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Tas T, Cakiroglu B. Do 'standard laparoscopic box trainers' represent real-life conditions during transperitoneal laparoscopical interventions of the upper tract? Urologia 2019; 86:202-206. [PMID: 31116682 DOI: 10.1177/0391560319850428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study is to investigate the representativeness of the conventional laparoscopic standard box trainers in terms of real-life circumstances in transperitoneal laparoscopical interventions of the upper tract, using questionnaire inquiries with experienced surgeons. MATERIALS AND METHODS The study was conducted with 44 laparoscopists, whose level of renal surgery experience was either high (primary surgeon in >100 cases), moderate (primary surgeon in >50 cases) or basic (primary surgeon in >20 cases). We used the box widely preferred in international training courses, which consists of a 10-mm 30° laparoscope, real endoscopic instruments, light source, monitor and chicken bone materials. Participants were asked whether they represent real-life situations while performing tasks by means of standard box trainers. RESULTS The medians of 'restrained body posture of the surgeon', 'position of monitor', 'trocars entry slots', 'tissue distance and region' and 'limited field of movement and restricted working space' were analysed on their difference from the ideal value. All the variables were shown to be significantly different from the ideal value of 5 (p < 0.001). These results suggest that experienced surgeons in our study did not find the box simulation conditions similar to real surgery conditions. CONCLUSION Conventional laparoscopic trainer box, which is currently being used, is far from representing for the real situation in transperitoneal laparoscopical interventions of the upper tract.
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Affiliation(s)
- Tuncay Tas
- İstanbul Cerrahi Hospital, İstanbul Esenyurt University, İstanbul,Turkey
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The value of simulation-based training in the path to laparoscopic urological proficiency. Curr Opin Urol 2017; 27:337-341. [DOI: 10.1097/mou.0000000000000400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Madec FX, Dariane C, Pradere B, Amadane N, Bergerat S, Gryn A, Lebacle C, Matillon X, Olivier J, Nouhaud FX, Panayotopoulos P, Peyronnet B, Rizk J, Sanson S, Seisen T, Salomon L, Fiard G. [French resident's performance on laparoscopic surgery box trainer: 7-year results of pelvitrainer contests]. Prog Urol 2016; 26:1171-1177. [PMID: 28279367 DOI: 10.1016/j.purol.2016.09.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The study objectives were to analyze the resident's laparoscopic surgery performance in order to build a self-assessment data set, to identify discriminatory exercises and to investigate the suturing time changes. METHODS From 2007 to 2014, the French Association of Urologist in Training (AFUF) organized 7 pelvitrainer contests. Participant scores on 11 laparoscopic surgery exercises were evaluated. RESULTS Sixty-six residents participated to these contests and performed 11 exercises each. Twenty-two (33.3 %) participants were beginners, 26 (39.4 %) intermediates et 18 (27.3 %) experienced. The participant scores were gathered into a data set including the average time per exercise. We found a time scoring improvement related to the resident experience for all exercises. A significant decline in time was noted for exercise 8 and 9 between beginners and intermediates (139s [±71]), (173.9s [±118.3]) and between beginners and experienced (80.6s [±26.7]), (94,1s [±42.7]) with a P<0.05. The correlation coefficient for the exercise 11 duration (vesico-uretral anastomosis) was 0.04 over a 7-year period (P=0.44). CONCLUSION The study provided a data set on 11 laparoscopic surgery tasks which can be consulted by all residents as a reference in a self-assessment process. Two exercises (8 and 9) discriminated beginners from intermediates and experienced groups and could be used as a benchmark ahead of an operating room procedure. The vesico-uretral anastomosis duration (exercise 11) did not improve significantly between 2006 and 2014. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- F-X Madec
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Dariane
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - B Pradere
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - N Amadane
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, hôpital Lapeyronie, CHRU de Montpellier, 371, avenue du Doyen-Giraud, 34295 Montpellier cedex 5, France
| | - S Bergerat
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, centre hospitalier universitaire de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - A Gryn
