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Journal of Pediatric Urology (2015) xx, 1.e1e1.e6
Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre R.P.J. Schroeder a, R.J. Chrzan b, A.J. Klijn c, C.F. Kuijper b, P. Dik c, T.P.V.M. de Jong c
a
Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
b
University Children’s Hospitals AMC Amsterdam and UMC Utrecht, AMC Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
c University Children’s Hospitals AMC Amsterdam and UMC Utrecht, UMC (WKZ) Utrecht, Postbus 85090, 3508 AB Utrecht, The Netherlands
Correspondence to: R.P.J. Schroeder, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands, Tel.: þ31 205994810; fax: þ31 205993802 [email protected] (R.P.J. Schroeder) [email protected] (R.J. Chrzan) [email protected] (A.J. Klijn) [email protected] (C.F. Kuijper) [email protected] (P. Dik) [email protected] (T.P.V.M. de Jong) Keywords Internship and residency; Hospital education department; Laparoscopy; Minimally invasive surgical procedures; Pediatrics; Urology
Summary Background Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. Objective To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). Study design The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients’ ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Results Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and
1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children 2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. Discussion There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Conclusion Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.
Received 16 October 2014 Accepted 14 March 2015 Available online xxx
http://dx.doi.org/10.1016/j.jpurol.2015.03.022 1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Figure Pyeloplasty and nephrectomy performed by open or minimally invasive surgery (MIS) in 2012 with reference to the age of the patient.
Introduction Paediatric urology is a relatively new medical specialty that grew out of urology and paediatric surgery. Minimally invasive surgery (MIS) is becoming a more prominent procedure in the field. Its foundation lies in the use of the cystoscope to inspect the peritoneal cavity. MIS has mainly been employed for the localization of non-palpable, undescended testes [1e3]. Over the years, MIS has evolved due to improvements in the instrumentation and the creativity of specialized surgeons. Simple diagnostic and ablative procedures have paved the way for intricate, reconstructive, laparoscopic surgery [4]. Currently, orchidopexy, partial nephrectomy, and ureteral reimplantation are widely performed in paediatric urology. Laparoscopic retroperitoneal and transperitoneal pyeloplasty is believed to be the gold standard procedure, and patients are increasingly requesting ‘keyhole’ surgery [5]. The outcomes of MIS are comparable to those of open techniques. Laparoscopy has been shown to be effective and safe with a low morbidity rate [2,6,7]. It is known to have a steep learning curve due its technical challenges. Extended training and repetition are needed to become a skilful laparoscopic surgeon [8,9]. In fact, the rate of complication in MIS is mainly dictated by the experience of the surgeon [7]. The intensive training needed for this procedure has become an important issue and has received increasing
attention from the medical community. Increased numbers of operations are needed to improve in MIS techniques. Nevertheless, no minimum number of procedures has been specified as a requirement for performing MIS procedures in paediatric urology. There is no consensus concerning the number of operations needed to become proficient in MIS. Assessment of surgeons is mainly based on their supervisors’ evaluations [8]. The Department of Paediatric Urology at UMC, Utrecht (UMCU) was accredited in 2006 by the Joint Committee of Paediatric Urology (JCPU). In 2008, a close collaboration began with the Department of Paediatric Urology of the Academic Medical Centre (AMC) in Amsterdam. As a result, one central centre (AMC-UMCU) has been formed under the same leadership and operates at two locations. In this centre ablative MIS is being performed by two staff members. Currently, the centre does not offer a separate structured MIS training programme. Therefore, MIS is included in the basic training programme. This article reviews and analyses the overall surgical MIS activity in a highly specialized, tertiary care, paediatric urology training centre to evaluate the centre’s potential as a MIS training centre.
