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Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

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The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

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Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

Article of the Week: Robotic Surgery – Development Of A Standardised Training Curriculum

Every Week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development Of A Standardised Training Curriculum For Robotic Surgery: A Consensus Statement From An International Multidisciplinary Group Of Experts

Kamran Ahmed, Reenam Khan, Alexandre Mottrie1, Catherine Lovegrove, Ronny Abaza2, Rajesh Ahlawat3, Thomas Ahlering4, Goran Ahlgren5, Walter Artibani6, Eric Barret7, Xavier Cathelineau7, Ben Challacombe, Patrick Coloby8, Muhammad S. KhanJacques Hubert9, Maurice Stephan Michel10, Francesco Montorsi11, Declan Murphy12Joan Palou13, Vipul Patel14, Pierre-Thierry Piechaud15, Hendrik Van Poppel16, PascalRischmann17, Rafael Sanchez-Salas7, Stefan Siemer18, Michael Stoeckle18, Jens-Uwe Stolzenburg19, Jean-Etienne Terrier20, Joachim W. Thuroff21, Christophe Vaessen22, Henk G. Van Der Poel23, Ben Van Cleynenbreugel16, Alessandro Volpe 1,24, Christian Wagner25Peter Wiklund26, Timothy Wilson27, Manfred Wirth28, Jorn Witt26 and Prokar Dasgupta

 

Department of Urology, Medical Research Council (MRC) Centre for Transplantation, Kings College London, GuyHospital, London, UK, 1Department of Urology, OLV Vattikuti Robotic Surgery Institute, OLV Hospital, Aalst, Belgium, 2Department of Urology, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital Richard J Solove Research Institute, Columbus, OH, USA, 3Medanta The Medicity, Gurgaon, Haryana, India, 4Department of Urology, University of California, Irvine, Orange, CA, USA, 5Department of Urology, Lund University Hospital, Lund, Sweden, 6Urology Clinic, A.O.U.I. Verona, Verona, Italy, 7Department of Urology, Institut Mutualiste Montsouris, Paris, France, 8Service dUrologie, Centre Hospitalier Rene-Dubos, Cergy-Pontoise, France, 9Service dUrologie, CHRU Nancy, Vandoeeuvre-les-Nancy, France, 10University Hospital, Mannheim, Germany, 11Department of Urology, San Raffaele Scientic Institute, Milan, Italy, 12Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Vic., Australia, 13Department of Urology, Fundacio Puigvert, Universitat Autonoma de Barcelona, Barcelona, Spain, 14Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA, 15Clinique Saint-Augustin, Bordeaux, France, 16Department of Urology, University Hospital, KU Leuven, Leuven, Belgium, 17Service de Chirurgie Urologique, CHU Purpan, Toulouse, France, 18Klinik fur Urologie und Kinderurologie, Universitatsklinikum des Saarlandes, Homburg/Saar, Germany, 19Department of Urology, University of Leipzig, Leipzig, Germany, 20Department of Urology, Foch Hospital, Suresnes, France, 21Department of Urology, Ulm University Medical Center, Ulm, Germany, 22Service D’Urologie et de Transplantation Réno-Pancréatique, Hôpital Pitié-Salpêtrière, Paris, France, 23Department Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands, 24University of Eastern Piedmont, Novara, Italy, 25St. Antonius-Hospital Gronau, Gronau, Germany, 26Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden, 27Division of Urology, City of Hope, Duarte, CA, USA, and 28Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany

 

OBJECTIVES

To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented.

MATERIALS AND METHODS

An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points.

RESULTS

In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions.

CONCLUSION

This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room.

Editorial: Towards a Standardized Training Curriculum For Robotic Surgery

The work of the authors [1] towards robotic training and credentialing is much needed and should be applauded as increased scrutiny is being placed on complications associated with robotic surgery [2]. The authors held three separate meetings in 2012 and 2013 in which they identified themes, developed a training curriculum, and assessed expert agreement with their proposed curriculum. The authors’ [1]quantitative survey of 24 experts revealed that all ‘agreed’ or ‘agreed strongly’ with the proposed curriculum. The curriculum includes three areas, cognitive, psychomotor, and teamwork/communication skills, which we feel are vital for good outcomes [3]. As was noted, there are available ‘E-learning’ tools online from organisations such as the AUA and from Intuitive Surgical, and these can be further expanded and validated [4, 5]. The AUA also has recommendations for credentialing requirements that are available online.

