Educational value of supine versus prone percutaneous nephrolithotomy videos on YouTube: A comparative analysis

Abstract

Purpose

The integration of video-based learning into surgical education highlights the need for high-quality instructional content, especially for complex procedures such as percutaneous nephrolithotomy (PCNL). This study aimed to systematically evaluate and compare the educational quality of YouTube videos demonstrating supine and prone PCNL techniques.

Materials and Methods

A comprehensive YouTube search was conducted between January 6 and 19, 2025, using the keywords “supine PCNL,” “prone PCNL,” “supine percutaneous nephrolithotomy,” and “prone percutaneous nephrolithotomy.” Eligible videos were assessed using three validated scoring systems: Global Quality Score (GQS), the DISCERN instrument (a validated tool for assessing the quality of health information), and the JAMA (Journal of the American Medical Association) criteria, along with a novel tool, the PCNL-Edu Score (educational score). A total of 120 videos (60 supine, 60 prone) were included.

Results

Supine PCNL videos demonstrated significantly higher DISCERN reliability scores (p=0.037), GQS scores (p=0.001), and PCNL-Edu Scores (p=0.018) compared to prone PCNL videos. Subgroup analyses showed no significant differences in educational quality based on video source (academic/individual) or video type (educational/surgical demonstration). In correlation analyses, video length positively correlated with PCNL-Edu Scores in both groups (prone: p=0.004, supine: p=0.001), whereas popularity metrics such as views (prone: p=0.069, supine: p=0.061) and likes (prone: p=0.183, supine: p=0.225) were not significantly associated with educational quality.

Conclusions

Supine PCNL videos currently offer superior instructional quality on YouTube. The PCNL-Edu Score provides a focused framework for evaluating surgical videos and underscores the need for standardized guidelines to improve video-based surgical education.

Graphical Abstract

INTRODUCTION

The increasing availability of surgical videos on digital platforms such as YouTube has significantly enriched medical education [1]. With the rapid advancement of minimally invasive techniques, video-based learning has emerged as a valuable complement to traditional surgical training, offering accessible demonstrations of procedural steps and facilitating skill acquisition [2]. Among urologic procedures, percutaneous nephrolithotomy (PCNL) remains the gold standard for the treatment of large and complex kidney stones [3]. This technique can be performed in either the prone or supine position, with the choice determined by surgeon preference, institutional practices, and patient-specific factors [4].

Traditionally, the prone position has been the preferred approach for PCNL as it provides optimal renal access and a large working field [5]. However, the supine position is gaining increasing acceptance due to its advantages, including shorter operative times, enhanced anesthetic safety, and easier management of obese or high-risk patients [6]. As supine PCNL continues to evolve and gain popularity, there is a growing need for high-quality educational materials that reflect these new techniques. Video-sharing platforms such as YouTube offer broad access to surgical information; however, concerns persist regarding the quality, accuracy, and reliability of available content [7].

Despite the widespread use of YouTube as a learning tool among urologists and trainees, the heterogeneity in video content raises important concerns regarding its educational value [8]. Several established scoring systems including the Global Quality Score (GQS), the DISCERN instrument (a validated tool for assessing the quality of health information), and the Journal of the American Medical Association (JAMA) benchmarks have been employed to assess the quality of online health information, providing structured frameworks to evaluate educational materials [9,10]. In addition to video-based resources, simulation-based training models have also been shown to enhance proficiency in endourological procedures. Jeong et al. [11] demonstrated that a porcine-based ultrasound-guided nephrostomy training model was effective in improving resident performance and satisfaction, further underscoring the importance of structured educational tools in urology.

Given YouTube’s expanding role in surgical education, PCNL-related content has become increasingly extensive, particularly for supine approaches. Moreover, videos explicitly designed for educational purposes often provide superior instructional quality compared to purely demonstrative content, underscoring the platform’s potential as a meaningful adjunct to traditional training. This study aims to systematically evaluate and compare the educational quality of supine and prone PCNL videos available on YouTube, utilizing established scoring systems to objectively assess their reliability, procedural clarity, and overall educational value. In addition to these validated tools, a novel scoring system the PCNL-Edu Score was developed to specifically assess instructional utility and technical clarity in PCNL videos from a surgical training perspective. By addressing this gap, our findings will contribute to the ongoing discourse on surgical education, guiding trainees and practitioners toward higher-quality instructional content while informing best practices for future educational material development.

