EUROPEAN UROLOGY 56 (2009) 865873

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Education

Assessment of Laparoscopic Suturing Skills of Urology

Residents: A Pan-European Study

Stephanie G.C. Kroeze a, Erik K. Mayer a,b,*, Samarth Chopra a, Rajesh Aggarwal b,
Ara Darzi b, Anup Patel a
a
Department of Urology, St Marys Campus, Imperial College Healthcare NHS Trust, London, UK
b
Department of Biosurgery and Surgical Technology, Imperial College London, London, UK

Article info Abstract

Article history: Background: It has been acknowledged that standardised training programmes are needed to
Accepted September 19, 2008 improve laparoscopic training of urologic trainees. Previous studies have suggested that simu-
Published online ahead of lator-based laparoscopic training can improve performance during real laparoscopic procedures.
print on October 1, 2008 Objective: To determine if there are performance differences for the completion of a simulated
laparoscopic suturing task among urology residents based on their postgraduate year of training
(PGY).
Keywords:
Design, setting, and participants: Using a validated scoring checklist, two independent observers
Education objectively scored the completion of a standardised laparoscopic suturing task in a bench-top
Laparoscopy laparoscopic box trainer. PGY and previous exposure to laparoscopic surgery and laparoscopic
Simulation simulated training was obtained from self-administered questionnaires.
Training Data acquisition was undertaken at the European Urological Residents Education Programme
Questionnaire (EUREP) 2007, run by the European School of Urology, and included a pan-European cohort of
201 urology residents.
Measurements: Reliability among those rating the suturing tasks was excellent (Cronbachs
a = 0.83). Each resident was scored for the suturing task. Residents were categorised into three
groups based on their PGY status (junior [n = 8]; intermediate [n = 37]; senior [n = 156]). The
Kruskal-Wallis test was used to measure trend across the PGY; the Mann-Whitney U test was
used to determine variation among categorised PGY groups.
Results and limitations: Laparoscopic suturing skill was signicantly different across PGY levels
( p = 0.032), and between junior residents and both intermediate and senior residents ( p = 0.008
and p = 0.012, respectively). There was no signicant difference between intermediate and senior
residents ( p = 0.697). Only 12% of participants rated their existing volume of laparoscopic operative
cases as sufcient, while 55% of participants had no regular opportunities, and 32% of participants
had not performed laparoscopic procedures as primary surgeon. Most residents (96%) reported the
use of laparoscopic simulators to be benecial in training, although current European training
programmes appear to provide <50% of residents with the opportunity to train with them.
Conclusions: A discernable relationship existed between the score obtained for a laparoscopic
suturing task and year of resident training. Modular simulator training as part of a formal
training programme may help to overcome some of the shortfall in residents exposure to
laparoscopic procedures as primary surgeon.
# 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Urology Research Registrar, Department of Biosurgery and Surgical

Technology, 10th Floor QEQM Building, St Marys Hospital Campus, Imperial College London, London,
W2 1NY, United Kingdom. Tel. +44 (0)207 886 1947; Fax: +44 (0)207 886 1546.
E-mail address: e.mayer@imperial.ac.uk (E.K. Mayer).

0302-2838/$ see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2008.09.045
866 EUROPEAN UROLOGY 56 (2009) 865873
1. Introduction
Ever since the first laparoscopic nephrectomy was per-
formed [1], laparoscopic urologic surgery has played an
increasingly important role in urology and is one of the
most rapidly expanding subspecialties. At present, the
availability of laparoscopically experienced urologists
throughout Europe is insufficient to meet the increasing
demand and application of laparoscopic procedures.
Laparoscopic surgeons need to acquire very different skills
than those needed for open surgery, and many of the
procedures have a significant learning curve. There is
therefore recognition of the need for a more formalised
laparoscopic training framework within urology.
In recent years it has become clear that the traditional
system of surgical education might not be ideal for teaching
laparoscopy, mainly due to a prolonged learning curve from
the inherent difficulties of the minimally invasive approach:
two-dimensional vision, lack of depth perception, and
counterintuitive movements as a result of the fulcrum
effect [2]. A complicating factor of urologic laparoscopic
training within the operating theatre is that there is no
simple high-volume procedure suitable for training akin
to laparoscopic cholecystectomy in general surgery.
