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.