MATERIALS AND METHODS

This study employed a cross-sectional, observational design to evaluate and compare the educational quality of YouTube videos demonstrating PCNL performed in supine and prone positions. A comprehensive search was conducted on YouTube, one of the most widely used platforms for surgical education, to identify relevant videos. The search was carried out over a two-week period (January 6 to 19, 2025) using the keywords “supine PCNL”, “prone PCNL”, “supine percutaneous nephrolithotomy”, and “prone percutaneous nephrolithotomy” to ensure broad coverage of available content. To minimize selection bias and algorithmic influence, the search was performed in incognito mode and using an unregistered browser, thereby avoiding the effects of browsing history and geographical location.

Initially, a total of 300 videos were screened. Inclusion criteria encompassed videos that demonstrated a full or partial surgical procedure of PCNL performed in either supine or prone positions, were available in English (or contained English subtitles or annotations), and had sufficient visual and audio quality to allow clear identification of procedural steps and anatomical structures. Videos featuring surgical narration, annotations, or step-by-step explanations were also deemed eligible for inclusion.

Exclusion criteria comprised non-English content without subtitles, videos shorter than two minutes, those primarily focused on postoperative outcomes or patient testimonials without surgical footage, and commercial advertisements or promotional materials lacking educational value. Duplicate videos or compilations without original surgical footage were likewise excluded. Following the application of these criteria, 120 videos were included in the final analysis, consisting of an equal distribution of 60 supine PCNL and 60 prone PCNL videos. The equal distribution of supine (n=60) and prone (n=60) PCNL videos was not arbitrarily determined; rather, it reflected the final pool of eligible videos that met our predefined inclusion and exclusion criteria following comprehensive screening.

All videos were independently reviewed and assessed by two board-certified urologists experienced in endourology and PCNL procedures (N.F.G. and A.A.). To ensure objectivity and minimize inter-rater variability, each reviewer scored the videos separately. In cases of disagreement, a third independent urologist (M.G.) reviewed the video, and consensus was reached through discussion, upon which the final score was established. This multi-reviewer approach strengthened the consistency and reliability of the evaluation process.

The educational quality and reliability of each video were evaluated using three well-established scoring systems: the GQS, the DISCERN instrument, and the JAMA benchmark criteria. The GQS is a five-point Likert scale assessing the overall educational value, depth of content, and utility for learners [12]. DISCERN is a validated 16-item tool evaluating the reliability and quality of medical information, with sub-scores for reliability, treatment quality, and overall content [13,14]. The JAMA benchmark criteria assess authorship, attribution, currency, and disclosure to determine the credibility of online medical resources [15].

In addition to these validated tools, a novel scoring system—PCNL-Edu Score—was developed specifically for this study to assess the instructional quality and technical clarity of PCNL videos. This 20-point system consists of 10 items covering key procedural and educational components such as patient positioning, access technique, guidewire placement, lithotripter type, and visual and narrative clarity. Each item was scored from 0 to 2 (0=not addressed, 1=partially addressed, 2=fully addressed), with the total score classifying videos as having high (16–20), moderate (11–15), low (6–10), or poor (0–5) educational quality (Fig. 1). The items of the PCNL-Edu Score were selected through a comprehensive review of the current literature on PCNL techniques and surgical video assessment [3,16], combined with expert consensus among three board-certified endourologists. Each item reflected a key procedural step or educational element considered essential for effective PCNL training.

Fig. 1. PCNL-Edu Score system for evaluating the educational quality of YouTube videos on PCNL. PCNL-Edu Score, percutaneous nephrolithotomy educational score; US, ultrasound.

In addition to educational scoring, video popularity and engagement metrics were recorded to explore their potential relationship with educational quality. Data collected included video length (minutes), number of days online (from upload date to analysis date), total number of views, likes, and comments.

1. Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp.). Descriptive statistics, including mean, standard deviation, median, and interquartile ranges, were calculated for all parameters. The Kolmogorov–Smirnov test was used to assess data normality. Since the data did not follow a normal distribution, the Mann–Whitney U test was applied to compare supine and prone PCNL videos. Correlations between video quality scores (GQS, DISCERN, JAMA, and PCNL-Edu Score) and engagement metrics (views, likes, comments) were evaluated using Spearman’s rank correlation coefficient (ρ). A p-value of <0.05 was considered statistically significant.

2. Ethical considerations

As this study utilized publicly available, non-human subject data, Institutional Review Board approval was not required. The study adhered to ethical guidelines for open-access data usage, and no personal identifiers or sensitive information were included in the analysis.

RESULTS

A total of 120 PCNL videos were included in the study, comprising 60 prone and 60 supine position procedures (Fig. 2).

Fig. 2. Flowchart of the video selection and analysis process for supine and prone PCNL content on YouTube. PCNL, percutaneous nephrolithotomy; JAMA, Journal of the American Medical Association benchmark criteria; GQS, Global Quality Score; PCNL-Edu Score, percutaneous nephrolithotomy educational score.

Baseline characteristics, evaluator scores, and PCNL-Edu Scores of the videos are summarized in Table 1. No statistically significant differences were identified between the prone and supine groups regarding video length (p=0.562), number of views (p=0.166), number of comments (p=0.067), number of likes (p=0.366), or duration online (p=0.244). Similarly, the distribution of video sources did not differ significantly between groups (p=0.339). Analysis of the DISCERN classification revealed a trend toward a higher proportion of videos rated as “very good” in the supine group compared to the prone group; however, this difference did not reach statistical significance (p=0.147). Evaluator assessments showed that DISCERN reliability scores were significantly higher for supine videos compared to prone videos (p=0.037). Although DISCERN treatment, quality, and total scores were numerically higher in the supine group, these differences were not statistically significant. GQS scores were significantly greater in the supine group than in the prone group (p=0.001). Similarly, PCNL-Edu Scores were significantly higher for supine videos (p=0.018). Subcategorization of PCNL-Edu Scores revealed no significant differences between groups in the distribution of poor, low, moderate, or high educational quality levels (p=0.292).

Table 1. Comparison of video characteristics, evaluator scores, and PCNL-Edu Scores between supine and prone PCNL videos.

Characteristic		Prone (n=60)	Supine (n=60)	p-value
Video length (min)		22.43±28.65	21.13±27.90	0.562
Views		2,880 (126–34,473)	1,144 (24–374,763)	0.166
Number of comments		3.30±4.48	1.93±2.53	0.067
Number of likes		68.66±75.12	116.56±376.05	0.366
Days online		1,278 (231–4,439)	1,397 (2–5,303)	0.244
Video source
	Individual (medical)	36 (60.0)	42 (70.0)	0.339
	Academic/Official	24 (40.0)	18 (30.0)
DISCERN classification
	Very poor	4 (6.7)	0 (0.0)	0.147
	Poor	16 (26.7)	10 (16.7)
	Fair	18 (30.0)	20 (33.3)
	Good	14 (23.3)	18 (30.0)
	Very good	8 (13.3)	12 (20.0)
DISCERN
	Reliability	25.5 (15–36)	29 (20–35)	0.037*
	Treatment	17 (9–31)	18.5 (12–29)	0.101
	Quality	3 (1–5)	3 (2–5)	0.194
	Total	46 (26–71)	51.5 (34–69)	0.076
JAMA score		2 (1–4)	3 (1–4)	0.096
GQS score		3 (1–5)	3.5 (1–5)	0.001*
PCNL-Edu Score		10 (4–20)	12.5 (5–20)	0.018*
PCNL-Edu Score
	Poor	5 (8.3)	2 (3.3)	0.292
	Low	27 (45.0)	21 (35.0)
	Moderate	16 (26.7)	18 (30.0)
	High	12 (20.0)	19 (31.7)

Values are presented as mean±standard deviation, median (range), or number (%).

PCNL-Edu Score, percutaneous nephrolithotomy educational score; PCNL, percutaneous nephrolithotomy; JAMA, Journal of the American Medical Association benchmark criteria; GQS, Global Quality Score.

^*p<0.05.

Subgroup analyses according to video source and video type for both prone and supine videos are presented in Tables 2 and 3. No significant differences were observed in DISCERN, JAMA, GQS, or PCNL-Edu Scores based on whether videos originated from individual medical professionals or academic/official sources, nor between videos designed for educational purposes and those intended solely for surgical demonstration.

