Long-Term Impact of a Robot AssistedLaparoscopic Prostatectomy Mini Fellowship

Training Program on Postgraduate Urological Practice Patterns

Aldrin Joseph R. Gamboa, Rosanne T. Santos, Eric R. Sargent, Michael K. Louie,Geoffrey N. Box, Kevin H. Sohn, Hung Truong, Rachelle Lin, Amanda Khosravi,

Ricardo Santos, David K. Ornstein, Thomas E. Ahlering, Darren R. Tyson,Ralph V. Clayman and Elspeth M. McDougall*

From the Department of Urology, University of California, Irvine, Orange, California

Abbreviations

and Acronyms

LRP � laparoscopic radicalprostatectomy

MF � mini fellowship

RAL � robot assistedlaparoscopic

RALP � robot assistedlaparoscopic prostatectomy

Submitted for publication June 5, 2008.Study received institutional review board ap-

proval.Supported by grant funding from Astellas

Pharma US.* Correspondence: Department of Urology,

University of California-Irvine, 333 City Blvd.West, Orange, California 92868 (telephone: 714-456-3429; FAX: 714-456-5062; e-mail: elspethm@uci.edu).

Purpose: Robot assisted laparoscopic prostatectomy has stimulated a great dealof interest among urologists. We evaluated whether a mini fellowship for robotassisted laparoscopic prostatectomy would enable postgraduate urologists toincorporate this new procedure into clinical practice.Materials and Methods: From July 2003 to July 2006, 47 urologists participatedin the robot assisted laparoscopic prostatectomy mini fellowship program. The5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lec-tures, tutorials, surgical case observation, and inanimate, animate and cadavericrobotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 yearsafter the mini fellowship program were analyzed.Results: One, 2 and 3 years after the program the response rate to the question-naires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24),respectively. The percent of participants performing robot assisted laparoscopicprostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78%(25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing theprocedure there was a progressive increase in the number of cases each year withincreasing time since the mini fellowship training. In the 3 attendees not per-forming the procedure 3 years after the mini fellowship training the reasons werelack of a robot, other partners performing it and a feeling of insufficient trainingto incorporate the procedure into clinical practice in 1 each. One, 2 and 3 yearsfollowing the mini fellowship training program 83%, 84% and 90% of partneredattendees were performing robot assisted laparoscopic prostatectomy, while only67%, 56% and 78% of solo attendees, respectively, were performing it at the samefollowup years.Conclusions: An intensive, dedicated 5-day educational course focused on learn-ing robot assisted laparoscopic prostatectomy enabled most participants to suc-cessfully incorporate and maintain this procedure in clinical practice in the shortterm and long term.

Key Words: prostate; prostatectomy; robotics; laparoscopy; education,

medical, continuing

778 www.jurology.com

LAPAROSCOPY has rapidly become anintegral part of urological surgery.

The application of minimally invasive

0022-5347/09/1812-0778/0THE JOURNAL OF UROLOGY®

Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION

surgery technology can decrease pa-tient morbidity and shorten postoper-

ative recovery time while maintaining

Vol. 181, 778-782, February 2009Printed in U.S.A.

DOI:10.1016/j.juro.2008.10.018

ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY FELLOWSHIP AND PRACTICE PATTERNS 779

surgical outcomes with efficacy equal to that of opensurgery.1,2 LRP is now an accepted option for local-ized prostate cancer. However, LRP is consideredone of the most technically demanding laparoscopicprocedures because it requires the mastery of lapa-roscopic reconstructive skills, in addition to an ex-tensive knowledge of prostate and periprostaticanatomy.3 These challenges for the surgeon result ina steep learning curve for LRP, which has limitedthe efficient mastery of this complex surgical tech-nique.4,5 Incorporating the robot into this surgicalprocedure provides the promise of an effective inter-face to make this challenging, minimally invasiveapproach to radical prostatectomy more attainablefor more oncological surgeons, thereby providing thebenefits of the laparoscopic approach with the effi-cacy of the open procedure.6

With any new technology there is need for effec-tive training of postgraduate urologists for the ac-quisition of technical skills and incorporation of theprocedure into clinical practice. This has been par-ticularly true for RALP, which is being adopted bysurgeons who may never have had any laparoscopicexperience in their surgical practice. Therefore,RALP represents a challenge for surgical educatorsto train competent surgeons expeditiously and withappropriate skills for competent application in clin-ical practice. To our knowledge the optimal curricu-lum and duration of training for postgraduate urol-ogists performing RALP remain to be determined.

