Impact of a Laparoscopic Renal Surgery Mini-Fellowship Program on Postgraduate Urologist Practice Patterns at 3-Year Followup

Effectiveness of an inexpensive short-term theoretical-practical course on videosurgery for surgeons in training

BACKGROUND

The rapid development of video surgery and minimally invasive surgical techniques prompted many studies on the methods of teaching these techniques to young surgeons in training. However, the characteristics of a short-term course that is both easily accessible and efficient for this group of surgeons remain controversial. To investigate this issue, a short-term training method was proposed for first year surgery residents, using inexpensive handmade wooden simulation boxes with the students smartphones as cameras. Its effectiveness was evaluated, as well as possible factors that could influence student performance, such as gender and previous experience with video games.

METHODS

Thirty-six first-year General Surgery residents, entering in 2019 and 2020, participated in the study: 21 were males and 15 were females with ages between 22 and 29 years old, (mean 25.47 years). All participants performed a pre-established exercise (placing two simple stitches using a laparoscopic simulator), which was timed and scored. They then participated in a short theoretical-practical course, consisting of an initial lecture followed by 4 exercises on handcrafted wooden laparoscopic video surgery simulators. Afterwards, they were asked to repeat the same exercise from the first step. Finally, they answered a questionnaire that included questions on previous videogame experience. The data were tabulated and submitted to statistical analysis.

RESULTS

In the pre-training exercise, 15 (41.66%) participants were able to perform the two simple stitches in the simulator box within the maximum time limit of 5 minutes. After the short course, 22 (61.11%) of participants were able to perform the complete exercise. Improvement in the time to complete the practical exercise was statistically significant (p = 0.0296) after participating in the theoretical-practical course. A better pre- and post-training performance was demonstrated by the 17 participants with experience with video games (p = 0.0116), and a better post-training performance was demonstrated by female participants (p = 0.0405).

CONCLUSION

This short-term inexpensive theoretical-practical course in laparoscopic training for surgeons in training was effective in reducing the execution time of a laparoscopic stitch in a simulation box. Previous experience with video games and/or female gender appear to be associated with improved performance.

The Impact of an International Elective on Anesthesiology Residents as Assessed by a Longitudinal Study

INTRODUCTION

Participation of anesthesiology residents in international electives may lead to the acquisition of skills as described in the Accreditation Council for Graduate Medical Education (ACGME) competencies. There is great interest in participating in such electives, but it is not clear there are educational or professional benefits. The purpose of this study was to evaluate the educational benefits of participating in overseas electives among anesthesiology residents.

METHODS

A longitudinal study design was used between 2010 and 2015 to survey all anesthesiology residents selected to participate in the nationally competitive Society for Education in Anesthesia-Health Volunteers Overseas (SEA-HVO) Traveling Fellowship Program in which third-year residents receive scholarships and ABA credit for 1-month teaching electives in a low-resource country. Pre-elective and post-elective surveys were sent via de-identified e-mails during the third year of residency. We investigated residents' expectations, plans, and comfort level with teaching techniques prior to the elective and after and asked about perceived benefits.

RESULTS

The response rate was 68.8% of the 45 residents who received the survey. Participants were motivated by professional and humanitarian goals. Residents reported improved comfort with teaching techniques, especially lecturing and giving feedback. Participants acquired better skills in assessing the learning needs of students. There was a slight but nonsignificant increased comfort dealing with cultural and language barriers. The major self-perceived unique benefit of international electives was improvement in intercultural communication. The systems' changes reported by residents as the most important to improve were those that affected patient safety.

CONCLUSION

Global health electives have a small positive effect on teaching, cultural proficiency, and systems assessment skills. Residents improve in their ability to identify educational needs and to give feedback. Patient safety during anesthetic care is appreciated as the most important systems' need.

No-cable and smartphone/tablet: A functional laparoscopic training box "Fu-Lap T-Box"

Because of the long and variable learning curve of laparoscopic surgery, before its actual application, a well-designed practical simulating instruments like laparoscopic training boxes are needed. But because of unfavourable cost-effectiveness and huge sizes of these boxes, surgeons hardly procure, and carry them. We aimed to design a new, cheap, light and handy laparoscopic training box. Our training box is made of aluminium and used with smartphone or tablet. There is no need for a power unit. Our foldable box has dimensions of 52×38×4 cm, and weighs 2.8 kg and foldable. There are 5 working ports in it. Compared to its alternatives "Fu-Lap T-Box" is much cheaper, lighter and more comfortable. In our opinion it is possible to design and use a new cheaper and portable simulator to gain more hands-on experience before the real surgery.

Postgraduate course in minimally invasive urological surgery

Background

Minimally invasive surgeries are increasingly common as the first option for most urological diseases. However, laparoscopic techniques are difficult to master, especially for surgeons who were not trained during their residency programs. Therefore, postgraduate courses are important for such matters. This study aims to evaluate the results of postgraduate courses in minimally invasive urological surgery.

