Laparoscopic training safely flattening the learning curve for urologists

May 15, 2007

Recent research has shown that urologists who have not been formally trained in laparoscopic or robotic surgery can safely flatten the learning curve with a combination of courses and mentoring that are designed to increase the uptake of skills.

Key Points

"The old idea of 'See one, do one, teach one, and, therefore, I'm qualified to do the procedure' is becoming less prevalent," explained George Haleblian, MD, clinical associate of urology at Duke University Medical Center, Durham, NC. "Metrics are being developed so that there can be objective proof that urologists are qualified to do minimally invasive pro-cedures.

"That is where things are heading in the future," Dr. Haleblian told colleagues at the Winter Urologic Forum here.

"The benefits of training are numerous," said David Albala, MD, professor of urology at Duke. "It offers the opportunity to have a leader in the field teach you how to do the approach safely, identify complications earlier, and learn some of the tricks that have taken the leaders a long time to develop."

Dr. Albala presented one study of 71 postgraduate urologists who attended a course on HAL at Duke. Participants were primarily private practice urologists. They were encouraged to perform their first laparoscopic cases under the guidance of an experienced laparoscopist. Upon completion of the training, follow-up surveys were sent to assess the practice patterns of participants. The impact of postgraduate courses on HAL and the effect of mentoring on the use of these newly acquired skills were examined.

A majority of participants (93%) who were mentored by a course instructor or an experienced laparoscopist following the training course were performing laparoscopy in their practices. Of the participants who did not participate in the mentoring program, only 44% were performing laparoscopic procedures in their practices. The authors of the analysis concluded that urologists who attend laparoscopy courses are more likely to incorporate these techniques into their practice if they are mentored during the first few cases.

Robot-assisted prostatectomy

Robotic surgery is another technology gaining wider acceptance in the urologic community as a treatment for organ-confined adenocarcinoma of the prostate. In 2003, an estimated 500 robot-assisted laparoscopic prostatectomies (RALP) were performed. By 2006, that number had increased to 10,000. Robotics is widely accepted to be technically less challenging than pure laparoscopic prostatectomy. However, there is still a learning curve for performing RALP.

Residents in training and some physicians in practice have gone through the training course for the daVinci robot of-fered by its manufacturer, Intuitive Surgical (Sunnyvale, CA). Aside from this course, there is not a universal standard for robotics training at this time. To answer this need, a concentrated training program for learning RALP has been developed at Duke.

The training divides the procedure into four distinct, non-sequential steps that allow for graduated advancement to more complex segments in a controlled and supervised manner. This training program allows trainees to enter practice with competence in RALP. To date, three residents have completed the program.

"Each resident has decreased their operative times and has shown proficiency in each stage of the procedure by the time they complete their training. Furthermore, their positive margin rates are comparable to those reported in the literature," Dr. Haleblian said. "Even though formal training guidelines haven't been established for either HAL or RALP techniques, we've shown that training courses with subsequent mentoring improve the up-take of skills and increase frequency of use of these procedures in physicians' daily practices."