Materials and methods The clinical activity of the AMC-UMCU centre was retrospectively reviewed. The data were collected from the
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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JAVA application ‘Zorgdesktop’ (AZD) (in-house-developed, Amsterdam, The Netherlands) at the AMC and from the ‘ziekenhuisinformatiesysteem’ (ZIS)/‘Elektronisch Patie ¨ntendossier’ (EPD) (ChipSoft, Amsterdam, the Netherlands) at the UMCU. The annual numbers of admissions, outpatient consultations and operative procedures were extracted. The operative procedures were divided into open and MIS procedures. More detailed analyses of the ages of the patients who underwent major procedures performed by either the open or MIS approach (nephrectomy and pyeloplasty) are provided. From these data, the potential number of laparoscopic procedures was determined. Currently, the AMC-UMCU policy on MIS is as follows: 1. Diagnostic and minor procedures (orchidopexy) in all ages; 2. Major ablative and reconstructive procedures: - No MIS below 24 months (12 kg) - MIS is preferred in children above 3 years (15 kg). In addition to these limits, the choice of an open or MIS procedure depends on the preferences of the parents and surgeon. Minor MIS can be performed by any of the staff, ablative MIS is only performed by two staff members (RC and AK), and reconstructive MIS is only performed by one surgeon (RC).
Results There are five staff members and one fellow working in the department. The number of out-patient consultations, hospital admissions and operative procedures gradually rose between 2008 and 2010. The numbers for the collaboration centre stabilized in 2011. Annually, the centre provides approximately 4300 out-patient consultations, 600 admissions and 1300 procedures under general anaesthesia for children with urological problems. Until 2006, only diagnostic and minor laparoscopic procedures were performed. The first laparoscopic nephrectomy and pyeloplasty in the department were performed after 2006. Table 1 provides a subdivision of all of the Table 1 Operative procedures in AMC-UMCU subdivided per procedure for 2006 and 2012. For 2012, the total operations for each category and the numbers performed using minimally invasive surgery (MIS) are shown. Operation
Orchidopexy Nephrectomy Incontinence surgery Pyeloplasty Ureteral reimplantation Heminephrectomy a
2006
2012
Total
Total
MIS
166 22 22b 44 82 11
25 8 11c 16 1 0
130 13 18b 22 65 11
a
Of which 30 patients by MIS (23%). Intravesical bladder neck reconstruction, colposuspension and fascia sling. c Intravesical bladder neck reconstruction and colposuspension. b
surgical procedures performed in the centre in 2006 and in 2012. These numbers are subdivided to indicate the number of MIS procedures performed each year. Laparoscopic inspection of the peritoneal cavity for impalpable testes was the only MIS performed until 2006 and was done in 30 patients. In 2012, ablative and reconstructive MIS were also done. In total, 61 laparoscopic procedures were performed. Thirty-five of these patients underwent major intricate MIS procedures, which included 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch and four bladder neck procedures). The remaining MIS procedures consisted of 25 orchidopexies and one intravesical ureteral reimplantation. Fig. 1 shows the subdivision of open and laparoscopic pyeloplasties and nephrectomies performed in 2012. The procedures are analysed according to the age of the patient. For the older patients, both nephrectomy and pyeloplasty were performed primarily by MIS. In patients older than two years, 16/21 pyeloplasties and 8/12 nephrectomies were performed laparoscopically.
Discussion In this article, the characteristics and numbers of open and MIS procedures performed in a large, JCPU-recognized, educational paediatric urological centre are shown. The numbers of MIS operative procedures were analysed. The percentage of MIS operations performed, based on the age of the patients, was assessed to determine the laparoscopic training potential of the educational centre. To our knowledge, there are no recognized or approved centres in Europe that offer a separate MIS training programme in paediatric urology. However, MIS is increasingly being requested in paediatric urology. The number of novel surgical procedures performed is dictated by patient demand and their perception of the techniques. The establishment of a gold standard for one of the first intricate MIS procedures, laparoscopic cholecystectomy, was mainly driven by the public [5]. In addition to safety and efficacy as the most important factors, the cosmetic consequences of a procedure are also important in surgical treatment decision making. This is especially true for younger patient groups [5,10]. There has been much debate concerning the pros and cons of MIS. The modern techniques usually introduce new medical costs. MIS is more expensive than the standard open procedures because of the need for specialized instruments, intensive training and extended operation times. In contrast, the hospital stay is generally shorter after MIS, resulting in reduced costs and a faster return to normal activities [2,3,7,11]. From the socioeconomic viewpoint, a child’s early return to normal activity after laparoscopic surgery does not directly add productivity, but their parents’ earlier resumption of work does. This is particularly important for families with young children [3,12]. In addition to cost, the clinical benefits of MIS need to be understood. Among these benefits are reduced postoperative pain and blood loss, faster return home and less scarring with better cosmetic outcomes [2,3,7,11].