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Département d'urologie, hôpital Rangueil, CHU de Toulouse, 1, avenue du Pr-Jean-Poulhès, 31059 Toulouse cedex, France
| | - C Lebacle
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Henri-Mondor, CHU Paris-Est, 51, avenue du Marechal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - X Matillon
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie et chirurgie de la transplantation, hôpital Édouard-Herriot, centre hospitalier universitaire de Lyon, 3, place d'Arsonval, 69003 Lyon, France
| | - J Olivier
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Claude-Huriez, CHU de Lille, 2, rue Michel-Polonovski, 59000 Lille, France
| | - F-X Nouhaud
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Rouen Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - P Panayotopoulos
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
| | - B Peyronnet
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Rennes, 2, rue Henri-le-Guilloux, 35000 Rennes, France
| | - J Rizk
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Claude-Huriez, CHU de Lille, 2, rue Michel-Polonovski, 59000 Lille, France
| | - S Sanson
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Département d'urologie, hôpital Rangueil, CHU de Toulouse, 1, avenue du Pr-Jean-Poulhès, 31059 Toulouse cedex, France
| | - T Seisen
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Pitié-Salpétrière, Assistance publique-Hôpitaux de Paris, université Pierre-and-Marie-Curie, 75013 Paris, France
| | - L Salomon
- Service d'urologie, hôpital Henri-Mondor, CHU Paris-Est, 51, avenue du Marechal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - G Fiard
- Association française des urologues en formation (AFUF), 11, rue Viète, 75017 Paris, France; Service d'urologie et de la transplantation rénale, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
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Azarnoush H, Alzhrani G, Winkler-Schwartz A, Alotaibi F, Gelinas-Phaneuf N, Pazos V, Choudhury N, Fares J, DiRaddo R, Del Maestro RF. Neurosurgical virtual reality simulation metrics to assess psychomotor skills during brain tumor resection. Int J Comput Assist Radiol Surg 2014; 10:603-18. [DOI: 10.1007/s11548-014-1091-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/09/2014] [Indexed: 01/22/2023]
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Abstract
In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.
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Affiliation(s)
- Clare Faurie
- Sydney Medical School, The University of Sydney, New South Wales, Australia.
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The Importance of Stressing the Use of Laparoscopic Instruments in the Initial Training for Laparoscopic Surgery Using Box Trainers: A Randomized Control Study. J Surg Res 2012; 174:90-7. [DOI: 10.1016/j.jss.2010.11.906] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 11/04/2010] [Accepted: 11/19/2010] [Indexed: 11/17/2022]
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Ahmed K, Miskovic D, Darzi A, Athanasiou T, Hanna GB. Observational tools for assessment of procedural skills: a systematic review. Am J Surg 2011; 202:469-480.e6. [PMID: 21798511 DOI: 10.1016/j.amjsurg.2010.10.020] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment. METHODS Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included. RESULTS Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse. CONCLUSIONS There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level.
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Affiliation(s)
- Kamran Ahmed
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital Campus, UK
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Salin A, Gaujoux S, Sarnacki S, Hardy P, Frileux P. Teaching laparoscopic techniques: The Surgical School of Paris experience. J Visc Surg 2010; 147:e385-8. [DOI: 10.1016/j.jviscsurg.2010.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Autorino R, Haber GP, Stein RJ, Rane A, De Sio M, White MA, Yang B, de la Rosette JJ, Kaouk JH, Laguna MP. Laparoscopic Training in Urology: Critical Analysis of Current Evidence. J Endourol 2010; 24:1377-90. [DOI: 10.1089/end.2010.0005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Riccardo Autorino
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Urology Clinic, Second University of Naples, Naples, Italy
| | - Georges-Pascal Haber
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert J. Stein
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Abhay Rane
- Department of Urology, East Surrey Hospital, Redhill, United Kingdom
| | - Marco De Sio
- Urology Clinic, Second University of Naples, Naples, Italy
| | - Michael A. White