There is a view that laparoscopic skill acquisition should
be undertaken in a skills laboratory before being transferred
to the operating theatre [3] and that simulation training can
improve resident operative performance [4,5]. Laparoscopic
training options developed over the years vary from bench-
top training courses with box trainers to virtual reality
simulators (dry-lab training) or live-animal models
(wet-lab training). Most of these courses have not been
designed from a scientific background, and until now, there
has been no consensus for a standardised training
programme [6]. To obtain adequate training globally, an
efficient, validated, and standardised teaching framework
needs to be developed.
One of the initial steps towards developing such a
framework is the ability to objectively assess laparoscopic
skills of trainees. Aggarwal et al [7] and others [8,9] have
started to look at the validity of the varying training
equipment and the creation of an objective assessment of
laparoscopic skills. Laparoscopic simulators have proven to
be an excellent medium for this assessment, and it has been
shown that basic skills can be taught and assessed well in
simple, inexpensive box trainers [10,11]. Importantly, proof
of transfer validity from simulators to real life has been
reported by several researchers [12,13].
Laparoscopic suturing and knot tying is a potentially
difficult task that requires good handeye coordination and
intensive practice. As in open surgery, it is a necessary skill
for many laparoscopic procedures. It also acts as a useful
benchmark when assessing laparoscopic skills because
good-quality knots can be taught in a short space of time to
both junior and senior trainees [14]. A complex laparoscopic
task can be subdivided into all necessary steps to teach and
assess this task adequately. An example of this is the
technique of endoscopic extraperitoneal radical prostatect-
omy (EERPE) [15]. Laparoscopic suturing can be assessed in
several ways with checklists that also subdivide the task or
validate measures such as time or path length [1618].
For several years it has been acknowledged that the
laparoscopic training of urologic trainees needs to be
improved and that better access to this training is needed
[19]. Therefore, this study aimed to investigate the standard
of a laparoscopic suturing task performed by urology
residents across Europe and to compare it with the
residents year of training. The study also sought to gain
insight into current exposure of urology residents to
laparoscopic procedures and laparoscopic simulators so
that this information could be used to guide future
development of structured laparoscopic training pro-
grammes.
2. Methods
2.1. Subjects
This study was conducted during the laparoscopic hands-on training
(HOT) portion of the European Urological Residents Education Pro-
gramme (EUREP) meeting 2007, EUREP is organised by the European
School of Urology (ESU) in collaboration with the European Board of
Urology and has been developed exclusively for all European urologic
residents. All participating residents who had signed up for the HOT
were considered eligible to be included in the study, and inclusion was
entirely voluntary. The study protocol was explained to all subjects, and
informed consent was obtained prior to participation in the study.
2.2. Task
Residents were assessed on their ability to complete a standardised
laparoscopic suturing task consisting of the placement and tying of a
single laparoscopic suture with three throws to oppose an iatrogenic
wound on articial tissue (Professional Skin Pad Mk 2, Limbs and Things,
Bristol, UK) within a laparoscopic box trainer environment (Pop-up
Trainer, Simulab Corporation, Seattle, WA, USA) (Fig. 1). To ensure
standardisation of the task, all residents used identical standard
laparoscopic instruments (hand instruments and needle holders
HiQ+, Olympus, Hamburg, Germany), suture material (Sal 2-0, B.
Braun Medical Ltd, Shefeld, UK), ergonomic conditions, and a xed
camera position. Premarked spots were placed at entry and exit points
on the tissue model. Residents, as part of the HOT course, underwent a
period of tutor-led laparoscopic training in groups of three (each resident
trained rst for 20 min). At the end of this period, residents were asked to
complete the assigned task with no external assistance. Time allowance
for suturing task performance was 10 min in order to limit the
frustrations of laparoscopically inexperienced junior residents [5].
2.3. Measurement tool
Each assigned task was recorded by digital video and saved for later
evaluation. Each task was coded with the EUREP participation number;
the observers were therefore blinded to the residents identity.