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Figure 1 Pyeloplasty and nephrectomy performed by open or minimally invasive surgery (MIS) in 2012 with reference to the age of the patient.
MIS is known to have a steep learning curve. A large number of operations are required to become a skilful surgeon. The number of procedures quoted for proficiency in paediatric MIS remains controversial. Nevertheless,
R.P.J. Schroeder et al. various proposed numbers appear to be consistent with those reported for proficiency in adult surgery. For intricate reconstructive MIS (such as laparoscopic pyeloplasty) approximately 30 procedures are proposed as necessary to develop proficiency [3,13]. Paediatric urology is a relatively low-volume surgical subspecialty. It is difficult to achieve MIS numbers high enough for adequate training. The study results support this, with only 16 pyeloplasties, eight nephrectomies and 11 incontinence MIS procedures performed in 2012. Over the years, the MIS numbers at the centre have increased, primarily due to the increased experience of the two skilled surgeons. The laparoscopic pyeloplasty numbers at this centre correspond to the yearly average of 12 (124/10) between 1999 and 2010 mentioned by Blanc et al. [13]. The numbers at this centre exceeded the yearly average of 5.4 (54/10) pyeloplasties and 5 (50/10) nephrectomies at the Children’s Hospital in Boston, USA, between 1995 and 2005 [6]. The number of laparoscopic procedures a surgeon needs to perform during training remains difficult to estimate, due to the lack of a consensus or guidelines on how to assess laparoscopic training in paediatric urology. Based on only the number of operations, it seems obvious that the number of laparoscopic procedures per paediatric urology clinic is not high enough to broadly teach MIS. This will predominantly affect medical doctors at the beginning of their surgical training (such as fellows and residents). Often, subspecialized paediatric surgeons are still training and gaining experience with MIS skills. As a result, only a few surgeons are sufficiently experienced to adequately supervise and teach laparoscopic procedures [14,15]. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Lowering the age for major ablative and reconstructive MIS would only slightly increase the number of MIS operations in the centre. In 2012, if the cut-off had been 10 kg (1 year old), 12 laparoscopic nephrectomies and 20 pyeloplasties could have been performed. This cut-off appears to be feasible both technically and in terms of anaesthesia [16]. With the introduction of robotic MIS, this goal might even be easier to accomplish [17,18]. Nevertheless, feasibility alone does not make a procedure good for the patient. The issue of what is best for the patient has not been addressed in feasibility studies, and there has been no validation of the cosmetic value or the postoperative pain after MIS in neonates. Modern MIS techniques have been introduced gradually and have been predominantly embraced by only the latest generation of surgeons. The introduction of advanced laparoscopy occurred more slowly in paediatric urology than in paediatric surgery. In particular, for the surgeons who exclusively practise paediatric urology, it is difficult to adequately learn the techniques. For this reason, the centre appointed only two staff members to perform MIS. It is hoped that the number of MIS procedures in patients who are eligible for it will be maximized. Possible expansion of the number of MIS procedures performed in paediatric urology is limited, and the centre must find other ways to improve the skills of the surgeons. Paediatric surgeons perform MIS on patients with a wide range of pathologies (including digestive tract and thoracic
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Training potential in minimally invasive surgery pathology) and thus achieve higher operation numbers. A potential solution to increase experience in MIS may include collaboration between laparoscopic paediatric surgeons and urologists. By increasing the number of procedures with which surgeons are involved, the training time necessary to master MIS will be shorter compared with that among paediatric urologists alone [8,19]. To increase laparoscopic exposure, centralizing the patients at one centre may also be a viable option. In The Netherlands, major laparoscopic procedures in the field of paediatric urology are currently performed in three university centres. Of course, proficiency cannot be assessed by operation numbers only. Quality of the training programme is essential. A new training concept for MIS, called modular surgical training, has been described by Stolzenburg et al. [20]. This training is similar to that used for laparoscopic radical prostatectomy and breaks the MIS procedure down into standardized