Methods

A specific questionnaire was used to evaluate the impact of the course on urologists' professional activities. The questionnaire also evaluated demographic data and previous surgical experience. The postgraduate course was divided into 10 monthly modules, each one with 36 hours of activities, from March to December. All students of the laparoscopic postgraduate course from the last five years were enrolled in the study.

Results

Forty-one students were included in the study. Thirty-nine students were male (95.1%), and the mean age was 39.5 years (range, 30-60 years). Students from all regions of the country were enrolled. Thirty (73.2%) students had minor laparoscopic experience. All students improved their laparoscopic skills and were able to include new procedures in their daily surgical practice. Eleven students (26.8%) had no laparoscopic experience, and all of them started to perform laparoscopic procedures. The median level of impact on professional life was 75 points (range, 0-100 points).

Conclusions

The postgraduate course is an appropriate way to acquire urological laparoscopic skills. The annual course allowed improvement and initiation of laparoscopic procedures, which significantly impacted urologists' daily activities.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon’s performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

Safe introduction of laparoscopic and retroperitoneoscopic nephrectomy in clinical practice: impact of a modular training program

PURPOSE

To describe and validate a novel modular training scheme (MTS) for trans-peritoneal laparoscopic nephrectomy (LN) and retroperitoneoscopic nephrectomy (RN).

METHODS

Four consultant urologists attended a Masterclass in "Advanced Laparoscopic and Robotic Surgery," certified by the University of Turin (IT). The Masterclass was based on a supervised MTS, which involved progressive, proficiency-based training through nine and seven steps for LN and RN, respectively. After becoming proficient in all the steps, each trainee performed a minimum of five procedures as first operator under direct observation of the mentor in the training centre. Then, each trainee independently performed 10 LN and 10 RN at his home institution. The surgical outcomes were compared with those from a contemporary series of procedures performed by the mentor.

RESULTS

All trainees successfully completed the 12-week MTS program. Median number of training cases to become competent in trans-peritoneal LN and RN was 13.0 (IQR 11.5-20.5) and 23.5 (IQR 19.5-32.0), respectively. A significantly higher rate of conversion to open surgery was observed for RNs independently performed by the trainees in their hospital compared to the mentor (p = 0.033). Failure to progress due to difficult anatomical orientation and abdominal wall bleeding during dissection of retroperitoneal space were the most frequent reasons of conversion.

CONCLUSIONS

A 12-week intensive modular program allows to achieve proficiency in performing independently LN and a RN after a median of 13 and 23.5 cases, respectively. Therefore, these procedures can be safely introduced and implemented in clinical practice within a relatively short time.

The American Society of Maxillofacial Surgery Preceptorship Program: A Product of the 2013 American Society of Maxillofacial Surgery Executive Board Strategy Session and Survey

One of the main goals of the American Society of Maxillofacial Surgery (ASMS) is to develop educational programs that increase expertise in maxillofacial surgery. We describe the outline of the new ASMS Preceptorship Program, a collective effort by ASMS members to increase access to all areas of maxillofacial surgery. Furthermore, we discuss the original survey pertinent to the development of this program, the results of the survey, and specifics regarding the structure of the program. We hope for the preceptorship program to be an excellent resource for members to mentor one another, develop intellectual and academic curiosity, provide avenues for collaboration, and further the ASMS's role in shaping maxillofacial surgery into the future.

Current status and effectiveness of mentorship programmes in urology: a systematic review

The objectives of this review were to identify and evaluate the efficacy of mentorship programmes for minimally invasive procedures in urology and give recommendations on how to improve mentorship. A systematic literature search of the PubMed/Medline databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In all, 21 articles were included in the review and divided into four categories: fellowships, mini-fellowships, mentored skills courses and novel mentorship programmes. Various structures of mentorship programme were identified and in general, mentorship programmes were found to be feasible, having content validity and educational impact. Perioperative data showed equally good outcomes when comparing trainees and specialists. Mentorship programmes are effective and represent one of the best current methods of training in urology. However, participation in such programmes is not widespread. The structure of mentorship programmes is highly variable, with no clearly defined 'best approach' for postgraduate training. This review offers recommendations as to how this 'best approach' can be established.

Description and validation of a modular training system for laparoscopic nephrectomy

BACKGROUND AND PURPOSE

Laparoscopic nephrectomy (LN) has largely replaced open nephrectomy. The aim of this study was to describe a validated modular system for training urologists in LN in the context of the shorter training times available in the current era.

METHODS

After attendance at dry and wet laboratory courses, three mentees (trainee, new consultant, and an experienced open surgeon) were mentored through a five-module LN training system in our center followed by the mentee's own hospital. A minimum of 25 independent procedures were then performed by mentees in their own hospital.

