Outcomes/Epidemiology/Socioeconomics

Impact of a Laparoscopic Renal Surgery Mini-Fellowship Program

on Postgraduate Urologist Practice Patterns at 3-Year Followup

Surendra B. Kolla, Aldrin J. R. Gamboa, Roger Li, Rosanne T. Santos,Jennifer M. Gan, Cynthia Shell, Lorena Andrade, Michael K. Louie,Ralph V. Clayman* and Elspeth M. McDougall†,‡From the Department of Urology, University of California-Irvine, Orange, California

Purpose: To assist practicing urologists incorporate laparoscopic renal surgeryinto their practice we established a 5-day mini-fellowship program with a mentor,preceptor and a potential proctor at our institution. We report the impact of ourmini-fellowship program at 3-year followup.Materials and Methods: A total of 106 urologists underwent laparoscopic abla-tive (44) or laparoscopic reconstructive (62) renal surgery training. The 1:2teacher-to-attendee experience included tutorial sessions, hands-on inanimateand animate skills training, and clinical case observations. Participants wereasked to complete a detailed questionnaire on laparoscopic practice patterns 1, 2and 3 years after the mini-fellowship.Results: The questionnaire response rate at 1 to 3 years was 77%, 65% and 68%,respectively. Of responders 72%, 71% and 71% performed laparoscopic renalsurgery at 1 to 3 years, respectively. Of the 106 participants 32 (39%) hadprevious laparoscopic experience, including 78% who responded to the question-naire at 3 years. Of those surgeons there was an increase in the practice oflaparoscopic radical nephrectomy (88% vs 72%), nephroureterectomy (56% vs13%), pyeloplasty (40% vs 6%) and partial nephrectomy (32% vs 6%) at 3 years.Of the 106 participants 74 (70%) were laparoscopy naïve, including 48 (65%) whoresponded to the questionnaire at 3 years. The take rate in this group was 76%,52%, 34% and 23% for laparoscopic radical nephrectomy, nephroureterectomy,pyeloplasty and partial nephrectomy, respectively. Of the participants 90% indi-cated that they would recommend this training to a colleague.Conclusions: An intensive 5-day laparoscopic ablative and reconstructive renalsurgery course enabled postgraduate urologists to effectively introduce and ex-pand the volume and breadth of their laparoscopic renal surgery practice.

Key Words: kidney, laparoscopy, nephrectomy, fellowships and scholarships,

Abbreviations

and Acronyms

LA � laparoscopic ablative

LR � laparoscopic reconstructive

LRS � laparoscopic renal surgery

M-F � mini-fellowship

Submitted for publication March 1, 2010.Study received institutional review board ap-

proval.Supported by Yamanouchi Pharma America

(Astellas).* Financial interest and/or other relationship

with Applied Medical, Boston Scientific, CookMedical, Galil Medical USA, Greenwald Surgical,Intuitive Surgical, Karl Storz Endoscopy America,Omeros, Orthopedic Service and Vascular Tech-nology.

† Correspondence: Surgical Education Center,Department of Urology, University of California-Irvine, 333 City Blvd. West, Suite 2100, Orange,California 92868 (telephone: 714-456-3429; FAX:714-456-5062; e-mail: elspethm@UCIrvine.edu).

‡ Financial interest and/or other relationshipwith Endocare, METI, Simbionix, Intuitive Surgi-cal, Ethicon Endo-Surgery, Karl Storz EndoscopyAmerica and Omeros.

physician’s practice patterns

SINCE the introduction of laparoscopicnephrectomy in 1991,1 laparoscopyhas become an integral part of urolog-ical surgery. The rapid developmentand recognized benefits of laparo-scopic surgery created an educationalchallenge for practicing urologists who

may have never experienced this treat-

0022-5347/10/1845-2089/0THE JOURNAL OF UROLOGY®

© 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RES

ment modality during residency train-ing. Acquiring laparoscopic skills isassociated with a steep learning curveand it has been traditionally learnedduring advanced year-long fellowshiptraining. However, it is impracticalfor most practicing urologists to enroll

in fellowship programs. Another re-

Vol. 184, 2089-2093, November 2010Printed in U.S.A.

