To report the guidelines of the British Association of Urological Surgeons (BAUS), commissioned by the National Institute for Health and Clinical Excellence (NICE) in response to safety concerns about the rapid uptake of new, complex laparoscopic procedures.
A combination of expert opinion and review of published studies was used to produce a consensus document.
Patient demand and excellent published reports have prompted many consultant urologists with little previous laparoscopic training to learn laparoscopic procedures. Laparoscopic urological surgery involves some of the most complex procedures in all of surgery and there has been a lack of formal training for consultants. The guidelines produced by BAUS are designed to help consultant urologists gain experience safely, by a combination of didactic learning and mentorship. We recommend that urologists work with a mentor and master ablative laparoscopic surgery before attempting more complex procedures such as prostatectomy, cystectomy, pyeloplasty and partial nephrectomy. These guidelines were approved by BAUS Council in October 2006.
These guidelines are intended to be complementary to the NICE guidelines on specific procedures (available at http://www.nice.org.uk).
Training in urological laparoscopic surgery in the UK has been inadequate because of several factors, i.e. a shortage of designated training centres, a shortage of recognized trainers, and the lack of appropriate facilities, in the form of either equipment, expertise or support from respective Trusts.
Laparoscopic surgery in urology differs from its counterparts in general surgery or gynaecology, in that there are no relatively simple high-volume procedures suitable for training. Consequently, laparoscopy in urology has traditionally been considered a sub-specialist procedure; in fact, most consultant urologists in the UK have had little if any training in laparoscopic urological procedures. Future training needs to be targeted and more structured for the trainee to gain experience while maintaining patient safety.
The UK has few centres of excellence for urological laparoscopic surgery. This situation is compounded by a lack of trained manpower, expertise, funding and flexibility. Britain has fewer consultant urologists per capita than in Europe or North America. The present funding structure of the UK NHS does not reward hospitals for undertaking complex procedures and new technological advances. The job plans of traditional consultant urologists, which typically include two or three inpatient theatre sessions per week, do not offer enough access to theatre time nor the flexibility needed to develop a timely and effective referral service focused on laparoscopic surgery.
Training in laparoscopy would be enhanced by a change in the law on the use of animal-based ‘wet labs’ for surgical training, which at present effectively amounts to a complete prohibition in the UK. Instead of mastering complex tasks in a training facility, UK trainees must learn within the context of clinical practice, i.e. on patients, with all of its limitations and risks. A training centre should be able to offer laparoscopic training in both a structured ‘dry’ and ‘wet’ laboratory facility, and in a busy clinical setting. Trainees at such a centre should be able to participate in complex laparoscopic surgery and undertake laboratory-based simulation practice on a daily basis. Currently no centre in the UK offers this level of training.
The goal of this report is to guide urological surgeons through the learning process and thus reduce the risks associated with the introduction of complex new procedures.
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Date added to bjui.org: 30/01/2008 (publication information)
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