The role of the adult urologist in the care of children: findings of a UK survey.

OBJECTIVE: To document the current role of adult urologists in the care of children in the UK and to consider the future provision of urological services for children within the context of published national guidelines. METHODS: A detailed postal questionnaire was sent to all 416 consultant urologists listed as full members of the British Association of Urological Surgeons and resident in the UK. The range of information sought from each urologist included details of personal paediatric training, scope of personal practice, and information about facilities and provision of urological services for children in their base National Health Service hospital. RESULTS: The response rate was 69%; most consultant urologists (87%) in District General Hospitals (DGHs) undertake paediatric urology, mainly routine procedures of minor or intermediate complexity. Of urologists in teaching hospitals, 32% treat children but their involvement is largely collaborative. Consultants appointed within the last 10 years are less willing to undertake procedures such as ureteric reimplantation or pyeloplasty than those in post for > or = 10 years. Currently, 18% of DGH urologists hold dedicated children's outpatient clinics and 34% have dedicated paediatric day-case operating lists. Almost all urologists practise in National Health Service hospitals which meet existing national guidelines on the provision of inpatient surgical care for children. CONCLUSION: Urologists practising in DGHs will retain an important role as providers of routine urological services for children. However, the tendency for recently appointed consultants to limit their practice to the more routine aspects of children's urology is likely to increase. Training and intercollegiate assessment should focus on the practical management of the conditions most commonly encountered in DGH practice. The implementation of national guidelines may require greater paediatric subspecialization at DGH level to ensure that urologists treating children have a paediatric workload of sufficient volume to maintain a high degree of surgical competence.     

Telesurgery. Remote monitoring and assistance during laparoscopy

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.     

Survey of urological laparoscopic practices in the state of California

PURPOSE: In the interest of maintaining our surgical domain we performed a survey aimed at establishing laparoscopic practice patterns as they pertain to urological disease. MATERIALS AND METHODS: Surveys were mailed to 2,902 surgeons in California who were listed with the American College of Surgeons, including 2,175 general surgeons, 510 urologists and 217 obstetricians-gynecologists. RESULTS: A total of 442 complete responses (15.2%) were tallied. Of urologists and of nonurologists 54% and 11% performed no laparoscopy, while 12% and 80%, respectively, devoted at least 5% of their time to laparoscopic surgery. Urologists and nonurologists performing no laparoscopy were older than those performing a significant volume (p < 0.05). Of urologists 16% thought that they were trained adequately during residency to perform laparoscopic surgery compared with 30% of nonurologists. Of the urologists who performed hand assisted laparoscopy, 50% tended to use it as a means of gaining familiarity with these techniques. These urologists performed more laparoscopic surgery than other urologists. While 80% of laparoscopy cases were community based, academic urologists are actively interested in laparoscopic surgery. The 2 most important reasons cited for performing laparoscopy were more rapid recovery and decreased morbidity. The leading laparoscopic procedures according to incidence for urologists performing laparoscopic surgery were diagnostic procedures (12.9%), varicocelectomy (12.1%), adrenalectomy (9.7%), pelvic lymphadenectomy (8.9%), and simple nephrectomy and renal cyst decortication (8.1% each). The leading laparoscopic cases according to the number of available cases per urologist were colposuspension-bladder neck suspension (1.06), donor nephrectomy (0.77), pelvic lymphadenectomy (0.52), varicocelectomy (0.48) and orchiopexy (0.45). Urologists performed more urological laparoscopy cases than nonurologists. CONCLUSIONS: Urological laparoscopic practice in California remains in its infancy. It is imperative that exposure should be increased in residency training programs.     

Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre

BACKGROUND: The National Institute for Clinical Excellence (NICE) guidelines of 2002 recommended the use of ultrasound (US) for central venous catheterization in order to minimize complications associated with central line placement. An ongoing audit of line placement by anaesthetists in the theatre complex of a tertiary referral centre looked at the associated complication rates. The objective of the study was to compare complication rates pre- and post-implementation of NICE guidelines. METHODS: This prospective, single centre audit looked at all patients in whom a central venous catheter was placed for surgery. Complication rates were assessed for procedures that were performed pre- and post-implementation of NICE guidelines. In total, 438 patients were identified for the study, and the procedures were performed either by trainee or by consultant anaesthetists. RESULTS: The pre- and post-implementation complication rates were 10.5% (16/152) and 4.6% (13/284), respectively, representing an absolute risk reduction of 5.9% (95% CI 0.5-11.3%). Comparison of those procedures in which US was used when compared with the landmark technique after implementation found a reduction of 6.9% in complications (95% CI 1.4-12.4%). The reduction in complication rates was larger for specialist registrars than for consultants (11.2% vs 1.6%). CONCLUSIONS: The implementation of NICE guidelines has been associated with a significant reduction in complication rates in our tertiary referral centre. In the light of the cross-speciality evidence of US superiority and our results, it is imperative that routine use of US guidance becomes more widespread.     

Short-term impact of a laparoscopic "mini-residency" experience on postgraduate urologists' practice patterns

BACKGROUND: To assist practicing urologists incorporate laparoscopic urology into their practice, a 5-day mini-residency (M-R) program with a mentor, preceptor, and proctor experience was established at the University of California, Irvine, and we report the initial results. STUDY DESIGN: Thirty-two urologists underwent laparoscopic ablative (n=17) or laparoscopic reconstructive (n=15) training, including inanimate model skills training, animal laboratory, and operating room observation. A questionnaire was mailed 1 to 15 months (mean, 8 months) after their M-R program, and responses were reviewed. RESULTS: A 100% response rate was achieved. The mean M-R participant age was 49 years (range 31 to 70 years). The majority of the participants (72%) had laparoscopic experience during residency training and had performed between 5 and 15 laparoscopic cases before attending the M-R program. Within 8 months after M-R, 26 participants (81%) were practicing laparoscopic surgery. Participants were performing laparoscopic radical nephrectomy (p=0.008), nephroureterectomy (p<0.0005), and pyeloplasty (p=0.008) at substantially higher rates after training. At the same time, fewer of the M-R participants were performing hand-assisted laparoscopic surgery after training (p=0.008) compared with before the M-R. Ninety-two percent of the participants indicated that they would recommend this training program to a colleague. CONCLUSIONS: A 5-day intensive laparoscopic ablative and reconstructive surgery course seems to encourage postgraduate urologists, already familiar with laparoscopy, to successfully expand the scope of their procedures to include more complex laparoscopic techniques such as nephrectomy, nephroureterectomy, and pyeloplasty into their clinical practice.     

A survey of inguinal hernia repair in Wales with special emphasis on laparoscopic repair

Background The National Institute of Clinical Excellence (NICE) recently published its guidance on the use of laparoscopic repair for inguinal hernias. This study aimed to assess the likely uptake of laparoscopic surgery for inguinal hernias in Wales. In addition the current practice with regards to day case surgery, use of local anaesthesia, antibiotic prophylaxis, thromboembolic prophylaxis and advice regarding convalescence was assessed. Methods A postal questionnaire survey of all consultant surgeons (n = 91) in Wales was performed. Results There was a 70% (n = 67) response to the questionnaire. Fifteen percent of surgeons (n = 9) perform laparoscopic inguinal hernia repair in Wales; 10% of surgeons in Wales agreed with the NICE guidance. Lichtenstein hernia repair was the most commonly used the technique to repair primary inguinal hernias in Wales (82%). No surgeon currently is using a laparoscopic repair as the technique of choice for repair of primary inguinal hernias. Eighteen percent of surgeons perform all the procedures as day cases; 15% of surgeons perform more than 90% of the procedures under local anaesthesia; 44% of surgeons do not use any form of thromboprophylaxis for elective inguinal hernia repair, while 78% of the surgeons used routine antibiotic prophylaxis. Post-operative advice regarding return to sedentary work and driving was highly variable (1–4 weeks), as was advice regarding heavy work and sport (2–12 weeks). Conclusions The uptake of laparoscopic surgery for inguinal hernia repair in Wales is low. Only a minority of surgeons agree with the NICE guidance. Similarly the uptake of day case repair and the use of local anaesthesia are minimal. The use of antibiotic and thromboembolic prophylaxis is empirical and inconsistent. There is a need for evidence-based guidelines to standardise the antibiotic prophylaxis, TE prophylaxis and advice regarding post-operative advice. Presented at the Association of Surgeons of Great Britain and Ireland, Edinburgh 2006.     

