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.     

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.     

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.     

New model for training in laparoscopic dismembered ureteropyeloplasty

PURPOSE: To create an animal model for teaching laparoscopic dismembered pyeloplasty in which a realistic anatomic environment and the technical points of the procedure could be duplicated. MATERIALS AND METHODS: Ten pigs underwent general anesthesia, and the ureter was dissected and spatulated. The small intestine near the renal hilum was trimmed to replace the enlarged renal pelvis, and the "ureteropelvic" anastomosis was performed according to the standard operation steps. A double-pigtail stent was placed in the ureter in antegrade fashion. This model was used by trainees during their year of fellowship in advanced laparoscopic urology. A mentor-trainee fellowship program was planned to guarantee the success of the operations and the quality of the anastomoses. The learning curve was analyzed in terms of the time necessary to perform the task. RESULTS: This model reproduced the technical complexity of laparoscopic dismembered pyeloplasty. The total operating time declined from 135 +/- 14.6 minutes (range 121-155 minutes) to 62 +/- 5.2 minutes (range 56-70 minutes) after the trainees had performed 12 pyeloplasties. The time needed for intraoperative antegrade stenting declined from 35 +/- 12 minutes to 8 +/- 2 minutes. Six pyeloplasties could be performed in every pig with adequate substitutes for an enlarged renal pelvis. With this training, all participants were able to perform ureteropelvic anastomosis and intraoperative antegrade stenting skillfully. CONCLUSION: This model not only allows trainees to acquire the skills necessary for laparoscopic dismembered pyeloplasty but also provides more practices with the use of a suitable renal pelvic substitute.     

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.     

Cadaveric versus porcine models in urological laparoscopic training

INTRODUCTION: Laparoscopy performed on anesthetized pigs is an established training model. In this pilot study, we performed laparoscopy on cadavers as a training modality for urologists participating in a laparoscopic seminar. MATERIALS AND METHODS: We compared data from two consecutive laparoscopy seminars performed at our institution. The first included a laparoscopy session performed on pigs. The second was in the same setup, yet laparoscopy was performed on fresh cadavers. We analyzed and compared the trainees' perspectives regarding the 2 modalities using a 5-scale satisfaction questionnaire. RESULTS: Seven trainees attended the cadaveric and 9 the porcine laparoscopy session. The two groups were similar in terms of age and previous laparoscopic and urological experience. The general satisfaction of the two training modalities was high in the two groups, as well as their will for another session of the same kind. Yet the trainees ranked their understanding of the surgical anatomy, laparoscopic technique and use of instruments significantly higher in the cadaveric laparoscopy group (p values were 0.007, 0.006 and 0.032, respectively). CONCLUSIONS: Cadaveric laparoscopy may offer an ideal surgical environment allowing dissection and performance of complete procedures. In this pilot study, we conducted the first reported cadaveric laparoscopy training seminar in urology. The trainees preferred the cadaveric laparoscopy and found it superior to porcine laparoscopy. We believe that cadaveric laparoscopy is an important training tool, which may be added to the armamentarium of urological laparoscopy training courses.     

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.     

腹腔镜保留肾单位术三级培训模式初探

目的 介绍腹腔镜保留肾单位术的三级培训模式.方法 三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作.以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式.临床实践操作又细分为三步进行,包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS. 结果 4名学员均成功完成全部三级培训内容.其中体外模拟培训累计时间平均为70 h.经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能.4名学员均完成动物模型LNSS 20例,其中半肾切除术6例.肾上极或下极平均手术时间由最初的(120.0±10.9)min降低到在完成12台LNSS时的(69.0±5.2)min,差异有统计学意义(P<0.01).学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7～9例后,各自成功地完成LNSS手术3例,均未出现术中并发症.LNSS平均手术时间为87 rain,肾脏热缺血时间平均为25 min.结论 "三级培训模式"能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术,显著地降低手术并发症的发生,提高手术疗效,有利于腹腔镜手术的推广应用.     

Transfer of skills from the experimental model to the patients

Laparoscopy is a major part of urologists’ daily practice. It is becoming more and more popular and interest in it is increasing, as is the number of urologists attracted by it. Patients also frequently demand a treatment through a laparoscopic approach. Nevertheless, laparoscopy is a physically and technically demanding surgery. It has been proven that it has a long learning curve with a high complication rate at the beginning. Thus, there is need for a training program that can effectively reduce its time of apprenticeship. The learning path is a multistep process that involves several phases. The pelvic trainer is the first step of this path that is made with increasing dif.culty. Gradually and gently the trainee faces up to different levels under the guidance of a mentor. At the end of training, trainees should be able to perform every procedure, both easy and dif.cult ones, by themselves.     

