Elspeth M. McDougall

Percutaneous and Laparoscopic Cryoablation of Small Renal Masses

PURPOSEnWe reviewed our 4-year experience with percutaneous cryoablation and laparoscopy for treating small renal masses.nnnMATERIALS AND METHODSnAfter institutional review board approval we retrospectively analyzed renal cryoablation procedures performed between March 2003 and October 2007. An in-depth analysis was performed concerning demographics, hospital course and short-term outcome with respect to percutaneous vs laparoscopic cryoablation.nnnRESULTSnA total of 37 patients underwent treatment for 43 renal masses. Of the 37 patients 19 underwent laparoscopic cryoablation (24 tumors) and 18 underwent percutaneous cryoablation (19 tumors) using computerized tomography fluoroscopy. For percutaneous cryoablation a saline instillation was used in 58% of cases to move nonrenal vital structures away from the targeted renal mass. There were 5 cases of hemorrhage requiring transfusion, all of which were associated with the use of multiple cryoprobes. The transfusion rate in the percutaneous and laparoscopic cryoablation groups was 11.1% and 27.8%, respectively. Operative time was significantly longer in the laparoscopic cryoablation group compared to the percutaneous cryoablation group at 147 (range 89 to 209) vs 250.2 (range 151 to 360) minutes, respectively. The overall complication rate (including transfusion) was lower in the percutaneous cryoablation group compared to the laparoscopic cryoablation group (4 of 18 [22.2%] vs 8 of 20 [40%], respectively). Hospital stay was significantly shorter in the percutaneous vs laparoscopic cryoablation group at 1.3 vs 3.1 days, p <0.0001, respectively. Narcotic use in the percutaneous cryoablation group was more than half that used by the laparoscopic cryoablation group (5.1 vs 17.8 mg, p = 0.03, respectively). Among patients with biopsy proven renal cell carcinoma during a median followup of 11.4 and 13.4 months in the percutaneous and laparoscopic cryoablation groups, cancer specific survival was 100% and 100%, respectively, and the treatment failure rate was 5.3% and 4.2%, respectively.nnnCONCLUSIONSnPercutaneous cryoablation is an efficient, minimally morbid method for the treatment of small renal masses and it appears to be superior to the laparoscopic approach. Short-term followup has shown no difference in tumor recurrence or need for re-treatment. Of note, hemorrhage was solely associated with the use of multiple probes.

Best Practices for Robotic Surgery Training and Credentialing

PURPOSEnWith the rapid and widespread adoption of robotics in surgery, the minimally invasive surgical landscape has changed markedly within the last half decade. This change has had a significant impact on patients, surgeons and surgical trainees. This is no more apparent than in the field of urology. As with the advent of any new surgical technology, it is imperative that we develop comprehensive and responsible training and credentialing initiatives to ensure surgical outcomes and patient safety are not compromised during the learning process.nnnMATERIALS AND METHODSnA literature search was conducted on surgical training curricula as well as robotic surgery training and credentialing to provide best practice recommendations for the development of a robotic surgery training curriculum and credentialing process.nnnRESULTSnFor trainees to attain the requisite knowledge and skills to provide safe and effective patient care, surgical training in robotics should involve a structured, competency based curriculum that allows the trainee to progress in a graduated fashion. This structured curriculum should involve preclinical and clinical components to facilitate the proper adoption and application of this new technology. Robotic surgery credentialing should involve an expert determined, standardized educational process, including a minimum criterion of proficiency.nnnCONCLUSIONSnRather than being based on a set number of completed cases, robotic surgery credentialing should involve the demonstration of proficiency and safety in executing basic robotic skills and procedural tasks. In addition, the accreditation process should be iterative to ensure accountability to the patient.