Qualitative analysis of the videoed task was performed by two
independent observers (SK, SC), urology trainees who have been
formally trained in the use of the objective checklist. The process of
scoring videotaped tasks has been established previously [14,18]. A
laparoscopic knot was dened according to the gold standard as
developed after discussion with expert surgeons and as described point
by point in a previously constructed, validated checklist (Fig. 2) [14,18].
The checklist scored technical features of the task such as needle position
 EUROPEAN UROLOGY 56 (2009) 865873
Fig. 1 Training set-up showing the four stages of the simulated laparoscopic task: (A) needle loading and driving; (B) pulling the suture through; (C) knot
technique; and (D) knot quality.
and driving, pulling through of the suture, and the technique and quality
of the knots. After all of the tasks had been scored, a matching process
was undertaken to correlate information obtained from the question-
naires.
2.4. Questionnaire
Each resident was asked to complete a self-assessment questionnaire
which was collected at the beginning of the course. This questionnaire
aimed to determine the current and previous laparoscopic exposure
during training, and contained three sections important for this study
(Fig. 3). The rst section concerned postgraduate year of training
(PGY) dened as year of resident or, where applicable, specialist
registrar training. The second section covered laparoscopic simulation
exposure: the opportunities for use of laparoscopic simulation in
current training and the interest in training with laparoscopic
simulation (marked on a Likert scale from 1 = not useful to 5 = very
useful). The third section was concerned with laparoscopic operative
experience, that is, at what stage of training the rst laparoscopic
procedure was performed as primary surgeon, the amount of
laparoscopic training per month, and the rating of volume of
laparoscopic versus open procedures.
2.5. Outcome measures
The primary end point was to determine whether a relationship existed
between laparoscopic suturing skill (as assessed by objectively scoring a
standardised laparoscopic task) and the PGY of urology residents. The
secondary end point was to explore the previous laparoscopic
experience of residents and to gain insight into their views on the use
of laparoscopic simulators as part of training.
2.6. Statistical analysis
Statistical analysis was performed using SPSS v.14.0 (SPSS, Chicago, IL,
USA). Nonparametric data were analysed using the Kruskal-Wallis test
867
for trend across the PGY, and the Mann-Whitney U test was used for
variation between PGY groups. A p value <0.05 was deemed signicant.
The interrater reliability for the two observers was dened using
Cronbachs a test.
Residents were subdivided into three groups based on their PGY;
junior (PGY 1 and PGY 2), intermediate (PGY 3 and PGY 4), and senior
(PGY 5 and PGY 6).
3. Results
Two hundred and one European urology residents present
at the EUREP 2007 laparoscopic HOT course were recruited
for this study. All performed the laparoscopic task in the
prescribed manner and completed the questionnaire.
Participants were mainly senior residents (79%), 37 were
intermediate (18%), and 8 were junior (4%).
The interrater reliability for the two observers scoring
the task checklist was excellent with Cronbachs a = 0.83.
There was a significant difference with regard to laparo-
scopic suturing skill across PGY level (Kruskal-Wallis
p = 0.032). With regard to these individual groups there
was a significant difference in score between junior
residents (median score: 10.5/29) and intermediate resi-
dents (median score: 14/29) ( p = 0.008). The performance
between junior and senior residents (median score: 13/29)
also showed a significant difference ( p = 0.012). However,
there was no significant difference between the intermedi-
ate and senior residents ( p = 0.697) (Fig. 4).
With regard to the time needed to complete the
laparoscopic suturing task, 42 participants (21%) were
unable to complete this task within the allotted 10 min.
There was no significant difference regarding time to
complete the task between the groups (Kruskal-Wallis
p = 0.393).
868 EUROPEAN UROLOGY 56 (2009) 865873

Fig. 2 Twenty-nine-point scoring checklist used for assessing performance of standardised laparoscopic suturing task.

Questionnaire responses regarding laparoscopic simula-
tion experience revealed that 81% (162/200) of residents
had seen a laparoscopic simulator and 96% (191/198) were
interested in training with it (Fig. 5a). Despite this
enthusiasm for laparoscopic simulators, the current train-
ing programmes across Europe afford just 41% (79/193) of
the residents with an opportunity to train with simulators
and, on average, only 56% (108/192) had used one (Fig. 5b).
