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TRAINING IN ENDOSCOPICUROLOGICAL SURGERY

GANESH GOPALAKRISHNAN
Professor, Department of Urology, Christian Medical College and Hospital Vellore, Tamilnadu, India.
One is often asked as to what is so special about urology that sets it apart from other surgical specialities. No doubt it is the ability to carry out most if not all surgical procedures via the natural passages of the body. This surely is an attraction not only for the patient but also for the trainee surgeon. From the patients point of view, the procedure is less painful, minimally invasive, involving a shorter stay in hospital and quicker return to activity. This of course at a higher cost which is offset by quicker return to work. From the surgeons view, it is an exciting way to deal with a condition and sets him apart from his other surgical colleagues but involves considerable time in training and of course at a higher investment.

Urologic endoscopy was the earliest endoscopic procedure recorded and cystoscopes were designed before other endoscopes. It was this aspect of urology that paved the way at least in our country to create a subspeciality with a structured training programme affiliated to the university. It also enabled urologists to create their own organizations across the world in recognition of this science. In fact the "Encyclopedia of Urology" Volume VI, devoted to endoscopic urological surgery by Dr. Roger Barnes was not only written within the four walls of the department of urology of Christian Medical College Hospital, Vellore, India but also proudly dedicated to the Urologists of India who at that time were struggling to create their own speciality. Today, endoscopic urology has advanced to such a degree that virtually the entire luminal aspect of the urinary tract can be visualized. What has really revolutionized endoscopic urology is the excellent quality of optics, camera systems, instrument range and flexibility and that has made urology attractive for surgeons to learn and for patients to agree to being treated; to the extent, in fact, asking for these newer minimally invasive procedures to be used for their treatment.

WHO SHOULD BE TRAINED?

With this background there is naturally a rush for being trained in endoscopic urology and one is faced with a lot of requests for training. There is no doubt that all trainees selected for the higher speciality programme must be trained. It is also clear that the younger man is usually more adept at learning the techniques than an older person. There are many requests from many general surgeons to learn these skills. While it is clear that with the paucity of training programmes in the country the void between supply and demand of urologists will never be met for a long long time, that does not translate into training for the occasional operator. Endoscopic skills are difficult to learn and one needs to be continually doing these operations to maintain proficiency. The old adage "see one, do one, teach one" does not apply to endoscopic urologic surgery.

TRAINING THE ENDOSCOPIC SURGEON


In the early 60’s, lower tract endoscopy was the only procedure being performed. Today both lower tract and upper tract endoscopy has to be learnt by the trainee and I believe that these two aspects of endourology require different skills and training. However both skills have to be learnt and can be learnt. The availability of endocameras has revolutionized endoscopic urologic training and surgery. It is possible for both trainee and trainer to watch each other. The clarity is stupendous and the magnification obtained enables the procedure to be watched very closely. No urological training programme should be given recognition if there is no endocamera in the department training candidates. A teaching attachment is cumbersome, impractical and no substitute for the camera. It would be fair to state that factional disparity and one-upmanship has riddled the training of endoscopic surgery, at least in our country. There are those who feel that there is no place for endoscopic surgery and those who believe that every condition should be treated endoscopically. The younger generation of urologists is more enthusiastic about endoscopic surgery than are its elders who have been trained in those schools with a bias against endoscopic surgery. The former are naturally ardent supporters of endoscopic procedures. Thus the urologists training is the prime influence which moulds his judgement concerning the relative merits of different endourological procedures. The techniques of endoscopic surgery has continued to improve and the number of urologists who are skilled in these procedures is rapidly increasing. However it must be remembered that the number of younger trainees waiting on the horizon to master these skills is rising.

The problems with which the endoscopic surgeon has to deal and the techniques which he must master are different to those encountered in open surgery. Experience in open surgery could certainly bale the trainee out of an endoscopic catastrophe provided of course he is able to recognize that there is a problem. It must be remembered that endoscopic surgery inexpertly performed could result in disastrous consequences.

TRAINING FOR ENDOSCOPIC SURGERY

Endoscopic surgery is a highly technical procedure. It requires preparation, patience and persistence. The trainee should submit to an intensive term of study, observation and supervised practice before attempting such procedures independently. No other surgical procedure is so difficult to teach. The technique of most open surgical operations can be learnt by the tenth procedure, but when it comes to endoscopic surgery it has often quoted that one must carry out over hundred procedures before one feels confident enough to do it independently.

