Gunter De Win

Learning curves for urological procedures: a systematic review

To determine the number of cases a urological surgeon must complete to achieve proficiency for various urological procedures.

Learning curves for urological procedures

To determine the number of cases a urological surgeon must complete to achieve proficiency for various urological procedures.

Pubertal Screening and Treatment for Varicocele do not Improve Chance of Paternity as Adult

PURPOSE We investigated the eventual positive effects of early screening and treatment for varicocele in pubertal boys without symptoms to determine their chance of paternity later in life. It has not been proved if the presence of varicocele during puberty has an influence on later fertility or paternity. However, since an influence is believed to exist, beginning in 1987 the Belgian Society of Pediatrics has recommended screening all boys 12 to 17 years old during their yearly medical examination and referral for followup or treatment if varicocele is detected. At our clinic patients and their parents were informed about and able to choose between varicocele treatment (antegrade sclerotherapy) and observation. We subsequently contacted these patients, who are now older than 30 years, and inquired about their paternity. MATERIALS AND METHODS We selected for this study pubertal boys 12 to 17 years old with a varicocele who were referred by screening pediatricians to our pediatric urology clinic between 1989 and 2005. We excluded patients with bilateral or unilateral right varicocele and patients with other medical problems that could influence fertility. A total of 661 patients were eligible for the study. Minimally invasive treatment of varicocele, ie antegrade sclerotherapy (with the patient under local or general anesthesia), was offered but not required. Of the patients 372 underwent treatment (mean age 15.3 years, median 15.6) and 289 were followed conservatively (mean age 17.1, median 16.4). All patients were contacted twice by letter and, if no response was received, once by telephone. Patients were asked about paternity, time to conception and whether they had visited a fertility center. RESULTS Of the 361 respondents 158 (43%) had an active desire to have a child. Paternity was achieved in 85% of the conservatively followed group and 78% of the active treatment group (p >0.05). CONCLUSIONS There is no beneficial effect of pubertal screening and treatment for varicocele regarding chance of paternity later in life.

Feasibility and construct validity of a novel laparoscopic skills testing and training model

The apprentice–tutor model was useful for training surgeons for many years, but the complexity of surgical technology in the 21st century, especially endoscopic surgery, has exponentially increased the demands for surgical education. Therefore, more and more people now accept that endoscopic surgery, demanding as it requires specific skills, should also be taught outside the operating theatre. Although many systems, including animal models and simulators, have been proposed, an in-house structured and validated method for testing and training laparoscopic skills is missing in gynaecology. We have developed a laparoscopic skills testing and training (LASTT) model and performed two studies evaluating its feasibility and the construct validity of three different exercises (camera navigation, camera navigation and forceps handling, and forceps handling and bi-manual coordination), specifically selected to test and train laparoscopic psychomotor skills (LPS). In the first study, ten experts and 14 novices repeated each exercise between 20 and 30 times. The results demonstrated that the model is useful for testing and training laparoscopic skills. Clear learning curves were observed for both experts and novices, with better scores for the former at the beginning and the end of the study, proving the construct validity of the model. In the second study, 42 experts and 241 novices repeated each exercise three times during skill evaluation workshops organised by the European Academy of Gynaecological Surgery. The results confirmed the construct validity of the model. In conclusion, the LASTT model seems a cost-effective tool for providing an in-house program for continuous training and evaluation of LPS in all surgical disciplines in which laparoscopic procedures are, or might be, performed.

Correlation between compression, tensile and tearing tests on healthy and calcified aortic tissues

An anastomosis performed in calcified tissues tears up faster than in healthy tissues. This study develops and validates an in vitro non-destructive method to distinguish healthy from calcified aortic tissues. An uniaxial unconfined compression test is able to distinguish healthy from calcified aortas (p<0.01). The compressive E-modulus at a strain level of 10% is 227+/-34kPa for artificially calcified and 147+/-15kPa for healthy porcine aortic tissues. Calcified aortic tissues have a lower tensile strength than healthy porcine aortic tissues (p<0.05). The ultimate tensile strength is 1.34+/-0.18MPa and 1.55+/-0.31MPa for artificially calcified and healthy porcine aortic tissues respectively. Calcified aortic tissues have a lower resistance to tearing than healthy aortic tissues (p<0.05). The resistance to tearing is 1.78+/-0.33N/mm and 2.16+/-0.64N/mm for artificially calcified and healthy porcine aortic tissues respectively.

Laparoscopy Training in Surgical Education: The Utility of Incorporating a Structured Preclinical Laparoscopy Course into the Traditional Apprenticeship Method

OBJECTIVE To investigate whether preclinical laparoscopy training offers a benefit over standard apprenticeship training and apprenticeship training in combination with simulation training. DESIGN This randomized controlled trial consisted of 3 groups of first-year surgical registrars receiving a different teaching method in laparoscopic surgery. SETTING The KU LEUVEN Faculty of Medicine is the largest medical faculty in Belgium. PARTICIPANTS Thirty final-year medical students starting a general surgical career in the next academic year. METHODS Thirty final-year medical students were randomized into 3 groups, which differed in the way they were exposed to laparoscopic simulation training but were comparable in regard to ambidexterity, sex, age, and laparoscopic psychomotoric skills. The control group received only clinical training during surgical residentship, whereas the interval group received clinical training in combination with simulation training. The registrars were allowed to do deliberate practice. The Centre for Surgical Technologies Preclinical Training Programme (CST PTP) group received a preclinical simulation course during the final year as medical students, but was not exposed to any extra simulation training during surgical residentship. At the beginning of surgical residentship and 6 months later, all subjects performed a standardized suturing task and a laparoscopic cholecystectomy in a POP Trainer. All procedures were recorded together with time and motion tracking parameters. All videos were scored by a blinded observer using global rating scales. RESULTS At baseline the 3 groups were comparable. At 6 months, for suturing, the CST PTP group was better than both the other groups with respect to time, checklist, and amount of movements. The interval group was better than the control group on only the time and checklist score. For the cholecystectomy evaluation, there was a statistical difference between the CST PTP study group and both other groups on all evaluation scales in favor of the CST PTP group. CONCLUSIONS Structured, preclinical proficiency-based training is better than clinical training combined with laboratory training or clinical training alone.