EARCH, INC. DOI:10.1016/j.juro.2010.06.097www.jurology.com 2089

LAPAROSCOPIC RENAL SURGERY MINI-FELLOWSHIP AND POSTGRADUATE PRACTICE2090

source for practicing urologists to learn these newsurgical techniques is by enrolling in postgraduateeducational courses, which typically consist of 2 to2½ days of didactic sessions, hands-on laboratoriesand case observations. However, the durable takerate of such courses is commonly only around 50%,implying that half of the participants felt poorlyequipped to introduce the new techniques into prac-tice.2

At our institution we developed a curriculum toassist practicing urologists acquire LRS and incor-porate it into practice. We report the long-term im-pact of our LRS M-F program on postgraduate uro-logical practice patterns.

MATERIALS AND METHODS

LRS M-F training at our institution is provided in 2 sep-arate 5-day modules, including LA and LR. Participationin either module is reserved for a maximum of 2 postgrad-uate urologists per week who have already completed abasic laparoscopy course. Registration is on a first come,first served basis. The M-F embraces a mentor-preceptor-proctor experience. Participants undergo 1:2 teacher-to-attendee instruction in a 5-day period, including tutorialsessions with expert laparoscopic surgeons, inanimatemodel skills training, animal laboratory skills trainingand operating room observation experience. After com-pleting the M-F experience participants are also offeredthe opportunity to have an instructor in laparoscopic sur-gery from our institution attend their center to serve as apreceptor for the initial laparoscopic procedure.

LA and LR module participants were required to com-plete a questionnaire immediately after completing M-F toevaluate the various training components using a 6-pointLikert-type scale from 0—no value to 5—extremely valu-able. Program areas assessed were didactic tutorial ses-sions, skills training practice, animal laboratory train-ing sessions and operating room observation. Using a6-point Likert-type scale, including 0—no skills and a lotof training needed, 1 and 2—some experience but moderate

Total number of attendeesN=106

Group 1-Performing LRS before M-F

Group 2- Not performing LRS /assisting only before M-F

(As primary surgeon)N=32 N=74 (70%)

Follow-up at 3-years

Follow-up at 3-years

N=25 (78%) N=48 (65%)

PerformingLRS

PerformingLRS

N=22 (88%) N=30 (63%)

Algorithm shows number of participants in M-F program withfollowup and take rates.

training needed, 3 and 4—moderate experience but some

training needed and 5—no additional training needed,participants also self-assessed laparoscopic skills relatedto establishing pneumoperitoneum, placing initial accessinto the abdomen, dissecting tissue, cutting tissue hemo-statically, suturing and knot tying, and entrapping andmorcellating specimens.

After receiving institutional review board approval wesent questionnaires to all M-F renal module participantsat 1, 2 and 3 years. They were also requested to completea questionnaire on subsequent operative experience afterthe M-F program. All questionnaire results were re-viewed, tabulated and statistically analyzed. We codedparticipant ratings of the M-F course components, self-assessed skills, and pre-program and post-program oper-ative experiences, and entered them into an SPSS® 13.0for Windows® database for analysis. Pre-program vs post-program skill and program component ratings were ana-lyzed with the paired sample t test. We compared the LAvs the LR training group with the independent groups ttest. The Wilcoxon signed rank exact or Fisher exact chi-square test was used to analyze data collected on noncon-tinuous variables with p �0.05 considered statisticallysignificant.

RESULTS

At our institution 106 urologists from a total of 28states and 5 countries attended the LA (44) or theLR (62) M-F program between September 2003 andJuly 2006. Participant age was 31 to 70 years and60% were 40 to 59 years old. Mean time since resi-dency training was 14 years (range 1 to 35). Thequestionnaire response rate at 1, 2 and 3 years was77%, 65% and 68%, respectively (see figure).

Table 1 lists practice patterns and prior partici-pant fellowship training. Of participants 90% prac-ticed in a nonacademic environment. Before attend-ing M-F at our center 32 participants (30%)performed LRS as the primary surgeon (group 1)while 74 (70%) only assisted or did not perform LRS

Table 1. Practice patterns and prior fellowship training of 97M-F participants

No. Participants (%)

Practice pattern:Single 20 (21)Group 61 (63)Academic 10 (10)Hospital 6 (6)

No training 69 (72)Training: 27 (28)

Oncology 7 (26)Endourology 4 (14)Pediatrics 10 (37)Transplantation 2 (7)Research 1 (4)Pathology 1 (4)Neurourology 1 (4)

Female urology 1 (4)

