Immediate impact of an intensive one-week laparoscopy training program on laparoscopic skills among postgraduate urologists.

INTRODUCTION: Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience. METHODS: Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of P

Effects of commonly used hemostatic agents on the porcine collecting system.

PURPOSE: Topical hemostatic agents have been particularly useful for preventing bleeding in tubeless percutaneous nephrolithotomy. In the present study, we investigated the effect of gelatin matrix hemostatic sealant (FloSeal), fibrin glue (Tisseel,), polyethylene glycol polymers (CoSeal), and bovine serum albumin/ glutaraldehyde (BioGlue) in the pig urinary collecting system after injection through a percutaneous nephrostomy (PCN) tract. MATERIALS AND METHODS: Percutaneous nephrostomy was performed in 40 kidneys in 24 domestic pigs. Animals were divided into four groups of six each: (1) FloSeal; (2) Tisseel; (3) CoSeal; and (4) BioGlue. In 16 animals that tolerated the procedure, the contralateral kidney was used as a control for PCN only. All tracts were dilated to 30F with the Amplatz dilator, and 2 mL of the hemostatic agent was injected into the collecting system before pulling back to seal the puncture. RESULTS: Among the control PCN kidneys, no obstruction was detected at the end of a 5-day period. However, three of six kidneys injected with FloSeal, Tisseel, or CoSeal and four of six kidneys injected with BioGlue were obstructed. In each of these cases, there was an associated retroperitoneal urinoma. CONCLUSION: FloSeal, Tisseel, CoSeal, and BioGlue, if injected directly into the porcine collecting system, can result in significant obstruction that does not resolve over a 5-day period. Until there are clinical data to the contrary, we believe that when using one of these hemostatic agents in association with a tubeless percutaneous procedure, a retrograde occlusion balloon catheter should be considered to prevent inadvertent injection of these materials into the collecting system.

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.

Comparison of results of virtual-reality simulator and training model for basic ureteroscopy training.

BACKGROUND AND PURPOSE: The traditional method of acquiring surgical skills is by apprenticeship and involves an extensive period of training with patients. Model-based and virtual reality simulation is gaining interest as alternative training, allowing repetitive practice in a low-risk environment. The objective of this study was to determine if a materials, model-based training format and an interactive virtual-reality simulator could provide equivalent teaching of basic ureteroscopy skills to the inexperienced medical student. SUBJECTS AND METHODS: Sixteen first-year medical students received the same didactic session and video viewing on cystoscopy, guidewire access to the upper urinary tract, and ureteroscopy with intracorporeal laser lithotripsy and stone extraction by the same instructor. The participants were then randomized into two study groups: Group 1 was trained on the ureteroscopy training model (TMU) from Limbs & Things and Group 2 on the Simbionix UROMentor virtual-reality simulator (VRS) until the participants could perform the procedure independently. Two months later, the participants independently performed a ureteroscopic procedure on a pig kidney/ureter model and were graded from 1 to 5 on their ability to complete the steps of the procedure and the quality of their performance (handling of tissue, efficiency, instrument handling, knowledge of instruments, flow of operation, use of assistants, and knowledge of the specific procedure) for a possible total of 35 points. RESULTS: All participants were able to perform the steps of the procedure correctly. The TMU group and the VRS group received a mean of 22.9 +/- 4.8 and 23.6 +/- 5.4 points, respectively (P = 0.38) for their qualitative assessment. CONCLUSION: The medical students' skills and ability to perform a basic ureteroscopic stone-management procedure was independent of the training modality (VRS or TMU). Incorporating either of these devices into the preliminary training of urology residents may improve their initial clinical performance of these skills.

Comparison of basic elements of human performance scores between urologists with various extents of experience.

BACKGROUND AND PURPOSE: An objective evaluation of innate ability and its ability to predict potential success as a surgical trainee is an appealing concept for the selection process of residency applications. The objective of this study was to evaluate whether basic elements of performance (BEP) could discriminate among resident applicants and urologists with various extents of surgical experience. SUBJECTS AND METHODS: One hundred forty-five participants were divided into four study groups: group A, 57 urology residency applicants to the 2002 and 2003 interview process; group B, 8 post-internship urology residents; group C, 19 urologists tested with BEP within 10 years of graduation from their residency training program; and group D, 61 urologists who had graduated from their residency training program more than 10 years prior to testing. The BEP measures consisted of 13 basic performance resources (BPR) including visual-information processing speed, visual-spatial immediate-recall capacity, and neuromotor channel capacity. RESULTS: The four study groups differed significantly in their mean age: group A=27.6 years, group B=29.1 years, group C=37.1 years, and group D=48.9 years (P<0.0005). There was essentially no significant difference between the groups with regard to immediate-recall memory, reaction time simple, or reaction time complicated. The younger participants (groups A and B) were faster than the older surgeons (groups C and D) (P<0.02). However, the older surgeons (groups C and D) were significantly more accurate than the younger groups (A and B) (P<0.0005). The only sex differences noted were in hand-grip strength and shoulder-strength scores, which were all higher in the men. CONCLUSIONS: There generally appears to be a lack of direct correlation between innate abilities and surgical experience. Urology resident applicants with no surgical experience and urology residents with limited surgical experience are faster but less accurate in innate skills testing than experienced practicing urologists.

Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns.

