Educational value of YouTube Surgical Videos of Thulium Laser Enucleation of The Prostate (ThuLEP): the quality assessment

Introduction

Surgical videos are a very important educational tool for medical students, residents, trainees and senior surgeons. With the development of the internet, high-definition video recording and portable electronic devices, online surgical videos are becoming useful medical education resources (1,2). Videos containing pictures and words/audio may help beginners to learn and understand complex surgical procedures (1). YouTube is the most widely used video platform in preparation for surgical procedures (3,4).

In 2010, Thulium laser enucleation of the prostate (ThuLEP) was first reported by Herrmann et al. as an enucleating technique for benign prostatic hyperplasia (5). ThuLEP is primarily focused on mechanical blunt dissection of the transitional zone (5,6). Some studies have shown that approximately 30 cases may be sufficient to overcome the learning curve with the help of a simulator (7-9).

Numerous ThuLEP surgical videos have been uploaded to the YouTube platform by individual surgeons, academic societies, hospitals or commercial companies. Due to a lack of peer review and quality assessment, the educational value of these videos remains uncertain. The high educational quality of videos can facilitate learning, whereas the poor educational quality of videos may mislead learners. Studies have shown that trainees preferred videos with rich educational content (4).

A consensus statement about how to report a laparoscopic surgical video for educational purposes known as the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) has been published (10). However, guidelines for reporting educational videos of urological endoscopic surgeries are lacking.

The purpose of this study is to assess the educational value of YouTube surgical videos of ThuLEP. Moreover, this study may promote the creation of an ideal educational video checklist for ThuLEP surgery. We hypothesize that the number of views may not be related to the educational value of the video. This study will also help beginners identify valuable ThuLEP videos from the YouTube platform.

Methods

This study focused on the evaluation of public-domain videos on ThuLEP surgery. Therefore, no ethical approval is required. A comprehensive search was performed on YouTube (https://www.youtube.com) on October 31, 2020 using the search terms “thulium laser enucleation of the prostate” and “ThuLEP”. The videos were collected by one author based on the following inclusion criteria: enucleation of the prostate must be performed using a thulium laser, live surgery recorded by endoscopic camera (no schematized video, cartoon, or multiple surgeries), professional videos made by professionals (not promotional videos or commercial advertisements), and commentary in English language. Any video that did not meet these inclusion criteria was excluded.

Given the lack of guidelines for reporting educational videos of urological endoscopic surgeries, we created an evaluation checklist. According to the LAP-VEGaS practice guidelines (10), two expert surgeons in our center who have experience with greater than 100 cases of ThuLEP surgery created the checklist (Table 1). The checklist included the essential educational contents to be shown in videos, such as authors’ information, case presentation, demonstration of the critical procedures, outcomes and image quality of videos (low: 480p resolution, moderate: 720p resolution, high: 1080p resolution). We referred to the structure of the LAP-VEGaS Practice Guidelines, which mainly included five categories and 20 items. Two surgeons discussed each item and made a final decision together. The major differences between the LAP-VEGaS and ThuLEP checklists were demonstration of the surgical procedure and procedure outcomes. The critical domains of the surgery referred to the techniques reported by Herrmann et al. (5,11). The reporting checklist included 20 options. Each option represented one point. The total score was the sum of all the points. A higher score represents a higher educational value.

Table 1 The checklist for the evaluation of ThuLEP surgical videos’ educational value
Full table

All videos were first reviewed for inclusion criteria by the first author. The baseline characteristics of the included videos were collected. Then, two surgeons who created the checklist simultaneously evaluated conformity to the reporting checklist. Two surgeons simultaneously viewed the videos and made the final decision together for each option of the checklist. The playback speed could be two times for videos longer than 30 min.

Statistical analysis

Data analysis was performed with SPSS Statistics (Version 22 for Windows, IBM Corporation). Continuous variables are presented as the mean, ranges, and standard deviation (SD). Pearson’s correlation coefficient was used to evaluate the correlations among variables. Correlation is significant at the P<0.05 level.

Results

A total of 70 videos of ThuLEP that met the inclusion criteria were identified. The characteristics of the videos are shown in Table 2. The median time available online was 1,120.5 days (range, 18–3,427 days). The oldest videos were uploaded in 2011, and the newest videos were uploaded in 2020. The average number of views was 1,366 (range, 11–30,884, SD 3,848). Figure 1 shows the distribution of the authors’ countries. The image quality was rated as high for 34 (48.6%) videos, moderate for 19 (27.1%) and low for 17 (24.3%). The mean video length was 16.59 mins (range, 1.20–70.35 mins, SD 14.29). The mean number of likes and dislikes per video was 4.9 (range, 0–55) and 0.4 (range, 0–9), respectively. All channels except one allowed the viewers to post comments. Thirty-six videos (51.4%) were uploaded to individual channels. Twenty-three videos (32.9%) were uploaded by academic institutions of hospitals, and 11 videos (15.7%) were uploaded by commercial companies. Several surgeons uploaded a series of videos about ThuLEP.

