|Year : 2002 | Volume
| Issue : 2 | Page : 195-197
Laparoscopic urologic surgery: Can our patients benefit while we learn?
AK Hemal1, Mani Menon2
1 Department of Urology, AIIMS, New Delhi - 110 029, India
2 Raj and Padma Vattikuti Professor & Director, Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
A K Hemal
Department of Urology, AIIMS, New Delhi - 110 029, India
Source of Support: None, Conflict of Interest: None
Keywords: Laparoscopy; Urology; Learning Curve; New Procedures
|How to cite this article:|
Hemal A K, Menon M. Laparoscopic urologic surgery: Can our patients benefit while we learn?. Indian J Urol 2002;18:195-7
Minimally invasive surgery in urology is not new and it dates back to over two and a half decades. However, laparoscopic urologic surgery is making slow progress in our country although it emerged ten years ago. New laparoscopic procedures are often heralded with the promise of smaller incisions, decreased pain, and quicker recovery time. Laparoscopic cholecystectomy (Lap. Chole) is a commonplace procedure, but not so are laparoscopic urological procedures. Urological surgeons are being asked by patients to perform operations that they are not yet convinced are efficacious and that they may not yet have the expertise to perform. This raises the important ethical question as how a urologist can balance the need to learn new skills with the fundamental obligation to benefit the patients and avoid harm ("primum non nocere")? Unfortunately, in urology there is no Lap Chole like procedure. Hence, learning is still necessary without harming the patient and should be peer reviewed to provide not only quality assurance and oversight but also strict evaluation.
Incentive to Learn
This totally depends on one's own perspective, as we know that medical eduation begins at medical school and continues life-long. The motivation for such advanced and ongoing learning arises from a desire to benefit patients by providing treatment options that are more effective, safer, cost effective and improve the patient's quality of life. This may also help surgeon to treat more patients of various urological disorders.
Urologist's self-interest can also play a role, to the extent that the satisfaction that comes with self-improvement and with mastering new techniques can be reward in itself. He may also earn more money due to new technology.
Industry can exert pressure in various meetings and conferences as they expose the urologist to new techniques but may do so in a way that encourages the use of expensive disposable gadgets and equipments, as these individuals' primary concern is the success of their their company's product rather than the health of patients.
Some of the incentives to use less invasive approaches can arise from hospitals with their interest to cure patients and decrease costs may be with shorter hospital stays.
Now with the changing world, thanks to information technology, perhaps the most compelling incentive to learn new skills comes from patients themselves too. Often, patients, private practitioners, doctors at primary health centre become aware of "cutting edge" surgical techniques by way of enthusiastic media coverage. For example laparoscopic nephrectomy and donor nephrectomy, as gradually referring doctors and patients are becoming aware of the advantages of less hospital stay, less pain, less morbidity and an early recovery with cosmesis for these procedures and they may seek actively urologists who can perform the new procedures and in the bargain if urologists can't provide these facilities then patients will seek care elsewhere who can offer latest, least invasive, or most effective approach to treatment. With the introduction of Lap Chole the cholecystectomy rate rose everywhere in the world including India and this all happened due to availability of the new procedure which gave rise to a change in the perceived risk/benefit ratio, leading patients who were previously tolerating low-grade symptoms to seek definitive treatment. 
The Learning Curve
Most of what has been published about the learning curve as it applies to urology has been related to lymphadenectomy.  However in well-established centers performing laparoscopic urologic surgery, it is observed that these procedures are not complication free. Soulie et al  report their experience with complications occurring in 350 laparoscopic procedures. The overall complication rate was 5.4%, mortality rate 0.3% and conversion rate 1.1 %.  In 1999 Fahlenkamp et al reported complication in 2.407 laparoscopic urological surgeries performed at 4 German centers.  Their incidence of complication was comparable to that reported by Soulie et al, with an overall complication rate of 4.4%, re-intervention rate of 0.8% and mortality rate of 0.08%. Nearly similar findings were noted by Kumar et al.  Reports on the efficacy and safety of new surgical techniques may not reflect the true experience with learning if the analysis excludes the first patients operated upon, an altogether too familiar scenario seen in the literature.
There are two important components of the learning curve : first, "Choreographing the procedure for successful completion" and, second, "mastering cases that are more complicated because of anatomic variation or the presence of adhesions". Though, usually urologists prefer the patients with fewer complications and simpler procedures in early stage with progression to more complicated cases as expertise is attained. What does this mean ?
No Harm to Patient
Emerging new urological techniques are generally touted in the medical literature and in the press because of the benefits they are expected to offer. Only after broad application of new procedures do the harms that may result from their application become evident. It should be apparent that maximal patient benefit will occur only when new procedures can be carried out with minimal complications, that is, with a minimum of harm. What are important components to determine safety and efficacy of urological procedures certainly depend on skill and experience of urologist. Senior urologists will struggle to reconcile the desire to learn a new technique with the knowledge that someone more experienced would probably do a better job with less potential for harm to the patient.
The obligation to avoid doing harm to patients is a serious one, central to the ethical practice of urology.
In general, society, in providing relative autonomy to organized medicine, expects the profession to regulate itself when it comes to the quality of medical care. The peer group not only has the knowledge and expertise to evaluate the care provided by colleagues and to assess the utility of new therapeutic techniques but also has an obligation to do so for the benefit of their patients. 
