The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation

BackgroundNo validated training program for robot-assisted partial nephrectomy (RAPN) exists.ObjectiveTo define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).Design, setting, and participantsA modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).Outcome measurements and statistical analysisTo define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann–Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence.Results and limitationsConsensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p > 0.05). Conversely, operative time was longer after cRAPN (p < 0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p < 0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.ConclusionsThe European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.Patient summaryPatients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.     

Microscopically assisted percutaneous nucleotomy,an alternative minimally invasive procedure for the operative treatment of lumbar disc herniation: preliminary results

Lumbar discectomy is one of the most frequent neurosurgical and orthopaedic procedures. In this study, a series of 43 consecutive patients operated with a minimally invasive technique referred to as "microscopically assisted percutaneous nucleotomy" (MAPN) is presented. After a follow-up period of 3 months, every patient was seen clinically, and after 12 months, telephone enquiries were performed by the first author. There were two recurrences. The results in improvement of sciatica and neurologic deficit corresponded to common microdiscectomy series with 80% excellent and good results. The MAPN method is compared with common microdiscectomy with regard to operating time, technical procedure, and especially in surgical indications. It proved to have the same effectivity in the treatment of lumbar disc herniations, however, with less approach damage. Electronic Publication     

Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety

Purpose

To evaluate the clinical and radiological risk factors for exiting root injuries during transforaminal endoscopic discectomy.

Methods

We retrospectively examined cohort data from 233 patients who underwent percutaneous endoscopic lumbar discectomy for lumbar disc herniation between January 1st, 2010 and December 31st, 2011. We divided the patients into the two groups: those who presented a postoperative exiting root injury, such as postoperative dysesthesia or motor weakness (Group A, n = 20), and those who did not suffer from a root injury (Group B, n = 213). We examined the clinical and radiological factors relating exiting root injuries. We measured the active working zone with the exiting root to the upper facet distance (Distance A), the exiting root to disc surface distance at the lower facet line (Distance B) and the exiting root to the lower facet distance (Distance C) in magnetic resonance imaging (MRI).

Results

Group A exhibited a shorter Distance C (6.4 ± 1.5 versus 4.4 ± 0.8 mm, p < 0.001) and a longer operation time (67.9 ± 21.8 versus 80.3 ± 23.7 min, p = 0.017) relative to Group B. The complication rate decreased by 23 % per each 1-mm increase in Distance C (p = 0.000). In addition, the complication rate increased 1.027-fold per each 1-min increase in the operation time (p = 0.027).

Conclusion

We recommend measuring the distance from the exiting root to the facet at the lower disc level according to a preoperative MRI scan. If the distance is narrow, an alternative surgical method, such as microdiscectomy or conventional open discectomy, should be considered.     

Jeunes neurochirurgiens français : conditions de travail et perspectives

IntroductionDue to the increase in the number of French neurosurgeon residents the neurosurgical workforce is changing. The main objective of this survey was to assess working conditions and perspectives for young French neurosurgeons.MethodAn on-line survey was sent to young French neurosurgeons based on a mailing-list (219 mail addresses of Residents and Fellows obtained during previous meetings). The form contained questions about career, amount of work, salary, quality of life, teaching and university work.ResultsWe received 78 replies from January to March 2014. A total of 56% from fellows saying they had undergone difficulties in obtaining a fellowship, although 78% were satisfied. Fellows considered a private career more often than residents. Overall, young neurosurgeons were worried about future employment. Some 33% admitted contemplating a different career from one they originally wanted. The average weekly working time of 76.8 hours was deemed to be excessive. Security rests after overnight shifts were lacking or incomplete in 91% of cases. The work atmosphere was good overall (3.7/5), and so was the quality of life (3.2/5). Theoretical teaching was unsatisfactory (2.43/5) as well as the time allowed for academic work (approximately 1.58 half-days per month). However, practical teaching was considered rewarding (3.63/5).ConclusionThis study provides some guidance for upcoming reforms, and should be considered again at a later date to evaluate progress.     

Resection of the inferior head of the pancreas: Report of a case

We developed a new technique for partial resection of the head of the pancreas with an end-to-side pancreaticoduodenostomy, while preserving the duodenum, the common bile duct, and the upper part of the head of the pancreas around the duct of Santorini. A resection of the inferior head of the pancreas was performed in a patient with an intraductal mucin-producing tumor of the pancreas. This procedure is considered to be appropriate for treating both benign disease and noninvasive malignant disease involving either the uncinate process or the duct of Wirsung, because it removes both the uncinate process and the pancreatic tissue around the duct of Wirsung. We thus believe that a resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy can help play a significant role in the management of patients with benign diseases and localized malignant tumors of the pancreas.     

Primary leiomyosarcoma of the jejunal mesentery: Report of a case

(Received for publication on May 29, 1996; accepted on Jan. 7, 1997)     

Working conditions and trainee shortage in operative disciplines—is our profession ready for the next decade?

Background  Increasing concern has been expressed worldwide on the problem of finding young doctors to enter a training programme in an operative speciality. Materials and methods  A survey comprising 22 questions on working conditions and job satisfaction was placed on the homepage of the Austrian Society of Surgery; 667 questionnaires were completed. Results  The question whether surgery is threatened by a trainee shortage was answered with “yes” by 68%. Only 37% were satisfied with their working conditions. The majority (61%) specified documentation as making up between 20% and 40% of their workload, 22.5% estimated an even higher percentage. Only 17.7% were satisfied with payment. A clear majority works 60 to 80 h per week or more. Only 32.5% stated that they can leave the hospital in the morning after weekend duty; for night duty during the week, this percentage decreased to just 4.2%. As for surgical training, 33.3% were satisfied. Regular assessments between the trainees and their department heads were confirmed by only 34%. A clear majority (96%) is in favour of rotations in other hospitals during residency for the sake of broader experience. Conclusion  Working hour restrictions are essential, but not enough: Substantial improvements in the professional profile and in training are required.