At our institution in an effort to assist communityurologists incorporate RALP into clinical practice adedicated 5-day MF program with mentor, preceptorand potential proctor experience was established.The long-term impact of RALP MF training on uro-logical practice patterns was analyzed.

METHODS

A new paradigm in postgraduate surgical training at ourinstitution has been developed, specifically a 5-day MFprogram in minimally invasive urological surgery. TheRALP training module was designed to accommodate 2postgraduate urologists per week. The 5-day course has a1:2 faculty-to-MF attendee ratio. The curriculum includeslectures, tutorials, hands-on in vitro laparoscopic and ro-botic skill training, animal and cadaver laboratories forpracticing the surgical skills and procedure of RALP, andsurgical case observation. Participants were also offered apost-program proctoring experience at their hospital ifthey so desired.

After receiving institutional review board approval allMF attendees were contacted by mail and requested tocomplete a questionnaire survey with a covering letterfrom the principal investigator. Additional remindersthrough e-mails and telephone calls were done as neces-sary to maximize the response rate. The returned surveyresponses were entered into a dedicated database. The

results were reviewed, tabulated and statistically ana-

lyzed. The questionnaire consisted of a pre-MF form and afollowup form, which were sent 1, 2 and 3 years aftertraining. The questionnaire included demographic data,the interval from residency to MF training, practice typeand pattern, prior laparoscopic procedures performed,laparoscopic workshops attended, number of RALPs beingperformed yearly after training, other robotic assisted uro-logical procedures and the take rate of partnered vs soloattendees.

RESULTS

Between July 2003 and July 2006, 47 urologistsfrom a total of 14 states and 5 countries participatedin the MF RALP program at our institution. Pre-MFquestionnaires were obtained from all MF partici-pants. The participant response rate when followed1 to 3 years after training was 89% (42 of 47), 91%(32 of 35) and 88% (21 of 24), respectively. Meanrespondent age was 46 years (range 32 to 63) andthe mean time after the residency training programwas 11.7 years (range 1 to 31).

The practice type setting was 17% academic (8 of47), 19% solo (47), 28% small group with 2 to 5physicians (13), 15% large group with greater than 6(7), 4% multispecialty (2), 2% health maintenanceorganization (1) and 15% no specified practice pat-tern (7). Of the participants 55% (26 of 47) practicedin an urban area, while 30% (14) were suburban and15% (7) were unspecified. Of the participants 53%(25 of 47) did not have any fellowship training. Ofthe 22 participants who had fellowship training thefellowships included laparoscopy for endourology in5 (23%), oncology in 4 (18%), transplantation in 4(18%), oncology/laparoscopy/endourology in 2 (9%)and unspecified in 1 (5%). A total of 32 participants(68%) had taken a basic laparoscopy course, includ-ing 13 (40%) who eventually took an advanced lapa-roscopy course. Of the 47 participants 45 (96%) hadperformed laparoscopic urological surgery, while 2(4%) did not specify their prior laparoscopic experi-ence. Most cases performed by participants who per-formed laparoscopic procedures were radical ne-phrectomy (31 or 69%) and partial nephrectomy (23or 51%), followed in descending order by adrenalec-tomy (22 or 49%), nephroureterectomy (19 or 42%),simple nephrectomy (16 or 36%), pelvic lymph nodedissection (15 or 33%), renal cyst decortication (14 or31%), undescended testis exploration (13 or 28%),radical prostatectomy (12 or 27%), cryoablation (6 or13%), cystectomy (6 or 13%), retroperitoneal lymphnode dissection (6 or 13%), varicocelectomy (5 or11%), donor nephrectomy (4 or 9%), ureterolysis (3or 7%), orchiectomy (3 or 7%) and renal biopsy (2or 4%).