Residents who had previously used a simulator or had the
opportunity to train with simulators in their training
curriculum performed significantly better than the group
that had not ( p = 0.002 and p = 0.037, Mann-Whitney U
test). This correlation transcends residency training level. In
response to whether residents thought the use of laparo-
scopic simulators was beneficial in training, 96% (189/196)
thought it would be useful (Likert score 3, 4, and 5). The
percentage of residents performing their first laparoscopic
procedure as primary surgeon occurred with equal fre-
quency in each PGY (ranging from 9% to 13% for each PGY).
Thirty-two percent of residents (56/176) said that they had
not yet performed a laparoscopic procedure as primary
surgeon, and 55% of residents (98/178) said that they had no
regular opportunities to perform laparoscopic procedures
as primary surgeon. When asked to rate the volume of open
versus laparoscopic operative cases, 56% (107/192) of the
residents found that the volume of open operative cases was
enough (Likert 3, 4 and 5) while only 12% (23/189) thought
the same about laparoscopic operative cases. There was no
 EUROPEAN UROLOGY 56 (2009) 865873
Fig. 3 Resident Experience Questionnaire (European Urological Residents Education Programme [EUREP]) 2007.
significant difference between the PGY in which the first
laparoscopic operation as a primary surgeon was performed
and the final score in the suturing task (Kruskal Wallis,
p = 0.15).
Fig. 4 Box plot showing checklist scores of the laparoscopic assessment.
The maximum score was 29; higher scores indicated better results. There
was a significant difference in performance between postgraduate years
(PGYs) 1 and 2 and PGYs 3 and 4 ( p = 0.008) and between PGYs 1 and 2
and PGYs 5 and 6 ( p = 0.012).
869
4. Discussion
This study has shown that there was a significant difference
in performance of a laparoscopic suturing task between
junior and more experienced urology residents. The
significant improvement in this task between junior and
intermediate residents suggests that much of the laparo-
scopic learning curve occurs early in the residents training.
This was partly reflected by the questionnaire responses,
which identified that 25% of residents performed their first
primary surgeon laparoscopic procedure as a junior
resident. The improvement in this task, however, seemed
to plateau when comparing the intermediate with the
senior group, for which there are two possible explanations.
First, it is possible that residents develop such a high level of
laparoscopic skill in their junior and intermediate years that
there is little room for improvement in senior years. Second,
supported by low-level scoring of the senior group, it could
be that senior residents show little improvement because of
limitations with laparoscopic training in existing training
programmes. These results suggest that all groups need
improvement in performance of the laparoscopic task. How
much improvement in the score that is necessary to
870 EUROPEAN UROLOGY 56 (2009) 865873
Fig. 5 (a) Percentage of urology residents who had ever seen and/or had an interest in laparoscopic simulators. (b) Percentage of urology residents who
had ever used and/or had the opportunity to train with laparoscopic simulators in their current training programmes.
determine competent completion of training needs to be
determined by future studies that include laparoscopic
suturing experts.
Time has been used as objective measure for assessing
laparoscopic suturing skills. Opinions differ with regard
to whether time is a good indicator of skill [12,17,18]. In
our study, time taken to complete the task did not
significantly improve with seniority and, therefore, was
not sensitive enough to detect skill differences among
years of training.
The questionnaires were used to determine residents
previous exposure to laparoscopic operating and laparo-
scopic simulators and their views on the role of laparoscopic
simulation in urology training programmes. One-third of all
participating residents had never performed a laparoscopic
procedure as primary surgeon, and more than half of the
residents had no opportunity to perform laparoscopic
procedures as a primary surgeon on a regular basis.
Furthermore, only 12% of residents were satisfied with
the current volume of laparoscopic procedures that they
performed in their training. As 78% of all participants were
senior residents, these results would suggest that laparo-
scopic training in existing curricula was suboptimal.
