LAPAROSCOPIC TRAINING IN UROLOGY

The main problem with clinical introduction of laparoscopic techniques in urology is that despite experience with endoscopy no significant e ndoscopic training is given. Laparoscopic nephrectomy, in particular, is a rather complicated procedure and needs an adequate training conce pt: The beginner should have the possibility of practising in vitro in a closed ''pelvi-trainer'' to learn video-optical coordination and or ientation; then it is necessary to get used to handling the instrument s and practise the different steps of the procedure (i. e. clipping of vessels, sacking of the kidney) either in phantom models or in explan ted animal organs. On this basis, we performed laparoscopic nephrectom y in an animal model (n = 18 porcine kidneys). We were able to standar dize the technique of creating a pneumoperitoneum, the positioning of the animal, the site and size of the trocars, and preparation and clip ping techniques (i. e. Endo-GIA) and entrapment of the kidney (testing different organ bags). A step-by-step approach was used for the intro duction to clinical application. For simulation and training of video- assisted preparation techniques in patients and step-wise introduction to laparoscopy (instruments, endocoagulation, trocars), we created a ''lappent,'' which was placed over the wound after exposition of Gerot a's fascia. Further preparation was performed under laparoscopic condi tions (without pneumoperitoneum) with a limited time allowed (1 h). Th ereafter, we started with time-limited laparoscopy and laparoscopic ly mphadenectomy prior to pelvic surgery (prostatectomy, cystectomy) to i ntroduce the staff to the technique of pneumoperitoneum and placement of the trocars and to the use of the instruments in general. Based on this step-by-step training concept, after a 6-months period we were su ccessful in introducing transperitoneal laparoscopic nephrectomy (TLN) to our clinical routine. So far, we have performed 20 laparoscopic ne phrectomies, 1 nephro-ureterectomy, 4 tumour nephrectomies (inducing a drenalectomy), 2 adrenalectomies, and 6 modified retroperitoneal lymph adenectomies. In the lesser pelvis we have experience with 20 laparosc opic varicocelectomies, 23 pelvic lymphadenectomies, and 5 diagnostic laparoscopies for cryptorchidism (February 1993).