Educational value assessment of YouTube surgical videos of tension-free vaginal tape obturator (TVT-O) and trans-obturator vaginal tape (TOT)

Introduction

Stress urinary incontinence (SUI) is a common disease in women. It refers to the complaint of involuntary urine leakage with effort, exertion, sneezing, or coughing (1). SUI seriously affects the quality of life and social activities of female patients. Among Chinese adult females, the incidence of SUI is as high as 18.9%, especially 28% in the 50–59 age group (2). In surgical treatment, mid-urethral sling operations have been proved to be an effective means for the treatment of SUI, with definite long-term efficacy and safety. In addition to traditional tension-free vaginal tape (TVT), tension-free vaginal tape obturator (TVT-O) and trans-obturator vaginal tape (TOT) are also widely used and have good therapeutic effects (3).

In the past, field instruction and clinical observation were the most important methods of surgical teaching. With the use of multimedia and the development of video recording equipment, surgical video has become an essential part of surgical education resources (4,5). YouTube, the popular video site, provides a platform for surgeons to share videos of their operations, regarded as the most frequently used educational video source for surgical preparation (6). Many people can learn and improve their own surgical abilities through videos posted by other doctors. However, due to the lack of professional peer review and quality evaluation system, the quality of surgical videos available on YouTube is irregular, which is not only a waste of time to find good resources, but some low-quality surgical videos may be the wrong example. Therefore, after the release of LAP-VEGaS practice guidelines reporting of educational videos in laparoscopic surgery (7), many scholars began to evaluate the quality of related surgery videos.

TVT-O and TOT surgery play an important role in the field of incontinence surgery (8-10). On YouTube, there are dozens of educational videos about these two procedures. This study aims to assess the educational value of surgical videos of TVT-O and TOT on YouTube. Moreover, to provide convenience for trainees and to provide a reference for educational video producers.

Methods

Two authors conducted a comprehensive search for “tension-free vaginal tape obturator”, “trans-obturator vaginal tape”, “TVT-O” and “TOT” on YouTube individually on August 22, 2021, then sorted and screened the videos according to the following inclusion and exclusion criteria. If the videos that met the inclusion and exclusion criteria were found in places other than the search results, such as similar videos recommended by YouTube, simplifying keywords and expanding the search scope would be carried out. Videos were included if they met these criteria: (I) the title or video should describe the procedure; (II) videos recorded complete main steps, not a partial segment; (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.

Due to the lack of a standard and authoritative urological surgery video quality evaluation checklist, we drew on the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) practice guidelines (7) and similar research scale of thulium laser enucleation of the prostate (11) to develop the final checklist, which was shown in Table 1. The checklist was developed by all authors, with the assistance of two experienced urogynecologists with over 700 incontinence surgery and at least 200 cases of TVT-O or TOT surgery experience, containing 5 major items (including author’s information and video introduction, case presentation, demonstration of the surgical procedure, outcomes of procedure, and associated educational content) and 18 minor items. The overall content was consistent with previously published scales, with adjustments for surgical procedures and outcome measures. For the standard procedure of TVT-O and TOT surgery, we referred to the published techniques by de Leval (12) and Delorme (13). Each sub-item counts for one point out of a total of 18. The higher the score, the higher the educational quality.

We collected the data of the videos included in the evaluation scope and recorded the baseline data, including days online, region, length, video definition (we regarded 1,080P as high, 720–480P as moderate and 360–240P as low video definition), number of likes and dislikes. Data collection and video evaluation were done by two authors separately (the video reviewers were both urogynaecology doctors who had watched and studied at least 20 TVT-O or TOT operations). Before video evaluation, they all learned standard surgical procedures referring to published techniques by de Leval (12) and Delorme (13). If the total scores difference of a video were more than 3 points, the third author would score the video and take the average score. The collation and proofreading of the data were done jointly by these three authors and supervised by all the other authors.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Statistical analysis

Data analysis was performed with SPSS Statistics (Version 26 for Windows, IBM Corporation). The mean, ranges, and standard deviation (SD) were recorded as the primary outcome measure. Pearson’s correlation coefficient was applied to evaluate the correlations among variables. Correlation is significant at the P<0.05 level.

Results

A total of 145 videos were retrieved. After screening by inclusion and exclusion criteria, 36 videos entered the final list, and the video inclusion process was shown in Figure 1. The baseline data were recorded in Table 2.

Figure 1 Flowchart of video inclusion.