Table 2. Subgroup analysis of prone PCNL videos according to video source and educational content.

	Video source			Video type
	Individual (medical)	Academic/Official	p-value	Educational	Surgical only	p-value
DISCERN reliability	25 (17–36)	27 (15–35)	0.309	27 (15–36)	25 (18–34)	0.739
DISCERN treatment	16 (9–29)	23 (10–31)	0.132	16.5 (10–31)	17.5 (9–29)	0.468
DISCERN quality	3 (2–5)	3 (1–5)	0.141	3 (1–5)	3 (2–4)	0.540
DISCERN total	44 (29–70)	57 (26–71)	0.176	47.5 (26–71)	45 (29–66)	0.629
JAMA score	2 (1–4)	3 (1–4)	0.343	2 (1–4)	2 (1–3)	0.949
GQS score	2 (1–5)	3 (1–4)	0.501	2.5 (1–5)	3 (1–3)	0.850
PCNL-Edu Score	6 (3–10)	7 (5–10)	0.195	7 (5–10)	5 (2–8)	0.802

Values are presented as median (range).

PCNL, percutaneous nephrolithotomy; JAMA, Journal of the American Medical Association benchmark criteria; GQS, Global Quality Score; PCNL-Edu Score, percutaneous nephrolithotomy educational score.

Table 3. Subgroup analysis of supine PCNL videos according to video source and educational content.

	Video source			Video type
	Individual (medical)	Academic/Official	p-value	Educational	Surgical only	p-value
DISCERN reliability	29.5 (20–35)	27 (20–34)	0.371	29 (20–35)	25 (21–34)	0.092
DISCERN treatment	19.5 (14–29)	17.5 (12–28)	0.405	20 (12–29)	18 (14–28)	0.195
DISCERN quality	3 (2–5)	3 (2–5)	0.340	4 (2–5)	3 (2–5)	0.061
DISCERN total	53 (36–69)	47.5 (34–67)	0.440	54 (34–69)	45 (37–67)	0.121
JAMA score	3 (1–4)	2 (1–4)	0.537	3 (1–4)	2 (1–4)	0.347
GQS score	4 (1–5)	3 (2–5)	0.831	4 (1–5)	3 (1–5)	0.320
PCNL-Edu Score	8 (6–10)	7 (3–9)	0.380	8.5 (6–10)	6 (3–9)	0.170

Values are presented as median (range).

PCNL, percutaneous nephrolithotomy; JAMA, Journal of the American Medical Association benchmark criteria; GQS, Global Quality Score; PCNL-Edu Score, percutaneous nephrolithotomy educational score.

Spearman’s correlation analysis between video characteristics and PCNL-Edu Scores is presented in Table 4. Among prone PCNL videos, PCNL-Edu Score was positively correlated with video length (p=0.004), DISCERN total score (p=0.001), JAMA score (p=0.001), and GQS score (p=0.001), whereas views (p=0.069), comments (p=0.643), and likes (p=0.183) were not significantly associated. In supine PCNL videos, strong positive correlations were identified between PCNL-Edu Score and video length (p=0.001), DISCERN total score (p=0.001), JAMA score (p=0.001), and GQS score (p=0.001), while views (p=0.061), comments (p=0.870), and likes (p=0.225) showed no significant correlation.

Table 4. Spearman’s correlation analysis of video characteristics with PCNL-Edu Score.

	Prone PCNL		Supine PCNL
	PCNL-Edu Score		PCNL-Edu Score
	Rho (ρ)	p-value	Rho (ρ)	p-value
Views	0.320	0.069	0.243	0.061
Video length	0.367	0.004*	0.682	0.001*
Number of comments	0.061	0.643	-0.022	0.870
Number of likes	0.289	0.183	0.159	0.225
DISCERN total	0.960	0.001*	0.971	0.001*
JAMA score	0.940	0.001*	0.953	0.001*
GQS score	0.897	0.001*	0.912	0.001*

PCNL-Edu Score, percutaneous nephrolithotomy educational score; PCNL, percutaneous nephrolithotomy; JAMA, Journal of the American Medical Association benchmark criteria; GQS, Global Quality Score.

