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.