Training postgraduate urologists in laparoscopic surgery: the current challenge

PURPOSE: We established a new mini-fellowship training model for teaching laparoscopic urological surgery to practicing urologists that provides a learning experience beyond that of a pelvic trainer or hands-on, animal laboratory based laparoscopic course. It provides the practitioner with clinical experience under mentor direct guidance and supervision before embarking on independent laparoscopic surgery at an individual hospital. MATERIALS AND METHODS: A mini-fellowship model was developed that consists of 3 phases, namely 1) completing a 2 to 3-day hands-on course in laparoscopy, including pelvic trainers and an animal model, 2) observing a clinical mentor perform 6 or more major renal laparoscopic cases and 3) performing 6 or more major renal procedures under mentor direct guidance in trainee patients at the mentor or trainee hospital after obtaining appropriate temporary privileges. RESULTS: Two community urologists underwent the mini-fellowship program in 2000. Trainee 1 performed 30 laparoscopic procedures, including 17 radical nephrectomies, 4 simple nephrectomies, 4 nephroureterectomies, 4 renal cyst ablations and 1 renal biopsy, within the first 8 months after training and hospital accreditation. Trainee 2 performed 10 laparoscopic procedures within the first 3 months after training and hospital accreditation. CONCLUSIONS: This mini-fellowship model provides practicing urologists with a clinically applicable teaching experience to learn a new surgical concept using a familiar training pattern. It may be a more rapid and safe process of disseminating laparoscopic urological surgery to community urologists. Based on this model it would be possible for centers of excellence in each state to establish similar training programs for the corresponding urological community, thereby, bringing the teaching of new surgical skills to a more clinically relevant level.     

Laparoscopic urology training in South Africa

BACKGROUND AND PURPOSE: Laparoscopic urologic surgery is not widely practiced in South Africa. After presenting a laparoscopic training course, we evaluated how effectively this training translated into clinical practice. SUBJECTS AND METHODS: Invitations to the course were sent to all South African urologists. Ten applicants attended the course, which consisted of dry and in-vivo animal surgery. Two questionnaires were sent out after the course. Questionnaire 1 (at course completion) aimed at identifying the precourse laparoscopic experience and expectations of the trainee. Questionnaire 2 (6 months postcourse) assessed how much laparoscopic surgery the participant had performed since the course. RESULTS: Seventeen percent of all South African urologists responded to the invitation. Prior to the course, 40% of trainees had performed >or=10 laparoscopic cases, 30% had performed <10 cases, and 30% had never performed laparoscopy, whereas 60% expected to be doing one or two cases a month after completing the course. Six months after the course, 60% had performed no laparoscopic cases. Of the three trainees who had never before done laparoscopic procedures, none had started to perform procedures since the course. The commonest procedures performed were varicocelectomy and diagnostic laparoscopy for nonpalpable testis. CONCLUSIONS: A hands-on laparoscopic training course to introduce laparoscopic urology into South African private urology practice has not translated into a satisfactory number of clinical cases being performed. The causes are likely multifactorial but are greatly influenced by social and economic forces. One possible solution may be to offer a mentor-based training program.     

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

OBJECTIVE: To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. METHODS: The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. RESULTS: Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. CONCLUSION: Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.     

