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significant difference between completion times of each task between MdVT and LBT platforms, even when factoring video game and musical instrument experience. Science majors outperformed non-science majors on the robotic platform. The MdVT may become a useful resource for urology resident education. Source of Funding: University of Virginia Young Scientist Award
1338 THE LEARNING CURVE OF LAPAROSCOPIC COMPARED TO ROBOTIC SURGEONS DURING THE IMPLEMENTATION OF A ROBOTIC PROSTATECTOMY PROGRAM Howard Jung*, Jennifer Kaswik, Melanie Wuerstle, Stephen Williams, Gary Chien, Los Angeles, CA INTRODUCTION AND OBJECTIVES: We previously reported a cohort of 300 patients undergoing robotic radical prostatectomy by either laparopic surgeons (LRP) who have performed at least 25 laparoscopic prostatectomies or fellowship-trained robotic surgeons (RALP) during the implementation of a robotic radical prostatectomy program in a large health maintenance organization. Robotic fellowship training had a beneficial impact on immediate post-operative outcomes, most notably because of lower positive surgical margin rates (PSMR). The purpose of this study is to evaluate the learning curve of the LRP surgeons, to see if their PSMR improved over time. METHODS: We retrospectively reviewed the initial 300 radical prostatectomies performed in our single institution robotics program from August 2008-March 2009. Four RALP surgeons and 8 LRP surgeons participated in this study. The cohort was chronologically divided into the first, second, and third 100 cases. PSMR between RALP surgeons was then compared to LRP surgeons within each division. RESULTS: RALP surgeons completed 128 cases, and LRP surgeons completed 172 cases. Overall, PSMR rates for RALP surgeons vs LRP surgeons was 24.97% vs 34.55% (OR ⫽ 1.91). In the initial 100 cases, PSMR rates for RALP surgeons vs LRP surgeons was 22.92% vs. 36.17% (OR ⫽ 2.00). In the second 100 cases, it was 23.08% vs 37.5%. In the third 100 cases, it was 26.47% vs 30.65% (OR ⫽ 1.23). PSMR in the LRP surgeon group were significantly higher in apical (21.2% vs 8.3%, p⬍0.003) and lateral (7.3% vs 1.7%, p⬍0.05) locations. There were no significant differences in complication rates, hospital stay days or transfusion rates. CONCLUSIONS: Despite being proficient in laparoscopy, LRP surgeons in our series have worse outcomes than RALP surgeons. We showed that LRP surgeons started to improve after their initial 200 cases, but they still do not perform as well as RALP surgeons. Because of the large number of surgeons participating in this robotics program, these results are more reflective of a community practice model where multiple urologists are granted robotic privileges. Source of Funding: None
1339 A PATIENT SPECIFIC SIMULATOR FOR LAPAROSCOPIC RENAL SURGERY Kazuhide Makiyama*, Yoshinobu Kubota, Manabu Nagasaka, Shin Hongo, Masato Ogata, Yokohama, Japan INTRODUCTION AND OBJECTIVES: A training system which simulates a surgical process is available on a commercial basis. They are useful for basic training, but not suitable for training to correspond to the specific conditions of each patient. We, therefore, have developed a unique training system, patient specific type simulator for laparoscopic surgery (henceforth: the Simulator). With the specific data of each individual patient taken in, this system facilitates surgeons to exercise a “rehearsal” operation. At AUA 2009 we have presented the prototype of this new system. Now its final completion is deemed to be underway.
