Minimal contamination of the human peritoneum after transvesical incision.

BACKGROUND AND PURPOSE: The recent literature has questioned the infectious risk of natural orifice translumenal endoscopic surgery (NOTES). The need for a clean portal of entry may be important to minimize peritoneal contamination after NOTES. Our study examines the resultant microbial contamination of the human peritoneum after transvesical incision and exposure of the abdomen to bladder contents during robot-assisted laparoscopic prostatectomy (RALP) to better understand the potential for infection in transvesical NOTES. PATIENTS AND METHODS: Sixty consecutive men undergoing RALP for clinically localized prostate adenocarcinoma from January to May 2008 were prospectively studied as part of a database approved by an Institutional Review Board. The patient's preoperative urine microscopy values, complete blood cell count, and prostate-specific antigen (PSA) levels were recorded, along with the total length of time the cystotomy was open to the peritoneum. Intraoperative samplings of peritoneal fluid were collected before and after transvesical incision and sent for anaerobic, aerobic and fungal cultures. RESULTS: Patients undergoing RALP had peritoneal exposure after transvesical incision for an average of 118 minutes. Five of 60 (8.3%) patients had evidence of novel aerobic bacterial contamination of the peritoneum after RALP. No patient had a positive anaerobic culture or fungal culture from the peritoneum. Preoperative serum leukocyte and PSA levels were elevated in patients with peritoneal contamination (P < 0.05). Remaining clinicopathologic features, total operative time, or open cystotomy time did not predict peritoneal contamination. CONCLUSION: Prolonged peritoneal exposure to bladder contents demonstrates minimal contamination of the abdominal cavity and is without postoperative infectious significance. This study may overestimate bacterial contamination via the bladder during RALP, because the specific bacteria seen may have originated from the seminal or prostatic fluid during prostatectomy. Transvesical incision would effectively be a clean portal of entry for NOTES with its low rate of peritoneal contamination.

Use of high fidelity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: initial experience.

PURPOSE: Structured opportunities for learning communication, teamwork and laparoscopic principles are limited for urology residents. We evaluated and taught teamwork, communication and laparoscopic skills to urology residents in a simulated operating room. MATERIALS AND METHODS: Scenarios related to laparoscopy (insufflator failure, carbon dioxide embolism) were developed using mannequins, urology residents and nurses. These scenarios were developed based on Accreditation Council for Graduate Medical Education core competencies and performed in a simulation center. Between the pretest scenario (insufflation failure) and the posttest scenario (carbon dioxide embolism) instruction was given on teamwork, communication and laparoscopic skills. A total of 19 urology residents participated in the training that involved participation in at least 2 scenarios. Performance was evaluated using validated teamwork instruments, questionnaires and videotape analysis. RESULTS: Significant improvement was noted on validated teamwork instruments between scenarios based on resident (pretest 24, posttest 27, p = 0.01) and expert (pretest 16, posttest 25, p = 0.008) evaluation. Increased teamwork and team performance were also noted between scenarios on videotape analysis with significant improvement for adherence to best practice (p = 0.01) and maintenance of positive rapport among team members (p = 0.02). Significant improvement in the setup of the laparoscopic procedure was observed (p = 0.01). Favorable face and content validity was noted for both scenarios. CONCLUSIONS: Teamwork, intraoperative communication and laparoscopic skills of urology residents improved during the high fidelity simulation course. Face and content validity of the individual sessions was favorable. In this study high fidelity simulation was effective for assessing and teaching Accreditation Council for Graduate Medical Education core competencies related to intraoperative communication, teamwork and laparoscopic skills.