Table 1 lists the robot assisted laparoscopic uro-logical procedures that were performed before and

after MF training. Of the 3 attendees not performing

ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY FELLOWSHIP AND PRACTICE PATTERNS780

RALP 3 years after MF training the reasons givenwere the lack of a robot, other partners performingRALP and a feeling of insufficient training in 1 each.

Table 2 lists the number of RALP cases that wereperformed after the MF program. Of the 47 partici-pants 18 attended the program at the same date orat a separate date with their partner, while 29 didnot attend with a partner. The number of RALPprocedures being performed by these 2 groups ofattendees was reviewed (table 3). One, 2 and 3 yearsafter the MF RALP training program 83%, 84% and90% of partnered attendees were performing RALP,respectively. However, only 67%, 56% and 78% ofsolo attendees were performing RALP 1, 2 and 3years after the MF, respectively.

Interestingly while proctoring was offered as partof this MF training program, only 7 of the 47 sur-geons who participated in the RALP MF took advan-tage of this component of the training program. The7 surgeons were from a total of 4 medical centers, ofwhich half were academic medical centers. Four sur-geons were from a total of 2 medical centers in theUnited States, 1 was from a Canadian medical cen-ter and 2 were from Australia. At 3 centers 1 casewas proctored by the expert faculty, while 5 wereproctored at the remaining center.

DISCUSSION

The rapid development of complex surgical technol-ogies has created an educational challenge for sur-geons who may have never experienced these tech-niques during residency training. The benefit ofthese newer, minimally invasive surgery proceduresin patients has become readily apparent and, there-

Table 1. Robot assisted laparoscopic experience beforeand after MF training

Procedure% Before

(No.)

% AfterYr 1(No.)

% AfterYr 2(No.)

% AfterYr 3(No.)

Overall (47) (42) (32) (21)Robot assisted laparoscopy 30 (14) 83 (35) 78 (25) 86 (18)RALP 26 (12) 74 (31) 72 (23) 81 (17)RAL pyeloplasty 4 (2) 19 (8) 25 (8) 52 (11)RAL cystectomy 0 12 (5) 16 (5) 14 (3)RAL nephrectomy 0 26 (11) 0 10 (2)

Table 2. RALP cases performed after MF

No. RALPs/yr % After Yr 1 (No.) % After Yr 2 (No.) % After Yr 3 (No.)

Overall (33) (25) (18)1–10 61 (20) 36 (9) 22 (4)11–20 12 (4) 20 (5) 17 (3)21–30 9 (3) 16 (4) 0

Greater than 30 12 (4) 24 (6) 56 (10)

fore, these surgeons are seeking effective educationprograms to learn these new technologies, such asrobot assisted surgery. These learners have a signif-icant need to rapidly develop knowledge and skills,and be able to apply them effectively to clinical prac-tice. To meet these needs the RALP MF was createdas an educational program that is strongly groundedin skill based activities in various simulated set-tings, such as inanimate, animate and cadavericbased models. In addition, MF participants observethe expert robotic surgeon perform several RALPprocedures and they have tutorials with these sur-geons to discuss specific aspects of the proceduresthat they observed. However, the optimal methodand duration of training remain unclear.