LAPAROSCOPIC RENAL SURGERY MINI-FELLOWSHIP AND POSTGRADUATE PRACTICE 2091

(group 2) (see figure). We separately analyzed theimpact of M-F on practice patterns in groups 1 and 2(tables 2 and 3). Three-year questionnaire responseand take rates were 78% (25 of 32 respondents) and88% (22 of 25) in group 1, and 65% (48 of 74) and63% (30 of 48) in group 2, respectively. The mostcommon laparoscopic renal procedure done by eachgroup at 3 years was laparoscopic nephrectomy, fol-lowed by nephroureterectomy, pyeloplasty, hand as-sisted laparoscopy and partial nephrectomy. Therewas a significant decrease in hand assisted laparos-copy at 3 years in group 1 (p � 0.002).

Table 4 shows laparoscopic skills self-rating byM-F participants. At training and at 3 years ratingsby the 55 and 23 LR participants were consistentlyhigher than ratings by the 32 and 15 LA partici-pants, respectively. Examination of mean skill rat-ings in the training groups showed that LA moduleparticipants rated skills on suturing and knot tying,and specimen entrapment and morcellation substan-tially lower than other laparoscopic skills (F � 22.6,p �0.001). A similar finding was observed in the LRgroup (F � 28.4, p �0.001). Overall participantsconsistently rated themselves substantially lowerimmediately after M-F training than at the 3-yearfollowup. Statistically relevant increases in self-rat-ing were noted in each category in the 2 groups(p �0.002). LA and LR module participants ratedthe various training program components of the M-Fprogram highly and similarly (table 5).

Table 2. M-F impact on group 1 participants

Procedure

No.Participants

Before M-F (%)

No.Participants at

3 Yrs (%)

p Value(Wilcoxon

signed rankexact test)

LRS:Hand assisted 15 (47) 4 (16) 0.002Nephrectomy 23 (72) 22 (88) 0.256Nephroureterectomy 4 (13) 14 (56) 0.008Pyeloplasty 2 (6) 10 (40) 0.042Partial nephrectomy 2 (6)

Greater than 10 LRSs/yr:Hand assisted 2 (13) 0Nephrectomy 3 (13) 9 (41) 0.062Nephroureterectomy 1 (25) 4 (29) 0.124Pyeloplasty 0 2 (20)Partial nephrectomy 0 2 (25)

Table 3. M-F impact on 35 group 2 participants

Laparoscopic Renal Procedure No. Participants (%)

Hand assisted 9 (26)Nephrectomy 23 (76)Nephroureterectomy 16 (52)Pyeloplasty 11 (34)

Partial nephrectomy 7 (23)

Of the 97 participants 81 (84%) thought that proc-toring was a useful component in such a trainingprogram but only 9 (8.5%) used the proctoring com-ponent. Five days were considered a satisfactorycourse duration by 80 of the 106 participants (75%),too short by 21 (20%) and too long by 5 (5%). M-Fwas rated valuable to extremely valuable by 80% ofparticipants while 90% indicated that they wouldrecommend it to a colleague interested in pursuingthis type of postgraduate surgical training.

DISCUSSION

Laparoscopy is increasingly used to treat surgicalrenal disease. This has created interest in laparo-scopic surgery among urological surgeons, of whommany are eager to adopt this technique despite hav-ing had little or no training during residency. Toaccommodate the increasing demand for laparo-scopic urological procedures there is an increasedneed by postgraduate urological surgeons to betrained in laparoscopic surgery. Shay et al notedthat participation in laparoscopic surgery duringresidency training is a major determining factor inperforming laparoscopy as a primary surgeon inpractice.3

Traditionally for individuals not exposed exten-sively to laparoscopy during residency laparoscopicskills are learned by pursuing a post-residency fel-

Table 4. Participant laparoscopic skill self-rating

Skill

Mean � SDRating atTraining

Mean � SDRating at 3

Yrs

p Value(independentgroup t test)

LA:Establishing pneumoperitoneum 1.4 � 1.1 3.8 � 0.6 0.001Placing 1st abdominal access 1.1 � 0.6 4 � 0.7 0.001Dissecting tissue 1.6 � 0.9 3.8 � 0.9 0.005Cutting tissue hemostatically 1.5 � 0.8 3.7 � 0.2 0.002Suturing � knot tying 0.6 � 1.2 1.9 � 0.8 0.04Entrapping � morcellating 0.3 � 1.1 2 � 0.9 0.001