Hand assisted laparoscopic training for postgraduate urologists: the role of mentoring

PURPOSE: Hand assisted laparoscopy (HAL) has recently been accepted as a safe alternative for nephrectomy. HAL courses have been offered at several institutions to train novice laparoscopic surgeons in this minimally invasive surgical procedure. Mentoring by a course instructor or an experienced laparoscopist provides assistance to surgeons with their initial operation. However, to our knowledge the impact of mentoring on the clinical practice of HAL is not known. Therefore, we evaluated the clinical practice patterns of urologists following a postgraduate HAL course, comparing course graduates who underwent subsequent mentoring with those who were not mentored. MATERIALS AND METHODS: A total of 71 urologists attended a postgraduate training course in HAL at our institution between March 2002 and October 2002. Graduates were given the opportunity for one of the instructors to travel to their home institution and mentor them during their initial case(s). Followup surveys were mailed to the graduates in March 2003 to evaluate their practice patterns. Responses from returned surveys were entered into a dedicated database and data analysis was performed. RESULTS: Of the 71 surveys mailed 56 were returned (79%). The majority of respondents (91%) described themselves as community based general urologists. Respondents were categorized into 1 of 2 groups, namely group 1-those who had mentoring by a course instructor (23.2%) or another experienced laparoscopist (30.4%) and group 2-those who were not mentored (46.4%). The majority of group 1 respondents (93%) reported that they were still performing laparoscopic procedures at 6 months of followup. However, only 44% of the surgeons in group 2 were performing laparoscopy at 6 months. The majority of surgeons in group 1 (72%) reported that their laparoscopic experience had been sufficient to maintain their expertise compared to only 42% in group 2. CONCLUSIONS: Mentoring provides a useful adjunct to postgraduate urological training and the integration of laparoscopic techniques into the community based practice of urology.     

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 simplified 5-step model for training laparoscopic urethrovesical anastomosis

PURPOSE: We developed a training model and program aimed at improving the skills of urologists with no previous experience in laparoscopy to perform a running suture urethrovesical anastomosis as is done during laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our program is performed on a pelvic trainer with a videolaparoscopic unit and consists of passage of a ligature, intracorporal knotting, intracorporal suturing, linear anastomosis and circular running suture anastomosis. The trainees performed the first 3 tasks during the initial lessons and then advanced to the 2 final tasks. At the end of each lesson time was recorded and progression curve was plotted for each participant for each task. The end point of the study was participant ability to perform an accurate circular anastomosis. Logarithmic regression analysis was used to assess the significance of progression. RESULTS: All 10 urologists who participated in this study showed a rapid and significant decrease in the time required to perform the first 3 tasks accurately. The participants were able to perform a linear anastomosis after 3 to 5 lessons and an accurate circular anastomosis after 5 to 10 lessons. CONCLUSIONS: By using this model and dividing a complicated surgical step to simplified tasks, we were able to improve trainee performance significantly in a short time. A training program for basic and advanced laparoscopic skills should be incorporated into the syllabus of urologists-in-training and available to those who wish to gain experience in laparoscopic surgery.     

Surgical simulators in urological training--views of UK Training Programme Directors

What's known on the subject? and What does the study add? The role of surgical simulators is currently being debated in urological and other surgical specialties. Simulators are not presently implemented in the UK urology training curriculum. The availability of simulators and the opinions of Training Programme Directors' (TPD) on their role have not been described. In the present questionnaire‐based survey, the trainees of most, but not all, UK TPDs had access to laparoscopic simulators, and that all responding TPDs thought that simulators improved laparoscopic training. We hope that the present study will be a positive step towards making an agreement to formally introduce simulators into the UK urology training curriculum. To discuss the current situation on the use of simulators in surgical training. To determine the views of UK Urology Training Programme Directors (TPDs) on the availability and use of simulators in Urology at present, and to discuss the role that simulators may have in future training. An online‐questionnaire survey was distributed to all UK Urology TPDs. In all, 16 of 21 TPDs responded. All 16 thought that laparoscopic simulators improved the quality of laparoscopic training. The trainees of 13 TPDs had access to a laparoscopic simulator (either in their own hospital or another hospital in the deanery). Most TPDs thought that trainees should use simulators in their free time, in quiet time during work hours, or in teaching sessions (rather than incorporated into the weekly timetable). We feel that the current apprentice‐style method of training in urological surgery is out‐dated. We think that all TPDs and trainees should have access to a simulator, and that a formal competency based simulation training programme should be incorporated into the urology training curriculum, with trainees reaching a minimum proficiency on a simulator before undertaking surgical procedures.     

