Laparoscopic Urological Surgery Training Program

With the promulgation of the guidelines on laparoscopic urology by the Southern African Endourology Society (SAES) , some urologists might aspire to enhance their skills in laparoscopic urology under guidance of a trainer in a structured program as set out in these guidelines. With this in mind, a laparoscopic training program was thereby founded with the purpose of supporting urologists who would like to join such a training program on a voluntary basis.

The basic principal of adequate training prior to performing any laparoscopic procedure should always be maintained and should be conducted according to strict adherence of these guidelines. These guidelines should protect the patient, medical aid and urologists against the wrong application and ill consequences of laparoscopic surgery.

The Laparoscopic Urology (LU) Training Program proposed by these guidelines is designed to adhere to the principles of the HPCSA. It also provides an opportunity to all urologists to enhance their skills in Laparoscopic Urological Surgery.

Eligibility of a surgeon in performing basic laparoscopic abdominal procedures

The urologists or urology registrars who wishes to perform laparoscopic procedures should, in general, be experienced in operating in the abdominal cavity. They should be familiar with anatomy, tissue tolerance, organ compliance and pathological processes of the diseases. They should also be familiar and proficient in performing open abdominal procedures. They should be prepared and competent in conversion to open procedures, and have a continuous update on the recent developments in the respective laparoscopic surgeries.

 

Entrance requirement

 

A. Trainer/Mentor

1. Registered Urologist with the HPCSA
2. Relevant experience in laparoscopic procedures with a special interest in laparoscopic urology with the required amount (a total of more than 700 cases) of laparoscopic surgery performed. He/She must provide a log book of their clinical experience and must have completed the minimum required of each type of operations to be eligibil.
3. Trainer/Mentor must be a member of the Endourological Society

 

B. Trainee

1. Registrar or private practice urologists registered as such with the HPCSA
2. Limited exposure in basic laparoscopic procedures
3. Trainee must be a member of the Endourological Society

The aim with the guidelines will be to provide a measurable endpoint when the training is completed as well as the methodology of the training process itself. The endpoint can be explained as when the trainee reach a point in his/her learning curve were all the laparoscopic urological procedures can be performed without the trainer with a similar clinical outcome in a cost effective manner. 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 operation type. Each operation will 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. Download the complete logbook templates here.

There are four new skill sets that a laparoscopic surgeon should learn in order to become proficient at laparoscopic urological surgery. New knowledge, fine motor skill and co-ordination, the ability to recognize laparoscopic anatomy and lastly the confidence and experience to apply this in practice. These form the four components of laparoscopic skill training to a sufficiency level that has optimal clinical outcome and minimal complications.

 

The four components of this laparoscopic training course are:

 

1. Knowledge

The acquisition of knowledge is achieved by the combination of theory and hands-on workshops with or without animal lab sessions. This forms the foundation of acquiring knowledge to move forward. The practical sessions can be done at any skills lab of the candidate’s choice but must include the following:

1. Patient selection
2. Pre-operative planning/preparation
3. Operating room set-up 
4. Instrumentation and equipment
5. Surgical technique
6. Tips and tricks

Recommended reading material must have comprehensive information on all aspects in laparoscopic surgery. Download the “Recommended Reading Material” here. It is expected that the trainee do this as self-study in order to gain sufficient knowledge on all the following topics:

1. Laparoscopic anatomy
2. Physiologic aspects of laparoscopy
3. Financial aspects of urologic laparoscopy
4. Laparoscopic surgery and the community urologist
5. Laparoscopic surgery and medicolegal aspects
6. Laparoscopic equipment, instrumentation and audiovisual equipment
7. Laparoscopic suturing
8. Laproscopic procedures
   • Laparoscopic adrenalectomy
   • Laparoscopic simple nephrectomy
   • Laparoscopic nephropexy
   • Laparoscopic renal cyst ablation
   • Laparoscopic surgery for calculous disease
   • Laparoscopic pyeloplasty
   • Laparoscopic ureteral surgery
   • Laparoscopic management of vesicovaginal fistula
   • Laparoscopic varicocelectomy
   • Laparoscopic inguinal hernia
   • Laparoscopic radical nephrectomy
   • Laparoscopic partial nephrectomy
   • Laparoscopic radical nephroureterectomy
   • Laparoscopic radical cystectomy
   • Laparoscopic radical prostatectomy
9. Laparoscopy in the child
10. Vascular and GIT complications

Refer to the section on “Recommended Reading Material” for a list of books and journals that can be used.

