7 - E-Lib FK UWKS

Modular Training in EERP
es. It was thus documented that previous experience
in open or laparoscopic surgery did not affect the performance
of the trainees learning EERPE in this programme.
12.5 The Learning Curve for Minimally
Invasive Radical Prostatectomy
The number of procedures required to complete the
learning curve and ascertain the safe and effective
practice of advanced laparoscopic procedures is still
into consideration. Although the learning curve for
LRPE has been estimated at 40–100 cases, it has been
shown that surgeons continue to improve in terms of
operative time even after 300 cases [23]. The adherence
to numerical values is surely of minor importance.
Tang et al. have shown that the training in
laparoscopic skills should be more flexible and individualised.
The innate ability for manipulative work
varies amongst trainees, and some will achieve competence
faster than others [10]. It is expected that the
conceptual knowledge and manual skill varies among
the trainees.
The laparoscopy guidelines of the EAU (2002) support
the concept that 50 laparoscopic procedures are
required before a plateau in the incidence of complications
is reached. It is therefore suggested that only
then should an individual surgeon regard himself
competent in laparoscopy. In the UK the Endourological
Society requires at least 40 laparoscopic procedures
to be undertaken or assisted in a 1-year period
for a fellowship to be recognised [30]. However, the
number of cases is always relative and depends upon
numerous factors, e.g. minor or major surgery; role as
assistant or first operator; surgery performed independently
or with major help from mentor; regular
spacing or all cases performed in 1–2 months.
In general, it seems to be problematic to require a
certain overall number of laparoscopic procedures for
certification. Instead, a defined number of procedures
per indication seems more realistic and helpful, especially
in procedures of intermediate and high complexity.
It is clear that 50 laparoscopic varicocele repairs
do not qualify a surgeon for laparoscopic
prostatectomy or cystectomy.
Urology residents should be exposed early to highvolume
laparoscopic operations (nephrectomy, radical
prostatectomy). These operations and training
programmes should be concentrated in high-volume
Chapter 12 175
centres of excellence in laparoscopy since individual
learning curves cannot be mastered in a low-volume
setting (i.e. 10–30 prostatectomies/nephrectomies per
year). The main goal should be the standardisation of
these daily (or weekly) performed operative procedures
as well as educational „modular training programmes“
in order to shorten individual learning
curves and generate common quality standards.
12.6 Conclusions
A highly standardised technique combined with a
modular training programme provides a feasible, safe
and effective way to teach EERPE. A short learning
curve is possible, regardless of the trainee’s experience
in open pelvic surgery. Although training residents
is of paramount importance to the future of
urology, it cannot come at the expense of patient safety.
Therefore, the main advantage of our modular
training proposal is that it provides training in a
highly complex laparoscopic procedure without putting
patients at risk.
Another fundamental advantage of the modular
concept is that the traditional routine of the trainer
spending very many hours patiently with the trainee
is overcome. In a high-volume centre (more than 200
cases per year) more than one mentor is allowed to
train the new trainees. More experienced trainees can
mentor the novice trainees in the easier modules.
Furthermore, the modular concept also allows for
preliminary training in the less complicated modules
to be performed remotely from the high-volume centre
(multi-centre training). This creates a particularly
attractive possibility for training surgeons in a setting
where mentors are few, numbers of cases for radical
prostatectomy per urology unit are small, and consultant
commitments and service obligations make it
almost impossible to travel to other hospitals to teach.
Provided that the steps of the procedure stay the same
and the volunteer mentor is committed to adhere
strictly to the standardised technique, there is the opportunity
for surgeons to start learning this procedure
(easier modules) in a local environment. The final
steps (more difficult modules) can then be learned
during a substantially shortened fellowship at a highvolume
centre.
Figure 12.5 outlines the recommendations for
training and implementation of laparoscopic/endoscopic
radical prostatectomy in a local hospital. It