Material and Methods
Eight RIRS courses were organized by SUST between November 2017 and
February 2020. Data of 24 patients who underwent live RIRS (as LSE
group) were consecutively enrolled to the study. The control group were
selected from patients who underwent regular RIRS on the same period at
the same centers. Surgeon and stone burden matched 24 control cases
included to the study by making one-to-one matching. All procedures were
performed in four different centers which has high institutional
experience in endourology field. Written informed consent was obtained
from all patients before the procedure. Patients who will undergo live
surgery were selected among those who were previously indicated for RIRS
and the operation was planned. Informed consent was specifically state
that the surgery was going to be viewed by course participants for live
surgery cases.
In the LSE group, the trainees watched operations directly in the
operation room, taking care of the sterile field. Four or 5 participant
were present in the operating room during the cases. Surgeons performing
the procedure interacted with the trainees and the details of the
operation were explained during the live cases by the surgeon. Also
there was a moderator to field questions in the operating room. The
moderator also acted as the patient’s advocate. Radiation protection
precautions were taken for all trainees.
Live surgery cases were performed by 5 different surgeons. All of them
had advanced RIRS experience (each surgeon performed at least 100 RIRS
procedures). All surgeons had previously participated in different LSEs.
If a guest surgeon performed the case, he was assisted by his regular
resident but not regular staff nurse. The same equipment, instruments
and devices which had been used by all surgeons previously were moved to
host institutes for each course. Surgeon’s familiarity status with all
external factors is shown in Table 1. Flex-X2® (Karl
Storz Endoscope), URF-P5® (Olympus) flexible URS and
URF-V® (Olympus) were used in procedures. All cases
were digitally recorded. Control cases were operated by the same 5
surgeons in their hospitals. Ureteral access sheath was used in all of
patients. Lithotripsy was done with Holmium laser lithotripters from
various companies (Stonelight 30®, Quanta System
Litho®). Surgical prophylaxis was given with
ceftriaxone (i.v.) before the operation.
Preoperative characteristics, perioperative and postoperative findings
of the LSE group were recorded and compared with the control group. The
patients were routinely evaluated with hemogram, routine biochemical
parameters, urinalysis and urine culture before the procedure. All
patients were evaluated by non-contrast low-dose computed tomography
(CT) before the procedure and the Hounsfield Unit (HU) of stones were
measured. Stone free status was evaluated perioperatively by using
fluoroscopy and in the postoperative first month by using non-contrast
low-dose CT. Perioperative and postoperative complications were
classified according to the Clavien and Satava Classifications
respectively (8-10). Based on the results of the procedure, the patients
were evaluated as stone-free or as having residual stone (any evidence
of persistent stone fragments irrespective of size). Besides, LSE
patients were divided into two subgroups according to the surgeon’s
status (host or guest surgeon) and the results were compared with each
other. Stone-free results and all complications from live surgery cases
has been presented back to the participants by e-mail.
The Chi-Square and Fisher exact tests were used for the difference
between the categorical variables. Mann-Whitney U test was used for the
difference between the means. The data were analyzed with the
Statistical Package for the Social Sciences v. 22 (SPSS Inc, Illinois,
USA). A p-value under 0.05 was considered statistically significant.