Spatial awareness in urologists: are they different?

OBJECTIVE: To compare innate spatial awareness skills, using the MIST-VR system (Ethicon Ltd, Edinburgh, a computer-based virtual reality system that objectively tests spatial awareness) among three groups of people (consultant urologists, urological trainees and controls who were not surgeons), because urological surgeons require spatial awareness for endoscopic and laparoscopic surgery, but trainees are selected by academic prowess rather than surgical aptitude. SUBJECTS AND METHODS: The MIST-VR system was used to test 122 volunteers in three groups, i.e. 39 consultant urologists, 46 urological trainees and 37 controls (not surgeons). The demographic data recorded for each group included age, sex, eyesight, handedness, and endoscopic and laparoscopic experience. Volunteers performed a repetitive series of three tasks using the system. Their performance was measured in terms of time, errors and economy of movement, as well as the duration and accuracy of diathermy in Task 3. RESULTS: The consultants were significantly older than the trainees and controls (both P<0.001) and had more endoscopic experience (P=0.005). In Task 1, the trainees made significantly fewer errors (P=0.045) and had a greater economy of movement (P=0.03) than the controls. In Task 2 the trainees performed the task more rapidly than the consultants (P=0.04) and controls (P=0.02). Trainees were more economical in movement than were consultants (P=0.031) and controls (P=0.046). In the more complex Task 3, trainees outperformed consultants in terms of errors (P=0.03), economy of movement (P=0.046), total diathermy time (P=0.005) and diathermy error (P=0.03). Controls performed similarly to the consultants. Although there was a trend towards better performance by trainees over controls, this was only significant for time (P=0.04) and total diathermy time (P=0.011). A few participants had results that were >2 SD above the mean and several people could not complete Task 3. CONCLUSIONS: Urologists do not differ from the general population in terms of innate spatial ability in this setting. There are several people who may have a defect in spatial awareness but the incidence was the same in each group. Urological trainees outperformed consultants in these tasks; the reasons for this are unclear. The MIST-VR system is of no help in aptitude testing for urological trainees, although it may have a role in teaching laparoscopic surgery. Testing other psychometric components may be more important for acquiring surgical skills than innate spatial-awareness skills. Further studies are required to investigate this possibility.     

Status of women in urology: based on a report to the Society of University Urologists

PURPOSE: Written responses from American trained women in urological surgery were obtained to evaluate practice patterns, career choices and workplace satisfaction. MATERIALS AND METHODS: A 3-page unblinded questionnaire was mailed in March 2003 to American trained women in urological surgery available through the databases of the Society of Women in Urology with subsequent statistical analysis. RESULTS: The response rate was 60% but inclusive of all women in current academic practice in the United States. A total of 61% reported working 51 or more hours a week whereas 2% have left practice due to retirement or medical infirmity. There were 41% who had completed fellowships including 87% reporting active practice within their subspecialty, whereas 62% of fellowship trained surgeons remained in an academic practice. Among United States women in academic urological practice, academic progression has occurred in a third of this cohort. CONCLUSIONS: Threats to successful practice, consistent with other workplace surveys of physicians and professional women including gender based role limitation and inadequate mentoring, were commonly reported. These correctable workplace deficiencies represent an opportunity for American urology to enhance the professional workplace for all urologists regardless of gender.     

腹腔镜手术治疗泌尿系疾病44例的总结

目的:探讨腹腔镜在泌尿外科手术中的临床应用价值。方法:用后腹膜腔和经腹腔(包括手辅式)术式治疗肾癌、肾盂癌、肾上腺肿瘤、无功能肾积水、乳糜尿、肾盂输尿管交界处狭窄、肾盂结石和肾囊肿。结果:41例手术均成功,手术时间30～140min,平均48min,术中出血10～100ml,平均40ml。术中患者生命体征平稳。3例中转开放手术。结论:只要术前做好充分准备,腔内操作技术熟练,腹腔镜手术治疗泌尿外科相关疾病不仅安全、微创,而且患者出血少、康复快,有些疾病可将腹腔镜手术作为首选的治疗方法。     

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.     

