Discussion
Live surgical events create unique learning opportunities for participants. SUST organized RIRS courses in different clinics between 2017-2020. Through these courses, close to 100 urologists have had the chance to learn the tips and tricks of RIRS by closely watching from experienced endourologists. In the present study, we report that all sessions were performed with satisfaction and there were no major complications during the live surgeries.
Despite the positive results in terms of educators and participants, live surgical activities bring about some ethical and legal debates from the patient’s point of view. Although the vast majority of respondents in a survey on the American Association of Genitourinary Surgeons found that live surgical activity was ethical, just 28.2% of them could allow themselves or their relatives to undergo surgery in such an event (11). It is argued that surgeons working under greater stress than regular surgery may cause potential hazards for the patient (12). In a study of surgeons reporting personal experience of LSE; 6.5% of respondents noted ’significant anxiety’ increasing to 19.4% when performing surgery away from home (13). It has been reported that more staff in the operating room during live surgical events may increase the risk of surgical site infection (14). But the size of the event can also affect the surgeon’s anxiety level. Live surgery during a course with a few course participants in the room does not cause the same level of stress/anxiety to the surgeon as live surgery during a large online or live event at a conference with often more than a thousand people watching the procedure. In our courses there were no more people than during regular education or training activity. Boutique live surgeries can eliminate ethical concerns in this area. Because, this is especially common in medical faculty clinics for training medical students and residents. Live surgeries are a requirement for effective medical education and postgraduate training. Our courses have been conducted in large centers with experienced staff who can manage the stress and the risks of event in such trainings.
Urological studies investigating LSE safety are limited. As expected, robotic surgery using state-of-the-art technologies provides the best data on this issue. In a study in which the results of 39 robotic partial nephrectomies were reported, patient outcomes were found to be similar to normal operating procedure (15). Similar results have been reported in another single-center study in which data from 36 robot assisted radical prostatectomy cases were included (12). The results of patients who underwent GreenLEP in live surgery events reported by Misrai et al. were compared with regular surgery results. The author emphasized that such practices do not endanger the skill and technique of the surgeon (16). The largest-scale study in this area has recently been reported by Rocco et al. (17). The overall rate of complications in laparoscopic and robotic surgery performed by 27 different surgeons was 11.6%. It was concluded that complication rates were low due to the difficulty of serially operated operations such as radical prostatectomy and cystectomy. To the best of our knowledge, there are no live surgery studies reported in the literature on RIRS. In this study, we found similar stone-free and complication rates for LSE’s and regular RIRS cases.
European Association of Urology (EAU) policy on live surgery events has been presented at the 28th Annual EAU Congress on behalf of the EAU Live Surgery Committee (EAU-LSC) (18). Accordingly, the association accepts the use of live surgery as an academic technique. The report concluded patient safety as the most important principle. In our study complication rates of live surgery patients similar to regular surgery patients.
Surgeons tend to stay away from extremes and choose standard cases in live surgical events. The EAU also recommends the selection of standard cases as much as possible so that the educational objectives are not overlooked. The preoperative characteristics of the cases in our series are summarized in Table 2 and it was similar to those of regular surgery performed. Some patients who have double J stent and unsuccessful SWL history were selected specifically. SWL-resistant kidney stones constitute a large area of indications for RIRS. It is also easier to access patients with ureteral double J stent prior to RIRS. The facts with the above features are especially preferred because it is an important part of the education. The slightly longer duration of the LSE cases can be attributed to the trainees being explained each level during the operation. Another reason could be guest surgeons unfamiliarity with the operating room set-up or staff (except assisting surgeon) The duration of any operation did not exceed 120 minutes except for a case that had an ipsilateral open ureterolithotomy history and a stone in the caliceal diverticulum.
We compared the outcomes and complication rates of patients undergoing live RIRS with the matched control group. We did not find a statistically significant difference between these groups according to the stone-free status and complication rates. Complication rates with RIRS are generally low. The number of patients in the study was not sufficient to obtain statistically significant differences between the complications and equivalency in other continuous clinical parameters. That was the main limitation of the study. Another limitation of our study, was that the surgeries were performed by five different surgeons (as host or guest). However, the results did not change according to the host or guest surgeons. We believe that organizing the same course with the same surgical team has a positive effect on live surgery courses. This is an important factor that minimizes surgeon anxiety, although we do not use an anxiety scale to compare the two groups.