 

2. Tactus eruditus or dexterity training

Tactus eruditus refers to the sensitivity of touch acquired by long practice. This can be accomplished by either dry box trainers or simulators. It is recommended that the trainee spend at least 60 hours on a dry lab for proficient dexterity. Different exercises and suturing techniques will be discussed and demonstrated by the trainer. Most of these have been discussed at the initial hands-on workshop and the trainee has the opportunity now to practice it till he/she can perform it perfectly every time. It is mandatory that all urologist complete this step before starting performing any surgery on patients in either a training or private practice setting.

 

3. Laparoscopic anatomy recognition

A combination of videos of each surgical procedure is available for the urologist in training or in private practice to refer to when preparing for surgery or while in training. It is often a over looked part of the proficiency training, however it takes much longer for a novice laparoscopic surgeon to understand the anatomy than it is to become dexterous enough to perform a specific procedure.  This in conjunction with live surgical cases will help orientate and make the trainee familiar with the laparoscopic anatomical landmarks. There are a complete list of all the LU operations available on the SAES website. This is a collection of edited video clips with commentary for teaching and instructional purposes. Download and watch each video in the video library here.

 

4. Mentorship

This is the key component of any training process. Like any other training in medicine and especially in surgery, the student can never start working alone without an initial mentor. Mentorship allows for the application of the surgeons knowledge, skill and instruments in a safe and controlled environment. It bridges the gap of inexperience with minimal complications and patient morbidity. It adheres to strict ethical principles by which all doctors should conduct themselves.

A mentorship program will safely improve and shorten the learning curve of any urologist starting with laparoscopic surgery. The advantages of working with a mentor in the initial period of inexperience are well documented. Working from easier too more complex scenarios has significant benefits and form the basis of the mentorship program.

In 1989, Reddick and Olsen reported that CBD injury after laparoscopic cholecystectomy is 5 times that with conventional cholecystectomy. As a result of this report the USA government announced that surgeons should do at least 15 laparoscopic cholecystectomy procedures under supervision before being allowed to perform this procedure on their own. With this in mind, similar parallel figures can be suggested as the safe norm for urological surgeons embarking on laparoscopy in urology.  The degree of difficulty and the corresponding number of operations a urologist must perform to become competent or proficient for that specific operation or groups of operations can be extrapolated from similar data and are divided into 4 groups for ease of reference.

 

These groups are:

1. Degrees of difficulty of kidney organ ablative procedures
2. Degrees of difficulty of kidney reconstructive procedures
3. Degrees of difficulty of pelvic organ ablative procedures
4. Degrees of difficulty of pelvic reconstructive procedures

 

Table 1. Degrees of difficulty of kidney organ ablative procedures

	Subgroup	Number of operations for proficiency	Degree of difficulty 1-10
1. Simple nephrectomy	Non-infective Infective	5 10	7 9
2. Radical nephrectomy	T1 T2 T3 T4	10	6 6 7 8
3. Partial nephrectomy		20	10
4. Adrenalectomy		20	8
5. Nephroureterectomy		15 - 20	8
6. Renal cyst ablation	Cortical Parapelvic	6	4 5
Any BM index above 35			Add 2

 

 

Table 2. Degrees of difficulty of kidney reconstructive procedures

	Subgroup	Number of operations for proficiency	Degree of difficulty 1-10
1. Nephropexy		5	5
2. Ureterolithotomy/ureter stricture		10	6
3. Pyelolithotomy	Single Staghorn	10 20	7 9
4. Pyeloplasty		20	8-9
Any BM index above 35			Add 2