It has been observed that hands-on interactiveeducational activities are generally more effective ascontinuing medical education activities for changingphysician knowledge, skills and attitudes related tophysician performance and, thus, improving patientcare.7 Shay et al noted that participation in laparo-scopic surgery during residency training has beenconsidered a major determining factor in the perfor-mance of laparoscopy as a primary surgeon in prac-tice.8 Similarly Rane has reported increased activityin laparoscopic renal surgery in clinical practice fol-lowing dedicated fellowship training focused onlaparoscopic urological surgery.9

Conversely Colegrove et al examined the practicepatterns of urologists after 2 or 3-day postgraduatecourses in laparoscopic renal surgery, including di-dactic lectures and animal laboratory practice.10

They found a decrease in the number of laparoscopiccases performed in the practice after 5 years from84% initially to 54%. The RALP MF at our institu-tion was designed to provide a more intensive,highly individualized training program than the 2 to3-day course and it was tightly concentrated ontransfer of a specific surgical skill to participants.This type of educational program requires the com-mitment of a coordinating director and dedicatedfaculty to provide a uniform and productive 5-dayimmersion learning experience for participants. The

Table 3. RALP performance by partnered and solo attendeesafter MF

% (No./Total No.)

After 1 Yr After Yr 2 After Yr 3

Response rate:Partnered 100 (18/18) 100 (16/16) 86 (12/14)Solo 83 (24/29) 84 (16/19) 90 (9/10)

RALP performed:Partnered 83 (15/18) 88 (14/16) 83 (10/12)Solo 67 (16/24) 56 (9/16) 78 (7/9)

p Value 0.4710 0.6675 0.6214

resulting dedicated, intensive, minimally invasive

ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY FELLOWSHIP AND PRACTICE PATTERNS 781

surgery program focusing on RALP at our institu-tion includes lectures, tutorials, model based lapa-roscopic and robotic skill training, animal laboratoryexperience with the robotic interface, cadaveric lab-oratory practice with robotic laparoscopic radicalprostatectomy and surgical case observation duringthe 5-day training period. Long-term results are en-couraging with a steadily increasing rate of practi-tioners incorporating the newly learned techniqueinto clinical practice, including 78%, 78% and 86%during years 1 to 3 after the RALP MF, respectively.This increasing use was complemented by a markedincrease in the average number of cases performedby each participant and an expansion of robotic as-sisted urological procedures, including pyeloplasty,cystectomy and nephrectomy.

It is interesting to note that MF attendees whoparticipated in this educational program with apartnered colleague had a higher rate of performingRALP after training. While there was a trend to-ward partnered trainees to be more likely to performRALP 1, 2 and 3 years after the MF compared to solotrained MF attendees, these results did not attainstatistical significance (p � 0.47, 0.67 and 0.62, re-spectively). This trend persisted out to 3 years offollowup, while solo attendees demonstrated a pro-gressive increase in RALP performance duringthis time. However, the solo trained group neverachieved the high rate of performing RALP as train-ees who were partnered with a colleague for train-ing. This educational effect may in part have beenrelated to the shared mentoring of the 2 surgeons atthe home institution. Based on the experience ofrobotic surgeons at our institution it has alwaysbeen our recommendation for MF participants toattend the training program as a partnered team.Because our training program commenced duringthe early integration of the robot into clinical prac-tice, the RALP MF program has trained many urol-ogists who now provide training and mentoring totheir urology colleagues in their communities,thereby decreasing the need for the RALP MF at ourinstitution. Only 7 of 47 surgeons 915%) who partic-ipated in the RALP MF chose to be proctored by oneof the expert faculty at our institution after thetraining program, which suggests that proctoring isnot considered a necessary component of this course.

The role of a mentoring surgeon has been evalu-ated by several educators as a critical component oflaparoscopic urological skills acquisition. Marguetet al reported that mentoring serves as an adjunct,especially to postgraduate urologists.11 Shalhavet al observed that an intensive 1:1 mentor-to-trainee experience provides practicing urologistswith a safe and effective process for assimilatinglaparoscopic urological surgery into clinical prac-

tice.12 The mentored program provides a structured

program in which to safely and effectively learn anew procedure under the guidance of an experiencedsurgeon, thereby potentially avoiding some of thepitfalls associated with the initial learning curve ofthese challenging minimally invasive surgery tech-niques. Mentoring may also allow greater exposureto clinical cases, a high level of assistance with theinitial experience with the procedure, a second opin-ion during intraoperative decision making and thepotential to share cases, thereby decreasing fatiguewhile increasing experience.13 The disadvantages ofthis type of training are geographic restrictions, thesignificant financial and time burden on the mentor,who is away from practice while mentoring, and thetrainee, who must take considerable time away frompractice to undergo the program during a 6-monthperiod. Self-mentoring by partnered training mayassist in resolving these dilemmas related to men-toring.13

