Modular training for residents with no prior experience with open pelvic surgery in endoscopic extraperitoneal radical prostatectomy

PURPOSE: To establish a teaching program for the performance of endoscopic extraperitoneal radical prostatectomy (EERPE) that would ascertain the safe and efficacious training of residents with no previous experience with open pelvic surgery. MATERIALS AND METHODS: The technique of EERPE was divided in 12 segments with 5 levels of difficulty. We thus designed a training program, where the resident learned the procedure in a mentor-defined schedule. During each educational EERPE, the trainee only performed the operative steps corresponding to his acquired skill level. The mentor performed the remaining parts of the EERPE, with the trainee assisting. The first 50 and consequent 100 cases performed by the residents were compared to the first 50 and last 100 cases (cases 521-621) performed by the mentor. RESULTS: Two residents with no prior experience with open pelvic surgery participated in the study, and required 43 and 38 procedures respectively, until they were considered to be competent. The initial 50 procedures performed completely independently by the residents had mean operative times of 176 and 173 minutes. There were 2 intraoperative rectal injuries (one patient developed recto-urethral fistula), and 1 hemorrhage, and 1 lymphocele, postoperatively. The positive margin rate for pT2 disease was 14.3 and 11.5%, and for pT3 tumors 38.8 and 29.1%, respectively. After an additional 100 procedures operated by the same residents, mean operative times were 142 and 146 minutes. There was one patient who needed a transfusion. Postoperative complications requiring re-intervention were 1 hemorrhage, 2 anastomotic leakages and 4 symptomatic lymphoceles. The positive margin rate for pT2 disease was 12.8% and 6.5%, and for pT3 tumors 33.3% and 26.3% respectively. No statistical significant differences were observed when comparing with the mentors cases. CONCLUSION: We have showed that residents with no prior experience in open surgery of the pelvis can adhere to the modular training scheme and successfully perform the EERPE procedure with similar risk of complications compared to the tutor.