Training centers: an essential step to developing skills in urolaparoscopy.

Choosing laparoscopy is an important investment for urologists, and it must be learned from basic principles to advance skills through a steep learning curve; the caseload is made of frequent but very demanding procedures. In training centers, scholars are confronted with real-life conditions through large animal models. For about 1500 urologists, the European Institute of Tele Surgery has offered such a program for a decade. We evaluate its impact through a self-administered, Internet-hosted questionnaire. Individual data concern number and type of courses attended, skill level and type of practice before training, and expectations at registration. Personal benefit is evaluated through the delay before starting routine laparoscopy or the major procedures volume facing open counterparts. The ability of this program to meet scholar's expectations is reflected by eventual need for further training or by trainee suggestions. In spite of 85% cumulated satisfaction index, further developments must improve practical training: clear, reproducible stepwise protocols, repeated under supervision in animal models today and hopefully in augmented reality simulators tomorrow. The knowledge transfer and companionship made of theoretical and practical lessons followed by a straight supervised application represent an essential model for gaining proficiency.

Mentor-initiated approach in laparoscopic radical prostatectomy.

PURPOSE: We evaluated the efficacy and safety of a mentor-initiated program for laparoscopic radical prostatectomy by analyzing its effect on the learning curve. PATIENTS AND METHODS: The mentor performed 16 procedures (group I) and the trainee, assisted by the mentor, 12 (group II). The next 16 procedures were performed by the trainee without the mentor (group III). The patient groups were comparable in terms of age, serum prostate specific antigen concentration, Gleason score, and clinical stage. The operating time, blood loss, complications, and outcomes were evaluated. Statistical analysis was performed using ANOVA with the multiple-comparisons test with Bonferroni correction and the Kruskal-Wallis test, when appropriate. RESULTS: There was a statistical difference in the mean operating time in groups I and II (271 and 381 minutes, respectively; P < 0.001) and in groups I and III (271 and 386 minutes, respectively; P < 0.001), but the difference between groups II and III was not significant (P > 0.05). The mean estimated blood loss was similar in all groups (362, 395, and 434 mL, respectively; P = 0.86). The mean postoperative day 1 decrease in hemoglobin was similar in the three groups (0.65, 0.66, and 0.66 mg/dL, respectively; P = 1.00). No patient required open conversion. Postoperative complication rates were the same in groups I and III (6.25%). The mean catheterization time was longer in group III (6, 7, and 12 days; P < 0.001). The mean hospital stays (9, 8, and 8 days; P = 0.28) were similar. Stage pT(3)-pT(4a) disease was found in 75%, 41.6%, and 75% of the specimens in groups I to III, respectively. There was no statistical difference in positive-margin rates in the three groups (43.8%, 33.3%, and 37.5%; P = 0.85). CONCLUSIONS: A mentored program allows safe introduction of laparoscopic radical prostatectomy into surgical practice. Nevertheless, during the learning curve, longer operating and catheterization times have to be expected.

EAU policy on live surgery events.

CONTEXT: Live surgery is an important part of surgical education, with an increase in the number of live surgery events (LSEs) at meetings despite controversy about their real educational value, risks to patient safety, and conflicts of interest. OBJECTIVE: To provide a European Association of Urology (EAU) policy on LSEs to regulate their organisation during urologic meetings. EVIDENCE ACQUISITION: The project was carried out in phases: a systematic literature review generating key questions, surveys sent to Live Surgery Panel members, and Internet- and panel-based consensus finding using the Delphi process to agree on and formulate a policy. EVIDENCE SYNTHESIS: The EAU will endorse LSEs, provided that the EAU Code of Conduct for live surgery and all organisational requirements are followed. Outcome data must be submitted to an EAU Web-based registry and complications reported using the revised Martin criteria. Regular audits will take place to evaluate compliance as well as the educational role of live surgery. CONCLUSIONS: This policy represents the consensus view of an expert panel established to advise the EAU. The EAU recognises the educational role of live surgery and endorses live case demonstration at urologic meetings that are conducted within a clearly defined regulatory framework. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery. PATIENT SUMMARY: Controversy exists regarding the true educational value of live surgical demonstrations on patients at surgical meetings. An EAU committee of experts developed a policy on how best to conduct live surgery at urologic meetings. The key principle is to ensure safety for every patient, including a code of conduct and checklist for live surgery, specific rules for how the surgery is organised and performed, and how each patient's results are reported to the EAU. For detailed information, please visit www.uroweb.org.