There was evidence to suggest that use of laparoscopic
simulation was increasing, with 81% of residents having
seen a laparoscopic simulator and 56% of residents having
actually used one. This notification is reenforced by the
questionnaire because just 24% performed their first
laparoscopic procedure as primary surgeon without having
used a simulator. Although there was a great degree of
interest in simulators and the vast majority of residents
believed them to have a role in laparoscopic training, they
appeared not to be commonplace, with only 41% of
residents afforded the opportunity to use them in their
training programmes.
Along with other studies [5,12], our results suggest that
simulators may improve laparoscopic skills; residents that
had used or had the opportunity to regularly train with a
simulator performed significantly better on the laparo-
scopic suturing task. However, there needs to be a degree of
caution in this observation as the objective performance
scores were compared with subjective questionnaire
responses. A laparoscopic simulator in this study is defined
as any simulator that can be used to train laparoscopic
skills, from box trainers to virtual reality simulation.
Although virtual reality seems to be superior to box trainers
for acquiring good performance on complex operations,
several studies have shown that basic laparoscopic skills
can be acquired equally well with box trainers as with
virtual reality simulators [10,20,21].
A limitation of this study is that the residents attending
the hands-on laparoscopic course at the EUREP 2007 are a
self-selecting group, already having a special interest in
laparoscopy or attending because they are curious about
their laparoscopic performance. This may explain the high
degree of favourable responses for interest in and useful-
ness of laparoscopic simulators. Because this group of
residents with a special interest in laparoscopy only receive
limited opportunities for laparoscopic skills training, it
could be argued that current laparoscopic training is
therefore far from adequate. Sampling a random group of
urology residents would help to answer these questions but
was not possible on this occasion due to the setting of this
study.
Although a single laparoscopic suturing task cannot be
used solely as a proxy indication for overall laparoscopic
 EUROPEAN UROLOGY 56 (2009) 865873
skill, it is a necessary skill required during many laparo-
scopic procedures and acts as a useful benchmark task [14].
The objective assessment of laparoscopic skills based on
experience is known as construct validity. Validity of
laparoscopic suturing can be assessed in several ways, such
as described by Van Sickle et al [16,17]. We used a checklist
that already proved construct validity in two previous
studies [14,18] and allowed us to objectively assess this
task. There is construct validity in terms of checklist score
compared with year of residency training for our study.
Development of objective measures for other laparoscopic
tasks may highlight further performance differences across
years of training.
A further limitation is the lower number of junior and
intermediate residents compared with the higher number
of senior residents, since the EUREP programme was
primarily targeted to senior urology residents. It should
be noted, however, that previous studies in this area had
much smaller numbers of total participants, with only 612
people in each experience category [14,22]. Furthermore,
this is the first study evaluating laparoscopic suturing skills
with such a large number of residents, but it is also
representative of such variability across training curricula.
The scoring checklist was limited by the absence of an
objective measure of knot strength as an indicator of knot
quality. This has been described previously by Hanna et al as
part of a knot quality score, which uses a tensiometre to test
knot strength [23]. The use of a tensiometre in this study
was not feasible due to the timing schedule of the HOT
session, and we were therefore limited to defining knot
quality visually by assessing whether all knots were
squared, not too tight or too loose, and not laid over the
incision.
Currently, general opinion of urology training implies
that because of a changing surgical environment, residents
lack the opportunities to train in laparoscopic procedures
adequately. This has led to proponents suggesting that
alternative methods of training, especially modular simula-
tion training, are required as a means to overcome this
problem and to preserve quality in urologic surgical
training. Studies interviewing programme directors, urol-
ogists, and urology residents showed that this opinion was
shared unanimously [19,24]. The challenge is how to
modify the traditional apprenticeship model such that it
incorporates a standardised laparoscopic training curricu-
lum. Urologic committees and societies are currently
accepting this challenge and are developing validated
laparoscopic training programmes.
5. Conclusions
This study has shown that there appears to be a significant
relationship between laparoscopic suturing task skills, as
assessed using a scoring checklist, and year of resident
training. In addition, residents suggested that they favoured
the use of simulation-based training tools as part of a more
formal laparoscopic training programme but that their
current resources and opportunities seemed limited. Wider
adoption of modular simulator training may help to
871
overcome some of the shortfall in European urology
residents exposure to laparoscopic procedures as primary
surgeon.
