigned a value of 1 point, and the total number of points was summed to obtain a final score, which ranged from 0–18. A higher total score indicated higher educational quality. Total scores from 0–6 were defined as “low” educational quality; 7–12, “moderate”; and 13–18, as “high”.
Table 1
| Item or sub-item | N (%) |
|---|---|
| Information about the video creators and introduction | |
| Information about the video creators | 38 (80.9) |
| Title of the video, including the procedure | 47 (100.0) |
| Conflict of interest disclosure | 0 |
| Case presentation | |
| Patient anonymity and privacy protection | 47 (100.0) |
| Baseline patient characteristics | 7 (14.9) |
| Preoperative work-up and treatments | 5 (10.6) |
| Assessment of prostate size via imaging | 1 (2.1) |
| Introduction to the surgery | 21 (44.7) |
| Anatomical demonstration | |
| Standardized surgical procedures, presented step by step | 14 (29.8) |
| Detailed explanation of critical steps | 21 (44.7) |
| Cystoscopy during the operation | 41 (87.2) |
| Outcomes of the procedure | |
| Operating time <1 h | 2 (4.3) |
| Associated educational content | |
| Diagrams, photos, snapshots or tables | 38 (80.9) |
| Subtitles | 18 (38.3) |
| Audio explanation | 22 (46.8) |
Each video was assessed by an investigator who had previously been trained in the TURP procedure by an experienced urology surgeon. Each video was also independently assessed by two urology surgeons from the same medical center, each of whom had previously performed at least 25 TURP operations. The three scores were averaged to obtain the final score used in all data analyses. If the two scores from the experienced surgeons differed by more than 3 points, then a second investigator assessed the video, and the four scores were averaged to obtain the final score.
Statistical analysis
Data were analyzed using SPSS 26 (IBM, Chicago, IL, USA). Associations between the characteristics of the videos and their final scores for educational quality were assessed using Pearson correlation analysis in SPSS. Results associated with P<0.05 were considered significant.
Results
The final analysis included 47 YouTube videos about TURP (Figure 1, Table 2). The average duration was 16.7±14.3 (range, 0.8–103.93) min, and the average number of views was 576,379±208,535 (range, 54–1,385,713). The average final educational quality score was 7.38±2.53 (range, 4–12) of a total possible 18 points. Of the 47 videos, 20 were of low quality, 27 were of moderate quality, and none were of high quality. Nearly half of the videos were posted after 1 July 2020, with 10 posted in the first half of 2021 (Figure 2).
Table 2
| Title | Date posted | Length (min) | Video resolution | Likes | Views | Total score |
|---|---|---|---|---|---|---|
| Button TURP in action | 2011/3/25 | 2.92 | Moderate 480p | 18 | 19,883 | 7 |
| Button TURP in action | 2011/3/25 | 2.92 | Moderate 480p | 18 | 19,833 | 8 |
| Bipolar Transurethral Resection of the Prostate (TURP) | 2011/9/28 | 2.52 | Moderate 480p | 45 | 39,995 | 5 |
| Azayem Procedures—TransUrethral Resection of the Prostate (TURP) | 2012/6/7 | 13.32 | Moderate 480p | 178 | 100,739 | 6 |
| Transurethral resection of the prostate without postoperative irrigation | 2013/4/8 | 3.55 | Moderate 480p | 206 | 159,149 | 11 |
| TURP Transurethral Resection Prostate, Penis and Bladder—PreOp® Surgery—Patient Education | 2013/12/8 | 4.5 | High 720p | 1019 | 380,865 | 7 |
| Modified Blandy’s Technique for Bipolar Trans Urethral Resection of Prostate by Dr. N.P.Gupta | 2015/7/14 | 7.98 | Moderate 480p | 153 | 27,347 | 11 |
| Plasmakinetic TURP and Plasma vaporisation in 100 cc prostate. Dr.Farid Gadimaliyev | 2015/9/19 | 16.18 | Moderate 480p | 19 | 4,819 | 5 |
| Bipolar turp 5 How to check landmarks assess prostate and stabilize resectoscope sheath | 2015/11/7 | 5.23 | Low 360p | 165 | 38,623 | 9 |
| Bipolar turp 6 How to resect right lobe of prostatic adenoma | 2015/11/7 | 5.45 | Low 360p | 99 | 20,125 | 9 |
| TURP for prostatic abscess | 2015/12/12 | 18.67 | Low 360p | 84 | 8,632 | 12 |