We agree with the authors [1] that simulation should include inanimate models, which provide a good cost to benefit ratio. There are increasing numbers of inanimate models for the simulation of procedures, e.g. partial nephrectomy and pyeloplasty. One limitation of inanimate training is that the entire robotic surgical system is used and it may only be free for training on nights and weekends when the robotic systems are not being used clinically. Virtual reality simulators offer a more convenient way to become familiar with the robotic environment, but at a cost of ≈$100 000 (American dollars). Virtual reality simulation is predominantly used to develop skills for a junior trainee or a novice surgeon. However, procedure-specific and augmented-reality simulation is being developed and will greatly enhance robotic training.

The authors [1] should be applauded for offering a specific curriculum consisting of online training, an 8-day ‘discovery’ course for simulation and observation, and a 6-month fellowship for step-wise progression to ‘live’ surgical console time. As the authors note, credentialing should be based on competency and not on the number of cases logged or the duration of training alone. The duration of the fellowship should be based on the learning objectives and research/academic requirements.

In the USA, robotic surgical training is included during residency in urology and a fellowship may not be required if a graduating resident is proficient according to the programme directors’ assessment. For surgeons who have not been trained during residency, proctoring by an experienced surgeon is recommended by the AUA [5], after completing a structured robotic surgical curriculum as described in this article [1]. However, a validated curriculum and benchmarks for competency have not been established. The Fundamentals of Robotic Surgery (FRS) curriculum will be validated during the next year for a multidisciplinary curriculum with skills testing [6].

We also agree with the authors [1] that non-technical skills such as trouble-shooting, teamwork, leadership, and communication are critically important for preventing adverse events. Many if not most complications occur due to failures in patient selection, trocar positioning, and bedside assisting. Also, many complications can be traced to ‘system’ problems rather than console performance. Robotic surgery requires a proficient team to ensure good outcomes.

Currently, there are no uniform credentialing requirements to practice robotic surgery in the USA or many other countries. A validated robotic training curriculum with competency-based assessments is essential and can be integrated into residency programmes where robotic technology is readily available. Where robotic surgical volume is inadequate, fellowship programmes can provide the needed training. A validated competency-based approach offers the hope of better patient outcomes and the continued acceptance of new technologies such as robotic surgery.

Clinton D. Bahler and Chandru P. Sundaram
Department of Urology, Indiana University, Indianapolis, IN, USA

 

References

 

 

2 Alemzadeh H, Iyer RK, Raman J. Safety Implications of Robotic Surgery: Analysis of Recalls and Adverse Event Reports of da Vinci Surgical Systems. The Society of Thoracic Surgeons Annual Meeting2014; Orlando, Florida. Available at: https://www.sts.org/sites/default/les/documents/pdf/annmtg/2014AM/50AM_MonJan27.pdf. Accessed February 2015.

 

3 Bahler CD, Sundaram CP. Training in Robotic surgery: simulatorssurgery, and credentialing. Urol Clin North Am 2014; 41: 5819.

 

4 The American Urological Association. E-Learning: Urologic Robotic Surgery Course. The American Urological Association Education and Research, Inc, 2012. Available at: https://www.auanet.org/education/modules/robotic-surgery/. Accessed April 2014.

 

5 The American Urological Association. Standard Operating Practices (SOPS) for Urologic Robotic Surgery. The American Urological Association, 2013. Available at: https://www.auanet.org/common/pdf/about/SOP-Urologic-Robotic-Surgery.pdf. Accessed April 2014.