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bo Yang
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jean J. de la Rosette
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jihad H. Kaouk
- Center for Laparoscopy and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - M. Pilar Laguna
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Ahmed K, Jawad M, Dasgupta P, Darzi A, Athanasiou T, Khan MS. Assessment and maintenance of competence in urology. Nat Rev Urol 2010; 7:403-13. [PMID: 20567253 DOI: 10.1038/nrurol.2010.81] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Methodologies for establishing validity in surgical simulation studies. Surgery 2010; 147:622-30. [DOI: 10.1016/j.surg.2009.10.068] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 10/26/2009] [Indexed: 01/22/2023]
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Miyajima A, Hasegawa M, Takeda T, Tamura K, Kikuchi E, Nakagawa K, Oya M. How do young residents practice laparoscopic surgical skills? Urology 2010; 76:352-6. [PMID: 20303153 DOI: 10.1016/j.urology.2009.09.098] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/06/2009] [Accepted: 09/16/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To investigate whether a training system using a dry box is feasible for training young urologists. Despite laparoscopic surgery being widely indicated for several urological diseases, a laparoscopic training system for young urologists has not been fully established yet. However, the learning curve for laparoscopic surgery has not yet been ascertained. METHODS We continued to test 11 sixth-year residents (postgraduate year: PGY6) and third-year residents (PGY3) in our department in terms of surgical skills using a dry box. We gave them several tasks (cutting and suturing) and let them practice until task completion. We continued to test all participants by these tasks for 16 weeks. RESULTS At the beginning of the present study, the PGY6 residents achieved significantly better scores than the PGY3 residents. However, the difference between the 2 groups became insignificant over time. Furthermore, statistical analysis revealed that a practice time of 100 minutes per week was the only significant factor affecting the last test score. For the final test, the mean practice time for all participants was 79.1 minutes per week. CONCLUSIONS These results suggest that laparoscopic surgical skills can definitely be polished by adequate voluntary practice.
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Zhang X, Wang B, Ma X, Zhang G, Shi T, Ju Z, Wang C, Li H, Ai X, Fu B. Laparoscopic adrenalectomy for beginners without open counterpart experience: initial results under staged training. Urology 2009; 73:1061-5. [PMID: 19394504 DOI: 10.1016/j.urology.2008.11.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 10/18/2008] [Accepted: 11/15/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To develop a staged laparoscopic training program for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility. METHODS From January 2002 to October 2007, 5 beginners (postgraduate years 1-5) without previous experience in open adrenalectomy were selected randomly to receive the staged laparoscopic training, including box-trainer, animal model, and mentor-initiated clinical training. During the clinical training, the trainees acted as the camera holder first, and then selectively performed simple operations, such as laparoscopic renal cyst unroofing. Finally, they performed 30 LAs independently under the mentor's supervision using the technique of anatomic retroperitoneoscopic adrenalectomy. The clinical data of the 30 LAs performed by each the trainees (150 LAs total) were collected and compared with the data from the initial 30 LAs of the mentor. RESULTS All LAs were completed successfully. No procedure required conversion to open surgery. The median operative time of the trainees was 82.3 minutes (range 59-133), which was obviously shorten than the mentor's (median operative time 131.5 minutes, range 73-230, P < .001). The learning curve among the trainees was shorter compared with that of the mentor. No major complications were observed. The minor intraoperative and postoperative complication rate for the trainees was 0.67% and 6.7%, respectively, not significantly different from those of the mentor (0% and 3.3%, respectively; both P > .05). All complications developing in patients treated by the trainees required only conservative therapy. CONCLUSIONS It was safe and feasible for beginners without previous open counterpart experience to perform LA using staged training.
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Affiliation(s)
- Xu Zhang
- Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital, Hai Dian District, Beijing, People's Republic of China.
