No-scar procedures, human simulators on the horizon for urologic surgical training

May 15, 2007

Two innovative technologies for surgical training are approaching urologic practice, but how long it will take for them to arrive depends on the hurdles they must leap.

Key Points

The first of these is an invasive technology that promises to leave no visible scarring because the instrumentation will enter the abdominal cavity through the mouth, vagina, or rectum. It bears the acronym NOTES: Natural Orifice Transluminal Endoscopic Surgery.

The second is the development of a simulator that will allow urologists to learn and to practice laparoscopic nephrectomies and, perhaps, other urologic procedures.

More recently, endoscopists at Columbia University Medical Center in New York reported on the removal of a woman's gall bladder using NOTES. The gall bladder was detached and removed through the vagina, which was then sutured, the group reported at the Society of American Gastrointestinal Endoscopic Surgeons meeting in Las Vegas.

Another aspect of NOTES is that, at this stage, the technology appears amenable to robotic control, Dr. McDougall pointed out.

"NOTES is where laparoscopy was in the late 1980s. Then there was just a paper suggesting that a kidney could be removed through three small incisions in the abdominal wall. There was a lot of skepticism," she said.

"The primary advantage [of NOTES] is the most obvious. There will be no incision in the patient's abdomen. There will be no scarring. However, it has to be shown that it is efficacious, that it is cost effective, and that it reduces patient morbidity."

Standing beside NOTES on the horizon is the development of electronic human simulators that mimic urologic presentations.

"The AUA is going to work with Medical Education Technologies Inc. (METI) of Sarasota, FL, to develop the very first dedicated laparoscopic renal surgery simulator," Dr. McDougall told Urology Times.

A January 2007 announcement by METI described the device as a "high-end, real-time, interactive graphic simulation platform for psychomotor skills and related didactic education content in the area of laparoscopic renal and prostate procedures."

Dr. McDougall said that community urologists will be among those deriving the greatest benefit from such simulators.

"The problem community urologists face is that laparoscopic nephrectomy is not a procedure they perform with any great frequency. Some may perform only two or three a year. How do they maintain difficult laparoscopic skills?" she said.

She suggested that simulators located in regional centers would allow community urologists to maintain and improve their skills at regular intervals. Another benefit is that the device might be able to mimic presentations and complications that even urologists practicing in large clinics infrequently see.

"The simulator would provide a risk-free environment in which to practice and experience complications that could be anticipated and avoided in practice. This would allow community urologists to maintain their skills at a level that allows them to confidently offer laparoscopic nephrectomies to their patients," she said.