| Transurethral resection of prostate TURP with 120 cc abscess cavity. Dr.Farid Gadimaliyev | 2015/12/26 | 27.7 | Low 360p | 13 | 2,917 | 6 |
| Bipolar Turp for BPH | 2016/7/13 | 10.89 | High 720p | 273 | 54,007 | 12 |
| T.U.R.P. | 2016/7/21 | 28.48 | Low 360p | 11 | 2,420 | 4 |
| TURP VIO resezione trans uretrale della prostate con RESETTORE BIPOLARE | 2017/3/1 | 13.35 | Low 360p | 15 | 7,222 | 6 |
| En Bloc HoLEP post-TURP | 2017/3/8 | 23.75 | Low 360p | 22 | 2,950 | 9 |
| TURP Transurethral Resection Prostate Surgery, patient education series | 2017/6/5 | 2.23 | Moderate 480p | 1546 | 1,385,713 | 7 |
| Matthew Sand—TURP with Plasma Button and Plasma Loop | 2017/12/7 | 2.2 | Low 360p | 0 | 6,971 | 6 |
| David Wilkinson—Plasma-OvalButton TURP | 2017/12/7 | 2.47 | Low 360p | 0 | 5,276 | 6 |
| Amazing Cutting Loop for Urology TURP by BONSS RF Plasma Bipolar LOOP, put an end to TURS | 2018/6/8 | 20.52 | Low 360p | 6 | 724 | 4 |
| Urolift vs. TURP: minimally invasive surgery takes on gold standard treatment for BPH | 2018/6/10 | 5.93 | Extremely high 1,080p | 566 | 50,403 | 10 |
| TURP—Animated Atlas of BPH and OAB | 2018/11/29 | 0.8 | Moderate 480p | 6 | 2,000 | 9 |
| TRANSURETHRAL RESECTION OF PROSTATE (TURP) BY PROF MAZHAR KHAN | 2018/12/16 | 17.18 | Low 360p | 29 | 1,455 | 5 |
| TURP | Transurethral resection of Prostate for enlarged prostate | Enlarged Prostate Surgery | 2018/12/17 | 40.25 | Moderate 480p | 51 | 6,668 | 5 |
| Transurethral Resection of Prostate (TURP) Surgery | Step by Step Procedure | Urology | | 2020/1/6 | 10.92 | Exremely low 240p | 14 | 1,135 | 4 |
| 220 Gm Prostate Bipolar TURP by Dr Debadarshi Rath | 2020/6/14 | 13.22 | Low 360p | 194 | 1,438 | 4 |
| TURP-Transurethral resection of prostate | Dr Brojen Barman | 2020/8/2 | 9.25 | Low 360p | 36 | 2,986 | 9 |
| Transurethral resection of ProstateTURP\Prostate operation\turp operation\turp surgery\bph surgery | 2020/8/20 | 21.05 | Low 360p | 166 | 8,532 | 6 |
| TURP Operation Dr.Monowarul Islam | 2020/9/7 | 8.1 | Low 360p | 1 | 180 | 9 |
| TURP | 2020/10/10 | 3.68 | Moderate 480p | 1 | 116 | 5 |
| Transurethral resection of Prostate (TURP) and Vesicolithotomy—Video abstract [ID 273375] | 2020/11/4 | 5.97 | Extremely high 1,080p | 196 | 39,400 | 9 |
| TURP 1/10000 by Dr. Kenji Niimura Case 1 2/4 | 2021/3/30 | 14.72 | Low 360p | 0 | 54 | 6 |
| BPH Treatments: Urolift vs. TURP vs. Medications | Answering YouTube Comments #10 | Mark Scholz, MD | 2021/4/16 | 5.48 | Extremely high 1,080p | 90 | 4,629 | 6 |
| TURP | LASER Prostatectomy | Enlarged Prostate (BPH) Surgical Treatment Options | 2021/4/20 | 7.42 | Extremely high 1,080p | 607 | 72,797 | 7 |
| BPH PART 2 (diagnosis and management including TURP) | 2021/4/26 | 74:12:00 | High 720p | 27 | 1,608 | 12 |
| TURP 1/10000 by Dr. Kenji Niimura Case 2 2/5 | 2021/4/28 | 14.5 | Low 360p | 0 | 65 | 5 |
| TURP 1/10000 by Dr. Kenji Niimura Case 2 1/5 | 2021/4/28 | 14.92 | Low 360p | 1 | 159 | 5 |
| TURP 1/10000 by Dr. Kenji Niimura Case 2 3/5 | 2021/5/16 | 14.5 | Low 360p | 0 | 101 | 5 |
| TURP 1/10000 by Dr. Kenji Niimura Case 2 5/5 | 2021/5/29 | 11.22 | Low 360p | 0 | 239 | 5 |
| TURP 1/10000 by Dr. Kenji Niimura Case 2 4/5 | 2021/5/29 | 14.5 | Low 360p | 0 | 56 | 5 |
| Monopolar TURP in very large Prostate of 180 grams (Unedited) | 2021/6/4 | 103.93 | Moderate 480p | 67 | 4,720 | 8 |
| Transurethral Resection of the prostate (TURP) | 2021/7/13 | 2.72 | Extremely high 1,080p | 2738 | 194,093 | 10 |
| Step by step TransUrethral Resection of the Prostate (Bipolar) | Surgical Videos | 2021/8/20 | 40.52 | Moderate 480p | 132 | 8,152 | 12 |
| Monopolar TURP | 2021/8/30 | 13.57 | Low 360p | 28 | 2,480 | 5 |
| TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) | 2021/9/14 | 9.8 | High 720p | 296 | 16,907 | 10 |
| TURP Surgery for Enlarged Prostate BPH | 2021/10/20 | 11.25 | Moderate 480p | 3 | 136 | 10 |
| Step By Step of TURP Dr Angadjyot Singh, Moderator—Dr Vinay Tomar | 2021/11/15 | 38.78 | Low 360p | 6 | 262 | 11 |