Evaluation of an intuitive writing interface in robot-aided laser laparoscopic surgery

Objective: The feasibility of the conceptual Intuitive Writing Interface (IWI) in robot-aided laser laparoscopic surgery has been demonstrated previously. This paper investigates the potential improvement of IWI by comparing conventional manipulation (CM) and IWI manipulation (IM) and conducting an animal experiment. Materials and Methods: Three tasks were designed that were considered to be representative of laser laparoscopic surgical procedures. All test participants used both CM and IM in all tasks. Completion time and error level of each task were taken as comparative indices and were integrated into a self-defined Index of Time and Error (ITE). Six sequential in vitro trials were carried out to investigate learning curves. In addition, nephrectomy was performed on a rabbit by employing IWI in robot-aided laser laparoscopic surgery. Results: The results showed significant advantages for IM, with shorter completion time, more successful shots, and smaller error length in the three tasks, as compared to CM. The learning curve showed a promising trend for IM. More than half of the participants performed better with IM. The animal model experiment demonstrated the clinical feasibility of IM, but at the same time revealed some limitations. Conclusions: The new IWI interface definitely improved laser laparoscopic procedures by taking advantage of familiar writing skills. With its flexibility of implementation and ease of use, IWI has clear potential for use in laser laparoscopic procedures.

An evidence-based laparoscopic simulation curriculum shortens the clinical learning curve and reduces surgical adverse events

Background Surgical simulation is becoming increasingly important in surgical education. However, the method of simulation to be incorporated into a surgical curriculum is unclear. We compared the effectiveness of a proficiency-based preclinical simulation training in laparoscopy with conventional surgical training and conventional surgical training interspersed with standard simulation sessions. Materials and methods In this prospective single-blinded trial, 30 final-year medical students were randomized into three groups, which differed in the way they were exposed to laparoscopic simulation training. The control group received only clinical training during residency, whereas the interval group received clinical training in combination with simulation training. The Center for Surgical Technologies Preclinical Training Program (CST PTP) group received a proficiency-based preclinical simulation course during the final year of medical school but was not exposed to any extra simulation training during surgical residency. After 6 months of surgical residency, the influence on the learning curve while performing five consecutive human laparoscopic cholecystectomies was evaluated with motion tracking, time, Global Operative Assessment of Laparoscopic Skills, and number of adverse events (perforation of gall bladder, bleeding, and damage to liver tissue). Results The odds of adverse events were 4.5 (95% confidence interval 1.3–15.3) and 3.9 (95% confidence interval 1.5–9.7) times lower for the CST PTP group compared with the control and interval groups. For raw time, corrected time, movements, path length, and Global Operative Assessment of Laparoscopic Skills, the CST PTP trainees nearly always started at a better level and were never outperformed by the other trainees. Conclusion Proficiency-based preclinical training has a positive impact on the learning curve of a laparoscopic cholecystectomy and diminishes adverse events.

Porcine cadaver organ or virtual-reality simulation training for laparoscopic cholecystectomy: a randomized, controlled trial.

OBJECTIVES As conventional laparoscopic procedural training requires live animals or cadaver organs, virtual simulation seems an attractive alternative. Therefore, we compared the transfer of training for the laparoscopic cholecystectomy from porcine cadaver organs vs virtual simulation to surgery in a live animal model in a prospective randomized trial. DESIGN After completing an intensive training in basic laparoscopic skills, 3 groups of 10 participants proceeded with no additional training (control group), 5 hours of cholecystectomy training on cadaver organs (= organ training) or proficiency-based cholecystectomy training on the LapMentor (= virtual-reality training). Participants were evaluated on time and quality during a laparoscopic cholecystectomy on a live anaesthetized pig at baseline, 1 week (= post) and 4 months (= retention) after training. SETTING All research was performed in the Center for Surgical Technologies, Leuven, Belgium. PARTICIPANTS In total, 30 volunteering medical students without prior experience in laparoscopy or minimally invasive surgery from the University of Leuven (Belgium). RESULTS The organ training group performed the procedure significantly faster than the virtual trainer and borderline significantly faster than control group at posttesting. Only 1 of 3 expert raters suggested significantly better quality of performance of the organ training group compared with both the other groups at posttesting (p < 0.01). There were no significant differences between groups at retention testing. The virtual trainer group did not outperform the control group at any time. CONCLUSIONS For trainees who are proficient in basic laparoscopic skills, the long-term advantage of additional procedural training, especially on a virtual but also on the conventional organ training model, remains to be proven.

Obstetric fistula in a district hospital in DR Congo: Fistula still occur despite access to caesarean section.

To study the profile of classification, etiology, and the relation between initial classification, and the results of vesicovaginal fistula surgery in a district hospital in DR Congo.