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METHODS: Dynamic CT of each patient, who is scheduled to undergo renal surgery, is captured into the model data generation system. Each patient’s specific volume data of the kidney and organs around the kidney are extracted on the model data generation system and entered into the Simulator. In the Simulator, the organs of each individual patient are reproduced. Thus, by using the Simulator based on these specific date, surgeons are now given an opportunity to perform a preoperative “rehearsal”. RESULTS: The Simulator is programmed to adapt both laparoscopic and retroperitoneoscopic surgery. The scope and other trocars are to be located anywhere on the skin in the Simulator. In the partial nephrectomy, the orderly approach and the location of the trocars are to be determined before the operation. It is possible not only to simulate the dissecting of the renal vessel, but also to simulate the extirpation of the kidney itself. Through this simulation we can create preoperatively images of the anatomy of each patient, which will be much useful, especially in case that the anatomy is complicated and/or anomalous. The elaborately designed haptic device of the Simulator is able to reproduce appropriate (“quasi real”) interactive resistance between organs and surgical tools, that will make a “rehearsal” operation reliable. The Simulator is also programmed to visualize lymph ducts and membrane structures, which, though not CT detectable, should be carefully taken into account for the surgical process. CONCLUSIONS: The patient specific simulator for laparoscopic renal surgery has been developed. The Simulator, taking the specific data of each individual patient in, facilitates surgeons to perform a “rehearsal” operation and, through which, may contribute to the safe completion of laparoscopic surgery. Source of Funding: None
1340 DESIGNING A HIGH-FIDELITY LAPAROSCOPIC PARTIAL NEPHRECTOMY MODEL: DETERMINING THE TISSUE RESISTANCE AND TEAR STRENGTH OF THE RENAL CAPSULE Rohan Shahani*, John Madjeruh, Piercey Kevin, Paul Whelan, Anil Kapoor, Edward Matsumoto, Hamilton, Canada INTRODUCTION AND OBJECTIVES: Despite the increasing number of laparoscopic radical nephrectomies being performed, laparoscopic partial nephrectomy has not gained wide-spread acceptance. This is likely due to the steep learning curve necessary to perform the procedure. We have endeavored to create a high fidelity laparoscopic partial nephrectomy (HFLPN) model in order to reduce the learning curve. This model will be employed as an ex vivo training tool for those learning to perform laparoscopic partial nephrectomies. In making the model, we ventured to identify the tissue resistance and tear strength of the renal capsule. METHODS: Using 2 fresh porcine kidneys and 2 immediate post-radical nephrectomy specimens, the tear strength was measured by placing a tied loop of 2-0 vicryl suture in the upper and lateral area. The loop of suture was then attached to a strain gauge which was fixed within a standardized apparatus to apply traction force. The tissue resistance of the renal capsule was measured using a commercial Durometer Model Type OO (Rex Durometer, Cedarhurst, NY) at ten points along the upper pole, the lateral aspect of the kidney and the tumor. The same measurements were obtained on our preliminary HFLPN model. Tissue resistance was measured in durometer points (dp) and tear strength measured in grams of pull (g). Student’s t-tests was used for statistical analysis. RESULTS: The tear strength of the renal capsule of the porcine kidney was significantly different between the lateral aspect and the upper pole (304 ⫾ 78 g vs 214 ⫾ 61 g, p⫽0.002); however, this was opposite to what was seen in the human kidney (242 ⫾ 26 g in the lateral aspect vs. 286 ⫾ 17 g in the upper pole, p⫽0.01). The tissue resistance of the human kidney in the lateral aspect was 17.4 ⫾ 2.8 dp and 17.1 ⫾ 2.3 dp in the upper pole. The tissue resistance of the tumor was significantly higher at 41.8 ⫾ 9.2 dp(p⬍0.01). The tear strength
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(526 ⫾ 51.2 g) and tissue resistance (35.7 ⫾ 3.1 dp) of the preliminary HFLPN model was significantly higher than that seen in the porcine or human kidney. CONCLUSIONS: There is a significant difference in the tear strength of the renal capsule in differing regions of the kidney. Also, the resistance of the renal capsule overlying a renal tumor was substantially higher than normal tissues. These characteristics will be used to modify our model to ensure it will be a high fidelity training tool. These results may also be the basis of studies into tissue characteristics and haptics in virtual reality surgery. Source of Funding: None