^*p<0.05.

DISCUSSION

The increasing integration of digital platforms such as YouTube into medical education has transformed the accessibility of surgical knowledge worldwide [17]. With the widespread availability of high-definition video content, trainees and practicing surgeons alike now have unprecedented access to step-by-step demonstrations of complex procedures [18]. As the landscape of surgical education continues to evolve, video-based learning has become an indispensable adjunct to traditional didactic and hands-on training, particularly in minimally invasive surgery where visual clarity and procedural nuance are paramount [16].

Among endourological procedures, PCNL is considered the standard of care for large and complex renal calculi [3]. While traditionally performed in the prone position due to perceived advantages in renal access and surgical ergonomics, supine PCNL has gained increasing acceptance in recent years, offering benefits such as reduced operative time, improved anesthetic safety, and greater ease in patient positioning, especially in high-risk populations [19,20]. In parallel with this technical evolution, there has been a growing demand for high-quality educational resources that reflect contemporary approaches to PCNL, including variations in patient positioning.

Although prior studies have evaluated the quality of YouTube content across various surgical domains—including prostatectomy, bariatric surgery, and laparoscopic procedures [21,22]—to our knowledge, this is the first study to comprehensively compare the educational quality of YouTube videos depicting supine versus prone PCNL. Leveraging validated scoring tools such as DISCERN, JAMA benchmarks, and GQS, alongside the novel PCNL-Edu Score specifically designed for this study, we sought to provide an objective assessment of procedural clarity and instructional value.

Our findings demonstrate that supine PCNL videos exhibited higher educational quality across multiple parameters. Supine videos achieved significantly higher scores in both DISCERN reliability and GQS assessments compared to prone videos, reflecting superior accuracy, comprehensiveness, and utility for learners. Moreover, the PCNL-Edu Score, tailored to capture procedure-specific educational elements, further confirmed this trend, with supine videos scoring higher than their prone counterparts. These results suggest that, despite the traditional dominance of prone PCNL in surgical practice, supine PCNL videos on YouTube currently offer superior instructional clarity for trainees. It is also possible that this educational advantage may, in part, reflect the relatively recent rise in the popularity of the supine approach, which could have prompted the creation of more contemporary, structured, and pedagogically oriented video content compared to the broader and more heterogeneous archive of prone PCNL videos. Although our analysis of upload dates (‘days online’) did not reveal a significant difference between supine and prone groups, future studies incorporating time-trend analyses could provide deeper insights into the relationship between novelty of technique and video quality.

Interestingly, subgroup analyses revealed that neither the source of the video (academic vs. individual) nor its intended audience (educational vs. surgical demonstration only) significantly influenced educational quality. This finding contrasts with previous studies in other surgical specialties, which reported higher educational value in videos from institutional or industrial sources, such as laparoscopic fundoplication and laparoscopic cholecystectomy videos [23,24]. However, our results are consistent with the findings of Arslan et al. [21], who demonstrated that, in the context of laparoscopic and robotic radical prostatectomy videos, the video source was not significantly associated with educational quality. These observations suggest that, at least within the context of PCNL, educational quality is not strictly dependent on authorship but may rather be influenced by factors such as video length and presentation style.

Indeed, our correlation analysis identified a positive association between video length and PCNL-Edu Score, aligning with prior studies suggesting that longer videos provide more comprehensive procedural coverage and thus greater educational value. While video length was positively correlated with educational quality, our study did not specifically evaluate which procedural elements within the PCNL-Edu Score drove this association. Future item-level analyses may help identify the most influential instructional components, thereby providing clearer guidance for the creation of high-quality surgical videos. Popularity metrics such as views and likes did not correlate significantly with educational quality (prone: views p=0.069, likes p=0.183; supine: views p=0.061, likes p=0.225). This finding highlights that popularity is not a reliable proxy for instructional value, underscoring the importance of structured content design over viewer engagement statistics [21,23].