A group of education researchers from Singaporeemphasized the role of the team for decreasing thelearning curve associated with minimally invasivesurgical techniques.14 This equates to the Crew Re-source Management concept, which grew out of ex-perience in the aviation industry that proved tosignificantly decrease errors.15,16 This concept isparticularly germane to robot assisted laparoscopy,in which the surgical team can significantly facili-tate robot preparation and docking, the exchange ofinstrumentation on the robot arms, and retractionand exposure of the tissues during the case to enablethe surgeon at the console to operate effectively andefficiently. Our study results show that eventualincorporation of RALP into clinical practice is con-sistently higher in the group that trained with apartner compared to solo training.

There is no consensus regarding the optimal wayof assessing the learning curve of any particularsurgical procedure. Frequently the learning curvehas been defined by the number of cases and thecorresponding operative time. Typically it is the self-perceived point of the comfort of the individual sur-geon with performing the procedure and it may varywith surgeon related factors, such as experiencewith similar technology and familiarity with theprocedure using an alternative approach. Ahleringet al found that the learning curve to achieve 4-hourproficiency with RALP performance was 12 cases fora laparoscopically naïve but oncologically experi-enced open surgeon.17 On the other hand, with mod-erate training in laparoscopy Menon et al estimatedthat it took them 18 RALP cases to achieve a level ofefficiency in the performance of the procedure.18

These surgeons who had extensive open surgicalexperience were able to successfully transfer theiropen surgical skills to the robotic platform during

the performance of minimally invasive surgery. Pa-

ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY FELLOWSHIP AND PRACTICE PATTERNS782

tel et al reported that with formal 1-year fellowshiptraining in laparoscopy a surgical time comparableto that of laparoscopic prostatectomy was achievedsimilarly after experience with 20 to 25 cases.19

Although we did not specifically ask each partic-ipant to define their learning curve, our results in-dicate a progressive increase in the number of casesbeing performed by MF participants during the 3years following training with 56% performing morethan 30 RALPs per year at 3 years of followup. Withthe increase in the number of cases we expect fur-ther improvement in clinicopathological outcomesand patient functional parameters, as shown by theexperience of Badani et al.20

While this training program is unique to our in-stitution, it would be possible to duplicate this cur-riculum at other medical centers. It relies on thecommitment of expert faculty to serve as tutorialinstructors and proctors, in addition to the availabil-ity of an animal and cadaveric skill training labora-tory. Although this program was tuition-free dur-ing the 3 years of this study due to grant funding,

this program was estimated to cost upward of

REFERENCES

continuing education activities change physician Cheng CW: Team-based ap

$10,000 per attending surgeon when all compo-nents of the teaching strategies were considered.Teaching laboratory costs alone were approxi-mately $3,500 per attending surgeon. When thesedirect costs are translated into a registration fee,this may well limit the ability of all centers to offerthis type of educational program as well as limitsignificant participation in the program.

CONCLUSIONS

An intensive, dedicated 5-day educational course fo-cused on learning RALP enabled most participantsto successfully incorporate and maintain this proce-dure in clinical practice. Team learning appeared tobe more effective than solo practice. This 5-day MFprogram provided an important and hitherto un-available opportunity for postgraduate urologists toattain a level of confidence with a new proceduresufficient to allow its introduction into daily clinicalpractice. The strong support of industry and philan-thropy is crucial if similar, much needed, 5-day,procedure oriented postgraduate training programs

are to be developed at other universities.

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