Current trends in urologic laparoscopic surgery

PURPOSE: We examined the status of laparoscopy in urology and the impact of residency and fellowship training on the performance of laparoscopy as primary surgeon. We also examined whether performing nonsurgical tasks requiring two-handed dexterity had any link to the adoption of laparoscopic techniques by urologists. MATERIALS AND METHODS: A total of 8760 laparoscopy questionnaires containing 135 queries were mailed to urologists listed on the American Urological Association practicing urologists mailing list. The questions sought information on area of practice, time in practice, fellowship training, ambidexterity, laparoscopic experience, and experience with robotics. The response rate was 1.8% (155 of 8760). RESULTS: There appeared to be no significant correlation between the performance of laparoscopic surgery and participation in activities requiring bimanual dexterity. However, a correlation of strong statistical significance did exist between laparoscopic residency training and performance of laparoscopy after residency (p=0.003. There also was a correlation between fellowship training in laparoscopy/endourology and doing laparoscopy as primary surgeon. CONCLUSIONS: Participation in laparoscopic surgery during residency training is a major determining factor in performance of laparoscopy as a primary surgeon in practice. Younger surgeons trained in laparoscopy during residency are performing more laparoscopy post residency than those without laparoscopic training during residency. At present, there is a need to train more urologists in laparoscopy at the postgraduate level.     

UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management

Study Type – Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision‐making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra‐operative demonstration of and, potentially, storage of sperm.

OBJECTIVES

• ? To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010.
• ? To make recommendations for contemporary practice.

SUBJECTS AND METHODS

• ? Three consecutive questionnaire‐based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010.
• ? Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso‐vasostomy used.
• ? In 2005 additional information was obtained about the availability of fertility treatments and sub‐specialization of the urologist and in 2010 about the eligibility criteria for in‐vitro fertilization (IVF) treatment and synchronous sperm retrieval.

RESULTS

• ? Overall there was a 47% response rate with >80% of respondents still performing vaso‐vasostomy.
• ? More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options.
• ? Only 41% gave their personalized outcomes from vaso‐vasostomy, whilst >80% were using some form of magnification intra‐operatively.
• ? Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso‐vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation.

CONCLUSIONS

• ? Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso‐vasostomy.
• ? Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome.
• ? Vaso‐vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub‐specialist with access to appropriate micro‐surgical training and assisted reproductive technologies.

     

Videotape mentoring and surgical simulation in laparoscopic courses

As laparoscopic approaches to core urologic procedures continue to supplant their open counterparts, the demand to train urologists who received inadequate exposure to these techniques during residency has intensified. The acquisition of laparoscopic skills has been aided greatly by the introduction of hand-assisted laparoscopic surgery (HALS). In another training method, participants completed the standard animate and inanimate course training, then entered a mentoring relationship with their instructor, including an observational period and performance of several complex laparoscopic operations with the assistance of the mentor surgeon. However, the time commitment, compensation issues, and need for temporary operating privileges are obstacles to this approach. A number of studies have demonstrated that laparoscopic skills can be measured on a videotrainer and that ability improves with repetitive performance. Senior urologists with minimal initial knowledge may benefit from laparoscopic skills training videotape analysis and critique. Laparoscopic simulators can improve, not only the psychomotor skills required to perform laparoscopy, but operative performance as well. Ultimately, preoperative images and data may be interfaced with robotic simulation software to allow practice of virtual operations with realistic tissue photo-representation prior to performing them on patients. Improvements in laparoscopic surgical simulation and application of these newly acquired skills to a simulated patient will ultimately eliminate the learning curve on actual patients and provide a useful means of establishing competence.     

A training module for laparoscopic urology.

OBJECTIVES: A fellowship training model in laparoscopic urological surgery has been established for interested urologists to help them proceed from the pelvic trainer/animal laboratory environment to safe clinical practice. The objective of the model is to provide trainees with clinical experience under direct mentor supervision before embarking on independent laparoscopic urological surgery at their own base hospitals. METHODS: The fellowship model incorporates 9 fluid phases: Phase 1 to complete basic and advanced training courses. Phase 2 to practice at home or in the office using pelvic trainers. Phase 3 to proceed to an animal laboratory course. Phase 4 to visit centers of international repute to observe high-volume laparoscopic urology. Phase 5 to observe the mentor perform several major renal laparoscopic cases. Phase 6 to perform several hand-assisted renal procedures under direct mentor guidance at the mentor hospital. Phase 7 to perform several laparoscopic or retroperitoneoscopic renal procedures, or both, under direct mentor guidance at the mentor hospital. Phase 8 to mentor assisted trainees to start laparoscopic surgery at their own hospitals. Phase 9 to practice laparoscopic urology independently. RESULTS: So far, 9 trainees have participated in the fellowship. Six have reached phase 9 with independent practice, 2 others are in phase 8, and 1 is in phase 7. Skills development has been steady, with progressive acquisition of surgical dexterity and spatial orientation. CONCLUSION: This fluid fellowship model provides urologists with clinically applicable teaching experience to learn a relatively new surgical concept safely and effectively, thereby promoting clinical governance. It may be possible for other centers to establish similar fluid "mini" fellowships to help disseminate laparoscopic surgical skills.     

