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OPERATIVE EXPERIENCE OF U.S. UROLOGY RESIDENTS WITH OPEN AND LAPAROSCOPIC RENAL SURGERY
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
2260 OPERATIVE EXPERIENCE OF U.S. UROLOGY RESIDENTS WITH OPEN AND LAPAROSCOPIC RENAL SURGERY Siamak Daneshmand*, Michael J Conlin, John M Barry, Portland, OR INTRODUCTION AND OBJECTIVE: The introduction and subsequent propagation of laparoscopic renal surgery has raised concern that resident experience with open renal surgery is declining. The aim of this study was to quantify the changes in open versus laparoscopic renal surgery over the past 7 years in U.S. residency training programs. To the best of our knowledge, resident experience in open and laparoscopic renal surgery has not been previously documented. METHODS: Aggregate national data for open and laparoscopic renal surgery was obtained from the Accreditation Council for Graduate Medical Education for academic years 2000 through 2007. The total number of cases reported by urology residents as surgeon and assistant were analyzed for all open and laparoscopic renal surgeries by CPT codes. Radical or total nephrectomy, nephroureterectomy, partial nephrectomy, and donor nephrectomy were included. RESULTS: The total number of renal surgeries performed as surgeon or assistant by graduating residents from US institutions increased from 16,297 in academic year 2000- 2001 to 21,449 in 20062007. During this time period there was a greater than five fold increase in the total number of laparoscopic renal surgeries (1825 to 9768 cases) performed by graduating residents. For total or radical nephrectomy (laparoscopic CPT codes 50545, 50546), the number of “resident as surgeon” laparoscopic renal cases increased from 937 in 2000-2001 to 4754 in 2006-2007. There was a concomitant decrease in the number of open total or radical nephrectomies (CPT codes 50220, 50225 and 50230), from 7174 to 5069, however, this decrease is lower than expected and reflected an increase by 60% in the number of open partial nephrectomies performed by residents during this time period. CONCLUSIONS: Since the introduction of laparoscopic kidney surgery into training programs, there has been a significant decrease in the number of open renal surgeries reported by graduating residents as surgeon or assistant. This decrease is compounded by the increase in the total number of renal cases being performed. If these trends continue, strategies should be explored to determine minimum training criteria in open renal surgery and, if necessary, improve this residency training experience. Source of Funding: None
2261 PREDICTION OF COMPLICATIONS IN LAPAROSCOPIC PARTIAL NEPHRECTOMY Kazumi Kamoi*, Georges-Pascal Haber, Berger Andre, Sebastien Crouzet, Ricardo Brandina, Inderbir S Gill, Cleveland, OH INTRODUCTION AND OBJECTIVE: We evaluate our experience with laparoscopic partial nephrectomy (LPN) to determine risk factors for postoperative complications. METHODS: A prospectively maintained database of 1000 LPN procedures since September 1999 was retrospectively analyzed with emphasis on postoperative complications. Various baseline patient and tumor characteristics were assessed using multivariate analysis in order to identify risk factors associated with postoperative urological and nonurological complications. Complication rates were also compared among the 1999-2003, 2004-2006 and 2007-2008 eras. RESULTS: In 1000 LPN procedures, a total of 200 including 68 urologic and 132 non-urologic postoperative complications occurred in 138 patients (13.8%). Of 200 complication, 20% were grade I, 45% were grade II, 30% were grade III, 4.5% were grade IV and 0.5% was grade V. Risk factor analysis with baseline patient characteristics demonstrated that body mass index more than 30 was associated with postoperative urine leak with 3.0 of odds ratio (p=0.011), Charlson comorbidity index greater than or equal to 1 was associated with nonurological complications with 2.0 of odds ratio (p=0.019). Tumor size was significantly associated with postoperative hemorrhage (requiring
819
interventional treatment) with 5.8 (p=0.0002) of odds ratio. The tumor abutting renal hilum was associated with intraoperative complications with 3.4 of odds ratio (p=0.037). Surgery eras was also significantly associated with urine leak, hemorrhage and non-urological complications (p<0.01 for all). These urological and non-urological complications were significantly lower in the recent era (10.2%, 4.9% and 4.4%, p=0.0044 and 22.8%, 11.4% and 8.8%, p<0.0001, respectively) despite increased technical difficulty to treat more complicated renal tumors. CONCLUSIONS: Tumor characteristics including size and location as well as baseline comorbidities are associated with intra and postoperative complications. Infrequent urological and non-urological complications are currently achieved by a laparoscopic expertise. Uni and multivariate logistic regression analysis to predict complications Univariate p value Intra-op Urine Non-Urological (optimal cutoff) Hemorrhage Complications Leak Complications Multivariate p value, (39 pts) (29 pts) (23 pts) (78 pts) odds ratio 0.013 0.031 (28) Body Mass Index 0.30 (30)0.011, 0.57 0.20, 1.4 3.0 Charlson Comorbidity Index Indication (Imperative/ Elective)