Author contributions: Erik Mayer had full access to all the data in the study
and takes responsibility for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Kroeze, Mayer, Aggarwal, Darzi, Patel.
Acquisition of data: Kroeze, Chopra.
Analysis and interpretation of data: Kroeze, Mayer, Aggarwal.
Drafting of the manuscript: Kroeze, Mayer, Aggarwal, Patel.
Critical revision of the manuscript for important intellectual content: Darzi,
Patel.
Statistical analysis: Kroeze, Mayer, Aggarwal.
Obtaining funding: Patel.
Administrative, technical, or material support: None.
Supervision: Darzi Patel.
Other (specify): None.
Financial disclosures: I certify that all conicts of interest, including
specic nancial interests and relationships and afliations relevant to
the subject matter or materials discussed in the manuscript (eg,
employment/afliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents led,
received, or pending), are the following: None.
Funding/Support and Role of the Sponsor: Olympus kindly supported the
project with the loan of workstations, laparoscopic equipment, and
recording equipment and with logistics as well as with an unrestricted
educational grant to the ESU for support of the EUREP.
Acknowledgment statement: The authors acknowledge the ESU and
EUREP organisers for allowing us to conduct this study during EUREP
2007 and the training faculty for their assistance with the collection of
the data.
References
[1] Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrect-
omy. N Engl J Med 1991;324:13701.
[2] Gallagher AG, McClure N, McGuigan J, Ritchie K, Sheehy NP. An
ergonomic analysis of the fulcrum effect in the acquisition of
endoscopic skills. Endoscopy 1999;30:61720.
[3] Reznick RK, Ed M, MacRae H. Teaching surgical skillschanges in
the wind. N Engl J Med 2006;355:26649.
[4] Banks EH, Chudnoff S, Karmin I, Wang C, Pardanani S. Does a
surgical simulator improve resident operative performance of
laparoscopic tubal ligation? Am J Obstet Gynecol 2007;197:541,
e15.
[5] Kirby TO, Numnum TM, Kilgore LC, Straughn JM. A prospective
evaluation of a simulator-based laparoscopic training program for
gynaecology residents. J Am Coll Surg 2008;206:3438.
[6] Kommu SS, Dickinson AJ, Rane A. Optimizing outcomes in laparo-
scopic urologic training: towards a standardized global consensus. J
Endourol 2007;21:37885.
[7] Aggarwal R, Grantcharov T, Moorthy K, et al. An evaluation of the
feasibility, validity, and reliability of laparoscopic skills assessment
in the operating room. Ann Surg 2007;245:9929.
[8] Katz R, Hoznek A, Salomon L, Antiphon P, de la Taille A, Abbou CC.
Skill assessment of urological laparoscopic surgeons: can criterion
levels of surgical performance be determined using the pelvic box
trainer? Eur Urol 2005;47:4827.
872 EUROPEAN UROLOGY 56 (2009) 865873
[9] Feldman LS, Sherman V, Fried GM. Using simulators to assess
laparoscopic competence: ready for widespread use? Surgery
2004;135:2842.
[10] Chandrasekera SK, Donohue JF, Orley D, et al. Basic laparoscopic
surgical training: examination of a low-cost alternative. Eur Urol
2006;50:128591.
[11] Bell R, Maseelall P, Fanning J, Fenton B, Flora R. A laparoscopic
simulator tool for objective measurement of residents laparoscopic
ability. JSLS 2007;11:4703.
[12] Verdaasdonk EGG, Dankelman J, Lange JF, Stassen LPS. Transfer
validity of laparoscopic knot-tying training on a VR simulator to a
realistic environment: a randomized controlled trial. Surg Endosc
2008;22:163642.
[13] Sugiono M, Teber D, Anghel G, et al. Assessing the predictive validity
and efcacy of a multimodal training programme for laparoscopic
radical prostatectomy (LRP). Eur Urol 2007;51:133240.
[14] Aggarwal R, Hance J, Undre S, et al. Training junior operative
residents in laparoscopic suturing is feasible and efcacious. Sur-
gery 2006;139:72934.
