Guidelines to Laparoscopic Urological Surgery
Laparoscopic urological surgery have been popularized over the past decade in SA to such an extent that the need for minimally invasive treatment options are more and more often requested than conventional open surgery. This places tremendous pressure on the urologist who has not received the necessary training in laparoscopy. The aim with these guidelines is to provide insight to the prospective urologist who wants to embark on laparoscopic urological surgery training as well as those who want to provide this service in his/her practice. These guidelines are intended to protect the patient, medical aid and urologists against the wrong application and ill consequences of laparoscopic surgery. It therefore benefits not only the urologist, but also the Medical Aid in facilitating authorization for laparoscopic procedures. In addition, both urologist who completed their laparoscopic training as well as urologist who want to enroll for formal training in laparoscopy will find this document helpful in fast tracking their goal. The need for laparoscopic services in private practice today can be broadly classified into 3 groups:
- Urologist that has received training in laparoscopic urology and can provide the service.
- Can perform only the basic laparoscopic procedures
- Can perform both basic and advanced laparoscopic procedures.
- Urologist that has not received training in laparoscopic urology but wants to enter into a formal training program.
- Urologist that has not received training in laparoscopic urology but don’t want to enter into a formal training program and who wants to provide this service in their private practice through an itinerant laparoscopic urological surgeon.
Determination of Competence
The competence of a urologists to perform basic or advanced laparoscopic procedures will depend on individual’s training and experience. Three types of laparoscopic urological surgeons can be identified depending on their level of training and overall experience. The learning curve of laparoscopic surgery is much steeper than open surgery and during the initial phase of the learning curve, not all procedures can be done with equal confidence.
The interest and exposure to laparoscopy will ultimately determine how quick one will go through the learning curve and to what level of expertize a urologist will aspire to. These levels are:
Level 1 – Basic laparoscopic urology for urologist in private pratice. This is the LU surgeon who has done prodominantly the basic laproscopic procedures with a mentor and has completed the prescribed number of procedures in his/her logbook to become proficient in the basic LU procedures. It is recommended that a urologist who completed only the basic laparoscopic urological training be focusing on the list of basic laparoscopic procedures as listed below:
|1.||Renal cyst ablation||basic|
|6.||Orchidectomy for intra abdominal testis||basic|
|7.||Pelvic lymph node dissection||basic|
|Inguinal hernia repair||basic|
Level 2 – Advanced laparoscopic urology for the dedicated laparoscopic urologist. This is the LU surgeon who has done extensive training with a mentor in all the laparoscic urological procedures or who has completed a formal Fellowship. During this traing he/she should have completed the prescribed number of procedures in his/her logbook to become proficient in both the basic as well as the advanced LU procedures.
Level 3 – Expert laparoscopic urologist. This is the LU surgeon who has done all the prescribed training, but more importantly has vast experience in LU surgery and his/her total experience in their log book far exeeds 700 LU cases as a absolute minumum. He/she may act as a mentor or a proctor for more inexperienced surgeons.
Those urologist that want to provide a laparoscopic urological surgery service to his/her patients, but does not have official training can easily achieve this by either entering into a formal lapaproscopic urological training program or contact a competent laparoscopic urologist is his/her area to perform the surgery on their behalf. Read more on this topic under the section titled “Laparoscopic Urological Surgery Training Program.”
Proficiency training may be obtained in various manners but in short one should have accumulated the knowledge and be able to apply it in a safe and cost effective environment. The endpoint of this proficiency can be explained by which time the urologist reach a point in his/her learning curve were all the laparoscopic urological procedures can be performed without the trainer or mentor with the similar clinical outcome in a cost effective manner. In a training program this endpoint is dependent on the level of skill of the trainee, objective assessment by the trainer as well as reaching the minimum required procedures for each type of operation. Each operation can be graded on the degree of difficulty (1-10) which will correspond to the number of times the particular operation needs to be performed in order to become clinical proficient Read more on this topic under the section titled “Laparoscopic Urological Surgery Training Program”.
The log book supplied in this document is designed to provide a standardized manner of keeping records of all the procedures you have observed, assisted or performed. From this logbook, one can easy achieve the minimum amount of each procedure type of the LU operations. It also indicates what degree of difficulty is associated with each operation. This degree of difficulty range from 1 to 10, where 1 represents the easiest and 10 represents the most complicated type of operation. All the LU operations are summarized in 3 different templates for quick reference and make provision to indicate weather the urologist observed, assisted or performed the procedure. Once all the blocks in the corrisponding column for that specific operation is ticked, the surgeon is proficient for that specific operation and so on. These 3 template are:
- Steps of ablative/reconstructive surgery kidney
- Steps of ablative surgery pelvis
- Steps of reconstructive surgery pelvis
As can be seen from the logbook templates, not all the laparoscopic procedures are equally difficult. The degree of difficulty range from 2 to 10 out of a score from 10. A score of 2/10 being the easiest and 10/10 being the most complicated. Similarly it can be extrapolated that an operation with a difficulty score of 2 requires a much shorter learning curve as opposed to operations with a difficulty score of 10. The total amount of operations required to reach your proficiency level has also been linked to the degree of difficulty and gives an indication of how many operations each surgeon must perform of each type of operation to become proficient in that operation.
However, to reach the minumum number of operations required to become proficient in a particular type of operation takes much quicker than first anticipated, because most of the procedures have steps that overlap. According to the log book design, the trainee score points for performing part of an operation as opposed performing the whole operation. In this way the trainee can score points on various operation types at the same time by performing a step that overlaps with other similar techniques. From the data that was analyzed from 30 urologists whom I mentored, on average each urologist in private practice sees between 25-30 laparoscopic cases per year which allows for ample opportunity to complete the log book in the prescribed time, especially for the basic LU procedures.
The log book template can be devited into 3 sections depending on whether the urologists have observed, assisted or performed a case. One would start by observing a few cases either video or live surgery. Once you undersatnd the anatomy the urolgist can move onto assisting and finally after adequate dexterity traing has been achieve, the urologist can start operating under the guidance of a mentor.
The gradual introduction training method would consist of the following:
a) Video session
- Edited operation videos for teaching and instructional purposes will be available on the Society’s website for self-learning.
- These videos consist of 12 types of basic laparoscopic surgeries as well as 14 types of advanced laparoscopic surgeries.
b) Observation session
- The trainee is required to only observe the surgery performed by the trainer.
c) Mentor guided sessions with trainee as assistant (5-10 sessions in this category, but the number of sessions will be determined by the complexity of the procedure)
- Trainee learns the procedures through acting as an assistant. Trainee is required to provide cases for the training during this process.
d) Trainee operating sessions with mentor as assistant (number of sessions will be determined by the complexity of the procedure)
- Trainee is able to operate in the surgery under the guidance of mentor. Trainee is required to provide cases for training during this process.