 

 

 

Article of the Week: Learning curves for urological procedures – a systematic review

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Learning curves for urological procedures: a systematic review

Hamid Abboudi, Mohammed Shamim Khan, Khurshid A. Guru*, Saied Froghi†, Gunter de Win‡, Hendrik Van Poppel§, Prokar Dasgupta and Kamran Ahmed

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, UK, *Roswell Park Cancer Institute, Buffalo, NY, USA, †The Oxford Cancer Centre, Oxford University, Churchill Hospital, Oxford, UK, ‡Department of Urology, University Hospital Antwerp, Antwerp, Belgium, and §Department of Urology, University Hospital, KU Leuven, Leuven, Belgium

OBJECTIVE
  • To determine the number of cases a urological surgeon must complete to achieve proficiency for various urological procedures.
PATIENT AND METHODS
  • The MEDLINE, EMBASE and PsycINFO databases were systematically searched for studies published up to December 2011.
  • Studies pertaining to learning curves of urological procedures were included.
  • Two reviewers independently identified potentially relevant articles.
  • Procedure name, statistical analysis, procedure setting, number of participants, outcomes and learning curves were analysed.
RESULTS
  • Forty-four studies described the learning curve for different urological procedures.
  • The learning curve for open radical prostatectomy ranged from 250 to 1000 cases and for laparoscopic radical prostatectomy from 200 to 750 cases.
  • The learning curve for robot-assisted laparoscopic prostatectomy (RALP) has been reported to be 40 procedures as a minimum number.
  • Robot-assisted radical cystectomy has a documented learning curve of 16–30 cases, depending on which outcome variable is measured.
  • Irrespective of previous laparoscopic experience, there is a significant reduction in operating time (P = 0.008), estimated blood loss (P = 0.008) and complication rates (P = 0.042) after 100 RALPs.
CONCLUSIONS
  • The available literature can act as a guide to the learning curves of trainee urologists. Although the learning curve may vary among individual surgeons, a consensus should exist for the minimum number of cases to achieve proficiency.
  • The complexities associated with defining procedural competence are vast.
  • The majority of learning curve trials have focused on the latest surgical techniques and there is a paucity of data pertaining to basic urological procedures.

Editorial: Is surgery a never ending learning process?

The concept of the learning curve is one of the most important issues in surgery and also one of the most overlooked. In the present issue of BJUI, Abboudi et al. [1] present an interesting review paper evaluating the concept of the learning curve in urological procedures. Specifically, the authors have conducted a methodologically consistent systematic review on the literature focused on the learning curve of some urological procedures, including mainly radical prostatectomy (RP), robot-assisted partial nephrectomy (RAPN) and percutaneous nephrolitotomy [1]. Surprisingly, nothing was available for BPH treatments, which are among the most prevalent urological procedures. 

Most of the studies are focused on robot-assisted RP (RARP), but the available literature is of poor methodological quality, including mainly surgical series evaluating a limited number of surgeons, with a heterogeneous selection of outcomes from which to study the learning curve and a focus on short-term outcomes. Conversely, the literature on retropubic RP or laparoscopic RP is of higher quality, including a few very large multi-institutional studies encompassing the performances of several surgeons (reference nos. 24, 26, 29 and 30 in the review) and adopting sophisticated statistical methodology; however, the current interest for these procedures is quite limited, RARP being more commonly preferred. With the above-mentioned limitations in mind, what we have learnt is that RARP operating time plateaus after 50–200 cases, positive surgical margin (PSM) rates after 50–1600 cases, and continence and potency after 200 cases [1]. Such data are only partially in line with the findings of a recent prospective Australian study [2], not included in the present systematic review, which evaluated the learning curve with RARP of a high-volume open surgeon (>3000 retropubic RPs performed before the study beginning). In that study, Thompson et al. [2] demonstrated that performances with RARP surpassed those with retropubic RP after ∼100 cases for sexual function scores and PSM rates in pT2 cancers, whereas ∼150 cases were needed to reach the same target with urinary function scores. Moreover, RARP performances kept on improving, with sexual and urinary scores plateauing after 600–700 and 700–800 cases, respectively. Similarly, with regard to PSMs, it was demonstrated that PSM rates in pT2 and pT3–4 cancers plateaued after 400–500 and 200–300 cases, respectively [2]. Although improvement is likely, it is not clear how much these performances might improve with further extension of the caseload. 