Before starting to perform any endoscopic surgery, the trainee must know his instruments. He should be familiar with the working of each gadget. He should go through the latest catalogues supplied by the instrument makers and have a clear idea of the function and ability of each item. He should be able to troubleshoot if there is a malfunction or a minor fault. The instruments are expensive and with proper care could serve an individual urologist for many years. He must therefore learn to care for them after use every day. Lastly, the trainee must be knowledgeable. He should read the relevant literature pertaining to the procedure before eventually beginning to learn the technique.

THE ROLE OF THE TRAINER

The trainer has a difficult role to play. He needs to be confident himself and be prepared to stand by his trainee and bale him out of a catastrophe before any harm comes to the patient. The margin for error is very small in endoscopic surgery. He should be free to watch on the television monitor undisturbed, the trainee carrying out the procedure. It is crucial that he be physically present in the operating room for the first 25 or more cases done by the trainee. He should not be in the office or some other part of the hospital while his trainee is operating. The trainer should have utmost patience as the level of skin and dexterity of each trainee is different. The trainer’s comment should be made carefully as to not shatter the confidence of the trainee.

THE TRAINING PROCESS

Lower Tract Surgery


I believe that the trainee should have done numerous simple cystoscopies before launching out to carry out his first transurethral resection. It is important to know landmarks in normal and in disease, because, during the course of an endoscopic procedure these can alter rapidly.

Preliminary practice using a beef heart or a standard clay model is useful as it enables the trainee to get a feel of the resectoscope and to achieve some degree of eye, hand and foot coordination. Resecting a prostate is quite different to resecting a bladder tumour and I believe that these procedures require different skills. While many books on the technique of transurethral prostatectomy have been written there is a paucity of material on the technique of resection of bladder tumours. It should be remembered that most of these procedures are carried out under regional anaesthesia and therefore there is a time constraint in completing the procedure.

A stepwise training schedule is important. In the early days it is useful to ask the trainee to achieve haemostasis after the trainer or other senior colleague has completed a resection. The next step would be to carry out a bladder neck incision or a transurethral incision of the prostate. This is followed by a stepwise resection of the middle lobe, then both middle and either right or left lobe and subsequently the entire prostate. This schedule is by no means the gold standard but serves as a suitable format in a training programme. Some trainees are in fact fast learners and need not go through this protocol. It must be emphasized continually that the prostate must be resected methodically and in a predetermined sequence. The sequence could vary with experience but for the trainee it should be constant. The trainer should emphasise that resection of the prostate should not be haphazard for this could result in one getting lost and losing landmarks. This is important because, during the course of a transurethral prostatectomy if one lands up in a complication and the procedure is stopped, then the patient is likely to void adequately if the resection in the first place was methodical. If a second look resection is deemed necessary then this would be easier if the above sequence is followed to completion. In the early days of prostatic resection, under resection is probably preferable to over resection and thus avoid unnecessary complications. The depth and extent of resection can be improved with experience.

One of the problems during resection which faces the trainee is undermining of the trigone. This is due to the novice resectionist "climbing up on the trigone." One of the ways I find to help the trainee solve the problem is to make deep grooves from the bladder neck to the veru montanum at 5 and 7 o’clock positions as in a transurethral incision of the prostate. This demarcates clearly not only the amount of intervening tissue to be resected but also the depth of resection.

Finally it should be remembered that in endoscopic surgery clarity of view is paramount. One should be proceed if anatomy is not identified and bleeding, the most important deterrent to progress of the procedure, should be controlled and for the novice resectionist all bleeding should be taken care off after every bit of tissue that is resected.