0.67
0.15
0.48
0.015 (1) 0.019, 2.0
0.037 0.33, 1.6
0.0097 0.20, 1.9
0.21
0.20
Tumor size on CT
0.53
0.75
0.086 (2.2) 0.0002, 5.8
0.022 (3.5) 0.16, 1.6
Hilar/non-Hilar Tumor
0.038 0.037, 3.4
0.65
0.27
0.97
Surgery Eras (-2003/2004-2006 /2007-)
0.43
0.032 0.0012, 4.3
0.27
<0.0001 <0.0001, 3.5
Variables with p value < 0.10 by univariate analysis are selected for multivariate variables
Source of Funding: None
2262 LAPAROSCOPIC EXPERIENCE CORRELATES WITH DIFFERENTIAL FUNCTIONAL BRAIN ACTIVATION: AN OXYGEN-15 LABELED PET SCAN STUDY Sero Andonian*, New Hyde Park, NY; Yilong Ma, Manhasset, NY; Edan Y Shapiro, New Hyde Park, NY; Vijay Dhawan, Manhasset, NY; Lee Richstone, New Hyde Park, NY; David Eidelberg, Manhasset, NY; Louis R Kavoussi, New Hyde Park, NY INTRODUCTION AND OBJECTIVE: Laparoscopic surgery is associated with a steep learning curve. The aim of the present study was to correlate functional brain activation with the degree of laparoscopic experience by measuring changes in regional cerebral blood flow with H215O PET. METHODS: Following IRB approval, five novice laparoscopists (medical students: mean age = 26 yr) were compared to five expert laparoscopists (mean age = 46 yr). All subjects were right-handed. Peg transfer task of the MISTELS protocol was used as a validated tool to compare subjects. Each subject was injected with 15O labeled water and scanned with PET during the performance of six different tasks. 1st scan (Rest) was done with the subject’s eyes closed. 2nd scan (Video 1) was performed while the subject was watching a video clip of the peg transfer task. 3rd scan (Peg 1) was acquired during the peg transfer task. The subject repeated the peg transfer task after a 15 minute practice for the 4th scan (Peg 2). After an additional 15 minutes of practice, 5th scan (Video 2) was performed with the subject watching a clip of laparoscopic partial nephrectomy. 6th scan (Peg 3) was conducted during a final peg transfer task. Brain images were processed using statistical parametric mapping software (SPM99) implemented in MATLAB. Differences in task-specific brain activation between the novice and expert groups were compared by using repeated measures ANOVA. RESULTS: The novice group had a significantly lower normalized mean scores than the expert group on the Peg tasks (42.2 vs 77.8; p<0.05). The first image analysis examined the difference between
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
2260 OPERATIVE EXPERIENCE OF U.S. UROLOGY RESIDENTS WITH OPEN AND LAPAROSCOPIC RENAL SURGERY Siamak Daneshmand*, Michael J Conlin, John M Barry, Portland, OR INTRODUCTION AND OBJECTIVE: The introduction and subsequent propagation of laparoscopic renal surgery has raised concern that resident experience with open renal surgery is declining. The aim of this study was to quantify the changes in open versus laparoscopic renal surgery over the past 7 years in U.S. residency training programs. To the best of our knowledge, resident experience in open and laparoscopic renal surgery has not been previously documented. METHODS: Aggregate national data for open and laparoscopic renal surgery was obtained from the Accreditation Council for Graduate Medical Education for academic years 2000 through 2007. The total number of cases reported by urology residents as surgeon and assistant were analyzed for all open and laparoscopic renal surgeries by CPT codes. Radical or total nephrectomy, nephroureterectomy, partial nephrectomy, and donor nephrectomy were included. RESULTS: The total number of renal surgeries performed as surgeon or assistant by graduating residents from US institutions increased from 16,297 in academic year 2000- 2001 to 21,449 in 20062007. During this time period there was a greater than five fold increase in the total number of laparoscopic renal surgeries (1825 to 9768 cases) performed by graduating residents. For total or radical nephrectomy (laparoscopic CPT codes 50545, 50546), the number of “resident as surgeon” laparoscopic renal cases increased from 937 in 2000-2001 to 4754 in 2006-2007. There was a concomitant decrease in the number of open total or radical nephrectomies (CPT codes 50220, 50225 and 50230), from 7174 to 5069, however, this decrease is lower than expected and reflected an increase by 60% in the number of open partial nephrectomies performed by residents during this time period. CONCLUSIONS: Since the introduction of laparoscopic kidney surgery into training programs, there has been a significant decrease in the number of open renal surgeries reported by graduating residents as surgeon or assistant. This decrease is compounded by the increase in the total number of renal cases being performed. If these trends continue, strategies should be explored to determine minimum training criteria in open renal surgery and, if necessary, improve this residency training experience. Source of Funding: None