Taken together, those data suggest that even with robotic assistance, a high volume of cases is strongly associated withimproving oncological and functional outcomes after RARP. This is not an extraordinarily original concept, but implies that the daVinci platform, by itself, cannot guarantee excellent surgical quality and that the relevance of the surgeon is as high as ever. 

Limited data are available on other major robotic procedures, such as RAPN and robot-assisted radical cystectomy (RARC). Specifically, 20–75 cases are thought to be needed to observe a plateau in warm ischemia time (WIT) during RAPN, which is in line with our previous findings demonstrating a continuous decrease in WIT during the first 50 cases [3]. Similarly, 20–30 cases are supposed to be needed to achieve acceptable operating times, lymph node yields and PSM rates after RARC; however, those findings do not take in account the burden of robotic experience achieved with RARP before embarking in RARC, which is clearly a major issue [4]. 

Considering that the improvements in performances along the learning curve exceeded any effect sizes we might reasonably expect from a novel drug [5], it is clear that any attempt to centralise treatments for complex procedures in high-volume centres with high-volume surgeons should be attempted. Obviously, that is a very critical target, which is hard to achieve in many realities. In parallel, interventions to improve the performance of surgeons in order to,reduce the learning curve are mandatory. For example, fellowship-trained RARP surgeons have been shown to outperform experienced open or laparoscopic surgeons moving to RARP without specific training [6,7]. For those surgeons for whom fellowship is unfeasible or unpractical, structured courses with integration of simulation, dry laboratory, wet laboratory and da Vinci modular training, for example, using the model of the recently concluded European Robotic Urology Society Pilot Study, can significantly ease the first steps of the learning curve, reducing patients risk. In parallel, intensive courses focused on specific procedures could help those surgeons who had completed the initial steps of their learning curve to master the specific technical details necessary to improve outcomes.

Alexander Mottrie*† and Giacomo Novara†‡

*OLV Vattikuti Robotic Surgery Institute and † Department of Urology, OLV Hospital Aalst, Aalst, Belgium and ‡ Department of Surgery, Oncology and Gastroenterology, Urology Clinic University of Padua, Padua, Italy

References

1 Abboudi H, Khan MS, Guru KA et al. Learning curves for urological procedures: a systematic review. BJU Int 2014; 114: 617–29

2 Thompson JE, Egger S, Böhm M et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol 2014; 65: 521–31

3 Mottrie A, De Naeyer G, Schatteman P et al. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. Eur Urol 2010; 58: 127–32

4 Hayn MH, Hellenthal NJ, Hussain A et al. Does previous robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology 2010; 76: 1111–6

5 Vickers AJ. What are the implications of the surgical learning curve? Eur Urol 2014; 65: 532–3

6 Kwon EO, Bautista TC, Jung H et al. Impact of robotic training onsurgical and pathologic outcomes during robot-assisted laparoscopicradical prostatectomy. Urology 2010; 76: 363–8

7 Leroy TJ, Thiel DD, Duchene DA et al. Safety and peri-operative outcomes during learning curve of robot-assisted laparoscopicprostatectomy: a multi-institutional study of fellowship-trainedrobotic surgeons versus experienced open radical prostatectomysurgeons incorporating robot-assisted laparoscopic prostatectomy. J Endourol 2010; 24: 1665–9

 

Article of the week: Behind the curve: residents’ access to RAL is poor in Europe

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Dr. Furriel discussing his paper.

If you only have time to read one article this week, it should be this one.

Training of European urology residents in laparoscopy: results of a pan-European survey

Frederico T.G. Furriel, Maria P. Laguna*, Arnaldo J.C. Figueiredo, Pedro T.C. Nunes and Jens J. Rassweiler

Department of Urology and Renal Transplantation, University Hospital of Coimbra, Coimbra, Portugal, *Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany

OBJECTIVE

• To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

• A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012.

• Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated.

• Data was analysed with descriptive statistics.

RESULTS

• In all, 219 European urology residents answered the survey.

• Conventional laparoscopy was available in 74% of the respondents’ departments, while robotic surgery was available in 17% of the departments.

• Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy.

• Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory.

• The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

• Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor.

• Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

 

Read Previous Articles of the Week

 

Editorial: Minimally invasive surgical training: do we need new standards?

The pan-European survey conducted by Furriel et al. [1] in this issue of BJUI is a timely address of a hot topic in urology.

More than 20 years have passed since the first laparoscopic nephrectomy was performed by Clayman et al. [2] in 1991, and now all urological major interventions have been performed with one or more different minimally invasive techniques (standard, single-site or robot-assisted laparoscopy); some of them have passed the judgment of time becoming ‘gold standard’ treatments, while others are still under evaluation. Specifically, the European Association of Urology (EAU) guidelines recommend laparoscopic radical nephrectomy as the ‘standard of care’ over open surgery, report favorable outcomes for robot-assisted laparoscopic radical prostatectomy, and propose as optional treatments laparoscopic or robot-assisted partial nephrectomy and radical cystectomy [3].

Obviously, this surgical revolution brings two major new issues: (i) Starting from academic and training centres, hundreds of Urology Departments throughout Europe need to update their surgical knowledge and expertise, making senior urologists perform up-to-date procedures; (ii) Residents and young urologists require adequate and possibly standardised training in minimally invasive surgery, learning at least the basic laparoscopic skills. The study by Furriel et al. [1] correctly highlights both problems.

First, according to the survey, penetration of laparoscopy in the most important urological training centres is unexpectedly low. In fact, more than one out of four centers (26%) do not perform minimally invasive surgery, even for the ‘standards of care’, such as laparoscopic radical nephrectomy. Moreover, as the survey was conducted specifically on the topic of minimally invasive surgery, it is probable that unexposed residents were less interested in responding, making the data of penetration probably even worse than reported. This fact reflects a serious problem present in most training centres. While previously surgery slowly evolved, laparoscopy and technology brought sudden innovations, putting several senior urologists ‘out of the game’. Hence, today, training is needed not only for residents, but also for consultants. In the meantime, it is important that residents are trained in centres were minimally invasive surgery is already widely available. In this perspective, European educational authorities should endeavour to certificate the residents’ training centres, for example on the basis of adherence to EAU guidelines. Academic or non-academic training centres not adherent to guidelines (and thus not performing minimally invasive surgery) should therefore be deprived of residents.

Secondly, training residents in minimally invasive surgery can be approached in different ways, from low-cost self-made dry laboratories to expensive virtual reality or robotic three-dimensional simulators. According to the survey, >40% of centres have no training facilities available. It has been shown that self-built, cheap, dry laboratories are as efficient in training as the industrial ones [4], so that it is not a matter of costs but a matter of interest. We strongly believe that watching surgical videos, observing live surgeries and using (low-cost or not) dry laboratories are fundamental steps in acquiring the basic skills in laparoscopy, while the modular training proposed by Stolzenburg et al. [5] for laparoscopic radical prostatectomy is the best live training model and can be exported to other kinds of surgery, such as radical or partial nephrectomy. In the centres where robot-assisted surgery is available, working as a table-side assistant is another good way to acquire laparoscopic skills.

A great debate is currently ongoing about credentialing in minimally invasive surgery training [6]. Pragmatically, when the European training centres are certificated for adherence to the EAU guidelines, there will be no need for a specific credentialing in laparoscopic skills, because it will be included in the standard training path, together with endoscopic and open surgery.

In conclusion, the survey by Furriel et al. [1] shows that times are changed: the old axiom ‘big cut, big surgeon’ is not valid anymore. The emerging urological generations know it, and ask to be adequately trained. Training centres must evolve, because in 2013 minimally invasive surgery has formally to be considered as part of the standard urological armoury.