teaching steps of variable complexity called modules. Modular training offers various advantages that may lead to a reduction in the time to proficiency. It facilitates step-by-step training, which can be offered during consecutive operations. Based on the mentor’s assessment of the trainee, the complexity can be gradually increased. Before progressing to the next step of the procedure, the trainee needs to obtain the requisite skills of the previous level. In this manner, highly complex laparoscopic procedures can be used for training on every level without putting patients at risk. Even beginners are able to perform some of the simpler steps of highly complex procedures. Furthermore, modular training allows for the teaching of more than one trainee during the same procedure. Currently, various laparoscopic procedures are being taught in modules [20,21]. The standardization of modules enables training at different sites, potentially in cooperation with other, high-volume centres. This method could also be of great value when teaching MIS in paediatric urology. The ex vivo laparoscopic training of surgeons is becoming increasingly important because hands-on training is critical in MIS. Both cognitive and psychomotor training on validated simulators are being incorporated to teach laparoscopic skills outside the operating theatre [22]. This technique enables novice surgeons to progress in their training before performing the procedure on a patient. Additionally, medical errors will decrease, which will improve the safety of the procedure [23]. Furthermore ex vivo training provides critical MIS training hours, which are difficult to obtain in vivo. A validated certification test, the Fundamentals of Laparoscopic Surgery, has been developed [23]. Several education departments only allow laparoscopic procedures to be performed on patients by certified residents [14,24]. Dutch medical residents are currently being assessed on MIS with the training tool called the Program for Laparoscopic Urologic Skills (PLUS). PLUS is considered appropriate for use as a primary training tool for an entry test or as part of a step-wise training program in which basic and procedural laparoscopic skills are integrated [25]. An effective curriculum for laparoscopic training combines inanimate models, animal labs, clinical exposure, and an individual review of experience. A mentor-initiated approach, combined with intensive dry and wet laboratory training, is considered the modern way to train surgeons in MIS [20].
1.e5 Conclusion, even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low. As a result, only a few staff members are able to adequately learn MIS procedures or maintain their skills. This situation leads to limited training opportunities for the surgeons. To provide highquality MIS training, exposure to laparoscopic procedures must be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities and training outside the operating theatre.
Ethical approval None sought.
Funding None declared
Conflict of interest None declared.
References [1] Cortesi N, Ferrari P, Zambarda E, Manenti A, Baldini A, Morano FP. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 1976;8:33e4. [2] Tomaszewski JJ, Casella DP, Turner 2nd RM, Casale P, Ost MC. Paediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations. J Endourol 2012;26:602e13. [3] Tam PK. Laparoscopic surgery in children. Arch Dis Child 2000; 82:240e3. [4] Norris RD, Ost MC. Evolution of laparoscopy in paediatric urology. Expert Rev Med Devices 2009;6:689e98. [5] Autorino R, White WM, Gettman MT, Khalifeh A, De Sio M, Lima E, et al. Public perception of ‘scarless’ surgery: a critical analysis of the literature. Urology 2012;80:495e502. [6] Passerotti CC, Nguyen HT, Retik AB, Peters CA. Patterns and predictors of laparoscopic complications in paediatric urology: the role of ongoing surgical volume and access techniques. J Urol 2008;180:681e5. [7] Peters CA. Complications in paediatric urological laparoscopy: results of a survey. J Urol 1996;155:1070e3. [8] Dagash H, Chowdhury M, Pierro A. When can I be proficient in laparoscopic surgery? A systematic review of the evidence. J Pediatr Surg 2003;38:720e4. [9] Tekgul S, Riedmiller H, Hoebeke P, Kocvara R, Nijman RJ, Radmayr C, et al. EAU guidelines on vesicoureteral reflux in children. Eur Urol 2012;62:534e42. [10] Olweny EO, Mir SA, Best SL, Park SK, Donnally Iii C, Cadeddu JA, et al. Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery. BJU Int 2012;110:268e72. [11] Scafuri AG, Miranda EP, Denes FT, Castilho LN, Mitre AI, Arap S. Comparison of videolaparoscopic versus open surgery for benign renal diseases in children. Actas Urol Esp 2009;33: 1115e21. [12] Behan JW, Kim SS, Dorey F, De Filippo RE, Chang AY, Hardy BE, et al. Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty. J Urol 2011;186:1663e7.
