Intensive laparoscopic training: the impact of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning curve.

We prospectively evaluated the learning curve (LC) for laparoscopic urethrovesical anastomosis (L-UVA) in an operator-training model and program using an innovative simplified pelvic-trainer model. Over a period of 12 months, 30 LRP were performed by one urologist skilled in open surgery but inexperienced in laparoscopy. During the first 15 procedures no systematic training was done. Consequentially, a systematic simplified daily program was performed on the pelvic trainer with a videolaparoscopic unit. The training lesson consisted of intracorporal knotting and suturing, linear and circular interrupted suture anastomosis. At the end of each lesson, time and performance error scores were recorded and progression curve was plotted for each task. The performances of each training tasks were plotted against the performance of L-UVA during the LRP. The significance of progression was evaluated using logarithmic regression analysis. A steady improvement in time and accuracy of performance skill was shown during the first 20 lessons (p<0.001). These improved skill acquisitions were proportionally correlated with the time and the accuracy (water-tight) of L-UVA performance during the last 15 L-RPE. Compared to the first 15 L-RPE, where no systematic training was performed, time and accuracy of L-UVA performance in the last 15 L-RPE were improved from a mean 51 (median 48, range: 38-75) to 26 (median 24, range 18-33) min (p<0.001) and from 10 to 15 watertight anastomoses (p<0.001), respectively. Using a continuing, systematic, simplified training model the LC of L-UVA can be improved significantly in a short time.

Laparoscopic radical prostatectomy: prospective evaluation of the learning curve.

OBJECTIVE: We prospectively evaluated the learning curve (LC) of laparoscopic radical prostatectomy (L-RPE) regarding the improvements in operative times (OT) and technical difficulty in one-operator-practice as it compares with open RPE. METHODS: Over 18 months, 50 L-RPE were performed by an inexperienced surgeon in laparoscopy but skilled in open surgery. Difficulty scores were obtained at the completion of each L-RPE comparing L-RPE to open RPE. OT, estimated blood loss (EBL), length of stay, and catheterization time were also obtained. RESULTS: In the ablative part of L-RPE the median difficulty score was significantly higher (p<0.001) for the first 10 cases, decreased dramatically by case 11 becoming equivalent (p=0.3) to open RPE and by case 31 the L-RPE becomes significantly easier than open RPE (p=0.002). The difficulty scores for the urethrovesical anastomosis performance is always uniformly higher for the whole patient series (p<0.001). Median OT decreased significantly from 293 minutes in the first 10 cases to 114 minutes in the last 10 cases (p<0.001). Catheterization time and length of hospitalization, decreased significantly with the progression of the LC. EBL remained stable throughout the patient cases. Obesity, prior surgery, and extension of the procedure (lymphadenectomy, nerve-sparing) significantly increased the OT. CONCLUSION: Although the ablative part of L-RPE has a relatively short LC for a skilled open surgeon reflected by the rapid decrease in difficulty scores and OT by case 21, the performance of anastomosis shows a longer LC. Intensive training on anastomosis may be necessary to master this skill.

Quality of life after surgery for localized renal cell carcinoma: comparison between radical nephrectomy and nephron-sparing surgery.

OBJECTIVES: To compare the impact of radical nephrectomy and nephron-sparing surgery (NSS) for localized renal cell carcinoma on quality of life (QOL). METHODS: Retrospectively, 357 patients who had undergone NSS (n = 158) or radical nephrectomy (n = 199) for localized renal cell carcinoma completed postal questionnaires, including measures of QOL with validated instruments (SF-36, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 [EORTC QLQ-C30]), the impact of the stress of cancer, fear of recurrence, and worry about having fewer than two normal kidneys. A subset of 51 patients diagnosed after 2000 were followed up prospectively for at least 1 year. RESULTS: The mental and physical health composite scores were not significantly different from the validated norms for an age and sex-matched community sample. Although the type of operation had no influence on patients' overall QOL, all patients who underwent elective NSS showed a significantly greater score on physical function than patients treated with radical nephrectomy (P <0.001). Predictors for higher scores included elective NSS, comorbidity (assessed with standardized checklist), tumor size, and time since nephrectomy. The overall QOL scores and recovery of stress from cancer in patients treated with NSS for tumor less than 4 cm with a normal contralateral kidney were significantly superior to those who underwent NSS for tumor greater than 4 cm (P <0.05). Patients questioned after mandatory NSS were significantly more concerned about cancer recurrence. CONCLUSIONS: Patients without evidence of disease have relatively normal physical and mental health after operative treatment for localized renal cell carcinoma, independent of the kind of surgery. The QOL correlates proportionally with the size of tumor and is significantly better for patients undergoing NSS for tumor less than 4 cm with a normal contralateral kidney.