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Ramirez-Backhaus M, Hellawell G, Melo M, Covita A, Stolzenburg JU. Teaching laparoscopy to residents: How can we select good candidates? Curr Urol Rep 2009; 10:106-11. [DOI: 10.1007/s11934-009-0020-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gettman MT. Editorial comment on: Assessment of laparoscopic suturing skills of urology residents: a pan-European study. Eur Urol 2008; 56:872-3. [PMID: 18922623 DOI: 10.1016/j.eururo.2008.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Assessment of laparoscopic suturing skills of urology residents: a pan-European study. Eur Urol 2008; 56:865-72. [PMID: 18922627 DOI: 10.1016/j.eururo.2008.09.045] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 09/19/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND It has been acknowledged that standardised training programmes are needed to improve laparoscopic training of urologic trainees. Previous studies have suggested that simulator-based laparoscopic training can improve performance during real laparoscopic procedures. OBJECTIVE To determine if there are performance differences for the completion of a simulated laparoscopic suturing task among urology residents based on their postgraduate year of training (PGY). DESIGN, SETTING, AND PARTICIPANTS Using a validated scoring checklist, two independent observers objectively scored the completion of a standardised laparoscopic suturing task in a bench-top laparoscopic box trainer. PGY and previous exposure to laparoscopic surgery and laparoscopic simulated training was obtained from self-administered questionnaires. Data acquisition was undertaken at the European Urological Residents Education Programme (EUREP) 2007, run by the European School of Urology, and included a pan-European cohort of 201 urology residents. MEASUREMENTS Reliability among those rating the suturing tasks was excellent (Cronbach's α=0.83). Each resident was scored for the suturing task. Residents were categorised into three groups based on their PGY status (junior [n=8]; intermediate [n=37]; senior [n=156]). The Kruskal-Wallis test was used to measure trend across the PGY; the Mann-Whitney U test was used to determine variation among categorised PGY groups. RESULTS AND LIMITATIONS Laparoscopic suturing skill was significantly different across PGY levels (p=0.032), and between junior residents and both intermediate and senior residents (p=0.008 and p=0.012, respectively). There was no significant difference between intermediate and senior residents (p=0.697). Only 12% of participants rated their existing volume of laparoscopic operative cases as sufficient, while 55% of participants had no regular opportunities, and 32% of participants had not performed laparoscopic procedures as primary surgeon. Most residents (96%) reported the use of laparoscopic simulators to be beneficial in training, although current European training programmes appear to provide <50% of residents with the opportunity to train with them. CONCLUSIONS A discernable relationship existed between the score obtained for a laparoscopic suturing task and year of resident training. Modular simulator training as part of a formal training programme may help to overcome some of the shortfall in residents' exposure to laparoscopic procedures as primary surgeon.
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Touijer K, Kuroiwa K, Eastham JA, Vickers A, Reuter VE, Scardino PT, Guillonneau B. Risk-Adjusted Analysis of Positive Surgical Margins Following Laparoscopic and Retropubic Radical Prostatectomy. Eur Urol 2007; 52:1090-6. [PMID: 17188801 DOI: 10.1016/j.eururo.2006.12.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 12/06/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To prospectively compare in a contemporary and contemporaneous series the positive surgical margin (PSM) rate between laparoscopic (LRP) and retropubic (RRP) radical prostatectomy at the same institution. METHODS Between 1 January 2003 and 30 June 2005, 1177 consecutive men with clinically localized adenocarcinoma of the prostate underwent radical prostatectomy at the same institution: 485 laparoscopically and 692 through a retropubic approach. Partin table probability of organ-confined (OC) disease was used as an index of disease aggressiveness: The PSM rate between the two approaches was compared, with adjustment for the OC probability. RESULTS Overall both surgical approaches had a comparable PSM rate of 11.3% after LRP and 11% after RRP. In a logistic regression analysis adjusting for OC probability, there was no statistically significant difference between LRP and RRP (odds ratio [OR]: 1.156; 95% confidence interval [%95 CI], 0.792, 1.686; p=0.5). There was a statistically significant decrease over time in the rate of PSM for LRP (OR: 0.71 per 100 patients treated; %95 CI, 0.57, 0.89; p=0.003), while that of RRP was unchanged (OR: 1.06 per 100 patients treated; %95 CI, 0.94, 1.21; p=0.3; p=0.002 for interaction between change over time and procedure). CONCLUSIONS In our institution, laparoscopic and retropubic radical prostatectomy provide comparable PSM rates for patients with clinically localized prostate cancer. The PSM rate over the study period remained unchanged in the RRP experience, indicating a mature and well-established operative technique, while that of LRP underwent a significant decrease, demonstrating that the procedure and therefore the results continued to evolve during the study.