Antonio Galfano and Aldo Massimo Bocciardi
Department of Urology, Ospedale Niguarda Ca’ Granda, Milan, Italy

References

  1. Furriel F, Laguna MP, Figueiredo A, Nunes P, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European surveyBJU Int 2013; 112: 1223–1228
  2. Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrectomyN Engl J Med 1991; 324: 1370–1371
  3. EAU Guidelines, edition presented at the 28th EAU Annual Congress, Milan 2013. ISBN 978-90-79754-71-7. EAU Guidelines Office, Arnhem, The Netherlands. Available at: https://www.uroweb.org/guidelines/online-guidelines/. Accessed September 2013
  4. Beatty JD. How to build an inexpensive laparoscopic webcam-based trainerBJU Int 2005; 96: 679–682
  5. Stolzenburg JU, Schwaibold H, Bhanot SM et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005; 96: 1022–1027
  6. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialingJ Urol 2011;185: 1191–1197

Video: How do urology residents rate their laparoscopic experience?

Training of European urology residents in laparoscopy: results of a pan-European survey

Frederico T.G. Furriel, Maria P. Laguna*, Arnaldo J.C. Figueiredo, Pedro T.C. Nunes and Jens J. Rassweiler

Department of Urology and Renal Transplantation, University Hospital of Coimbra, Coimbra, Portugal, *Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany

OBJECTIVE

• To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

• A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012.

• Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated.

• Data was analysed with descriptive statistics.

RESULTS

• In all, 219 European urology residents answered the survey.

• Conventional laparoscopy was available in 74% of the respondents’ departments, while robotic surgery was available in 17% of the departments.

• Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy.

• Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory.

• The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

• Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor.

• Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

Article of the week: Robotic surgery training methods: take your pick

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Dr. Goh discussing standardized robotic surgery training methods.

If you only have time to read one article this week, it should be this one.

Comparative assessment of three standardized robotic surgery training methods

Andrew J. Hung, Isuru S. Jayaratna, Kara Teruya, Mihir M. Desai, Inderbir S. Gill and Alvin C. Goh*

USC Institute of Urology, Hillard and Roclyn Herzog Center for Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, and *Department of Urology, Methodist Institute for Technology, Innovation and Education, The Methodist Hospital, Houston, TX, USA

OBJECTIVES

• To evaluate three standardized robotic surgery training methods, inanimate, virtual reality and in vivo, for their construct validity.

• To explore the concept of cross-method validity, where the relative performance of each method is compared.

MATERIALS AND METHODS

• Robotic surgical skills were prospectively assessed in 49 participating surgeons who were classified as follows: ‘novice/trainee’: urology residents, previous experience <30 cases (n = 38) and ‘experts’: faculty surgeons, previous experience ≥30 cases (n = 11).

• Three standardized, validated training methods were used: (i) structured inanimate tasks; (ii) virtual reality exercises on the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA, USA); and (iii) a standardized robotic surgical task in a live porcine model with performance graded by the Global Evaluative Assessment of Robotic Skills (GEARS) tool.

• A Kruskal–Wallis test was used to evaluate performance differences between novices and experts (construct validity).

• Spearman’s correlation coefficient (ρ) was used to measure the association of performance across inanimate, simulation and in vivo methods (cross-method validity).

RESULTS

• Novice and expert surgeons had previously performed a median (range) of 0 (0–20) and 300 (30–2000) robotic cases, respectively (P < 0.001).

• Construct validity: experts consistently outperformed residents with all three methods (P < 0.001).

• Cross-method validity: overall performance of inanimate tasks significantly correlated with virtual reality robotic performance (ρ = −0.7, P < 0.001) and in vivo robotic performance based on GEARS (ρ = −0.8, P < 0.0001).

• Virtual reality performance and in vivo tissue performance were also found to be strongly correlated (ρ = 0.6, P < 0.001).

CONCLUSIONS

• We propose the novel concept of cross-method validity, which may provide a method of evaluating the relative value of various forms of skills education and assessment.

• We externally confirmed the construct validity of each featured training tool.

 

Read Previous Articles of the Week

 

Editorial: Three robotic surgery training methods: is there a clear winner?

All training adds value. A craft-based specialty such as surgery has always recognised this. The advent of advanced minimally invasive surgical technology and techniques has provided both new challenges and new opportunities for surgical performance and for the delivery of training. Conceptually, we have moved from the Halstedian model of ‘See one, do one, teach one’ [1] to an environment where skills are acquired away from the operating room in simulator, inanimate and in vivo (animal) laboratory training sessions. Increased scrutiny of credentialling and medico-legal aspects of robotic surgery have reinforced the importance of training and have led to a number of papers outlining pathways to facilitate this [2, 3].