Table 2 Characteristic of the 70 reviewed surgical videos on ThuLEP on YouTuBe (The data were collected on October 31, 2020)
Full table

Figure 1 The distribution of the authors’ countries.

The evaluation of the videos’ educational value was completed by two surgeons simultaneously. No disagreement occurred. Only 22.9% (16/70) of videos had audio or/and written commentary in English language. Audio commentary alone was present in 1.4% (1/70) of the videos. Written commentary alone was present in 12.9% (9/70) of the videos. Six videos (8.6%) contained audio and written educational content. The patient privacy was protected in 98.6% (69/70) of the videos. However, the patients’ characteristics were introduced in 14.3% of videos, and the preoperative volume of the prostate was reported in 32.9% (23/70). Anatomic landmarks were shown in 72.9% (51/70) videos. Although surgery information was presented in a step-by-step fashion in 67.4% (47/70) of videos, only 21.4% (15/70) of videos provided a detailed explanation of critical steps. Three-lobe, 2-lobe, and en bloc enucleation were present in 44.3% (31/70), 24.3% (17/70) and 31.4% (22/70) of the videos, respectively. Most of the videos reported no procedure outcomes.

The mean score of the videos was 5.5 points (range, 1–15, SD 3.1). No video received all the points from the checklist. Three videos uploaded by UROLOGIE SAINT AUGUSTIN had the highest scores of 15 points. One of these three videos was shown at the European Association of Urology Annual Congress of 2019. This channel also uploaded a series of videos about urological surgeries. The mean percentage conformity of the videos was 28% (range, 5–75%).

The correlation test showed that the number of views was significantly positively correlated with number of days posted online and the number of likes (r=0.718, P<0.01) and dislikes (r=0.935, P<0.01). Although the number of views had a negative relationship with video length, the correlation was not significant. The educational score of the videos had no significant positive correlation with the number of views (Table 3).

Table 3 Correlation test for the factors influencing the views
Full table

Discussion

This study reports the educational evaluation of ThuLEP surgical videos on YouTube on October 31, 2020. These videos were available on YouTube for a mean of 3.1 years and were watched by trainees, residents and beginners worldwide. Considering that these videos have potential educational value and enormous influence, a quality assessment of these videos may be essential and reasonable for trainees. To our knowledge, this is the first quality assessment of ThuLEP surgical videos posted on YouTube. We are also the first to report an evaluation checklist for ThuLEP educational videos.

Watching videos is a good method to learn surgical methods, especially minimally invasive endoscopic surgeries. Some studies have revealed that YouTube is the most frequently used video source for surgical learning and preparation (3,4,12). However, without peer review and quality assessment, some studies have revealed that YouTube is not a reliable education or information resource (13-16). This finding reminds us that the quality assessment of surgical videos is necessary when we use them as the educational tool.

In laparoscopic surgical education, LAP-VEGaS is a good example for producing an educational video with a logical structure (10,15). These guidelines can improve the educational value of surgical videos. Therefore, we assume that a similar requirement for reporting educational videos of urological endoscopic surgeries is also useful. Given the lack of a published evaluation checklist for ThuLEP videos, two experienced ThuLEP surgeons created an initial vision of this checklist (Table 1). The content of this checklist was finally established based on the LAP-VEGaS checklist and ThuLEP surgery characteristics.

In our study, we found that the most popular videos did not have the highest educational value. In contrast, the highest valued videos were not the most popular videos. The correlative analysis demonstrated that the educational score of the videos is not correlated with the number of views. This in an interesting phenomenon, which is consistent with findings from other studies (3,13,17-19).

We noted that many urological journals have video sections that encourage authors to submit videos. Very few journals are open access and most journals are not free. Two ThuLEP surgery videos created by experts in this field were published in Videourology (20,21). These videos can only be viewed after purchase. We also found that one of the reviewed videos had been published in the Urology Video Journal, which is an open access journal (22). The European Association of Urology and the American Urological Association both have video libraries. However, these libraries are only open to registered members or eligible learners.

There are some inevitable limitations in this study. We only evaluated ThuLEP videos posted on the YouTube platform given that this platform is the most frequently used educational video source for residents and trainees. We only search for videos using English language. Thus, selective bias exists. Given that authors may upload their videos with non-English language, and the fact that YouTube is an open platform, new videos will be uploaded, and old videos may be removed. In addition, there is still no generally accepted consensus for reporting an educational video about ThuLEP. The checklist that we created must be approved by more experts. Although YouTube is a public and nonacademic video platform, more requirements for uploading surgical videos may improve its educational value.

Conclusions

Although YouTube is the most frequently used educational video source for surgical learning, the majority of ThuLEP videos have low educational value. Videos often lack important and detailed explanations about surgical procedures. These findings remind us that a global effort should be made to improve the educational value of YouTube surgical videos, and more reporting guidelines are needed.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://dx.doi.org/10.21037/tau-21-263

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/tau-21-263). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. No ethical approval is required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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