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Affiliation(s)
- Karim Touijer
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Sugiono M, Teber D, Anghel G, Gözen AS, Stock C, Hruza M, Frede T, Klein J, Rassweiler JJ. Assessing the Predictive Validity and Efficacy of a Multimodal Training Programme for Laparoscopic Radical Prostatectomy (LRP). Eur Urol 2007; 51:1332-9; discussion 1340. [PMID: 17137707 DOI: 10.1016/j.eururo.2006.11.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 11/09/2006] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess the predictive validity (ability to correlate to real-life environment) and efficacy of a training programme for laparoscopic radical prostatectomy (LRP), based on a structured and progressive pelvitrainer component with hands-on clinical training in the operating room (OR). METHODS Prospective data on 500 LRP cases were analysed with 80 excluded due to incomplete records. The operation was divided into multiple steps. Times for these steps were compared among 11 surgeons with different laparoscopic expertise (first-, second-, and third-generation surgeons in order of decreasing experience) and correlated to times for specific exercises on the pelvitrainer that simulated particular steps. Perioperative parameters were also evaluated among the three groups. RESULTS Pelvitrainer times achieved by trainees (third-generation surgeons) did not differ significantly with times for corresponding steps of LRP. There was also no significant difference for total OR time between the second- and third-generation surgeons (205 and 207 min, respectively; p>0.05) although the time for the first-generation surgeons was faster than both (176 min). Short-term quality indicators for first, second, and third generations included transfusion rates (2.3%, 2.4%, and 2.6%, respectively), positive margin rates (20.3%, 21.5%, and 23.0%) and complications, which did not differ significantly among the generations although the first-generation surgeons had the lowest rates. CONCLUSIONS A carefully designed training programme that incorporates both pelvitrainer and mentor-based operative training is essential for the effective and safe transfer of skills and knowledge required to learn LRP.
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Affiliation(s)
- Marto Sugiono
- Department of Urology, SLK-Klinikum Heilbronn, University of Heidelberg, Am Gesundbrunnen 20, D-77074 Heidelberg, Germany
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Rassweiler J, Klein J, Teber D, Schulze M, Frede T. Mechanical Simulators for Training for Laparoscopic Surgery in Urology. J Endourol 2007; 21:252-62. [PMID: 17444768 DOI: 10.1089/end.2007.9983] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE The introduction of laparoscopic surgery into urology has led to new training concepts differing significantly from previous concepts of training for open surgery. This paper focuses on the type and importance of mechanical simulators in laparoscopic training. MATERIALS AND METHODS On the basis of our own studies and experience with the development of various concepts of laparoscopic training, including different modules (i.e., Pelvi-trainer, animal models, clinical mentoring) since 1991, we reviewed the current literature concerning all types of simulators. We focused on training for laparoscopic ablative and reconstructive surgery using mechanical simulators. RESULTS The principle of a mechanical simulator (i.e., a box with the possibility of trocar insertion) has not changed during the last decade. However, the types of Pelvi-trainers and the models used inside have been improved significantly. According to the task of the simulator, various sophisticated models have been developed, including standardized phantoms, animal organs, and even perfused segments of porcine organs. For laparoscopic suturing, various step-by-step training concepts have been presented. These can be used for determination of the ability of a physician with an interest in laparoscopic surgery, but also to classify the training status of a laparosopic surgeon. CONCLUSIONS Training in laparoscopic surgery has become an important topic, not only in learning a procedure, but also in maintaining skills and preparing for the management of complications. For these purposes, mechanical simulators will definitely play an important role in the future.
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Affiliation(s)
- Jens Rassweiler
- Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heidelberg, Germany.
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22
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Chandrasekera SK, Donohue JF, Orley D, Barber NJ, Shah N, Bishai PM, Muir GH. Basic Laparoscopic Surgical Training: Examination of a Low-Cost Alternative. Eur Urol 2006; 50:1285-90; 1290-1. [PMID: 16860459 DOI: 10.1016/j.eururo.2006.05.052] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 05/31/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE "Dry lab" facilities are integral to laparoscopy training, but access is often limited due to the high costs of video-laparoscopy equipment. We assessed the effectiveness of a cheap and simple training model compared to conventional video-laparoscopy for basic training using a randomised, blinded study. METHODS Thirty-six third-year medical students without previous surgical skills were randomised into two groups: group A students were taught basic laparoscopy skills using a conventional video-laparoscopy pelvic trainer and group B students were taught similar techniques using a cardboard box with a cut-out top to allow light and visualisation. Participants in group B had one eye obscured to reduce their stereoscopic vision. After eight sessions of training amounting to 24h, the two groups were assessed by a blinded adjudicator on set tasks using both the video-laparoscopy pelvic trainer and the cardboard box. Accuracy, timing and depth perception were assessed and the results compared. RESULTS There was no significant difference in performance scores or times between the two groups in any of the parameters when tested on the cardboard box. However, when assessed on the video trainer, the cardboard box-trained group had significantly faster times with equivalent scores in the majority of tasks. CONCLUSION For basic laparoscopic training the cardboard box, costing nothing, is a simple and effective alternative, which can be used in conjunction with sophisticated video-laparoscopy equipment costing thousands of dollars.