As part of the peer review process, physicians have a responsibility to assess their colleagues and report those who are incompetent or unethical. Trust can be undermined if physicians are not able to regulate or assure the quality of the care they provide. This is in fact what occurred in New York State in 1992, in response to the high rate of surgical complications resulting from the rapid adoption of Laparoscopic cholecystectomy. The New York State Health Department mandated that a surgeon show adequate skill in at least 15 supervised cases before being granted privileges to perform the operation independently. 
Therefore, it is important that urologists evolve mechanisms for evaluating new techniques and assuring their safe and effective introduction into practice. Here comes the role of Medical Council of India and Urological Society of India to work as a regulatory mechanism so no harm is done to the patients on the name of hype created by new technology.
The evolution of surgical skill, incorporating new insights from courses, conferences, and the literature, depends to a significant degree on peers to provide ongoing feedback to both the safety and the effectiveness of the surgical modifications and the skill of the surgeon who is beginning to perform them. A conscientious assessment of the evidence supporting the safety and the efficacy of the procedure in question should be carried out. Settings such as the operating room, departmental conferences, and inter-group meeting can serve as a forum for the discussion of evolving techniques.
The role of colleagues in the ongoing development of a surgeon's skill should not be underestimated. In one survey of urologic surgeons 3 and 12 months after a 2-days' laparoscopic training course, certain predictors of a decreased complication rate were noted. 
Basic laparoscopic training and performance must be a pre-requisite for seeking privileges in advanced laparoscopic techniques. In India too like the West, credentialing requirements should include formal didactic training, participation in animal laboratories, and the performance of several procedures in the setting of a preceptorship to ensure that surgeons have acquired both an understanding of the new techniques and an ability to perform it safely. New computer programs involving visual computing technology permit surgeons to perform virtual operations or procedure before applying new skills to their patients.  Generally speaking, a week-end course in laparoscopy would not be adequate to provide the required level of knowledge or skill. The fact that all laparoscopic procedures are performed with a video monitor, gives an unique opportunity to use videotapes of procedures performed by those seeking to learn.
The acquisition of new surgical skills has particular implications for the process of informed consent. Engaging a patient in a process of co-operative decision making and encouraging understanding of the process by which new surgical skills are acquired and developed can provide patient with the opportunity to make an informed decision while maximizing the chances that the less experienced surgeon will remain involved. Open and honest communication builds the sort of trusting relationship that a patient may value over the reputed superior skills of an unknown expert.
Disclosure of Complications
A bond of trust is fundamental to a relationship in which a patient permits a urologist to apply skills at which he or she is not yet proficient. Just as trust can be strengthened before a procedure by full disclosure, trust should not be undermined by a failure to disclose that a complication has occurred or that a mistake has been committed.
Complications may arise because a relatively inexperienced surgeon is unaware of common pitfalls and is therefore unlikely to anticipate and avoid them. Mistakes, when acknowledged, can serve as an impetus to the further refinement of skills or to other charges in clinical practice. Rather than concealing mistakes, urologists should examine them and make part of the learning process. Sharing with colleagues mistakes made and complications encountered in the acquisition of new skills can enhance the educational process of the entire group.
| Conclusion|| |
It is important that urologists find a way to assess new technology, introduce it safely, and provide excellent care for patients while also developing needed skills among themselves. The decreasing surgical volume in many departments, coupled with the continuing evolution of technically challenging surgical treatments, necessitates ongoing training in urologic surgery for many in the specialty and here comes the role of Government hospitals, teaching hospitals and academic institutes. The growing patient demand for laparoscopic urologic procedure in future with the responsibility for cost-effectiveness compounds the need for urologists to be skilled in effective new techniques. Urologists, patients and hospitals stand to benefit if safe, effective and less costly methods of treating urological disease become widely available. Assuring patient safety while new procedures are introduced and learned will require a collective effort on the part of experts, novices and patients. Needless to say urologists must awaken to new challenges lest their procedure be taken away by others who are better equipped.
| References|| |
|1.||Legoretta AP. Silber JH, Constantino GN et al. Increased cholecystectomy rate after the introduction of Laparoscopic Cholecystectomy. JAMA 1993: 270: 1429-1432. |
|2.||Griffith DP, Schuessler WW, Nickell KG, Meaney JT. Laparoscopic Pelvic Lymphadenectomy for Prostatic Adenocarcinoma. Urol Clin North Am 1992: 19: 407-415. |
|3.||Chandler JG. Corson SL, Way LW. Three spectra of laparoscopic entry access injuries. J Am Coll Surg 2001: 192: 478-491. |
|4.||Fahlenkamp D. Ross Weiler J. Fornara P et al. Complications of laparoscopic procedures in urology : experience with 2,407 procedures at 4 German Centers. J Urol 1999: 162: 765. |
|5.||Kumar M. Kumar R, Hernal AK, Gupta NP. Complications of retroperitoneoscopic surgery at one centre. Br J Urol Int 2001; 87: 607-612. |
|6.||Lo B. Resolving ethical dilemmas : a guide for clinicians. Baltimore, Williams and Wilkins, 1995. |
|7.||Altman LK. When patient's life is price of learning new kind of surgery. The New York Times 1992 June 23; Sect.B:6. |
|8.||See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complications after formal training in laparoscopic surgery. JAMA 1993: 270: 268-292. |
|9.||Hasson HM. Nakka V. Kumari A. Training simulator for developing laparoscopic skills. JSLS 2001: 5: 249-254. |