2261 PREDICTION OF COMPLICATIONS IN LAPAROSCOPIC PARTIAL NEPHRECTOMY Kazumi Kamoi*, Georges-Pascal Haber, Berger Andre, Sebastien Crouzet, Ricardo Brandina, Inderbir S Gill, Cleveland, OH INTRODUCTION AND OBJECTIVE: We evaluate our experience with laparoscopic partial nephrectomy (LPN) to determine risk factors for postoperative complications. METHODS: A prospectively maintained database of 1000 LPN procedures since September 1999 was retrospectively analyzed with emphasis on postoperative complications. Various baseline patient and tumor characteristics were assessed using multivariate analysis in order to identify risk factors associated with postoperative urological and nonurological complications. Complication rates were also compared among the 1999-2003, 2004-2006 and 2007-2008 eras. RESULTS: In 1000 LPN procedures, a total of 200 including 68 urologic and 132 non-urologic postoperative complications occurred in 138 patients (13.8%). Of 200 complication, 20% were grade I, 45% were grade II, 30% were grade III, 4.5% were grade IV and 0.5% was grade V. Risk factor analysis with baseline patient characteristics demonstrated that body mass index more than 30 was associated with postoperative urine leak with 3.0 of odds ratio (p=0.011), Charlson comorbidity index greater than or equal to 1 was associated with nonurological complications with 2.0 of odds ratio (p=0.019). Tumor size was significantly associated with postoperative hemorrhage (requiring
819
interventional treatment) with 5.8 (p=0.0002) of odds ratio. The tumor abutting renal hilum was associated with intraoperative complications with 3.4 of odds ratio (p=0.037). Surgery eras was also significantly associated with urine leak, hemorrhage and non-urological complications (p<0.01 for all). These urological and non-urological complications were significantly lower in the recent era (10.2%, 4.9% and 4.4%, p=0.0044 and 22.8%, 11.4% and 8.8%, p<0.0001, respectively) despite increased technical difficulty to treat more complicated renal tumors. CONCLUSIONS: Tumor characteristics including size and location as well as baseline comorbidities are associated with intra and postoperative complications. Infrequent urological and non-urological complications are currently achieved by a laparoscopic expertise. Uni and multivariate logistic regression analysis to predict complications Univariate p value Intra-op Urine Non-Urological (optimal cutoff) Hemorrhage Complications Leak Complications Multivariate p value, (39 pts) (29 pts) (23 pts) (78 pts) odds ratio 0.013 0.031 (28) Body Mass Index 0.30 (30)0.011, 0.57 0.20, 1.4 3.0 Charlson Comorbidity Index Indication (Imperative/ Elective)
0.67
0.15
0.48
0.015 (1) 0.019, 2.0
0.037 0.33, 1.6
0.0097 0.20, 1.9
0.21
0.20
Tumor size on CT
0.53
0.75
0.086 (2.2) 0.0002, 5.8
0.022 (3.5) 0.16, 1.6
Hilar/non-Hilar Tumor
0.038 0.037, 3.4
0.65
0.27
0.97
Surgery Eras (-2003/2004-2006 /2007-)
0.43
0.032 0.0012, 4.3
0.27
<0.0001 <0.0001, 3.5
Variables with p value < 0.10 by univariate analysis are selected for multivariate variables
Source of Funding: None
2262 LAPAROSCOPIC EXPERIENCE CORRELATES WITH DIFFERENTIAL FUNCTIONAL BRAIN ACTIVATION: AN OXYGEN-15 LABELED PET SCAN STUDY Sero Andonian*, New Hyde Park, NY; Yilong Ma, Manhasset, NY; Edan Y Shapiro, New Hyde Park, NY; Vijay Dhawan, Manhasset, NY; Lee Richstone, New Hyde Park, NY; David Eidelberg, Manhasset, NY; Louis R Kavoussi, New Hyde Park, NY INTRODUCTION AND OBJECTIVE: Laparoscopic surgery is associated with a steep learning curve. The aim of the present study was to correlate functional brain activation with the degree of laparoscopic experience by measuring changes in regional cerebral blood flow with H215O PET. METHODS: Following IRB approval, five novice laparoscopists (medical students: mean age = 26 yr) were compared to five expert laparoscopists (mean age = 46 yr). All subjects were right-handed. Peg transfer task of the MISTELS protocol was used as a validated tool to compare subjects. Each subject was injected with 15O labeled water and scanned with PET during the performance of six different tasks. 1st scan (Rest) was done with the subject’s eyes closed. 2nd scan (Video 1) was performed while the subject was watching a video clip of the peg transfer task. 3rd scan (Peg 1) was acquired during the peg transfer task. The subject repeated the peg transfer task after a 15 minute practice for the 4th scan (Peg 2). After an additional 15 minutes of practice, 5th scan (Video 2) was performed with the subject watching a clip of laparoscopic partial nephrectomy. 6th scan (Peg 3) was conducted during a final peg transfer task. Brain images were processed using statistical parametric mapping software (SPM99) implemented in MATLAB. Differences in task-specific brain activation between the novice and expert groups were compared by using repeated measures ANOVA. RESULTS: The novice group had a significantly lower normalized mean scores than the expert group on the Peg tasks (42.2 vs 77.8; p<0.05). The first image analysis examined the difference between