BACKGROUND AND PURPOSE: Laparoscopic surgical techniques are difficult to master, especially for surgeons who did not receive this type of training during their residencies. We have established a 5-day mentor-preceptor- proctor-guided postgraduate "mini-residency" (M-R) experience in minimally invasive surgery. The initial results from the first 16 participants in the laparoscopic M-R modules are presented. PARTICIPANTS AND METHODS: On the first and the last day of the M-R, all participants underwent surgical skills testing using an open-surgery, standard laparoscopic, and robot-assisted laparoscopic format. A written examination was also administered on the last day. The influence of M-R on the participants' practice pattern was then assessed by a follow-up questionnaire survey 1 to 7 months after their attendance. RESULTS: Data from the first 16 participants were analyzed. Of note, the score was significantly improved for only one of the four tested laparoscopic skills (i.e., threading a suture through loops). Nonetheless, on the follow-up survey, of the 15 respondents, two laparoscopically naïve participants had performed laparoscopic nephrectomy, and of the eight participants who had prior renal-ablative laparoscopic experience, four had performed advanced reconstructive laparoscopic cases. CONCLUSIONS: A 5-day dedicated postgraduate M-R in laparoscopy appears to be helpful for urologists wishing to incorporate this surgical approach into their practices. The "take rate" among participants is initially at the 40% level, similar to what has been previously reported after a 1 to 2-day hands-on didactic laparoscopy course.

Uteroglobin: a potential novel tumor suppressor and molecular therapeutic for prostate cancer.

Currently, there are very few diagnostic or therapeutic strategies targeted at controlling tumor growth and progression towards metastasis. Uteroglobin (UG) is a naturally occurring, small, stable, secretory protein that is normally expressed by most cells of epithelial origin but is known to be lost during the progression of prostate, lung, and uterine cancers to invasive malignancy. Uteroglobin -/- knockout mice appear to be extremely cancer prone. Both pharmacological and transgenic reconstitution of recombinant human UG (rhUG) to prostate, lung, and endometrial tumor cell lines markedly inhibits their invasiveness and antagonizes the neoplastic phenotype. In preliminary studies, rhUG inhibited angiogenesis in the ex vivo rat aorta model and showed antitumor activity against human prostate tumor cells (PC-3) in the chick chorioallantoic membrane assay, reducing both tumor volume and vascularity. A recent in vivo pilot study showed that twice daily dosing with rhUG resulted in a statistically significant increase in survival without evidence of toxicity in severe combined immunodeficient mice challenged with a PC-3 cell metastasizing tumor. Thus, rhUG may slow the progression of cancer by inhibiting both tumor cell invasiveness and tumor angiogenesis. It therefore holds the potential to serve as a new weapon in the arsenal of cytostatic, antimetastatic, adjuvant treatment for cancer. In this paper, we will briefly discuss the therapeutic potential of uteroglobin-based strategies for managing prostate cancer.

Short-term impact of a robot-assisted laparoscopic prostatectomy 'mini-residency' experience on postgraduate urologists' practice patterns.

INTRODUCTION: To assist practising urologists acquire and incorporate robot-assisted laparoscopic prostatectomy (RALP) into their practice, a 5 day mini-residency (M-R) programme with a mentor, preceptor and potential proctor experience was established at the University of California, Irvine, Yamanouchi Center for Urological Education. The follow-up results from the initial 21 RALP M-R participants are presented. METHODS: Between September 2003 and September 2004, 21 urologists from six states and four countries underwent a RALP M-R. Each participant underwent 1:2 teacher:attendee instruction over a 5 day period, which included inanimate model skills training, animal/cadaver laboratory skills training and operating room observation experience. Participants were also offered a proctoring experience at their hospital if they so desired. A questionnaire survey was mailed 1-14 months (mean 7.2 months) following completion of the mini-residency and these results were tabulated and reviewed. RESULTS: A 100% response rate was achieved from the mailed questionnaires. The mean M-R participant age was 43 years (range 33-55 years). One-third of the M-R participants were practising in an academic environment. Most of the participants (55%) had no fellowship training. Of those with fellowship training (45%), three (15%) were in laparoscopy and three (15%) were in oncology; 25% of the participants were in large (>6 physicians), 25% in small (2-6 physicians) and 15% in solo practices; 70% of the participants were located in an urban setting. The majority of the participants (80%) had laparoscopic experience during residency training and had performed 20-60 laparoscopic cases prior to attending the M-R programme. Within 7.2 months after M-R (range 1-14 months), 95% of the participants were practising robot-assisted laparoscopic prostatectomy and 25% of the RALP M-R participants had also performed robotic-assisted laparoscopic pyeloplasty. Of the M-R participants, 38% availed themselves of the preceptor/proctor component of the programme; among these, 100% reported that they were performing RALP vs. only 92% of the MR participants who did not have a proctor experience. The 5 day length of the M-R was considered to be of satisfactory duration by 90% of the participants, while 1 participant considered it too brief and 1 considered it too long. All but one of the participants rated the M-R as a very or extremely valuable experience. All the M-R participants indicated that they would recommend this training programme to a colleague. CONCLUSIONS: A 5 day intensive RALP M-R course seems to encourage postgraduate urologists, already familiar with laparoscopy, to successfully incorporate robotic surgery into their practice. The take rate, or the percentage of participants performing robotic-assisted surgery within 14 months after M-R, was 95%. Continued follow-up will ultimately determine the long-term effectiveness of this 1 week intensive training programme for postgraduate urologists.