Some urologists push for new training standards for RALP

According to a Reuters report issued yesterday, some members of the urology community have been pushing hard for better standards of training on the use of robotic surgical equipment — particularly in the treatment of prostate cancer.

The report states that, “The issue of standards will be addressed at next month’s World Congress of Endourology in Munich. The American Urology Association (AUA) will consider the recommendations.”

The “New” Prostate Cancer InfoLink considers that the increasing use of specialized treatment techniques, requiring a detailed appreciation of the use of highly technical procedures (including things like the da Vinci Surgical System, Sonablate and Ablatherm equipment for high-intensity focused ultrasound, the various types of brachytherapy, and the various types of external beam radiotherapy) absolutely necessitate the development of well-coordinated and sophisticated training and certification of clinicians in the use of such equipment. It is not enough for someone to just “see one, do one” any more.

It is very clear that the recent brachytherapy debacle at the Veterans Administration hospital in Philadelphia was largely a consequence of an under-trained and under-supervised team attempting to carry out a procedure that they really did not have the skill set or the technical knowledge to conduct. The Reuters article reports similar problems in the application of robotic surgery.

Manufacturers are perfectly capable of developing simulators and/or simulation systems that would allow physicians to become well trained on new equipment and meet specific standards before they started treating patients. We also have massive amounts of evidence confirming that, for every physician using some new technique, his or her earliest patients are the ones at the greatest risk for adverse events.

The “New” Prostate Cancer InfoLink calls upon the Endourological Society, the American Urological Association, the American Society for Therapeutic Radiology and Oncology, and other professional bodies to take strong and definitive steps to implement appropriate, high quality, training and certification initiatives that will be in the best interests of patients. The need to meet such training standards may also encourage some physicians with low case loads to consider not doing certain types of procedures, which would help to consolidate such procedures among a group of physicians who really do specialize in the use of specific techniques.

Apparently, “as of mid-2009, there were 1,242 da Vinci Surgical Systems in place throughout the world, up from 286 in 2004.” That means that something like 4.3 times as many radical prostatectomies are being done with robot assistance today as was the case in 2004. Dr. Kevin Zorn, chief of urology at Weiss Memorial Hospital at the University of Chicago, is quoted in the article as saying that “a surgeon must use the system at least 20 times before becoming familiar enough with the set-up and the procedure to do the surgery safely.” The “New” Prostate Cancer InfoLink suspects that it may take more like 50 procedures to be sufficiently familiar with the system to do a radical prostatectomy safely and with a reasonable degree of skill (which by no means is intended to imply that the surgeon could consider himself highly skilled at that stage).

We would also call attention to one highly inappropriate statement from a urologist, mentioned in the article, who supposedly said that “Patients are demanding” robot-assisted surgery, and continued by saying, “If you don’t do robotic surgery, you may as well get out of the prostate surgery business.” If surgeons are unable to convince patients that open or laparoscopic radical prostatectomies are as appropriate as a robot-assisted procedure, that says more about their stature as surgeons than it does about the equipment. As The “New” Prostate Cancer InfoLink has pointed out previously, the skill of the surgeon has very little to do with the use or non-use of a robot — and there are some very real constraints to the use of the da Vinci robot.

One Response

  1. Editorial note: A set of recommendations on “Training, credentialing, proctoring and medicolegal risks of robotic urological surgery” have now been published by the Society of Urologic Robotic Surgeons.

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