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1.e6 [13] Blanc T, Muller C, Abdoul H, Peev S, Paye-Jaouen A, Peycelon M, et al. Retroperitoneal laparoscopic pyeloplasty in children: long-term outcome and critical analysis of 10-year experience in a teaching center. Eur Urol 2013;63:565e72. [14] Brindley PG, Jones DB, Grantcharov T, de Gara C. Canadian Association of University Surgeons’ Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled? Can J Surg 2012;55:S200e6. [15] Stormer EJ, Sabharwal AJ. Review of laparoscopic training in paediatric surgery in the United Kingdom. J Laparoendosc Adv Surg Tech A 2009;19(Suppl. 1):S3e6. [16] Garcia-Aparicio L, Blazquez-Gomez E, Martin O, Manzanares A, Garcia-Smith N, Bejarano M, et al. Andersonhynes pyeloplasty in patients less than 12 months old. Is the laparoscopic approach safe and feasible? J Endourol 2014;28: 906e8. [17] Bansal D, Cost NG, Bean CM, Vanderbrink BA, Schulte M, Noh PH. Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery. J Pediatr Urol 2014;10:869e74. [18] Pelizzo G, Nakib G, Goruppi I, Avolio L, Romano P, Raffaele A, et al. Paediatric robotic pyeloplasty in patients weighing less than 10 kg initial experience. Surg Laparosc Endosc Percutan Tech 2014;24:e29e31. [19] Schneider CL, Cobb WS, Carbonell AM, Hill LK, Flanagan WF. A collaborative approach reduces the learning curve and
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improves outcomes in laparoscopic nephrectomy. Surg Endosc 2011;25:182e5. Stolzenburg JU, Schwaibold H, Bhanot SM, Rabenalt R, Do M, Truss M, et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005;96: 1022e7. Hemandas A, Flashman KG, Farrow J, O’Leary DP, Parvaiz A. Modular training in laparoscopic colorectal surgery maximizes training opportunities without clinical compromise. World J Surg 2011;35:409e14. Palter VN, Orzech N, Reznick RK, Grantcharov TP. Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial. Ann Surg 2013;257:224e30. Pellegrini CA, Sachdeva AK, Johnson KA. Program for Accreditation of Education Institutes becomes a reality. Bull Am Coll Surg 2006;91:34e5. Derevianko AY, Schwaitzberg SD, Tsuda S, Barrios L, Brooks DC, Callery MP, et al. Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety. Surg Endosc 2010;24:616e23. Tjiam IM, Persoon MC, Hendrikx AJ, Muijtjens AM, Witjes JA, Scherpbier AJ. Program for laparoscopic urologic skills: a newly developed and validated educational program. Urology 2012;79:815e20.
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Journal of Pediatric Urology (2015) xx, 1.e1e1.e6
Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre R.P.J. Schroeder a, R.J. Chrzan b, A.J. Klijn c, C.F. Kuijper b, P. Dik c, T.P.V.M. de Jong c
a
Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
b
University Children’s Hospitals AMC Amsterdam and UMC Utrecht, AMC Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
c University Children’s Hospitals AMC Amsterdam and UMC Utrecht, UMC (WKZ) Utrecht, Postbus 85090, 3508 AB Utrecht, The Netherlands
Correspondence to: R.P.J. Schroeder, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands, Tel.: þ31 205994810; fax: þ31 205993802 [email protected] (R.P.J. Schroeder) [email protected] (R.J. Chrzan) [email protected] (A.J. Klijn) [email protected] (C.F. Kuijper) [email protected] (P. Dik) [email protected] (T.P.V.M. de Jong) Keywords Internship and residency; Hospital education department; Laparoscopy; Minimally invasive surgical procedures; Pediatrics; Urology
Summary Background Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. Objective To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). Study design The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients’ ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Results Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and
1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children 2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. Discussion There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Conclusion Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.
Received 16 October 2014 Accepted 14 March 2015 Available online xxx
http://dx.doi.org/10.1016/j.jpurol.2015.03.022 1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Figure Pyeloplasty and nephrectomy performed by open or minimally invasive surgery (MIS) in 2012 with reference to the age of the patient.