Urological involvement in renal transplantation

Historically, urologists were the primary surgeons in renal transplantation. Specialization and increased complexity of the field of transplantation, coupled with a de‐emphasis of vascular surgical training in urology, has created a situation where many renal transplants are carried out by surgeons with a general surgery background. Because of its genitourinary nature, however, urological input in renal transplantation is still vital. For living donors, a urologist should be involved to help evaluate and prepare certain patients for eventual donation. This could involve both medical and surgical intervention. Additionally, urologists who carry out living donor nephrectomy maintain a sense of ownership in the renal transplant process and provide a unique opportunity to the trainees of that particular program. For renal transplant recipients, preoperative evaluation of voiding dysfunction and other genitourinary anomalies might be necessary before the transplant. Also, occasional surgical intervention to prepare a patient for renal transplant might be necessary, such as in a patient with a small renal mass that is detected by a screening pretransplant ultrasound. Intraoperatively, for patients with complex urological reconstructions that might be related to the etiology of the renal failure (urinary diversion, bladder augmentation), a urologist who is familiar with the anatomy should be available. Postoperatively, urological evaluation and intervention might be necessary for patients who had a pre‐existing urological condition or who might have developed something de novo after the transplant. Although renal transplant programs could consult an on‐call urologist for particular issues on an as‐needed basis, having a urologist, who has repeated exposure to the particular issues and procedures that are involved with renal transplantation, and who is part of a dedicated multidisciplinary renal transplant team, provides optimal quality of care to these complex patients.     

Objective Assessment of Small Bowel Anastomosis Skill in Trainee General Surgeons and Urologists

Introduction The object of this study was to compare the technical ability of general surgery and urology trainees to perform a small bowel anastomosis using a life-like bench model. Methods Forty subjects were divided into two groups based on the stage of their training. Specialist registrars (SpRs) trained for 1 to 3 years were defined as junior SpRs, and those with 4 to 6 years of training were defined as senior SpRs. They were asked to perform a small bowel anastomosis on a standard latex model using the same equipment, suture material, and standardized instructions. Trainees were assessed by three trained observers based on a global rating scale. Results Interrater reliability was 0.83 for the general surgical group and 0.88 for the urology group. The median scores obtained by the junior SpRs were lower than those achieved by the senior SpRs, and general surgical trainees consistently performed better than their matched urology group. This difference reached statistical significance for the senior group. Conclusions Global rating scores provide a reliable, valid method for assessing technical skills between specialties when performing a small bowel anastomosis. We provide reasons why general surgeons may be more proficient at this task than urologists. These findings have possible application to identifying trainees who need additional training and may also provide a mechanism to ensure competence in this task.     

The need for training opportunities in advanced laparoscopic surgery

Background: There is controversy regarding the amount of training necessary to safely perform advanced laparoscopic surgery. General surgical residency often provides only a low volume of advanced laparoscopic cases and there is growing interest in nonaccredited fellowships focused on laparoscopic surgery.Objective: To assess surgical residents' perception of the need for training in advanced laparoscopic surgery in addition to that provided in a standard general surgical residency. Methods: A 15-item questionnaire was mailed to 985 physicians who either were Society of American Gastrointestinal Endoscopic Surgeons (SAGES) candidate members or had attended a SAGES resident course in 1998 or 1999. For the purposes of the survey, laparoscopic Nissen fundoplication, laparoscopic herniorrhaphy, laparoscopic splenectomy, and laparoscopic colectomy were chosen as advanced procedures. Results: Of the 85 responses obtained, 81% were from respondents who were at the postgraduate fourth-year (PG4) level or higher. Furthermore, 58% of the respondents had taken a course in advanced laparoscopic surgery outside their residency program. The respondents believed that to perform the procedures safely and with confidence on entering practice, they needed to do at least eight each of the selected laparoscopic procedures. As reported, 45% of the respondents had performed three or fewer laparoscopic hernias; 60% had performed three or fewer laparoscopic Nissen fundoplications; 81% had performed three or fewer laparoscopic colectomies; and 86% had performed three or fewer splenectomies. Only 32% of the residents expected to perform more than 10 laparoscopic Nissen fundoplications, only 10% expected to perform more than 10 colectomies, and only 4% expected to perform more than 10 splenectomies before completing their residency. Many respondents (65%) said they would pursue an additional year of advanced laparoscopic training if it were available. In programs unaffiliated with a fellowship in advanced laparoscopic surgery, 65% of the residents were concerned that such a fellowship would interfere with residency training in laparoscopic surgery. In comparison, only 24% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery believed that the fellowship interfered with their training, whereas 47% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery thought that the fellowship had no impact on their training. Conclusions: Residents clearly perceive a need for additional training in advanced laparoscopic surgery. Residents from programs without a laparoscopic fellowship are concerned about a negative impact on their experience from a laparoscopic fellow, but residents from programs with a laparoscopic fellowship are neutral about the impact of a fellow.