Laparoscopic Urologic Surgery Research Articles

Stratification of Expert vs Novice Laparoscopists Using the Basic Laparoscopic Urologic Surgery (BLUS) Curriculum at a Single Institution

PurposeTo assess determinants of performance applying the tasks of the Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum administered at a single institution. MethodsAfter obtaining institutional review board approval, fourth-year medical students, urology residents (postgraduate year 1-5), and staff attending surgeons from an academic institution were recruited. Participants were grouped by level of experience and evaluated on 4 different BLUS modules testing fundamental laparoscopic techniques from September 2012 to September 2013. Task completion time (TCT) and missed objectives were compared with previous laparoscopic experience, amount of endourological training, and scores obtained through the EDGE simulator. ResultsTCTs among the participants were slower and accrued greater errors in the novice group (n = 10) than in the intermediate-level (n = 9) and expert-level (n = 9) groups. Completion times on the peg transfer were 213.4, 128.1, and 108.7 seconds (p < 0.05); on the circle cutting were 182.4, 128.3, and 97.2 seconds (p < 0.05); on the clip application were 44.4, 43.2, and 38.1 seconds (p = 0.08); and on the suturing were 286.1, 177.3, and 123.6 seconds (p < 0.05) for novice, intermediate, and expert groups, respectively. When past laparoscopic numbers of participants were compared with TCTs, a positive correlation of R2 = 0.39 was seen, signifying a relationship between number of laparoscopic cases and TCT outcomes. ConclusionPerformance on the EDGE simulator device during the BLUS modules significantly correlated with the amount of laparoscopic experience. Increase in the years of experience and number of laparoscopic cases led to faster and more accurate TCTs.

Human error identification for laparoscopic surgery: Development of a motion economy perspective

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles.

984 Complications of laparoscopic urologic surgery performed through umbilical multichannel platform with or without an accessory port

984 Complications of laparoscopic urologic surgery performed through umbilical multichannel platform with or without an accessory port

Are structured curriculums for laparoscopic training useful? A review of current literature.

To review previous, recent, and future perspectives of laparoscopic training. Published studies showed the importance and benefits of training programmes in urologic laparoscopic surgery. In addition, laparoscopy at present can be performed for most of surgical modalities specifically in experienced centres. Thereof, well designed training programmes are needed for performing all-purpose laparoscopic surgeries. Additionally, training programmes may help to reduce the laparoscopic complications. However, training programmes should include some steps for performing future surgeries. Thus, structured training programmes can be more useful for urologists and hence should be preferred. Nonetheless, structured training programmes can be difficult to perform and need patience with long learning curve. These can help urologists to prepare for their first urologic laparoscopic procedures. Usage of laparoscopic procedures in urological field has been increasing parallel to developments in minimally invasive technologies worldwide. Therefore, there has been an increase in the numbers of urologists who want to learn laparoscopy. At this point, a structured curriculum for laparoscopic training comes into question. However, laparoscopic surgical modalities need to be trained, in large quantities. Training programmes can help surgeons learn and perform laparoscopy properly. However, these should be well designed and structured.

The 'complements' to virtual simulation.

With the advancement of minimally invasive procedures in urology, the goal is to train a urologist who is highly competent and confident in performing these techniques. Because of the specific risks, visuospatial relationships, and the steep learning curve that is unique to laparoscopy, hands-on training on a box or a visual simulator is the recommended way to start learning laparoscopic skills. However, as Preece et al. [1] stated in their interesting article, simulation should complement other essential components of urology training programs such as participation in mentorship schemes and clinical fellowships, which also aid progression along the learning curve. Residents who are willing to perform laparoscopic surgery should train their laparoscopic skills on a regular basis. Previous research by Stolzenburg et al. [2] suggested that those who are willing to learn laparoscopic prostatectomy should practice daily on a pelvic trainer, especially knot tying and suturing. Laguna et al. [3] stated that it is almost impossible to finalize the residency training as a qualified laparoscopic surgeon. Based on the low level of laparoscopic skills displayed by last year's residents, it is advisable that those who are willing to perform laparoscopy as a urologist should improve their training and exposure to laparoscopy during residency or should consider a fellowship in laparoscopic surgery. Cadaveric educational programs are unique programs that may simulate real clinical experience in the operating room. In Turkey, this dedicated educational program consists of 3 main theoretical and practical parts and many subtopics. The cadaveric educational program allows all urology residents to perform basic and complex surgical operations on fresh frozen cadavers. The surgeries that may be performed as an example include simple procedures such as prostatic biopsies to complex laparoscopic procedures such as partial nephrectomy. This program is still in continuous growth and we hope to be able to expand it over all of Europe. There are several circumstances that may reduce the number of procedures according to the training of the surgeons such as: 1) the development of their individual laparoscopic skills, 2) the access to simulator training, 3) animal or cadaveric training and 4) clinical experience with an experienced mentor [4]. Also, the importance of training with animals has been published in the past [5]. Following the La Paz University Hospital training program, every kind of training in laparoscopic surgery is desirable, but a scheduled program with a frequent presence in the operating room and a constant suture training on the simulators, ensures a consistent training in laparoscopic urological surgery.