Nevertheless, several limitations of our study should be acknowledged. First, although we conducted a systematic and comprehensive search on YouTube, our analysis was restricted to this single platform. Other reputable online resources such as WebSurg, UROsource, or MEDtube were not included, and potentially valuable content may have been overlooked. In addition, by limiting the search to English-language videos, we may have excluded relevant material from other regions and languages. Future studies incorporating multi-language and multi-region searches would provide a more global perspective on the educational quality of surgical videos. Second, the dynamic nature of online content presents an inherent challenge, as videos are frequently uploaded, modified, or removed. Our findings therefore represent a snapshot in time and may not fully capture the evolving landscape of digital educational resources. Third, while the PCNL-Edu Score was specifically developed to capture procedure-specific educational elements, it has not yet undergone formal validation. Although two experienced endourologists independently assessed all videos and discrepancies were resolved by a third reviewer to ensure consistency, formal statistical measures of inter-rater agreement (e.g., Cohen’s kappa) were not calculated. Furthermore, the score has not been externally validated across different reviewer groups or platforms. Future studies employing statistical reliability testing and multi-center validation are needed to strengthen the credibility and generalizability of this tool. In addition, while independent multi-reviewer scoring was used to minimize evaluator bias, subjectivity cannot be fully eliminated. Future studies should incorporate formal interrater reliability metrics and may also explore artificial intelligence– based approaches as potential tools to enhance objectivity in video evaluation. Fourth, the educational utility of surgical videos may differ according to the viewer’s level of training, such as medical students, residents, or attending surgeons. Since our study did not stratify outcomes by user demographics or professional experience, the applicability of our findings across different learner groups may be limited. Future research incorporating user-level stratification will provide more nuanced insights into how educational content is perceived and utilized. In addition, our study evaluated the quality of video content but did not assess its direct educational impact on learners. Future studies employing controlled designs, such as pre- and post-training assessments or skill-based evaluations, are warranted to determine how video quality translates into measurable improvements in trainee knowledge and surgical proficiency. Moreover, videos that were explicitly structured for educational purposes may have been more likely to achieve higher scores, raising the possibility of selection bias related to content type. In addition, although our scoring systems evaluated the completeness and clarity of the videos, they cannot fully assess the authenticity or accuracy of the surgical techniques demonstrated. Future studies should incorporate methods to evaluate both the educational quality and the authenticity of online surgical content. Finally, although engagement metrics such as views, likes, and comments were recorded, these parameters are influenced by external factors (e.g., video titles, thumbnails, language, or marketing strategies) and do not necessarily reflect educational quality. Controlled experimental studies are required to clarify these relationships.

As a practical extension of our findings, we propose a set of actionable recommendations for improving the instructional value of surgical videos. These guidelines are summarized in Box 1 to assist content creators in developing structured, transparent, and educationally effective PCNL videos.

Box 1. Practical takeaways for PCNL video creators

• • Prioritize structure and narration: Provide a clear step-by-step explanation with concise narration or annotations to maximize instructional clarity.

• • Optimize video length: Ensure sufficient duration to cover all procedural steps comprehensively, while avoiding unnecessary pauses.

• • Highlight key elements: Consistently demonstrate critical steps such as patient positioning, access technique, guidewire placement, and lithotripter use.

• • Ensure transparency: Include authorship details, date of creation, and relevant references to improve credibility (aligned with JAMA benchmarks).

• • Avoid relying on popularity metrics: Views, likes, and comments do not reliably indicate educational value—focus instead on completeness and accuracy.

• • Leverage standardized tools: Apply structured checklists such as the PCNL-Edu Score to guide video preparation and ensure balanced coverage of technical and educational components.

CONCLUSIONS

In conclusion, our study highlights that PCNL videos on YouTube exhibit variable educational quality, with supine PCNL videos demonstrating superior instructional value compared to prone PCNL videos. The newly developed PCNL-Edu Score offers a novel, procedure-specific framework for evaluating the clarity and educational content of surgical videos. While our findings provide valuable insights for both trainees and content creators, further validation of the PCNL-Edu Score and the development of standardized guidelines for surgical video production are essential to enhance the quality and reliability of online surgical education. From a practical perspective, our findings suggest that content creators particularly medical professionals producing surgical videos should aim to provide structured, comprehensive, and clearly narrated demonstrations. Emphasizing procedural clarity, adequate length, and adherence to educational frameworks such as the PCNL-Edu Score could significantly enhance the instructional value of surgical videos available online.