Phillip Mucksavage

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.

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.

High Fidelity Simulation Based Team Training in Urology: A Preliminary Interdisciplinary Study of Technical and Nontechnical Skills in Laparoscopic Complications Management

PURPOSEnSimulation based team training provides an opportunity to develop interdisciplinary communication skills and address potential medical errors in a high fidelity, low stakes environment. We evaluated the implementation of a novel simulation based team training scenario and assessed the technical and nontechnical performance of urology and anesthesiology residents.nnnMATERIALS AND METHODSnUrology residents were randomly paired with anesthesiology residents to participate in a simulation based team training scenario involving the management of 2 scripted critical events during laparoscopic radical nephrectomy, including the vasovagal response to pneumoperitoneum and renal vein injury during hilar dissection. A novel kidney surgical model and a high fidelity mannequin simulator were used for the simulation. A debriefing session followed each simulation based team training scenario. Assessments of technical and nontechnical performance were made using task specific checklists and global rating scales.nnnRESULTSnA total of 16 residents participated, of whom 94% rated the simulation based team training scenario as useful for communication skill training. Also, 88% of urology residents believed that the kidney surgical model was useful for technical skill training. Urology resident training level correlated with technical performance (p=0.004) and blood loss during renal vein injury management (p=0.022) but not with nontechnical performance. Anesthesia resident training level correlated with nontechnical performance (p=0.036). Urology residents consistently rated themselves higher on nontechnical performance than did faculty (p=0.033). Anesthesia residents did not differ in the self-assessment of nontechnical performance compared to faculty assessments.nnnCONCLUSIONSnResidents rated the simulation based team training scenario as useful for interdisciplinary communication skill training. Urology resident training level correlated with technical performance but not with nontechnical performance. Urology residents consistently overestimated their nontechnical performance.

Smoking Knowledge Assessment and Cessation Trends in Patients With Bladder Cancer Presenting to a Tertiary Referral Center

OBJECTIVEnTo determine the knowledge level of patients with bladder cancer (BC) regarding smoking risks. We also sought to determine the role of their urologists in initiating smoking cessation at the diagnosis. Smoking is the leading risk factor for BC in industrialized nations. However, little information is available regarding patients knowledge of the risks of smoking and the role of their urologists in initiating smoking cessation at diagnosis.nnnMETHODSnA smoking knowledge and cessation questionnaire was administered to 71 patients referred to the Johns Hopkins Hospital for BC from April 2008 to June 2009. The questionnaire captured data on demographics, BC history, smoking status and history, risk factor knowledge, and cessation patterns.nnnRESULTSnThe mean age of the cohort was 65.1 years (range 42-86) and 72% were men. At the referral, all 71 patients (100%) knew smoking was a risk factor for lung cancer compared with 61 (86%) who knew it was for BC. Only 36 patients (51%) knew smoking was the leading risk factor for BC. Of the 17 patients (24%) who were smokers at their BC diagnosis, 12 (71%) were counseled by their referring urologist to quit smoking; however, the significant majority (76%) was not offered any specific intervention.nnnCONCLUSIONnThe association between smoking and BC was not as well known as that of lung cancer in our cohort of patients. Most current smokers were advised to stop smoking by their primary urologist; however, few were offered any intervention to aid in cessation. Urologists should assume a more active role both in educating patients regarding smokings link to BC and in initiating smoking cessation.

Robotic Pyeloplasty: The University of California-Irvine Experience

PURPOSEnFor the treatment of ureteropelvic junction obstruction laparoscopic dismembered pyeloplasty and open pyeloplasty have similar outcomes. We present our experience with robot assisted laparoscopic dismembered pyeloplasty.nnnMATERIALS AND METHODSnWe retrospectively reviewed all adult robot assisted laparoscopic dismembered pyeloplasties performed at our institution between November 2002 and July 2009. Preoperative evaluation included abdominal computerized tomography angiogram to assess for crossing vessels and diuretic renal scan to quantify the degree of obstruction. Followup with diuretic renal scan and a patient pain analog scale was performed 3, 6 and 12 months after surgery. If the study was normal at 12 months, the patient was followed with ultrasound of the kidneys and bladder to look for ureteral jets. Absent ureteral jets, worsening hydronephrosis or patient complaint of pain necessitated repeat diuretic renogram.nnnRESULTSnA total of 61 robot assisted laparoscopic dismembered pyeloplasties were performed in 21 men and 40 women. Followup was available for 57 patients with an average ± SD age of 35 ± 16 years and average followup of 18 ± 15 months. Mean operative time was 335 ± 88 minutes and estimated blood loss was 61 ± 48 ml. Average hospitalization time was 2 ± 0.9 days and the average postoperative analgesia requirement was 13 ± 9.6 mg morphine sulfate equivalents. The overall success rate was 81% based on a normal diuretic renogram and lack of pain using a validated pain scale. There were 3 grade III Clavien complications for a 4.9% major complication rate.nnnCONCLUSIONSnRobot assisted laparoscopic dismembered pyeloplasty is a feasible technique for ureteropelvic junction reconstruction. When measured by the more stringent application of diuretic renography and analog pain scales, the success rate for ureteropelvic junction obstruction management appears similar to that of open or standard laparoscopic approaches.

Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy: Experience of Novice Robotic Surgeons

The introduction of robot-assisted laparoscopic surgery has facilitated the application of minimally invasive surgical techniques to many complex reconstructive and extirpative procedures. Even early on in their learning experience, robotic surgeons have been able to complete procedures using a minimally invasive approach, but would not have been able to do so using a purely laparoscopic technique. Although the open surgical approach remains the standard of care in the management of large renal tumors presenting with a thrombus within the vena cava, robot-assisted surgery may provide the precision and dexterity necessary to allow for the safe application of minimally invasive techniques to such complex clinical scenarios, perhaps even by relatively novice robotic surgeons. We describe the management of a large renal mass with vena caval thrombus (cT3b), which required complete cross-clamping of the vena cava, with the use of a purely robot-assisted laparoscopic approach.

A History and Evolution of Laparoscopic Nephrectomy: Perspectives From the Past and Future Directions in the Surgical Management of Renal Tumors

June 25, 2010 marks the twentieth anniversary of the first clinical laparoscopic nephrectomy. Since the advent of this procedure a paradigm shift toward minimally invasive options for urological surgery has been witnessed, resulting in rapid technological innovations and improved patient outcomes. A history of the minimally invasive surgical management of renal masses is presented with a focus on laparoscopic nephrectomy.

Sprayed Fibrin Sealant as the Sole Hemostatic Agent for Porcine Laparoscopic Partial Nephrectomy

PURPOSEnTisseel® is used to control minor bleeding during laparoscopic procedures. The DuploSpray MIS™ spray system allows thin, even application over a larger surface area. We use sprayed Tisseel as the sole agent to control hemorrhage and seal the renal collecting system after severe porcine laparoscopic partial nephrectomy.nnnMETHODS AND MATERIALSnWe performed staged bilateral severe laparoscopic partial nephrectomy in 12 Yucatan pigs using a longitudinal cut from upper to lower pole through the entire collecting system. In each pig 1 kidney was harvested immediately while the other was harvested after 4 weeks. After hilar clamping laparoscopic partial nephrectomy was done with cold scissors in 6 pigs while LigaSure™ was used in the other 6. Sprayed Tisseel was applied, and bleeding and urinary leakage were evaluated. Additional Tisseel was applied for repeat bleeding. We performed retrograde pyelogram (chronic) and burst pressure testing of the arterial and collecting systems.nnnRESULTSnAll animals survived 4 weeks. One urinoma was seen on retrograde pyelogram in the cold cut group. Average hilar clamp time was similar in the acute and chronic study arms. Average estimated blood loss was significantly less in the LigaSure group (p = 0.0045). Average arterial burst pressure was significantly different in the chronic and acute groups (605.8 vs 350.4 mm Hg, p = 0.008) but average collecting system burst pressure was similar (186.3 and 149.5 mm Hg, respectively).nnnCONCLUSIONSnSprayed Tisseel without suturing effectively sealed the arterial and collecting system after severe laparoscopic partial nephrectomy in the porcine model.

Medical Students Pursuing Surgical Fields Have No Greater Innate Motor Dexterity than Those Pursuing Nonsurgical Fields

INTRODUCTIONnMedical students pursue different career paths based on a variety of factors. We sought to examine the impact of innate manual dexterity, both perceived and objective, on the career interests of medical students.nnnMETHODSnThird-year medical students from the University of California, Irvine were recruited for this study. Subjects completed a pretest questionnaire followed by assessment of gross and fine motor dexterity using the Purdue Pegboard test. A total of 6 independent trials were performed, 3 for each hand. The scores were recorded as an integer value between 0 and 25. A statistical analysis was performed using student t tests, the Fischer exact test, or the χ(2) test, where appropriate.nnnRESULTSnA total of 100 students completed the questionnaire while 58 completed the dexterity testing. Students interested in a surgical field (SF) were similar in handedness, gender, video game exposure, and learning style as those interested in a nonsurgical field (NSF). In the SF group, personal skill set was reported as the most common factor influencing career selection, and interest in disease process/patient population was reported most commonly by NSF students (p = 0.015). Although a perceived innate manual dexterity was higher among SF students compared with NSF students (p = 0.032), no significant objective differences were found in right hand, left hand, or combined dexterity scores.nnnCONCLUSIONSnPerceived personal skill set may influence strongly a medical students career choice. Despite greater perceived manual dexterity, students interested in an SF do not have greater objective innate manual dexterity than those interested in an NSF.

Comparison of radiographical imaging modalities for measuring the diameter of renal masses: is there a sizeable difference?

Study Type – Diagnostic (case series)