Intraoperative laparoscopic complications for urological cancer procedures.

To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

PYJ04: Preliminary learning curve of robot-assisted laparoscopic intrafascial radical prostatectomy of a single surgeon with experience in more than 1,000 laparoscopic urologic surgeries: A comparative analysis with recently performed 100 laparoscopic radical prostatectomies

PYJ04: Preliminary learning curve of robot-assisted laparoscopic intrafascial radical prostatectomy of a single surgeon with experience in more than 1,000 laparoscopic urologic surgeries: A comparative analysis with recently performed 100 laparoscopic radical prostatectomies

Néphrectomie polaire supérieure gauche robot assistée avec urétérectomie associée, dans le cadre d’un système urinaire double complet symptomatique

We report the case of a laparoscopic robot assisted left upper polar partial nephrectomy with total ureterectomy performed in a teenager. A 14 year-old girl was referred to our institution for stress urinary incontinence. The morphological assessment (ultrasound scan and uro-MRI) showed a double collecting system with a complete ureteral duplication complicated by a dysplasia of the upper moiety of the duplex left kidney and a mega ureter. The surgery started on a lateral decubitus position by the upper polar partial nephrectomy and the ureter section behind superior polar renal vessels. The patient was placed in a supine position and the mega ureter was released and sectioned at the level of the distal adynamic segment in the left uterine parameter. The transperitoneal route was chosen as it provides a large workspace and allows the dissection of the ureters into their pelvic portion by a simple repositioning of the robot ports without additional incision and without any modification of the operative field. No intraoperative and postoperative complication was noticed. Laparoscopic robotic assisted surgery in pediatric urology is increasing, and to our knowledge, we reported this technique and surgery for the first time in France and in children. In the reported case, we showed that the robotic minimally invasive surgery in children is an innovative and safe technique for the treatment of symptomatic upper urinary tract malformations.

Exploring for the safer ventilation method in laparoscopic urologic patients? Conventional or low tidal?

To study the effects of low tidal volume with positive end-expiratory pressure (PEEP) on arterial blood gases of patients undergoing laparoscopic urologic surgeries. Eighty-six laparoscopic urologic patients were enrolled in this study. Patients were randomized into two groups according to the ventilatory settings. In the conventional group (Group C) (n=43), the tidal volume was 10 mL/kg, and the PEEP was set at 0 cm of H2O. In the low tidal volume with PEEP group (Group LP), the tidal volume was 6 mL/kg, with PEEP of 5 cm of H2O. In both groups total minute volume was 6 L/kg. Peak and plateau airway pressure (PPEAK and PPLAT, respectively) and arterial blood gases were recorded before pneumoperitoneum (PNP) (T1) and the first and third hour (T3) after PNP induction and also after extubation in the intensive care unit. Additionally, heart rate, mean arterial pressure, and peripheral O2 saturation of hemoglobin were recorded. Heart rate, PPEAK, and PPLAT values were similar in both groups. Partial arterial O2 pressure values measured postoperatively were significantly higher in Group LP, whereas those measured before PNP induction were similar (P=.014 and P=.056, respectively). Compared with the baseline, partial arterial CO2 pressure values measured at T1 and at T3 after PNP induction were significantly higher in Group C than in Group LP (P<.001). The pH values of Group C at T1 and at T3 postoperatively were significantly lower than the values of Group LP (P<.001). Extubation times were significantly lower in Group LP. The results of the present study suggest that low tidal volume with PEEP application may be a good alternative for preventing high CO2 levels and yielding better oxygenation and lower extubation times in patients undergoing prolonged laparoscopic urology.