Resecting bladder tumours is slightly different. Although hand-eye coordination is the same as for TURP, movement of the resectoscope is different. The depth of resection is different as the amount of tissue between the tumour base and the bladder wall is minimal and hence perforation of the bladder wall both intraperitoneal and extraperitoneal is highly likely. In most cases these tumours are multiple and large areas of bladder mucosa and wall are denuded and could result in extravasation of irrigating fluid in the retropubic space. A judicious combination of bladder filling and emptying is necessary so that the far wall of the bladder beyond the edge of the tumour is not included in the resection. A continuous flow resectoscope makes it far easier to carry out the resection. It is important that each movement of the resectoscope loop is meticulous and deliberate keeping in view the bladder wall and activating the current just prior to the movement of the loop over the tumour. Lateral wall tumours produce the "obturator reflex" and the trainee should be forewarned lest he is taken unawares. This reflex is largely unavoidable but one needs to adjust the strength of the current to the lowest possible to effectively cut the tissue keeping the bladder minimally full at this time. This reflex can sometimes be so powerful that the surgeon loses the grip of the resectoscope and if the loop is still active at that time, then it is almost certain that an extraperitoneal perforation is likely to occur. The trainee should be taught to anticipate this problem and take precautions mentioned above or request for a general anaesthetic or carry out an obturator nerve block. The other area of the bladder that is likely to produce a complication is from tumours located at the far wall of the bladder where the peritoneal reflection skirts of the bladder. If one is not careful, then a intraperitoneal perforation is likely to occur. Special bladder wall loops are available to resect tumours in difficult locations. It takes time and experience to learn to resect using these bladder wall electrodes where the activated loop is moved along with the entire resectoscope across the mucosal surface of the bladder wall. Since most of these patients have multiple tumours it is important that once the resection is complete that the trainee inspect the entire bladder with a lateral telescope in order to ensure that all tumours are resected.

In concluding this section of lower tract endoscopy, it would be fair to state that patient safety is paramount and that the trainee be warned at all times that clear vision of the goal is important and if landmarks are not identified then not to proceed but to go back to the basics.

UPPER TRACT ENDOSCOPY

Upper tract endoscopy for the treatment of renal calculi, pelvic tumours and pelviureteric junction obstruction has added another dimension to the minimally invasive nature of urologic procedures. These procedures are totally different to the other lower tract endoscopic procedures just described. It requires the trainee to have a three dimensional image of the kidney and its pathology. Puncturing the collecting system is simple and can be done under ultrasound guidance or even using an image intensifier opacifying the collecting system with contrast via a retrograde ureteric catheter. The trainee should be given the opportunity of puncturing initially a dilated collecting system and later on move onto normal and less dilated systems.

Placing the puncture according to anatomical landmarks is well defined and if one follows these basic steps and not cut corners then the margin for error is greatly reduced. It is essential to make sure that the puncture and subsequent tract dilatation is not across the infundibulum of the calyx; it should be through the apex of the papilla. In order to facilitate subsequent tract dilatation, it would be ideal to get the guide wire across the pelviureteric junction and into the ureter at all times. Various manoeuvres and instrumentation are available to facilitate this process and the trainee should have a thorough knowledge about these aspects of upper tract endourology. However in many situations especially where the calculus has occupied the entire calyx completely it would be impossible to get the wire into the ideal position just described and one is left carrying out the dilatation short of the calyceal lumen. Such cases are not for the trainee to perform initially but in time to come this is possible. Whatever be the case, the crux of all tract placement is to aim for the shortest and most straight tract into the collecting system. This would prevent buckling and subsequent kinking of the guide wire.

It has been suggested that for the first few cases it would be preferable for the trainee to use either a Lunderquist or a super-stiff Amplatz guide wire to grips with the technique of dilatation as both these wires do prevent buckling. In all situations, it would be better if the trainer makes the initial dilatation and then allow the trainee to redo the same dilatation over the tract already made so as to get the feel of tissues and the depth of dilatation. It is important for the trainee to have an image of the direction of the tract and this can be memorized. It does help ultimately to reduce the amount of radiation. The present trend is to carry out percutaneous surgery as a single stage procedure, "however whenever the clinical situation demands that a nephrostomy be placed prior to the actual procedure then such cases would be ideal for the trainee to perform under supervision as the technique of tract dilatation can be learnt quite readily from a preplaced nephrostomy. It is necessary for the trainee to assist on these cases to understand the procedure. The various manouevres employed by the trainer and to carry out nephroscopy prior to actual treatment enables the trainee to identify landmarks in the collecting system, the pelviureteric junction, the papilla, the calyceal neck and in fact the urothelium. The latter landmark is very useful because in difficult situations where the dilatation has fallen short of the calyceal lumen, identifying the urothelium helps in establishing the fact that the situation is not out of control. It would be appropriate at this stage to state that placing a safety guide wire is an essential and invaluable part of the procedure.

There is no doubt in my mind that lower tact endoscopic surgery and upper tract endoscopic surgery are different procedures. Some trainees are able to grasp one and have problems with the other; some are equally adept at both procedures. There is no fixed time during the training schedule that one imparts these skills to the trainee but it would be better to do so after the trainee has spent about 18 months in the speciality. Both upper tract surgery and lower tract surgery should be taught and ultimately the trainee has to decide if he has the confidence to pursue these skills as he launches out on his own career.


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