1341 FEASIBILITY AND UTILITY OF A CLIP APPLYING EXERCISE FOR THE FUNDAMENTALS OF LAPAROSCOPIC SURGERY TECHNICAL SKILLS CURRICULUM Omer B Argun, Troy Reihsen, Minneapolis, MN; Elspeth McDougall, Irvine, CA; Robert Sweet*, Minneapolis, MN INTRODUCTION AND OBJECTIVES: In response to the charge of the AUA Laparoscopy and Robotic Surgery Committee, we examined the value of the addition of a novel clip applying exercise to the Fundamentals of Laparoscopic Surgery (FLS) technical skills curriculum. METHODS: We designed a 7-9 mm artery model and integrated a clip-applying skills task into the FLS skills exercises amongst a cohort of practicing surgeons at the Society for Laparoendoscopic Surgeons meeting 2009 (Boston, MA). Organosilicate models were molded and filled with red colored water to a mean arterial pressure of 80 ⫾ 2 mmHg. Subjects were instructed to place two 10 mm titanium clips within the black lines on both sides of the model (4 clips total), then divide the structure (Figure 1). We measured time to task, clip accuracy and assessed for leakage. Upon completion, participants filled out a survey assessing face and content aspects of validity on a 5-point likert scale. RESULTS: Thirty-seven laparoscopic surgeons (General Surgery⫽ 24, Gyn⫽ 12, Urol⫽ 1) completed the clipping exercise with a mean of 81.76⫾34.05 seconds (Std Error⫽ 5.598). Mean assessment scores from the participants are listed below (Figure 2). CONCLUSIONS: Version 1 of the clipping exercise seems to fill a basic core skill not covered by SAGES FLS Curriculum. These results encourage the future refinements of the model for further investigations.
Source of Funding: None
1342 DO LAPAROSCOPIC VR SIMULATORS DEMONSTRATE CONVERGENT VALIDITY? Omer B Argun, Troy Reihsen, Ricardo Miyaoka, Franc¸ois Sainfort, Minneapolis, MN; Michael S Kavic, Rootstown, OH; Phillip P Shadduck, Durham, NC; Robert M Sweet*, Minneapolis, MN INTRODUCTION AND OBJECTIVES: To examine convergent aspects of construct validity across four commercially available laparoscopic virtual reality (VR) simulator platforms for navigation & dissection tasks. METHODS: A single navigation & dissection task was chosen on each simulator by five experts prior to the experiment. A convenient sample of 25 multidisciplinary practicing laparoscopic surgeons participated in a study in which they performed navigation and/or dissection tasks on one or more of four simulators (Haptica ProMIS, METI SurgicalSim VR, Simbionix LAPMentor and Surgical Science LapSim (with & without haptic force-feedback). Subjects rotated at each simulator for 10 minutes. Performance metrics (navigation task completion time & path lengths; dissection task completion time) were logged on all simulators & uploaded for subsequent analysis. Data were cleaned using outlier analysis and tested for normality. Both Pearson & rankorder Spearman correlation analyses were used to analyze the performance data. RESULTS: For navigation task completion time, correlation coefficients were moderate to high (Pearson 0.619-0.807, Spearman 0.258-0.810) between Haptica, Simbionix, & Surgical Science Haptic. For navigation task path lengths, there was minimal correlation between simulators (Spearman x-0.476). For dissection task completion time, small to moderate correlations were found between Surgical Science Haptics and Haptica, METI, & Simbionix. CONCLUSIONS: Practicing laparoscopic surgeons performed similarly in comparison to their peers on navigation and dissection tasks across four commercially available laparoscopic VR simulation platforms containing force-feedback. There is small to moderate and moderate to strong correlation for navigation and dissection skills respectively. As convergence contributes to construct validity, this study strengthens the claims of construct validity for navigation and dissection tasks on these simulators. Source of Funding: None
1343 EVALUATION OF LAPAROSCOPIC CURRICULA IN AMERICAN UROLOGY RESIDENCY TRAINING Behfar Ehdaie*, Chris Reynolds, Charlottesville, VA; Chad Tracy, Iowa City, IA; Noah Schenkman, Charlottesville, VA INTRODUCTION AND OBJECTIVES: Surgical residency training is changing and curricula are being developed that incorporate