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Megali G, Sinigaglia S, Tonet O, Dario P. Modelling and Evaluation of Surgical Performance Using Hidden Markov Models. IEEE Trans Biomed Eng 2006; 53:1911-9. [PMID: 17019854 DOI: 10.1109/tbme.2006.881784] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Minimally invasive surgery has become very widespread in the last ten years. Since surgeons experience difficulties in learning and mastering minimally invasive techniques, the development of training methods is of great importance. While the introduction of virtual reality-based simulators has introduced a new paradigm in surgical training, skill evaluation methods are far from being objective. This paper proposes a method for defining a model of surgical expertise and an objective metric to evaluate performance in laparoscopic surgery. Our approach is based on the processing of kinematic data describing movements of surgical instruments. We use hidden Markov model theory to define an expert model that describes expert surgical gesture. The model is trained on kinematic data related to exercises performed on a surgical simulator by experienced surgeons. Subsequently, we use this expert model as a reference model in the definition of an objective metric to evaluate performance of surgeons with different abilities. Preliminary results show that, using different topologies for the expert model, the method can be efficiently used both for the discrimination between experienced and novice surgeons, and for the quantitative assessment of surgical ability.
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Aggarwal R, Grantcharov TP, Eriksen JR, Blirup D, Kristiansen VB, Funch-Jensen P, Darzi A. An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg 2006; 244:310-4. [PMID: 16858196 PMCID: PMC1602164 DOI: 10.1097/01.sla.0000218094.92650.44] [Citation(s) in RCA: 212] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To develop an evidence-based virtual reality laparoscopic training curriculum for novice laparoscopic surgeons to achieve a proficient level of skill prior to participating in live cases. SUMMARY BACKGROUND DATA Technical skills for laparoscopic surgery must be acquired within a competency-based curriculum that begins in the surgical skills laboratory. Implementation of this program necessitates the definition of the validity, learning curves and proficiency criteria on the training tool. METHODS The study recruited 40 surgeons, classified into experienced (performed >100 laparoscopic cholecystectomies) or novice groups (<10 laparoscopic cholecystectomies). Ten novices and 10 experienced surgeons were tested on basic tasks, and 11 novices and 9 experienced surgeons on a procedural module for dissection of Calot triangle. Performance of the 2 groups was assessed using time, error, and economy of movement parameters. RESULTS All basic tasks demonstrated construct validity (Mann-Whitney U test, P < 0.05), and learning curves for novices plateaued at a median of 7 repetitions (Friedman's test, P < 0.05). Expert surgeons demonstrated a learning rate at a median of 2 repetitions (P < 0.05). Performance on the dissection module demonstrated significant differences between experts and novices (P < 0.002); learning curves for novice subjects plateaued at the fourth repetition (P < 0.05). Expert benchmark criteria were defined for validated parameters on each task. CONCLUSION A competency-based training curriculum for novice laparoscopic surgeons has been defined. This can serve to ensure that junior trainees have acquired prerequisite levels of skill prior to entering the operating room, and put them directly into practice.
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Affiliation(s)
- Rajesh Aggarwal
- Department of Surgical Oncology & Technology, Imperial College, London, UK.
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25
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Abstract
During the past decade, the clinical applications of laparoscopic surgery in urology have been growing steadily. The laparoscopic version of various procedures, such as nephrectomy, is becoming the standard of care. This has led to an increased need for laparoscopic training in urology and focused the attention on the various modalities for laparoscopic skill acquisition. The common training modalities for laparoscopy are box trainers, animal and cadaveric laparoscopy, and virtual reality simulators. Each modality carries its own benefits to the practicing surgeon. The box trainers are the first practiced and are basic training simulators. They were first designed to help with training in basic laparoscopic skills and to assist surgeons in getting acquainted with instruments. However, these simple boxes are being upgraded constantly by tissue- and organ-specific models, allowing the surgeon to train in a convenient and cost-effective environment. This article describes the ways to work with box trainers, from basic skills to advanced laparoscopic tasks, and discusses the contribution of these trainers to real surgery as well as their role in defining criterion levels of surgical performance.