The longest video showed the entire surgical procedure without any narration or comments. The shortest video simply showed cystoscope images of some steps in the surgical procedure. The three videos obtaining the highest score of 12 points in the study demonstrated TURP to treat BPH or prostatic abscess. In 41 of 47 videos, the procedure was carried out using cystoscopy, and information was conveyed using diagrams, photographs or tables. Measures for protecting patients’ anonymity were taken in all 47 videos.
Only seven videos demonstrated the preoperative collection of patient information, while only one preoperatively assessed prostate size via imaging, as recommended by the American Urological Association (2). Fewer than half introduced the surgery, and only 14 showed the operation step-by-step. Only 22 provided audio explanation or commentary, and 18 featured subtitles, and five demonstrated preoperative preparations.
Discussion
Medical students and junior clinicians increasingly turn to easily accessible online resources for learning new techniques, such as videos on YouTube (9-15). Indeed, two-thirds of TURP videos in our analysis were produced in 2021–2022. However, such online resources are generally not curated by medical experts, so whether viewers are learning correct medical techniques and principles is unclear (16-22). Here we performed what appears to be the first assessment of the educational quality of TURP videos on YouTube, for which we custom-designed a quality checklist. Our results suggest that most videos of this procedure on YouTube are of low quality, emphasizing the need for medical instructors and mentors to guide junior clinicians’ use of online resources and the need for experts to produce learning videos of adequate quality. In this regard, our custom-designed checklist may be useful as an initial set of minimum standards.
We found that fewer than half of the videos provided introductory background to TURP or an audio explanation, and even fewer had subtitles. Most did not show preoperative work-up. We did not find a significant correlation between educational quality score and the number of likes and views, which is consistent with other studies of videos demonstrating information on surgical treatment of BPH on YouTube is highly biased and misleading (8,9) and which indicates that the most-viewed videos are usually not of high instructional value. These observations suggest an urgent need to standardize quality criteria for the production of surgical videos.
There are two major limitations in our research. Firstly, while our analysis is based on a relatively small number of videos, all of which focused on a single surgical procedure, it suggests the need for a more extensive investigation on the educational quality of medical resources online and the standardization of criteria for producing such resources. Our quality checklist may provide a starting point for developing such standards. Secondly, we found that YouTube is just one of the resources for medical students to learn new surgical techniques and patients to assess some information of a certain disease. Nowadays, there is a way combining conventional education with virtual reality (VR) videos to educate outpatients for bowel preparation before colonoscopy (23). This example suggests that exploring the value of the new techniques used in medical education is a topic for future researchers to pay attention to.
Conclusions
Most YouTube videos related to TURP are not of high educational value, in large part because they do not demonstrate preoperative preparations or explain the steps of the surgical procedure in detail. Standard quality criteria should be developed and disseminated to ensure the production of accurate learning resources for medical students and junior clinicians.
Acknowledgments
Funding: Research on
Footnote
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-23-394/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-23-394/coif). The authors have no conflicts of interest to declare.
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