‘Scarless' Laparoscopic Urologic Surgery by the Combination of Mini-Laparoscopic and Laparoendoscopic Single-Site Surgery Equipment

Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless' urologic surgery.

Practice and rethinking of the clinical training model of urological robotic-assisted laparoscopic surgery

By first introducing and carrying out the robotic surgery,we accumulated affluent clinical and teaching experiences of robotic surgery.Based on that,we proposed a novel standardized step-by-step robotic surgery training model for urological surgeons who have some experiences of laparoscopic surgery.The first stage is basic theory study by internet multimedia,which is to get an online certification by fully understanding the basic knowledge of robotic surgery.Then comes the simulation module training device operation,mainly focused on the training of vary robotic surgical skills,which are evaluated by the system automatically.In virtual reality simulators training stage,trainees can experience the open anatomy signs and its clinical application,learn the operating procedure and how to prevent and handle the complications and every student' operating time and score can be determined.In animal in vivo operation stage,trainees are enabled to master the standard operation method in vivo by robotic arms,cultivating the feeling of vision and touching.The aim of the animal robotic operation training stage is to understand the right use of the robotic surgical instruments.The last stage is the operation video watching and demonstration.By this stage,the members will know the common body position of urological robotic surgery and how to choose the puncture point,understand the three-dimensional anatomical landmarks and their clinical application,and learn the operation steps and complication prevention and treatment principle of robot Key words: Urology; Surgical robotics; Clinical training

458 A retrospective comparison of the microbiological profile of urinary tract infections in patients undergoing open and laparoscopic urological surgery

458 A retrospective comparison of the microbiological profile of urinary tract infections in patients undergoing open and laparoscopic urological surgery

Current status of robot-assisted laparoscopic surgery in pediatric urology.

Laparoscopic procedures for urological diseases in children have been proven to be safe and effective. However, the availability of laparoscopic procedures is still partly limited to experienced, high-volume centers because the procedures are technically demanding. The da Vinci robot system is being used for an increasing variety of reconstructive procedures because of the advantages of this approach, such as motion scaling, greater optical magnification, stereoscopic vision, increased instrument tip dexterity, and tremor filtration. Particularly in pediatric urologic surgery, where the operational field is limited owing to the small abdominal cavity of children, robotic surgical technology has its own strengths. Currently, robots are used to perform most surgeries in children that can be performed laparoscopically. In this review, we aimed to provide a comprehensive overview of the current role of robot-assisted laparoscopic surgery in Pediatric Urology by analyzing the published data in this field. A growing body of evidence supports the view that robotic technology is technically feasible and safe in pediatric urological surgery. Robotic technology provides additional benefits for performing reconstructive urologic surgery, such as in pyeloplasty, ureteral reimplantation, and enterocystoplasty procedures. The main limitations to robotic surgery are its high purchase and maintenance costs and that the cost-effectiveness of this technology remains to be validated.

Robot-assisted laparoscopic urological surgery in children

Robot-assisted laparoscopic surgery (RALS) has been proven to be safe and effective for various urological procedures in children, including pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation. The robot system enables delicate and precise movements, which are ideal for the types of reconstructive surgeries that children with urological issues often require, overcoming many of the impediments associated with the conventional laparoscopic approach. RALS helps the relative novice to perform fine surgical techniques and is thought to reduce the learning curve associated with some surgical techniques, such as intracorporeal suturing, owing to the improved freedom of movement of the surgical instruments, the ergonomic positioning of the surgeon, and the 3D vision provided by the robotic system. Given the favourable safety profile and associated benefits of the robot system, including reductions in mean postoperative hospital stay compared with conventional procedures, RALS is becoming more widely adopted by paediatric urologists.