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Affiliation(s)
- Ran Katz
- Department of Urology, Hadassah Medical Centre, PO Box 12000 Ein Kerem, Jerusalem 91120 Israel.
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Hoznek A, Salomon L, de la Taille A, Yiou R, Vordos D, Larre S, Abbou CC. Simulation training in video-assisted urologic surgery. Curr Urol Rep 2006; 7:107-13. [PMID: 16526994 DOI: 10.1007/s11934-006-0068-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The current system of surgical education is facing many challenges in terms of time efficiency, costs, and patient safety. Training using simulation is an emerging area, mostly based on the experience of other high-risk professions like aviation. The goal of simulation-based training in surgery is to develop not only technical but team skills. This learning environment is stress-free and safe, allows standardization and tailoring of training, and also objectively evaluate performances. The development of simulation training is straightforward in endourology, since these procedures are video-assisted and the low degree of freedom of the instruments is easily replicated. On the other hand, these interventions necessitate a long learning curve, training in the operative room is especially costly and risky. Many models are already in use or under development in all fields of video-assisted urologic surgery: ureteroscopy, percutaneous surgery, transurethral resection of the prostate, and laparoscopy. Although bench models are essential, simulation increasingly benefits from the achievements and development of computer technology. Still in its infancy, virtual reality simulation will certainly belong to tomorrow's teaching tools.
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Affiliation(s)
- András Hoznek
- Service d'Urologie, Centre Hospitalier Universitaire Henri Mondor, Université Paris XII, 51. Av;du Ml. De Lattre de Tassigny, 94010 Créteil-cedex, France.
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Abstract
PURPOSE OF REVIEW Training in laparoscopy has become an important issue in the current surgical scenario. In this overview we aim to update the current knowledge in the field of laparoscopic urological training and to highlight the potential dangers of using simulation for accreditation and selection purposes at this stage. RECENT FINDINGS Physical simulators are widely available and seem to be equally efficient as virtual reality simulators. Transfer of training has been proven to be beneficial in randomized controlled trials for virtual reality and cholecystectomy. A model for the vesico-urethral suture has been described and integrated in a skills laboratory program. The program has construct validity and can discriminate at least between beginners and advanced laparoscopists. Efforts have still to be made in defining appropriate tools to assess competence and evidence for reliability, and validity must be obtained before including simulators in accreditation programs. SUMMARY In spite of the abundant literature there is still little evidence about the learning mechanism involved in acquiring laparoscopic skills. Physical and virtual reality simulators have been proven to be efficient in improving dexterity and some evidence exists of a positive transfer from virtual reality to the operating room in cholecystectomy. Very few models, however, have been described for reconstructive urology, and effective transfer to the operating room has not yet been proven, although validation work is in progress in the field of urology.
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Affiliation(s)
- Ma Pilar Laguna
- Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.