LR:Establishing pneumoperitoneum 3 � 0.6 4.3 � 0.5 0.036Placing 1st abdominal access 3.1 � 0.3 4.4 � 0.6 0.066Dissecting tissue 2.7 � 0.5 4.3 � 0.6 0.002Cutting tissue hemostatically 2.8 � 0.8 4.3 � 0.7 0.008Suturing � knot tying 1.1 � 1.3 2.8 � 1.1 0.012Entrapping � morcellating 1 � 2.1 2.8 � 1 0.016

Table 5. Participant M-F component ratings

ComponentMean � SD

LAMean � SD

LR

p Value(independentgroup t test)

Didactics 4.4 � 0.2 4.0 � 0.4 0.76Skills training 4.6 � 0.4 4.2 � 0.3 0.23Animal laboratory 4.2 � 0.8 4.9 � 0.6 0.34

Operating room observation 4.2 � 0.4 3.9 � 0.7 0.64

LAPAROSCOPIC RENAL SURGERY MINI-FELLOWSHIP AND POSTGRADUATE PRACTICE2092

lowship or during brief, 2 to 2½-day hands-oncourses. The former typically involves 1 to 2 dedi-cated years of training and includes a clinical and aresearch component. Currently in the United Statesthis training can be acquired through an Endourol-ogy Society or Society of Urological Oncology ap-proved fellowship program, or through an indepen-dent program outside the society.4 Studies showthat urologists with at least 1 year of dedicatedfellowship training in minimally invasive surgeryshow the best practice pattern numbers in regard tothe number of laparoscopic cases performed and alower complication rate than those with alternativeforms of training.5,6 In a review of laparoscopic fel-lowship graduates Cadeddu et al noted that theyperformed an average of 25 laparoscopic surgerycases yearly.5 In contrast, urologists who soughtlaparoscopic training through short courses 2 to 2½days in duration with predominantly didactic andhands-on laboratory sessions did not show a durabletake rate.2 Despite the initial 84% take rate forthese short courses at 5 years only 54% of partici-pants continued to perform laparoscopic surgery andonly 8% noted that laparoscopy comprised 10% ormore of their surgical practice.

For a practicing urologist who seeks training inlaparoscopic surgery these short courses may notinstill enough confidence or the necessary skill set toperform laparoscopic surgery independently. At thesame time the additional rigors of academic trainingimposed by dedicated fellowship courses precludemost urologists from obtaining sufficient training.To achieve better results than short courses in termsof the take rate while at the same time curtailing thetime required for a formal, intensive, minimally in-vasive surgery fellowship we developed a dedicated5-day LRS M-F program at our institution. Theshort-term results of our M-F program were re-ported previously7 and in this study we report itslong-term impact. M-F participants were contacted1, 2 and 3 years after training in our M-F programusing a questionnaire specifically looking at practicepatterns.

Results of our LRS M-F program reveal that at 1,2 and 3 years more than 70% of participants stillactively performed renal laparoscopy. This high takerate occurred although most participants in our M-Fprogram had no prior fellowship training in laparos-copy or another area of urology. In the group withprior laparoscopic experience the most common pro-cedure was nephrectomy. After M-F this group ex-panded laparoscopic practice to include other, morecomplex laparoscopic urological procedures such asnephroureterectomy, pyeloplasty and partial ne-phrectomy (table 2).

Our experience with the robotic assisted laparo-

scopic prostatectomy M-F module, in which partici-

pants are encouraged to train as a team of 2 sur-geons from 1 center, showed a better take rate of78%, 78% and 86% at 1, 2 and 3 years, respectively.8

While paired attendance in laparoscopic renal M-Fcourses was encouraged, only 16 of the 106 partici-pants (15%) did so. However, based on our prosta-tectomy M-F experience we believe that participantswho seek training in pairs can then assist each otherat their home institution, especially during the ini-tial laparoscopic surgery experience, thereby serv-ing as a mentor for each other to provide a broaderbase of experience and support. In participants whodid not perform LRS after training the most commonreason for not performing LRS was lack of a partnerat the home institution (table 6). This further un-derscores the importance of shared mentoring toimprove the take rate for these challenging surgicalprocedures in clinical practice.