The advantages of hand-assisted laparoscopy

The technical challenges of performing laparoscopic renal surgery require fellowship training and are associated with a steep learning curve. For the established urologist in practice, fellowship training is not a reality. As a result of these obstacles, in the late 1990s, laparoscopic renal surgery was entering the domain of the general surgeons who had a large number of laparoscopic procedures at their disposal to develop laparoscopic skills. Handassisted laparoscopic renal surgery is a hybrid procedure combining the most salient features of open renal surgery and laparoscopic renal surgery. By allowing the surgeons to place their non-dominant hand into the abdominal cavity, palpation and spatial orientation became possible, lessening the learning curve for laparoscopic surgery. Moreover, hand-assisted laparoscopic surgery could be applied to a variety of renal surgeries, extirpative and reconstructive, with results similar to those already achieved by standard laparoscopy. Throughout the past 5 years, hand-assisted laparoscopy has allowed urologists to incorporate laparoscopic renal surgery into their practices to the benefit of their patients and of their specialty. This review article offers a historical review of the development of hand-assisted laparoscopy and describes the procedures commonly performed today using this technique.     

Laparoscopic practice patterns among North American urologists 5 years after formal training

PURPOSE: We assessed urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training. MATERIALS AND METHODS: Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience. RESULTS: Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use included decreasing and/or lack of indications, increased cost, decreased patient interest, higher complication rates, decreased institutional support and increased operative time. Respondents practicing in academic or residency affiliated centers, or those who had completed residency after 1980 were more likely to have performed more procedures than anticipated (p = 0.044) compared to community based colleagues. CONCLUSIONS: Laparoscopic use by urologists trained in the postgraduate setting is decreasing. Few respondents are maintaining the skills acquired during the original training course. Decreased use appears to be multifactorial.     

Questionnaire survey on the theory of antimicrobial prophylaxis in urologic surgery

In order to establish an acceptable guideline for prevention of perioperative infection following urologic surgery, a questionnaire survey on the theory of antimicrobial prophylaxis (AMP) was conducted among urologists in Japan in February 2004. A reply was obtained from 149 urologists working for institutes located all over Japan from Hokkaido to Kyushu areas. Ninety-two percent of the urologists agreed that AMP should be administered 30 min before an incision, and 44% replied that an additional dose of AMP is required in the case of prolonged intervention. Penicillins or the 1st or 2nd generation cephems were used by 89 to 93% of the urologists in operations not including bowel segments, while 78% preferred such AMP agents in the procedures including bowel segments. AMP was terminated within 3 days in 87% for genital operations, in 70 to 76% for laparoscopic operations, in 54 to 65% for other clean or clean-contaminated operations, and in 24% for operations without the bowel segments. Especially, 58% of the urologists continued AMP for more than 5 days after operations with urinary diversion using the intestine. When compared with the previous questionnaire survey by Shinagawa et al, our survey demonstrated that standard consensus of AMP has spread widely among urologists in Japan, although the recommendations published in Europe and United States are still controversial in Japan. Thus, further well-designed clinical trials are required to establish original guidelines in Japan.     