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Stolzenburg JU, Rabenalt R, Do M, Horn LC, Liatsikos EN. Modular Training for Residents with no Prior Experience with Open Pelvic Surgery in Endoscopic Extraperitoneal Radical Prostatectomy. Eur Urol 2006; 49:491-8; discussion 499-500. [PMID: 16359780 DOI: 10.1016/j.eururo.2005.10.022] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 10/25/2005] [Indexed: 11/16/2022]
Abstract
PURPOSE To establish a teaching program for the performance of endoscopic extraperitoneal radical prostatectomy (EERPE) that would ascertain the safe and efficacious training of residents with no previous experience with open pelvic surgery. MATERIALS AND METHODS The technique of EERPE was divided in 12 segments with 5 levels of difficulty. We thus designed a training program, where the resident learned the procedure in a mentor-defined schedule. During each educational EERPE, the trainee only performed the operative steps corresponding to his acquired skill level. The mentor performed the remaining parts of the EERPE, with the trainee assisting. The first 50 and consequent 100 cases performed by the residents were compared to the first 50 and last 100 cases (cases 521-621) performed by the mentor. RESULTS Two residents with no prior experience with open pelvic surgery participated in the study, and required 43 and 38 procedures respectively, until they were considered to be competent. The initial 50 procedures performed completely independently by the residents had mean operative times of 176 and 173 minutes. There were 2 intraoperative rectal injuries (one patient developed recto-urethral fistula), and 1 hemorrhage, and 1 lymphocele, postoperatively. The positive margin rate for pT2 disease was 14.3 and 11.5%, and for pT3 tumors 38.8 and 29.1%, respectively. After an additional 100 procedures operated by the same residents, mean operative times were 142 and 146 minutes. There was one patient who needed a transfusion. Postoperative complications requiring re-intervention were 1 hemorrhage, 2 anastomotic leakages and 4 symptomatic lymphoceles. The positive margin rate for pT2 disease was 12.8% and 6.5%, and for pT3 tumors 33.3% and 26.3% respectively. No statistical significant differences were observed when comparing with the mentors cases. CONCLUSION We have showed that residents with no prior experience in open surgery of the pelvis can adhere to the modular training scheme and successfully perform the EERPE procedure with similar risk of complications compared to the tutor.
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Bibliography. Current world literature. Minimally invasive surgery in urology. Curr Opin Urol 2006; 16:112-7. [PMID: 16479214 DOI: 10.1097/01.mou.0000193398.85092.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Touijer K, Kuroiwa K, Vickers A, Reuter VE, Hricak H, Scardino PT, Guillonneau B. Impact of a multidisciplinary continuous quality improvement program on the positive surgical margin rate after laparoscopic radical prostatectomy. Eur Urol 2006; 49:853-8. [PMID: 16455183 PMCID: PMC1951513 DOI: 10.1016/j.eururo.2005.12.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 12/30/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Outcome after radical prostatectomy is highly sensitive to fine nuances in the surgical techniques. We sought to determine the impact of a process of continuous control and monitoring on the positive surgical margin rate in a contemporary series of laparoscopic radical prostatectomy. METHODS Between January 2003 and October 2004, 301 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer (cT1-cT3a). A weekly case review conference involving surgeons, radiologists, and uropathologists was held to discuss the preoperative, intraoperative, and pathologic findings of significant cases. We analyzed the trend of positive surgical margins and compared the clinical and detailed pathologic characteristics of the cancer during the study period. RESULTS We created logistic regression models with positive margin as the dependent variable and surgical experience as the predictor, adjusting for possible secular changes in disease severity (prostate-specific antigen, pathologic stage, and Gleason grade). There was a decrease in the rate of surgical margins: odds ratio 0.68/100 patients treated (95% confidence interval [CI] 0.44, 1.05; p=0.08). The predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 301st. These values are close to the observed rates for the first and last 50 patients. There was no important change in surgical risk over the course of the study, and the rate of nerve sparing remained stable throughout the study period. CONCLUSIONS In this contemporary series, which is unaffected by downward stage migration, the decreasing rate of positive surgical margins can be explained by subtle surgical technique modifications and a continuous multidepartmental effort for quality improvement.
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Affiliation(s)
- Karim Touijer
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Kentaro Kuroiwa
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Victor E. Reuter
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Hedwig Hricak
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Peter T. Scardino
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Bertrand Guillonneau
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- * Corresponding author. Memorial Sloan Kettering Cancer Center, Sidney Kimmel Center for Prostate & Urologic Cancers, 353 East 68th Street, New York, NY 10021, USA. Tel. +1 646 422 4406; Fax: +1 212 988 0806. E-mail address: (B. Guillonneau)
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Stolzenburg JU, Schwaibold H, Bhanot SM, Rabenalt R, Do M, Truss M, Ho K, Anderson C. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005; 96:1022-7. [PMID: 16225521 DOI: 10.1111/j.1464-410x.2005.05803.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial. SUBJECTS AND METHODS The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study. RESULTS After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%. CONCLUSION The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.
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Affiliation(s)
- Jens-Uwe Stolzenburg
- Department of Urology, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
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LiteratureWatch. J Endourol 2005; 19:1045-62. [PMID: 16253079 DOI: 10.1089/end.2005.19.1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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