In the present paper, Hung et al. evaluate the construct validity of three standardised training methods (inanimate, simulator and in vivo) and also compare the three different platforms for cross-method training value. As others have shown, the latest generation of robotic surgery simulators have high face, content and construct validity [4, 5] and the present paper confirms the value of both inanimate and simulator training for novice surgeons. In addition, the authors confirmed the construct validity of a simple in vivo exercise using the daVinci© surgical system by demonstrating that experts outperformed novices. Using Spearman’s rank correlation coefficient, the authors compared the three training methods under evaluation and concluded that they were strongly correlated for construct validity between exert and novice surgeons. While construct validation of these exercises may be established, are they useful for experts? Until realistic virtual reality surgical simulations are available, only a novice, an inexperienced or an occasional robot-assisted surgeon may benefit from virtual reality exercises.

What are we therefore to conclude from this? For certain, the advent of excellent surgical simulators and structured inanimate exercises has provided tools for novice surgeons to acquire console skills in a safe and structured environment. This will enhance their operating performance and reduce aspects of the learning curve such as operating time; however, the lack of availability of in vivo training opportunities greatly limits the applicability of this method of surgical training. In many countries (including Australia and the UK), this type of training is illegal or not available. The robotic surgery industry has strongly recommended that in vivo training should be undertaken in one of their official training facilities before surgeons are given the credentials to use this technology; however, even in the USA where most of these facilities are located, key leaders within the AUA have called for the awarding of credentials for robotic surgery ‘not to be an industry driven process, but one that is a result of a standardized, competency based, peer evaluation system’ [2]. Notably, the current AUA Standard Operating Practices (guidelines) for the awarding of credentials for robotic surgery list in vivo training as being optional.

Our view is that although all training has value, there is not enough evidence that in vivo training (particularly on an animal with a rudimentary prostate), which requires international travel and considerable expense, adds sufficient value to be mandatory in any credentialling process. In fact, we have dropped the requirement to complete in vivo training from our requirements at major robotic surgery centres in Australia in favour of structured Mini-Fellowship training [6]. Hung et al. have confirmed what we already knew, which is that all training adds value; however it is likely that only simulator and inanimate training adds enough value to be incorporated into standardised training in robotic surgery.

The multi-disciplinary ‘Fundamentals of Robotic Surgery’ (FRS) curriculum being created by Dr Richard Satava and associates is working on psychomotor skills tasks that include inanimate models as well as corresponding virtual reality exercises. Multi-institutional validation of the FRS or similar curricula will allow the establishment of training milestones and proficiency benchmarks. We must continue to strive for further development of robotic and surgical simulation to change the training paradigm so that surgical training does not need to be at the expense, however minor, of increased operating time or adverse patient outcome.

Declan G. Murphy* and Chandru P. Sundaram
*Peter MacCallum Cancer Centre, Division of Cancer Surgery, University of Melbourne, Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, Melbourne, Australia, and Department of Urology, Indiana University, Indianapolis, IN, USA

References

  1. Halsted WS. The training of the surgeon. Bull Johns Hop Hosp 1904; XV: 8
  2. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialingJ Urol 2011;185: 1191–1197
  3. Zorn KC, Gautam G, Shalhav AL et al. Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeonsJ Urol 2009; 182: 1126–1132
  4. Finnegan KT, Meraney AM, Staff I, Shichman SJ. da Vinci Skills Simulator construct validation study: correlation of prior robotic experience with overall score and time score simulator performanceUrology 2012; 80: 330–335
  5. Abboudi H, Khan MS, Aboumarzouk O et al. Current status of validation for robotic surgery simulators – a systematic reviewBJU Int 2013; 111: 194–205
  6. Melbourne Uro-Oncology Training Program. Robotic surgery training. Available at: https://www.declanmurphy.com.au/training. Accessed 28 February 2013
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