[15] Stolzenburg J-U, Rabenalt R, Do M, Horn LC, Liatsikos EN. Modular
training for residents with no prior experience with open pelvic
surgery in endoscopic extraperitoneal radical prostatectomy. Eur
Urol 2006;49:491500.
[16] Van Sickle KR, McClusky DA, Gallagher AG, Smith CD. Construct
validation of the ProMIS simulator using a novel laparoscopic
suturing task. Surg Endosc 2005;19:122731.
Editorial Comment on: Assessment of Laparoscopic
Suturing Skills of Urology Residents: A Pan-European
Study
Matthew T. Gettman
Department of Urology, Mayo Clinic, Rochester, Minnesota,
USA
Gettman.Matthew@mayo.edu
In the era of minimally invasive surgery, efforts to
improve technical skills training among urology residents
are sorely needed. Indeed, the current manuscript by
Kroeze and colleagues highlights a number of interesting
observations regarding the current status of laparoscopic
skills training for urology residents in Europe [1]. In the
voluntary study, a bench-top laparoscopic box trainer was
used to assess laparoscopic suturing. Study participants
included 201 residents attending the European Urological
Residents Education Program. Technical performance was
evaluated using validated checklists by two independent
observers who were blinded to each participants year of
training and laparoscopic experience. Residents technical
performance was correlated to results of information
obtained from self-administered questionnaires.
Despite some overall concerns with the study design,
the take-home point of this manuscript is that laparo-
scopic suturing significantly improves as residents pro-
gress through training. The gap in suturing skills was most
apparent when comparing junior residents with senior
residents. Although these results are not unexpected, the
opportunities for training, as reported by the residents, are
[17] Van Sickle KR, Baghai M, Huang IP, Goldenberg A, Smith CD, Ritter
EM. Construct validity of an objective assessment method for
laparoscopic intracorporeal suturing and knot tying. Am J Surg
2008;196:7480.
[18] Moorthy K, Munz Y, Dosis A, Bello F, Chang A, Darzi A. Bimodal
assessment of laparoscopic suturing skills. Surg Endosc 2004;18:
160812.
[19] Laguna MP, Schreuders LC, Rassweiler JJ, et al. Development of
laparoscopic surgery and training facilities in Europe: results of a
survey of the European Society of Uro-Technology (ESUT). Eur Urol
2005;47:34651.
[20] Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A. Laparoscopic virtual
reality and box trainers: is one superior to the other? Surg Endosc
2004;18:48594.
[21] Hamilton EC, Scott DJ, Fleming JB, et al. Comparison of video trainer
and virtual reality training systems on acquisition of laparoscopic
skills. Surg Endosc 2002;16:40611.
[22] Derossis AM, Fried GM, Abrahamowicz M, Sigman HH, Barkun JS,
Meakins JL. Development of a model for training and evaluation of
laparoscopic skills. Am J Surg 1998;175:4827.
[23] Hanna GB, Frank TG, Cuschieri A. Objective assessment of endo-
scopic knot quality. Am J Surg 1997;174:4103.
[24] Le CQ, Lightner DJ, VanderLei L, Segura JW, Gettman T. The current
role of medical simulation in American urological residency train-
ing programs: an assessment by program directors. J Urol
2007;177:28891.
concerning; for instance, only 12% reported sufficient
volumes of laparoscopy in training and only 32% reported
that they performed laparoscopic cases as primary
surgeon. Furthermore, <50% of residents had an oppor-
tunity to train on simulators to refine laparoscopic skills.
Acquisition of surgical skills in the 21st century should
not follow the traditional teachings of Halsted [24]. Since
laparoscopy is performed using monitors and trocars, the
approach is easily adapted to simulation. This concept
is supported by urology residents and even program
directors, yet many hurdles exist [15]. Dissemination of a
standardized, proficiency-based curriculum may be the
goal, but issues of simulator development, device realism,
training validation, and added training costs must be
addressed. Hopefully this manuscript will provide further
motivation to address these concerns and foster improved
urologic training in the modern era.
References
[1] Kroeze SGC, Mayer EK, Chopra S, Aggarwal R, Darzi A, Patel A.