Several groups have evaluated the role of thementoring surgeon as the critical component inlaparoscopic training courses for successful skill ac-quisition. Marguet et al reported that mentoringserves as an adjunct, especially to postgraduateurologists.9 Shalhav et al developed a M-F modelinvolving an intensive 1:1 mentor-trainee experi-ence, in which the trainee completes a 2 to 3-dayhands-on course in laparoscopy, observes the mentorperform 6 or more laparoscopic renal surgeries andthen performs 6 or more major renal proceduresunder direct mentor guidance at the mentor ortrainee hospital.10 In that study the 2 urologists whoentered this time intensive program subsequentlyincorporated laparoscopy into surgical practice im-mediately after training. However, this type oftraining may extend up to 5 months and imposesignificant financial and time constraints on thementor and the trainee. Indeed, the program initi-ated by Shalhav et al has since been abandoned.

A mentored program allows safe, effective learn-ing under the guidance of an experienced surgeon,potentially avoiding some pitfalls associated withthe initial learning curve of these challenging min-imally invasive surgery techniques.11 In this regardit was interesting that, although most study partic-

Table 6. Participant reasons for not performing LRS after M-F

Reason No. Participants

Lack of mentor/partner 7Not enough case vol 3Hospital budget cannot support 2Hospital hired fellowship trained urologist 1Practicing other specialty 1Partner resistance 1Not confident enough 1

Total No. 16*

* Five of 21 participants who did not perform LRS did not answer the question.

LAPAROSCOPIC RENAL SURGERY MINI-FELLOWSHIP AND POSTGRADUATE PRACTICE 2093

ipants considered a preceptor experience to bean important component of the M-F, only 9% availedthemselves of this feature of our curriculum. Thislow use rate occurred although the cost of the pre-ceptor experience, ie airfare, lodging etc, was com-pletely borne by the M-F program. The small num-ber of M-F participants using the preceptor optionmay reflect concerns about obtaining credentialingfor the preceptor or perhaps participants alreadyhad laparoscopic experienced colleagues at the homeinstitution who could work with them. Unfortu-nately neither hypothesis was included in our ques-tionnaire.

LA M-F module participants self-rated laparo-scopic skills consistently at a lower level than LRmodule participants (table 4). This likely reflectsdifferences in laparoscopic experience. This differ-ence in experience was also reflected in the rating ofM-F teaching components (table 5). The LA renalsurgery group tended to consider the didactic andskill training components more useful than the LRgroup while the LR group tended to consider theanimal laboratory session more beneficial to train-ing.

To our knowledge the M-F urology training pro-gram remains unique to our institution to date. Whileregrettable, it is understandable, given the consider-able commitment in personnel, space, equipment andfinances needed to equip and maintain a training fa-cility of this nature. The success of a M-F programrelies on the commitment of expert faculty to serveas tutorial instructors and proctors. In addition, a

completely outfitted laparoscopic laboratory with ac-

REFERENCES

Oncol 2009; 27: 208. prostatectomy mini fellow

cess to animals and cadavers is necessary. Due to anindustry grant this program was tuition free duringthe initial 3 study years but each program was es-timated to cost more than $10,000 per attendingsurgeon. Consumable teaching laboratory costsalone were approximately $3,500 per attending sur-geon. When these direct costs are added to the costof maintaining the laboratory and the cost of thetime of the various instructors, the result is $10,000.While we have continued to offer M-F training tourologists around the country and internationally,the number of registrants has markedly decreasedsince tuition is now $3,500 for the LRS module.Compared to the initial 3 years of the program,when 106 individuals completed LRS M-F training,in the subsequent 3 years when a registration fee of$3,500 has been necessary only 38 urologists havegone through the program. Lastly, the M-F format ismalleable. With time we have added additional mod-ules, such as holmium laser prostatectomy and nee-dle ablative renal therapy.

CONCLUSIONS

Five-day intensive LA and LR surgery M-Fs appearto enable postgraduate urologists already familiarwith laparoscopy to successfully increase their casevolume and advance the complexity of the laparo-scopic procedures that they are able to perform inclinical practice. Also, M-F empowers laparoscopi-cally naïve postgraduate urologists to incorporaterenal laparoscopy into practice. These observedchanges in LRS practice patterns were maintained

at least 3 years after M-F training.

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4. Pierorazio PM and Allaf ME: Minimally invasivesurgical training: challenges and solutions. Urol

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