From our primary outcome measure, the average score of the included videos was 7.39 (range, 3–16, SD: 3.57). The video with the highest score of 16, titled Transobturator Tape Operation (TOT), was created by Dr. Mehmet Akyuz from France in 2019. Most videos can be performed in a standard surgical procedure (94.4%) with clear indications of how the procedure is performed (88.9%), protecting patient privacy (100%). However, as educational videos, only a few videos cover associated educational content (41.7%) and outcomes of procedure (27.7%).

The average number of days available for existing educational videos (as of August 22, 2021) was 1,956.6 days (range, 190–4,152 days, normal distribution, median: 1,846.5), with the earliest videos dating back to 2010. Among these included videos, the average length was 9.7 min (range, 1.8–73.6 min, SD: 13.65). Although the shortest video was composed of fragments of each step, the key surgical steps were complete, and there were figures to assist teaching, which could be used as learning materials for surgical beginners. The majority of videos originate from India (33%), except for those without a clear country of authorship, and the country distribution of videos is shown in Figure S1. Video definition is divided into high, moderate and low, accounting for 22%, 36% and 42% respectively. The average number of likes was 98.8 (SD: 177.5) and the average number of dislikes was 21.8 (SD: 62).

Although the correlation analysis indicated that the video quality score had a negative correlation with the length of the video (r=−0.37, P<0.05), the correlation was not strongly significant. Moreover, video quality score had no significant correlation with the number of likes and dislikes, and the number of days of release, meanwhile there was no significant correlation between audience likes and other factors. The results of correlation analysis are performed in Table 3.

Discussion

This study evaluates the quality of videos by searching YouTube for educational videos of TVT-O and TOT, with the aim of identifying videos that have pedagogical value, as well as figuring out the shortcomings of existing instructional videos and providing a reference for more and better-quality videos in the future. To our knowledge, this is the first research to evaluate the quality of TVT-O and TOT educational videos on YouTube, as well as the first to use our modified checklist to evaluate the video quality of these surgical procedures.

With the increasing use of multimedia, people have more and more ways to obtain information. After the release of the laparoscopic checklist (7), some scholars have carried out some studies on video quality evaluation of abdominal surgery, providing a reference for surgical beginners (11,14-16). Unfortunately, many studies have shown that the included videos are generally not rated high, with incomplete content and little teaching significance, failing to meet the standards of a good surgical teaching video. YouTube, as a video-sharing website facing the public, lacks a professional video review and quality assessment system, which leads to the uneven quality of uploaded surgical videos, and further demonstrates the importance of video quality assessment.

In the preparation stage of the study, we found that the formulation of the checklist was the most important part of the video quality assessment. Previous articles related to laparoscopic surgery have checklist guidelines, but there is a temporary lack of relevant guidelines for TVT-O and TOT surgery, which poses a challenge for our study. After referring to the previous scale and with the help of two experienced gynecologists and urologists, we jointly developed this checklist to evaluate the video quality of this kind of surgery comprehensively.

Most of the videos still fall short of the requirements for a good surgical teaching video, with only half explaining critical steps in detail and only 11.1% showing cystoscopic results. In the correlation analysis, video scores were not significantly associated with many factors, only with video length, which is in accordance with previous studies’ results. The positive correlation with video length maybe because the longer the video, the richer and more comprehensive the content, the higher the score.

There are still many unavoidable limitations in this study. Firstly, the retrieval scope of our videos is only limited to YouTube, and more websites should be included to obtain the videos. However, as a well-known video-sharing platform, YouTube has a low registration threshold and a large number of audiences worldwide, so we hope that more high educational value videos can be published on YouTube to help trainees. The English audio commentary level of the videos was uneven, which made it difficult for us to judge whether the key surgical steps were accurately described, and affected the assessment to some extent. Besides, due to the lack of relevant statistical processing technology, we were unable to analyze the video comments. Owing to the lack of professional comments and mature supervision system, it is difficult for readers to benefit from comments. It is hoped that relevant studies can be carried out in subsequent studies. Finally, there is a lack of video quality evaluation criteria recommended by the guidelines. Although we have produced the checklist according to specific surgical methods, more expert advice is still needed to jointly develop an authoritative checklist.

Conclusions

On YouTube, we still lack high educational value videos about TVT-O and TOT, and the existing videos are deficient in the explanation of critical steps, the key points of patients’ perioperative management, and the application of auxiliary teaching tools (such as drawings, tables, 3D animations, accompanying subtitles and audio explanations). This further indicates the importance of improving educational videos of surgery, and an authoritative checklist for urologic surgery.

Acknowledgments

Funding: This study was funded by the National Natural Science Fund of China (No. 81770673) and 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (No. ZY2017310).

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-21-814/coif). 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. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

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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