The British Association of Urological Surgeons Section of Endourology audit of laparoscopic nephrectomy

OBJECTIVE: To report the first UK national audit of laparoscopic nephroureterectomy, radical and simple nephrectomy. METHODS: All members of the British Association of Urological Surgeons (BAUS) undertaking laparoscopic nephrectomy were invited to submit prospectively collected data from their centres to a nationally established database, using a standard proforma. The period covered by the audit was 1 July 2001 to 30 June 2002. The indications for surgery, peri- and postoperative data, and some demographic details were collected. RESULTS: Data were received from 25 centres; 13 had undertaken five or fewer cases per year; 263 procedures were reported, including 20 of hand-assisted nephrectomy. Most cases were for nonfunctioning kidneys, or renal cell carcinoma, with transitional cell cancer and stones forming a smaller proportion. The mean (range) operative duration was 173 (89-335) min. The median postoperative stay was 4 days, with a wide range reflecting clinical and other reasons for delayed discharge. Two deaths were reported, giving a mortality of 0.7%. The mean conversion rate was 5.7% and the mean complication rate 16.8%; these rates were no higher in centres undertaking fewer than five cases per year than in the centres with a greater volume. CONCLUSION: Encouragingly, this first UK audit of laparoscopic nephrectomy shows similar results to those published worldwide. The lack of any difference in outcome between smaller and larger centres may be explained by case selection and the use of mentors, as recommended by the BAUS Section of Endourology.     

Radical prostatectomy in Britain and Ireland at the millennium

OBJECTIVE: To report a national questionnaire survey of all consultant urologists, providing a 'snapshot' of attitudes, current practice and referral patterns for radical prostatectomy (RP) in Britain and Ireland at the millennium. METHODS: During 1999/2000 a simple questionnaire about RP was sent to the 487 urologists registered as full BAUS members. From 418 (86%) returns nine were excluded, to leave a study group of 409 urologists. RESULTS: In all, 157 (38%) consultants were undertaking RP, whilst 252 (62%) were not; 29 (18.5%) performed > 20 operations/year, 44 (28%) undertook 11-20, but 84 (53.5%) carried out < or= 10. During the survey period, 741 (51%) RPs were conducted in teaching hospitals and 724 (49%) in district general hospitals. Of the 252 not undertaking RP, 23 (9%) stated they wished to learn the technique. CONCLUSIONS: This questionnaire suggests that the number of urologists undertaking RP in the UK and Ireland has stabilized but confirms that over half perform < or = 10/year; outcome data are now required. Any change towards concentrating cases will have significant consequences for patient distribution and resources.     

Survey of residency training in laparoscopic and robotic surgery

PURPOSE: We determined the current status of residency training in laparoscopic and robotic surgery in the United States and Canada. MATERIALS AND METHODS: A total of 1,188 surveys were sent via the Internet to all 1,056 current urology residents and 132 program directors with an Internet address registered with the American Urological Association. RESULTS: Responses were received from 372 residents (35%) and 56 program directors (42%). Of respondents 47% reported greater than 100 laparoscopic procedures performed yearly by 1 (36%) or more (51%) faculty members. Robotic procedures were performed at 54% of the institutions, mainly consisting of prostatectomy and pyeloplasty. At all institutions laparoscopic radical nephrectomy was performed and those at 69% of the institutions believed that it is the gold standard for renal tumors today. Urologists were involved in 87% of adrenal surgeries and 54% of respondents believed that is the gold standard approach. However, only 35% of respondents had participated in laparoscopic adrenalectomy. Of respondents 36%, 42% and 17% reported that laparoscopic donor nephrectomy was performed by only urologists, only a nonurology transplant team and shared equally, respectively. Of respondents 41% planned on performing laparoscopic donor nephrectomy in the next year. Laparoscopic needle ablation renal surgery was done in 51% of the programs and percutaneous needle ablation was done in 63%. None of the respondents (0%) believed that it is the gold standard but 51% believed that ablative procedures look promising for renal tumors. Of respondents 39% had participated in robotic radical prostatectomy and 53% thought that it looked promising but was not the gold standard. Of respondents 31% believed that they will be performing robotic surgery after residency, 30% were unsure and 29% will not be using the robot. Overall 38% of residents thought that their laparoscopic experience was at least average or acceptable. CONCLUSIONS: A large number of laparoscopic urological procedures are being performed at training institutions with robotic procedures being performed at 54% of respondent facilities. Residents are participating in most cases but only 38% consider their laparoscopic experience to be satisfactory. A need still exists for increased laparoscopic training for residents, which can be accomplished by expanding training facilities and increasing the number of faculty members performing laparoscopic procedures.     

Modular surgical training for endoscopic extraperitoneal radical prostatectomy

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.