Methods for laparoscopic training using animal models.

To reduce the learning curves in humans, several training models have been developed for teaching laparoscopic surgery. The aim of various in vitro or in vivo training models is to help surgeons acquire basic laparoscopic skills such as hand-eye coordination, depth perception, and knot-tying, which should always be acquired prior to organ- or procedure-specific skills. Inexpensive video box trainers are best suited for this purpose. However, advanced laparoscopic skills, such as dissection, cutting, coagulation, and stitching, require more sophisticated animal or human cadaver models. The perfect training model should teach the skills required and should be inexpensive, universally available, and anatomically and physiologically identical to an anesthetized patient. In this paper, we review the different animal models for acquiring advanced laparoscopic skills and try to define their advantages and disadvantages.

Prevention and management of complications in urological laparoscopic port site placement.

OBJECTIVES: To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management. METHODS: Review of the literature using Medline. RESULTS: Laparoscopy now plays a key role in urological surgery. Its applications are expanding with experience and evolving data confirming equivalent long-term outcome. Although significant port-site complications are uncommon, their occurrence impacts significantly on perioperative morbidity and rate of recovery. The incidence of such complications is inversely related to surgeon experience. Ports now utilise bladeless tips to reduce the incidence of vascular and visceral injuries, and subsequently port-site herniation. Metastases occurring at the port site are preventable by adhering to certain measures. CONCLUSIONS: Whether performing standard or robot-assisted laparoscopy, port-site creation and maintenance is critical in ensuring minimal invasiveness in laparoscopic urological surgery. Although patient factors can be optimised perioperatively and port design continues to improve, it is clear that adequate training is central in the prevention, early recognition, and treatment of complications related to laparoscopic access.

Laparoscopic radical prostatectomy: transperitoneal versus retroperitoneal approach: is there an advantage for the patient?

PURPOSE OF REVIEW: Radical prostatectomy is the standard treatment for localized prostate cancer; its translation to a laparoscopic approach is considered today not only as feasible and reproducible but also as a valid and teachable alternative to its open counterpart. Beyond the "classical" transperitoneal antegrade route codified by the Montsouris group, several extraperitoneal approaches were developed, claiming clinical equivalence and reduced risks of morbidity and operative times. This article summarizes various aspects of different approaches and their outcome. RECENT FINDINGS: Complications reported about transperitoneal procedures definitely further the discovery or learning curves of the pioneering teams; the groups who developed extraperitoneal alternatives established their "new approaches" on a solid base of technical skills, acquired transperitoneally. Beyond the unsurpassed qualities of visual and working spaces belonging to the transperitoneal route, which should be taken into account with respect to teaching, transperitoneal antegrade approach to the prostate enables the surgeon with early hemostatic control and essential tactical choices to achieve negative surgical margins. SUMMARY: So far, as oncological and functional results of both approaches seem equivalent, both approaches should be further developed and remain available for teaching purposes. The true benefit for patients lies more in global quality control of surgery than in an obsessional search for alternatives to established techniques that have already stood the proof of time.

Laparoscopic radical cystectomy with and without orthotopic bladder replacement.