Introduction Paediatric urology is a relatively new medical specialty that grew out of urology and paediatric surgery. Minimally invasive surgery (MIS) is becoming a more prominent procedure in the field. Its foundation lies in the use of the cystoscope to inspect the peritoneal cavity. MIS has mainly been employed for the localization of non-palpable, undescended testes [1e3]. Over the years, MIS has evolved due to improvements in the instrumentation and the creativity of specialized surgeons. Simple diagnostic and ablative procedures have paved the way for intricate, reconstructive, laparoscopic surgery [4]. Currently, orchidopexy, partial nephrectomy, and ureteral reimplantation are widely performed in paediatric urology. Laparoscopic retroperitoneal and transperitoneal pyeloplasty is believed to be the gold standard procedure, and patients are increasingly requesting ‘keyhole’ surgery [5]. The outcomes of MIS are comparable to those of open techniques. Laparoscopy has been shown to be effective and safe with a low morbidity rate [2,6,7]. It is known to have a steep learning curve due its technical challenges. Extended training and repetition are needed to become a skilful laparoscopic surgeon [8,9]. In fact, the rate of complication in MIS is mainly dictated by the experience of the surgeon [7]. The intensive training needed for this procedure has become an important issue and has received increasing
attention from the medical community. Increased numbers of operations are needed to improve in MIS techniques. Nevertheless, no minimum number of procedures has been specified as a requirement for performing MIS procedures in paediatric urology. There is no consensus concerning the number of operations needed to become proficient in MIS. Assessment of surgeons is mainly based on their supervisors’ evaluations [8]. The Department of Paediatric Urology at UMC, Utrecht (UMCU) was accredited in 2006 by the Joint Committee of Paediatric Urology (JCPU). In 2008, a close collaboration began with the Department of Paediatric Urology of the Academic Medical Centre (AMC) in Amsterdam. As a result, one central centre (AMC-UMCU) has been formed under the same leadership and operates at two locations. In this centre ablative MIS is being performed by two staff members. Currently, the centre does not offer a separate structured MIS training programme. Therefore, MIS is included in the basic training programme. This article reviews and analyses the overall surgical MIS activity in a highly specialized, tertiary care, paediatric urology training centre to evaluate the centre’s potential as a MIS training centre.
Materials and methods The clinical activity of the AMC-UMCU centre was retrospectively reviewed. The data were collected from the
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Training potential in minimally invasive surgery
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JAVA application ‘Zorgdesktop’ (AZD) (in-house-developed, Amsterdam, The Netherlands) at the AMC and from the ‘ziekenhuisinformatiesysteem’ (ZIS)/‘Elektronisch Patie ¨ntendossier’ (EPD) (ChipSoft, Amsterdam, the Netherlands) at the UMCU. The annual numbers of admissions, outpatient consultations and operative procedures were extracted. The operative procedures were divided into open and MIS procedures. More detailed analyses of the ages of the patients who underwent major procedures performed by either the open or MIS approach (nephrectomy and pyeloplasty) are provided. From these data, the potential number of laparoscopic procedures was determined. Currently, the AMC-UMCU policy on MIS is as follows: 1. Diagnostic and minor procedures (orchidopexy) in all ages; 2. Major ablative and reconstructive procedures: - No MIS below 24 months (12 kg) - MIS is preferred in children above 3 years (15 kg). In addition to these limits, the choice of an open or MIS procedure depends on the preferences of the parents and surgeon. Minor MIS can be performed by any of the staff, ablative MIS is only performed by two staff members (RC and AK), and reconstructive MIS is only performed by one surgeon (RC).
Results There are five staff members and one fellow working in the department. The number of out-patient consultations, hospital admissions and operative procedures gradually rose between 2008 and 2010. The numbers for the collaboration centre stabilized in 2011. Annually, the centre provides approximately 4300 out-patient consultations, 600 admissions and 1300 procedures under general anaesthesia for children with urological problems. Until 2006, only diagnostic and minor laparoscopic procedures were performed. The first laparoscopic nephrectomy and pyeloplasty in the department were performed after 2006. Table 1 provides a subdivision of all of the Table 1 Operative procedures in AMC-UMCU subdivided per procedure for 2006 and 2012. For 2012, the total operations for each category and the numbers performed using minimally invasive surgery (MIS) are shown. Operation
Orchidopexy Nephrectomy Incontinence surgery Pyeloplasty Ureteral reimplantation Heminephrectomy a
2006
2012
Total
Total
MIS
166 22 22b 44 82 11
25 8 11c 16 1 0
130 13 18b 22 65 11
a
Of which 30 patients by MIS (23%). Intravesical bladder neck reconstruction, colposuspension and fascia sling. c Intravesical bladder neck reconstruction and colposuspension. b
surgical procedures performed in the centre in 2006 and in 2012. These numbers are subdivided to indicate the number of MIS procedures performed each year. Laparoscopic inspection of the peritoneal cavity for impalpable testes was the only MIS performed until 2006 and was done in 30 patients. In 2012, ablative and reconstructive MIS were also done. In total, 61 laparoscopic procedures were performed. Thirty-five of these patients underwent major intricate MIS procedures, which included 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch and four bladder neck procedures). The remaining MIS procedures consisted of 25 orchidopexies and one intravesical ureteral reimplantation. Fig. 1 shows the subdivision of open and laparoscopic pyeloplasties and nephrectomies performed in 2012. The procedures are analysed according to the age of the patient. For the older patients, both nephrectomy and pyeloplasty were performed primarily by MIS. In patients older than two years, 16/21 pyeloplasties and 8/12 nephrectomies were performed laparoscopically.