Surgical Simulation: A Urological Perspective

PURPOSEnSurgical education is changing rapidly as several factors including budget constraints and medicolegal concerns limit opportunities for urological trainees. New methods of skills training such as low fidelity bench trainers and virtual reality simulators offer new avenues for surgical education. In addition, surgical simulation has the potential to allow practicing surgeons to develop new skills and maintain those they already possess. We provide a review of the background, current status and future directions of surgical simulators as they pertain to urology.nnnMATERIALS AND METHODSnWe performed a literature review and an overview of surgical simulation in urology.nnnRESULTSnSurgical simulators are in various stages of development and validation. Several simulators have undergone extensive validation studies and are in use in surgical curricula. While virtual reality simulators offer the potential to more closely mimic reality and present entire operations, low fidelity simulators remain useful in skills training, particularly for novices and junior trainees. Surgical simulation remains in its infancy. However, the potential to shorten learning curves for difficult techniques and practice surgery without risk to patients continues to drive the development of increasingly more advanced and realistic models.nnnCONCLUSIONSnSurgical simulation is an exciting area of surgical education. The future is bright as advancements in computing and graphical capabilities offer new innovations in simulator technology. Simulators must continue to undergo rigorous validation studies to ensure that time spent by trainees on bench trainers and virtual reality simulators will translate into improved surgical skills in the operating room.

Validation Study of a Virtual Reality Robotic Simulator—Role as an Assessment Tool?

PURPOSEnVirtual reality simulators are often used for surgical skill training since they facilitate deliberate practice in a controlled, low stakes environment. However, to be considered for assessment purposes rigorous construct and criterion validity must be demonstrated. We performed face, content, construct and concurrent validity testing of the dV-Trainer™ robotic surgical simulator.nnnMATERIALS AND METHODSnUrology residents, fellows and attending surgeons were enrolled in this institutional review board approved study. After a brief introduction to the dV-Trainer each subject completed 3 repetitions each of 4 virtual reality tasks on it, including pegboard ring transfer, matchboard object transfer, needle threading of rings, and the ring and rail task. One week later subjects completed 4 similar tasks using the da Vinci® robot. Subjects were assessed on total task time and total errors using the built-in scoring algorithm and manual scoring for the dV-Trainer and the da Vinci robot, respectively.nnnRESULTSnSeven experienced and 13 novice robotic surgeons were included in the study. Experienced surgeons were defined by greater than 50 hours of clinical robotic console time. Of novice robotic surgeons 77% ranked the dV-Trainer as a realistic training platform and 71% of experienced robotic surgeons ranked it as useful for resident training. Experienced robotic surgeons outperformed novices in many dV-Trainer and da Vinci robot exercises, particularly in the number of errors. On pooled data analysis dV-Trainer total task time and total errors correlated with da Vinci robot total task time and total errors (p = 0.026 and 0.011, respectively).nnnCONCLUSIONSnThis study confirms the face, content, construct and concurrent validity of the dV-Trainer, which may have a potential role as an assessment tool.

Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach.

Increasingly, laparoscopy is being employed in the treatment of urologic malignancies. This is most apparent in kidney cancer, where laparoscopic radical nephrectomy is now considered to be a gold standard. Herein, we compared early postoperative morbidity in a contemporary series of open and laparoscopic radical nephrectomies. We reviewed all patients that underwent a radical nephrectomy between October 1999 and May 2001 at our institution. We then compared open radical nephrectomy patients to those undergoing laparoscopic approaches with specific attention to early complications. A total of 74 radical nephrectomies were performed: 41 open, 18 hand-assisted and 15 pure laparoscopic nephrectomies. Overall, complication rates between the open, hand-assist and pure laparoscopic groups were similar (10%, 17% and 12%, respectively, P = 0.133). There was no statistically significant difference in ASA score (P = 0.144), pre-operative hematocrit (P = 0.575) or intra-operative blood loss (P = 0.364). The open nephrectomy group had a statistically larger average tumor size (7.4 cm vs. 4.6 cm; P = 0.005) and younger average age (57 vs. 63; P = 0.019) than the laparoscopic group. Length of hospital stay was significantly shorter in the laparoscopic group (3.6 days vs. 1.7 days; P < 0.0001). Laparoscopic radical nephrectomy has an acceptably low complication rate and compares favorably to open radical nephrectomy. The low rate of complications combined with the advantages of laparoscopic surgery favor a laparoscopic approach for the majority of patients with stage T1 and T2 tumors.

Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care

OBJECTIVESnTo determine the extent to which laparoscopy has replaced open surgery for renal malignancy.nnnMETHODSnThe records of all 537 patients at Washington University who underwent surgery for localized renal malignancies from January 1997 to December 2001 were examined for clinical and pathologic information.nnnRESULTSnThe total procedures per year increased from 1997 to 2001, but the distribution of pathologic stages throughout the 5 years was similar. In 1997, laparoscopic approaches were used in 15% of cases; this increased to 65% by 2001. Nephron-sparing surgery (NSS) was used in 31% to 42% of patients yearly, but laparoscopic NSS increased in frequency. By 2001, only 3.3% of T1 tumors were removed by open radical nephrectomy compared with 55% treated by laparoscopic nephrectomy. The rest of the T1 tumors in 2001 were treated by open partial nephrectomy (20.2%) or laparoscopic NSS (21.3%). In 2001, 61% of T2 lesions were treated laparoscopically, an increase from 37% in 1997. Most open radical nephrectomies in 2001 were performed for T3 disease. The number of surgeons performing laparoscopic renal surgery has increased at our institution, from two in 1997, both endourologists, to eight in 2001, representing the entire urology faculty that treats renal cancer.nnnCONCLUSIONSnLaparoscopic radical nephrectomy has replaced open radical nephrectomy for low-stage renal neoplasia. Although laparoscopic NSS is increasing in frequency, it has not yet replaced open partial nephrectomy. At our institution, the laparoscopic approach has become the standard of care when radical nephrectomy is needed for T1 or T2 renal cancer.

Long-Term Impact of a Robot Assisted Laparoscopic Prostatectomy Mini Fellowship Training Program on Postgraduate Urological Practice Patterns

PURPOSEnRobot assisted laparoscopic prostatectomy has stimulated a great deal of interest among urologists. We evaluated whether a mini fellowship for robot assisted laparoscopic prostatectomy would enable postgraduate urologists to incorporate this new procedure into clinical practice.nnnMATERIALS AND METHODSnFrom July 2003 to July 2006, 47 urologists participated in the robot assisted laparoscopic prostatectomy mini fellowship program. The 5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lectures, tutorials, surgical case observation, and inanimate, animate and cadaveric robotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 years after the mini fellowship program were analyzed.nnnRESULTSnOne, 2 and 3 years after the program the response rate to the questionnaires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24), respectively. The percent of participants performing robot assisted laparoscopic prostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78% (25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing the procedure there was a progressive increase in the number of cases each year with increasing time since the mini fellowship training. In the 3 attendees not performing the procedure 3 years after the mini fellowship training the reasons were lack of a robot, other partners performing it and a feeling of insufficient training to incorporate the procedure into clinical practice in 1 each. One, 2 and 3 years following the mini fellowship training program 83%, 84% and 90% of partnered attendees were performing robot assisted laparoscopic prostatectomy, while only 67%, 56% and 78% of solo attendees, respectively, were performing it at the same followup years.nnnCONCLUSIONSnAn intensive, dedicated 5-day educational course focused on learning robot assisted laparoscopic prostatectomy enabled most participants to successfully incorporate and maintain this procedure in clinical practice in the short term and long term.

RENAL PHYSIOLOGY: Laparoscopic Considerations

Oliguria is a recognized component of the physiologic effect of increased intra-abdominal or retroperitoneal pressure. The cause is multifactorial, emanating from vascular and parenchymal compression, and is associated with systemic hormonal effects. Ureteral obstruction does not play a significant role. These changes are pressure-dependent and are usually not apparent until pressures reach 15 mm Hg or more. This effect is not associated with any histologic pathology or evidence of renal tubular damage. After the release of the pneumoperitoneum or pneumoretroperitoneum, the renal function and urine output return to normal with no long-term sequelae, even in patients with pre-existing renal disease. The entire operative team must understand the physiologic effects of CO2 insufflation, which allows appropriate intraoperative monitoring and management and minimizes intraoperative and postoperative complications.

Single-Center Comparison of Purely Laparoscopic, Hand-Assisted Laparoscopic, and Open Radical Nephrectomy in Patients at High Anesthetic Risk

BACKGROUND AND PURPOSEnThe laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications.nnnPATIENTS AND METHODSnAll patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnetts T for pairwise comparisons.nnnRESULTSnThe ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN (

Preliminary Study of Virtual Reality and Model Simulation for Learning Laparoscopic Suturing Skills

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