The successful introduction of laparoscopic radical prostatectomy at the end of the last millennium represented a quantum leap in the technical development of minimally invasive surgery in urology. Therefore it seemed a logical step that, at the beginning of this millennium, first centers reported their initial experience with laparoscopic radical cystectomy. Based on more than 2000 laparoscopic radical prostatectomies, two centers have performed this procedure in 48 patients including a variety of urinary diversion (i.e. ileal conduit, ileal neobladder, sigmoid neobladder). In this article, all important surgical steps of laparoscopic radical cystectomy are presented, including the description of the most important techniques of urinary diversion. Based on our own experience, the results of 238 cases presented in the current literature are reviewed. The operating time mainly depended on the type and technique of urinary diversion and ranged between 352 and 430 minutes for ileal conduit, and between 478 and 649 minutes for orthotopic neobladder. The complication rate ranged between 16 and 18%, and the reintervention rate was 4-6%. Long-term follow-up is not available, disease-free survival after three years in a limited number of series ranges between 50 and 67%. No port site metastases have been reported so far. Even for the experienced surgeon laparoscopic radical cystectomy with urinary diversion represents a technically challenging procedure. Nevertheless, feasibility and safety have been proved by various authors. However, larger studies with long-term clinical outcome are necessary to determine the final value of the procedure.

Technique for laparoscopic running urethrovesical anastomosis:the single knot method.

OBJECTIVES: To describe a technique for facilitating the urethrovesical anastomosis at the time of laparoscopic radical prostatectomy. METHODS: Two 6-in. polyglycolic acid sutures (one dyed, one white) are tied together at their tail ends and delivered into the operative field by way of a 12-mm port. A running suture is completed from the 6:30 to the 12:00-o'clock position and from the 5:30 to the 12:00-o'clock position, at the end of which a single intracorporeal tie is completed. The catheter is placed before completing the anterior row of sutures; the catheter is left in place for 5 to 7 days. RESULTS: This anastomotic technique has been used in 122 laparoscopic radical prostatectomies and 8 robot-assisted laparoscopic radical prostatectomies. The average time for the anastomosis was 35 minutes (range 14 to 80). All anastomoses were watertight. No symptomatic postoperative urinary leaks have occurred, and no clinically evident clinical bladder neck contractures resulted. CONCLUSIONS: We describe a simple, watertight, running laparoscopic suture technique for accomplishing the urethrovesical anastomosis during laparoscopic radical prostatectomy.

Metastatic prostate cancer treated by flutamide versus cyproterone acetate. Final analysis of the "European Organization for Research and Treatment of Cancer" (EORTC) Protocol 30892.

OBJECTIVES: This trial was designed to compare the efficacy of Flutamide (FLU) versus Cyproterone acetate (CPA) in men with metastatic prostate cancer and favourable prognostic factors. The primary endpoint of the trial was overall survival, disease specific survival, time to progression and side effects were secondary endpoints. The results pertaining to sexual function were already reported [Br J Cancer 82(2) (2000) 283]. MATERIAL AND METHODS: The trial was designed to detect a 50% improvement in median overall survival with 80% power. At the time of the present report, the trial provides 88% power to detect the planned difference of 50% with a 2-sided Logrank test and 80% power to detect a difference of 43% in median survival. RESULTS: 310 patients were randomized to treatment by FLU (250 mg t.i.d. p.o.) or CPA (100 mg t.i.d. p.o.). Of the 310 patients, 12 (3.9%) were ineligible. The baseline characteristics of the two groups were similar except for age which was significantly younger in the CPA group and for the presence of soft tissue metastases which were absent in the FLU group and present in 6 patients in the CPA group. The median follow-up was 8.6 years, 245 patients died, 158 (64.5%) of prostate cancer. There was no significant difference between the treatment arms with respect to overall survival, specific survival nor time to progression. Side effect profiles were studied and found to be more favourable for CPA overall and in particular with respect to gynecomastia, diarrhea and nausea. CONCLUSIONS: The trial shows no significant differences in efficacy between Flutamide and CPA monotherapy. The number of patients who died of prostate cancer up to this time is insufficient for a definitive analysis of specific survival. Erectile function and sexual activity are not preserved with FLU but decay slowly with both antiandrogens, toxicity is more pronounced with FLU.