Discussion In this article, the characteristics and numbers of open and MIS procedures performed in a large, JCPU-recognized, educational paediatric urological centre are shown. The numbers of MIS operative procedures were analysed. The percentage of MIS operations performed, based on the age of the patients, was assessed to determine the laparoscopic training potential of the educational centre. To our knowledge, there are no recognized or approved centres in Europe that offer a separate MIS training programme in paediatric urology. However, MIS is increasingly being requested in paediatric urology. The number of novel surgical procedures performed is dictated by patient demand and their perception of the techniques. The establishment of a gold standard for one of the first intricate MIS procedures, laparoscopic cholecystectomy, was mainly driven by the public [5]. In addition to safety and efficacy as the most important factors, the cosmetic consequences of a procedure are also important in surgical treatment decision making. This is especially true for younger patient groups [5,10]. There has been much debate concerning the pros and cons of MIS. The modern techniques usually introduce new medical costs. MIS is more expensive than the standard open procedures because of the need for specialized instruments, intensive training and extended operation times. In contrast, the hospital stay is generally shorter after MIS, resulting in reduced costs and a faster return to normal activities [2,3,7,11]. From the socioeconomic viewpoint, a child’s early return to normal activity after laparoscopic surgery does not directly add productivity, but their parents’ earlier resumption of work does. This is particularly important for families with young children [3,12]. In addition to cost, the clinical benefits of MIS need to be understood. Among these benefits are reduced postoperative pain and blood loss, faster return home and less scarring with better cosmetic outcomes [2,3,7,11].
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Figure 1 Pyeloplasty and nephrectomy performed by open or minimally invasive surgery (MIS) in 2012 with reference to the age of the patient.
MIS is known to have a steep learning curve. A large number of operations are required to become a skilful surgeon. The number of procedures quoted for proficiency in paediatric MIS remains controversial. Nevertheless,
R.P.J. Schroeder et al. various proposed numbers appear to be consistent with those reported for proficiency in adult surgery. For intricate reconstructive MIS (such as laparoscopic pyeloplasty) approximately 30 procedures are proposed as necessary to develop proficiency [3,13]. Paediatric urology is a relatively low-volume surgical subspecialty. It is difficult to achieve MIS numbers high enough for adequate training. The study results support this, with only 16 pyeloplasties, eight nephrectomies and 11 incontinence MIS procedures performed in 2012. Over the years, the MIS numbers at the centre have increased, primarily due to the increased experience of the two skilled surgeons. The laparoscopic pyeloplasty numbers at this centre correspond to the yearly average of 12 (124/10) between 1999 and 2010 mentioned by Blanc et al. [13]. The numbers at this centre exceeded the yearly average of 5.4 (54/10) pyeloplasties and 5 (50/10) nephrectomies at the Children’s Hospital in Boston, USA, between 1995 and 2005 [6]. The number of laparoscopic procedures a surgeon needs to perform during training remains difficult to estimate, due to the lack of a consensus or guidelines on how to assess laparoscopic training in paediatric urology. Based on only the number of operations, it seems obvious that the number of laparoscopic procedures per paediatric urology clinic is not high enough to broadly teach MIS. This will predominantly affect medical doctors at the beginning of their surgical training (such as fellows and residents). Often, subspecialized paediatric surgeons are still training and gaining experience with MIS skills. As a result, only a few surgeons are sufficiently experienced to adequately supervise and teach laparoscopic procedures [14,15]. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Lowering the age for major ablative and reconstructive MIS would only slightly increase the number of MIS operations in the centre. In 2012, if the cut-off had been 10 kg (1 year old), 12 laparoscopic nephrectomies and 20 pyeloplasties could have been performed. This cut-off appears to be feasible both technically and in terms of anaesthesia [16]. With the introduction of robotic MIS, this goal might even be easier to accomplish [17,18]. Nevertheless, feasibility alone does not make a procedure good for the patient. The issue of what is best for the patient has not been addressed in feasibility studies, and there has been no validation of the cosmetic value or the postoperative pain after MIS in neonates. Modern MIS techniques have been introduced gradually and have been predominantly embraced by only the latest generation of surgeons. The introduction of advanced laparoscopy occurred more slowly in paediatric urology than in paediatric surgery. In particular, for the surgeons who exclusively practise paediatric urology, it is difficult to adequately learn the techniques. For this reason, the centre appointed only two staff members to perform MIS. It is hoped that the number of MIS procedures in patients who are eligible for it will be maximized. Possible expansion of the number of MIS procedures performed in paediatric urology is limited, and the centre must find other ways to improve the skills of the surgeons. Paediatric surgeons perform MIS on patients with a wide range of pathologies (including digestive tract and thoracic
Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
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Training potential in minimally invasive surgery pathology) and thus achieve higher operation numbers. A potential solution to increase experience in MIS may include collaboration between laparoscopic paediatric surgeons and urologists. By increasing the number of procedures with which surgeons are involved, the training time necessary to master MIS will be shorter compared with that among paediatric urologists alone [8,19]. To increase laparoscopic exposure, centralizing the patients at one centre may also be a viable option. In The Netherlands, major laparoscopic procedures in the field of paediatric urology are currently performed in three university centres. Of course, proficiency cannot be assessed by operation numbers only. Quality of the training programme is essential. A new training concept for MIS, called modular surgical training, has been described by Stolzenburg et al. [20]. This training is similar to that used for laparoscopic radical prostatectomy and breaks the MIS procedure down into standardized teaching steps of variable complexity called modules. Modular training offers various advantages that may lead to a reduction in the time to proficiency. It facilitates step-by-step training, which can be offered during consecutive operations. Based on the mentor’s assessment of the trainee, the complexity can be gradually increased. Before progressing to the next step of the procedure, the trainee needs to obtain the requisite skills of the previous level. In this manner, highly complex laparoscopic procedures can be used for training on every level without putting patients at risk. Even beginners are able to perform some of the simpler steps of highly complex procedures. Furthermore, modular training allows for the teaching of more than one trainee during the same procedure. Currently, various laparoscopic procedures are being taught in modules [20,21]. The standardization of modules enables training at different sites, potentially in cooperation with other, high-volume centres. This method could also be of great value when teaching MIS in paediatric urology. The ex vivo laparoscopic training of surgeons is becoming increasingly important because hands-on training is critical in MIS. Both cognitive and psychomotor training on validated simulators are being incorporated to teach laparoscopic skills outside the operating theatre [22]. This technique enables novice surgeons to progress in their training before performing the procedure on a patient. Additionally, medical errors will decrease, which will improve the safety of the procedure [23]. Furthermore ex vivo training provides critical MIS training hours, which are difficult to obtain in vivo. A validated certification test, the Fundamentals of Laparoscopic Surgery, has been developed [23]. Several education departments only allow laparoscopic procedures to be performed on patients by certified residents [14,24]. Dutch medical residents are currently being assessed on MIS with the training tool called the Program for Laparoscopic Urologic Skills (PLUS). PLUS is considered appropriate for use as a primary training tool for an entry test or as part of a step-wise training program in which basic and procedural laparoscopic skills are integrated [25]. An effective curriculum for laparoscopic training combines inanimate models, animal labs, clinical exposure, and an individual review of experience. A mentor-initiated approach, combined with intensive dry and wet laboratory training, is considered the modern way to train surgeons in MIS [20].
1.e5 Conclusion, even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low. As a result, only a few staff members are able to adequately learn MIS procedures or maintain their skills. This situation leads to limited training opportunities for the surgeons. To provide highquality MIS training, exposure to laparoscopic procedures must be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities and training outside the operating theatre.
Ethical approval None sought.
Funding None declared
Conflict of interest None declared.
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Please cite this article in press as: Schroeder RPJ, et al., Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.022