 

 

Table 3. Degrees of difficulty of pelvic organ ablative procedures

	Subgroup	Number of operations for proficiency	Degree of difficulty 1-10
1. Bladder diverticulectomy		10-12	8
2. Radical cystectomy	Male Female	10-12 8	8 7
3. Partial cystectomy		5	4
4. Pelvic LND		10	6
5. Radical prostatectomy		20	8-10
6. Orchidectomy UDT/varicocele		4	2
Any BM index above 35			Add 2

 

 

Table 4. Degrees of difficulty of pelvic reconstructive procedures

	Subgroup	Number of operations for proficiency	Degree of difficulty 1-10
1. VVF repair		15-20	8
2. Orchidopexy		8	3
3. Inguinal hernia repair		10	5
4. Bladder stone removal		6	3
5. VUR repair		15-20	8
6. Sacrocolposuspension		20	10
7. Ureteroneocystostomy or Boari flap		20	8-10
Any BM index above 35			Add 2

 

 

The advantages of the mentorship program starting with easier procedures and gradually working up to more complex scenarios have significant benefits and form the basis of the mentorship program. These benefits include:

1. Eliminates fatigue
2. Eliminates non-progression
3. Minimizes patient morbidity
4. Produces a faster learning curve

 

Role of Trainer or Mentor

1. To assess and verify the knowledge and skills of the surgeon learner using valid and reliable methods.
2. Assist with Medical Aid authorization.
3. Advise on the most cost effective service.
4. Strategize the choice of equipment in order to have the optimal outcome in the most cost efective way for the patient, Hospital and Medical Aid.
5. Trainee is necessary to be monitored by the trainer in the operating sessions during the entire surgery.
6. The trainer would act in the best interest of the patient and has the right to stop or intervene at any time deemed necessary during the training session.
7. The decision to case selection of the laparoscopic procedure should be jointly discussed between trainee and trainer.

 

Continuous Monitoring and Quality Control

Surgeons practicing laparoscopic procedures are recommended to participate in continuous educational activities including training courses - local or international meetings on minimal access surgery. This serves to update surgeons with the latest advances in technology and to improve their skills in performing such procedures.

For the succes and sustainability of LU in general in any envirnment, strict quality control measures has to be adhered to. Both the trainer and trainee are compelled to strive for a optimal clinical outcome, adhering to the highset ethical principles therefore avoiding any legal litigation. The pressure for a optimal clinical outcome comes from many parties involved:

1. Patient
2. Medical Aid or Medical Insurer
3. Hospital Service Provider
4. Trainee Urologists
5. Trainer Urologist
6. HPCSA
7. Refering physician

Of all these the patient deserves top priority and nothing less than the best clinical outcome should be norm. There are also considerable pressure from the Medical Aid and Insurers with a tremendous responsibility on the trainee as well as the trainer to make sure that the outcome is not only a clinical succes but it should also be achieved in the most cost effective manner. The 3 most important reasons for prohibitively high cost of an laparoscopic procedure are:

1. Long operating times
2. Complications warrenting long ICU stay
3. Poor choice of equipment

The responsibility lies with the trainer to overcome these factors by implimenting strict goals and endpoints for each operation. To curb unnesessary long operating times resulting in prohibitively expensive costs, limitations on time has to be implemented to insure optimal clinical outcome but also allowing for sufficient training of the trainee. Service delivery and cilincal outcome always takes priority. In this regards the trainer can take over an operation at any stage deemed overly protracted or complicated as well as make suggestions as to which equipment will be most appropriate for the particular clinical situation. A guide on the anticipated duration of each operation can be difficult to pridict, however to view the suggested operating times that should be aimed for, download the OR times here. The operating times listed are active surgical or cutting time and does not include anaesthetic and patient preparation time. Generally an extra 30 minutes can be added to get the overall theatre time. 

 

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