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Editorial Comment on: Training in Percutaneous Nephrolithotomy—A Critical Review
european urology 54 (2008) 994–1003
Editorial Comment on: Training in Percutaneous Nephrolithotomy—A Critical Review Thomas Knoll Department of Urology, Mannheim University Hospital, Mannheim, Germany [email protected] Percutaneous nephrolithotomy (PNL) achieves excellent stone-free rates (SFR) with acceptable complication rates and is therefore still the treatment of choice for large renal calculi [1]; however, the reported complications rates in the literature differ widely, with transfusion rates up to 20% and including even more severe cases. It is generally agreed that the establishment of a proper access tract is the crucial step, and it has been demonstrated that both SFR and complication rates are superior when renal access is achieved by the urologist [2]. Because PNL is a difficult surgical technique with reported learning curves of up to 50 procedures, it is clear that standardized, continuous training options are necessary to teach young urologists and to maintain proficiency [3]. The paper of de la Rosette and colleagues highlights these issues [4]. The traditional way of acquiring surgical skills through apprenticeship should be displaced in the near future by training on models or simulators. Today, only animal organ models offer training in the whole procedure; current virtual reality (VR) simulators just allow placement of percutaneous nephrostomies and do not provide ultrasound guidance (which significantly reduces access-related complications) [5]. Furthermore, costs limit the distribution of VR models. Without any doubt, VR has the potential to overcome the limitations of organ models and will
1003
be the future standard. Until then, each model offers individual advantages. Most importantly, training under the supervision of a dedicated, experienced trainer will most effectively reduce the learning curve. Participation in educational programs at experienced stone centres offers ideal opportunities to achieve competence in PNL. The observation of rising PNL frequencies worldwide underscores the need for such programs to maintain satisfactory surgical standards.
References [1] Osman M, Wendt-Nordahl G, Heger K, Michel MS, Alken P, Knoll T. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases. BJU Int 2005;96:875–8. [2] Watterson JD, Soon S, Jana K. Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. J Urol 2006;176:142–5. [3] Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C. The learning curve in the training of percutaneous nephrolithotomy. Eur Urol 2007;52: 206–12. [4] de la Rosette JJMCH, Laguna MP, Rassweiler JJ, Conort P. Training in percutaneous nephrolithotomy—a critical review. Eur Urol 2008;54:994–1003. [5] Mozer P, Conort P, Leroy A, et al. Aid to percutaneous renal access by virtual projection of the ultrasound puncture tract onto fluoroscopic images. J Endourol 2007;21:460–5.
DOI:10.1016/j.eururo.2008.03.055 DOI of original article: 10.1016/j.eururo.2008.03.052
Editorial Comment on: Training in Percutaneous Nephrolithotomy—A Critical Review Thomas Knoll Department of Urology, Mannheim University Hospital, Mannheim, Germany [email protected] Percutaneous nephrolithotomy (PNL) achieves excellent stone-free rates (SFR) with acceptable complication rates and is therefore still the treatment of choice for large renal calculi [1]; however, the reported complications rates in the literature differ widely, with transfusion rates up to 20% and including even more severe cases. It is generally agreed that the establishment of a proper access tract is the crucial step, and it has been demonstrated that both SFR and complication rates are superior when renal access is achieved by the urologist [2]. Because PNL is a difficult surgical technique with reported learning curves of up to 50 procedures, it is clear that standardized, continuous training options are necessary to teach young urologists and to maintain proficiency [3]. The paper of de la Rosette and colleagues highlights these issues [4]. The traditional way of acquiring surgical skills through apprenticeship should be displaced in the near future by training on models or simulators. Today, only animal organ models offer training in the whole procedure; current virtual reality (VR) simulators just allow placement of percutaneous nephrostomies and do not provide ultrasound guidance (which significantly reduces access-related complications) [5]. Furthermore, costs limit the distribution of VR models. Without any doubt, VR has the potential to overcome the limitations of organ models and will
1003
be the future standard. Until then, each model offers individual advantages. Most importantly, training under the supervision of a dedicated, experienced trainer will most effectively reduce the learning curve. Participation in educational programs at experienced stone centres offers ideal opportunities to achieve competence in PNL. The observation of rising PNL frequencies worldwide underscores the need for such programs to maintain satisfactory surgical standards.
References [1] Osman M, Wendt-Nordahl G, Heger K, Michel MS, Alken P, Knoll T. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases. BJU Int 2005;96:875–8. [2] Watterson JD, Soon S, Jana K. Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. J Urol 2006;176:142–5. [3] Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C. The learning curve in the training of percutaneous nephrolithotomy. Eur Urol 2007;52: 206–12. [4] de la Rosette JJMCH, Laguna MP, Rassweiler JJ, Conort P. Training in percutaneous nephrolithotomy—a critical review. Eur Urol 2008;54:994–1003. [5] Mozer P, Conort P, Leroy A, et al. Aid to percutaneous renal access by virtual projection of the ultrasound puncture tract onto fluoroscopic images. J Endourol 2007;21:460–5.
DOI:10.1016/j.eururo.2008.03.055 DOI of original article: 10.1016/j.eururo.2008.03.052