Ergonomic Status of Laparoscopic Urologic Surgery: Survey Results from 241 Urologic Surgeons in China

BackgroundThe prolonged and frequent use of laparoscopic equipment raises ergonomic risks that may cause physical distress for surgeons. We aimed to assess the prevalence of urologic surgeons’ physical distress associated with ergonomic problems in the operating room (OR) and their awareness of the ergonomic guidelines in China.MethodsA sample of 300 laparoscopic urologists in China was assessed using a questionnaire on demographic information, ergonomic issues in the OR, musculoskeletal symptoms, and awareness of the ergonomic guidelines for the OR.ResultsThere were 241 survey respondents (86.7%) with valid questionnaires. Among the respondents, only 43.6% placed the operating table at pubic height during the actual operation. The majority of the respondents (63.5%) used only one monitor during the procedure. Only 29.9% placed the monitor below the eye level. More than half of the respondents (50.6%) preferred to use manual control instead of the foot pedal. Most of the respondents (95.0%) never used the body support. The respondents experienced discomfort in the following regions, in ascending order: leg (21.6%), hand (30.3%), wrist (32.8%), shoulder (33.6%), back (53.1%), and neck (58.1%). The respondents with over 250 total operations experienced less discomfort than those with less than 250 total operations. Most of the respondents (84.6%) were unaware of the ergonomic guidelines. However, almost all of the respondents (98.3%) regarded the ergonomic guidelines to be important in the OR.ConclusionsMost of the laparoscopic urologists were not aware of the ergonomic guidelines for the OR; hence, they have been suffering from varying degrees of physical discomfort caused by ergonomic issues. There is an urgent need for education regarding ergonomic guidelines in the OR for laparoscopic urologists in China.

Single-Port Laparoscopic Retroperitoneal Surgery Using a Modified Single-Port Device in Urology

Objectives: To investigate the use of a flexible instrument platform in performing single-port laparoscopic retroperitoneal urologic surgeries and to verify the safety and feasibility of these surgeries. Methods: The homemade instrument platform consisted of two control loops and a powder-free surgical glove to form multichannels. 56 patients underwent this kind of single-port surgery for different urologic diseases, including radical nephrectomy in 31 patients, nephroureterectomy in 7 patients, partial nephrectomy in 8 patients, living donor nephrectomy in 4 patients, adrenalectomy in 3 patients, renal cyst surgery in 2 patients and ureterolithotomy in 1 patient. Results: All surgeries were completed successfully with no switch to conventional laparoscopic or open surgery. The mean hospital stay was 13.13 days (range 6-36). All patients were satisfied without major complications. Conclusions: Retroperitoneal laparoendoscopic single-site surgery using our cost-effective homemade instrument platform appears to be a feasible and safe surgical strategy to perform retroperitoneal laparoscopic urologic surgery.

Determinants of Performance on the Transfer Task of the Basic Laparoscopic Urologic Surgery (BLUS©) Curriculum Administered at Objective Structured Clinical Examinations

To assess determinants of performance on the Transfer Task of the Basic Laparoscopic Urologic Surgery (BLUS(©)) skills curriculum administered at Objective Structured Clinical Examinations (OSCEs). After obtaining Institutional Review Board approval and informed consent, urology trainees (Postgraduate Year [PGY]-3 to PGY-5) from four different training programs (A, B, C, D) were recruited for the study. Transfer Task Times (TTTs) were compared and correlated with previous laparoscopic experience, amount of endotrainer practice and scores obtained at practice sessions and other OSCE stations. A total of 37 trainees were evaluated on three successive semiannual OSCEs from May 2011 to May 2012, including 16 (43.2%) trainees from program A with a dedicated laparoscopic skills training program. Compared with trainees from programs B, C, and D, trainees from program A had significantly more practice per week (0 v 45 minutes, p=0.001) and significantly lower median TTTs at OSCEs (114 [68-209] v 74 [52-189] seconds, p=0.001) despite significantly lower number of laparoscopic cases assisted within the previous 6 months (13 [0-57] v 2 [0-35], p=0.001). For program A trainees, TTTs moderately correlated with median TTTs at practice sessions (r=0.57, p=0.001) and negatively correlated with amount of practice per week (r=-0.41, p=0.003). Thus, more training resulted in faster times at OSCEs. On multivariate analysis, amount of practice per week was the only significant predictor of TTTs at OSCEs (p=0.028). Performance on the transfer task of BLUS during OSCEs significantly correlated with the amount of practice rather than the number of laparoscopic cases assisted.