RESULTS

There were 17 to 32 mentored cases needed to become competent in LN, followed by up to 5 observed cases in the mentee's own center. Subsequently, data from the first 105 cases (80 LN and 25 laparoscopic nephroureterectomies [LNU]) performed by the three surgeons after the end of their training without observation by their mentor were retrospectively collected and analyzed. There were three conversions (2.9%). For LN and LNU, respectively: median operative time was 140 minutes (65-390 min) and 180 minutes (90-300 min); median estimated blood loss was 30 mL (0-2000 mL) and 50 mL (0-2000 mL); median postoperative stay was 4 days (2-45 days) and 6 days (3-27 days). Four (3.8%) patients needed a postoperative transfusion. There was no 30-day mortality.

CONCLUSION

Mentees matched the median British Association for Urological Surgeons (BAUS) registry operative time (LN, 120-180 min, LNU, 180-240 min) and had lower conversion rates (2.9% vs 6.4% for BAUS). Mentees matched median BAUS database reported blood loss (LN and LNU <500 mL) and length of stay (LN-4 days, LNU-5 days). This modular training program allows urologists to become independent in LN after a short period of focused training in the training center followed by a short period of mentoring in the mentee's own center.

Complications and failure to rescue after laparoscopic versus open radical nephrectomy

PURPOSE

Since to our knowledge the population level impact of laparoscopy on post-radical nephrectomy morbidity and mortality remains unknown, we compared the rates of postoperative complications and failure to rescue (the fatality rate in patients with a complication) in patients treated with laparoscopic vs open radical nephrectomy.

MATERIALS AND METHODS

Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data we identified patients with kidney cancer who were treated with laparoscopic or open radical nephrectomy from 2000 through 2005. After measuring the frequency of postoperative complications and failure to rescue we fit multivariate logistic regression models to estimate the association of these outcomes with surgical approach, adjusting for patient characteristics, cancer severity and surgery year. We also assessed the relationship between case volume, complications and failure to rescue.

RESULTS

We identified 2,108 (26%) and 5,895 patients (74%) treated with laparoscopic and open radical nephrectomy, respectively. The overall rates of complications and failure to rescue were 36.9% and 5.3%, respectively. The predicted probability of any, major, medical and surgical complications was 15%, 12%, 13% and 23% lower, respectively, after laparoscopic than after open radical nephrectomy (each p <0.05). Despite less frequent complications patients treated with laparoscopic radical nephrectomy had a greater probability of failure to rescue (7.6% vs 4.6%, p = 0.010). Higher volume surgeons and hospitals had a lower rate of failure to rescue in patients treated with radical nephrectomy (each p <0.05) but not with open radical nephrectomy.

CONCLUSIONS

Supporting the decreased morbidity of laparoscopy, patients treated with radical nephrectomy had fewer complications than those who underwent open radical nephrectomy. However, failure to rescue was more common in patients with a complication after radical nephrectomy, suggesting that these events may be more difficult to recognize and manage successfully, especially among less experienced surgeons and hospitals.

Population-level comparative effectiveness of laparoscopic versus open radical nephrectomy for patients with kidney cancer

BACKGROUND

Because there is limited population-based evidence supporting the comparative effectiveness of laparoscopic radical nephrectomy (LRN) after its widespread adoption, we compared trends in hospital-based outcomes among patients with kidney cancer treated with LRN or open radical nephrectomy (ORN).

METHODS

Using linked SEER-Medicare data, the authors identified patients with kidney cancer who were treated with LRN or ORN from 2000 through 2005. The authors measured 4 primary outcomes: intensive care unit (ICU) admission, prolonged length of stay, 30-day hospital readmission, and in-hospital mortality. The authors then estimated the association between surgical approach and each outcome, adjusting for patient demographics, tumor characteristics, and year of surgery.

RESULTS

The authors identified 2108 (26%) and 5895 (74%) patients treated with LRN and ORN, respectively. Patients treated with LRN were more likely to be white, female, of higher socioeconomic position, and to have tumor sizes of ≤4 cm (all P < .05). The adjusted probability of ICU admission and prolonged length of stay was 41% and 46% lower, respectively, for patients undergoing LRN (P < .001). Although uncommon for both groups, the adjusted probability of in-hospital mortality was 51% higher (2.3% vs 1.5%, P = .04) for patients treated with a laparoscopic approach.

CONCLUSIONS

At a population level, patients treated with LRN have a lower likelihood of ICU admission and prolonged length of stay, supporting the convalescence benefits of laparoscopy. In-hospital mortality, however, was higher among patients treated with LRN. The latter finding suggests a potentially unanticipated consequence of this technique and highlights the need for long-term monitoring during and after the widespread adoption of new surgical technologies.