The feasibility of robotic urologic surgery in infants and toddlers

ObjectiveTo determine the feasibility and safety of performing robotic-assisted laparoscopic urological surgery (RALS) in infants and young children, highlighting technical challenges posed by the smaller body size and their potential solutions. Patients and methodsWe retrospectively reviewed perioperative records of all patients less than 3 years of age who underwent RALS at our institution between January 2006 and October 2012. Intraoperative data included difficulties with the robotic instruments or surgical procedure. Post-operative data included length of hospital stay and any complications. ResultsA total of 65 children less than 3 years underwent RALS. The average patient age was 1.6 years ± 0.7, with 14 patients under 1 year of age. Median patient weight was 11.6 kg ± 2.5 kg. Mean operative time was 153.3 ± 57 min. No conversions to open technique or intra-operative complications were reported. A total of 12 post-operative complications were identified after a mean follow-up of 13.6 months: 7 early complications and 5 late complications. Smaller children did not have more complications than larger children. ConclusionThere are inherent challenges with performing RALS in infants and young children. However, they may be overcome with specific technical maneuvers and through understanding of the limitations of the robotic system.

Management of major blood vessel injury during urological laparoscopic surgery

Objective To explore the causes,management and prevention of major blood vessel injury during urological laparoscopic surgery.Methods Six cases of major blood vessel injuries happened in 1700 laparoscopic surgeries from January 2007 to July 2011.All of the cases were males.Patient age was (53 ± 14) years.There were 4 extraperitoneal and 2 transperitoneal procedures including 3 adrenalectomies,1 radical cystectomy,1 radical prostatectomy and 1 radical nephrectomy.There were lacerations in 3 cases of vena cava,2 cases of external iliac vein and one case of renal vein.The length of laceration was (0.68 ±0.29) cm and blood lost was (114 ++ 79) ml.Results Five of the patients were managed with laparoscopic techniques by suction compressing bleeding sites,dissecting related vessels,adding extra trocar and repairing laceration by suturing in four cases and clipping bleeding site in one case.The bleeding control management lasted (21.0 ± 5.6) min.One laparoscopic adrenalectomty for the treatment of pheochromocytoma converted to open surgery because of increasing blood pressure.All the patients were followed up for (4 ± 2) months.No more related complication occurred.Conclusions Lymph node dissection,local adhesion and energy source are the main causes for blood vascular injuries.This kind of injuries may occur at any stages during a laparoscopic surgery and laparoscopic repairing is safe and feasible. Key words: Laparoscopy; Intraoperative Complications; Blood Vessels; Retroperitoneal Space; Retrospective Studies

Efficacy and Safety of Enoxaparin for Preventing Venous Thromboembolic Events following Urologic Laparoscopic Surgery

There is a paucity of definitive evidence that supports the use of enoxaparin to prevent venous thromboembolism (VTE) after urologic laparoscopic surgery. The purpose of this study was to evaluate the efficacy and safety of postoperative subcutaneous enoxaparin injection in patients who underwent urologic laparoscopic surgery. A total of 63 patients were evaluated from June 2010 to December 2012. All patients received postoperative prophylaxis with enoxaparin (2000 IU twice daily for 5 days). None of the patients treated with enoxaparin developed symptomatic VTE, but two cases (3.2%) of pulmonary embolism were noted before initial enoxaparin administration. Statistically significant differences were observed between the prothrombin time (PT) and activated partial thromboplastin time (APTT) values and D-dimer levels obtained at baseline and on day 7 after surgery; however, the PT and APTT values did not exceed the normal range. In addition, signs of any adverse events were not encountered in any of the patients treated with enoxaparin. The use of enoxaparin immediately after a surgery may confer valuable thromboprophylaxis benefits for urologic laparoscopic surgery.