Assessment of laparoscopic suturing skills of urology residents: a
pan-European study. Eur Urol 2009;56:86573.
[2] Katz R, Hoznek A, Salomon L, Antiphon P, de la Taille A, Abbou CC.
Skill assessment of urological laparoscopic surgeons: can criterion
levels of surgical performance be determined using the pelvic box
trainer? Eur Urol 2005;47:4827.
[3] Stolzenburg J-U, Rabenalt R, Do M, Horn LC, Liatsikos EN. Modular
training for residents with no prior experience with open pelvic
 EUROPEAN UROLOGY 56 (2009) 865873
surgery in endoscopic extraperitoneal radical prostatectomy. Eur
Urol 2006;49:491500.
[4] Laguna MP, Schreuders LC, Rassweiler JJ, et al. Development of
laparoscopic surgery and training facilities in Europe: results of a
survey of the European Society of Uro-Technology (ESUT). Eur
Urol 2005;47:34651.
[5] Le CQ, Lightner DJ, VanderLei L, Segura JW, Gettman MT.
The current role of medical simulation in American urological
Editorial Comment on: Assessment of Laparoscopic
Suturing Skills of Urology Residents: A Pan-European
Study
Antonio Galfano
Department of Surgical and Oncological Sciences,
Urology Clinic University of Padua, via Giustiniani, 2,
35100 Padova, Italy
antoniogalfano@gmail.com
The European Urological Residents Education Pro-
gramme (EUREP) is a noteworthy occasion of learning
for European residents, with the top experts in virtually all
urologic fields available as teachers. The introduction of
the hands-on training programme provided a further
improvement in the usefulness of this event, giving a
practical cut to the course, although with a lab model. The
authors of this study [1] should be applauded for the idea
of further transforming this educational event into an
occasion for evaluating the practical skills provided by
European urology schools to residents.
Different training models have already been proposed
for teaching endoscopic, endourologic [2], and laparo-
scopic skills, but no standardised global consensus has yet
been reached concerning optimised outcomes to be
achieved during laparoscopic training [3].
Considering the timely and fashionable widespread
attraction exerted by laparoscopy in urology, it is not
surprising that 96% of residents are interested in training on
a laparoscopic simulator. In contrast, it is disappointing that
only 41% of them had had the opportunity to use a
laparoscopic simulator during the course of residency [1].
Moreover, most of the residents reported having few or
insufficient skills in laparoscopic models, even in the final
years of residency. This admission shows that, too often,
residents programmes suffer from a limited use of
constantly updated surgical programmes. A possible
explanation for this problem might be limited economic
873
residency training programs: an assessment by program direc-
tors. J Urol 2007;177:28891.
DOI: 10.1016/j.eururo.2008.09.046
DOI of original article: 10.1016/j.eururo.2008.09.045
resources, especially in developing countries. Nevertheless,
low-cost alternative lab models can be used with good
results in terms of skills improvement [4].
One last point is the real transferability of the technical
skills acquired through a lab model to the surgical patient.
Even though transfer validity from lab models to the
operating room has already been demonstrated [5], virtual
training must be considered only the first step of a surgical
learning curve that should begin as soon as possible during
the residency year, before learning skills, visual memory,
and psychomotor performances drop down [6].
References
[1] Kroeze SGC, Mayer EK, Chopra S, Aggarwal R, Darzi A, Patel A.
Assessment of laparoscopic suturing skills of urology residents: a
pan-European study. Eur Urol 2009;56:86573.
[2] Schout BMA, Hendrikx AJM, Scherpbier AJJA, Bemelmans BLH.
Update on training models in endourology: a qualitative systema-
tic review of the literature between January 1980 and April 2008.
Eur Urol 2008;54:124761.
[3] Kommu SS, Dickinson AJ, Rane A. Optimizing outcomes in laparo-
scopic urologic training: toward a standardized global consensus.
J Endourol 2007;21:37885.
[4] Chandrasekera SK, Donohue JF, Orley D, et al. Basic laparoscopic
surgical training: examination of a low-cost alternative. Eur Urol
2006;50:128591.
[5] Sugiono M, Teber D, Anghel G, et al. Assessing the predictive validity
and efcacy of a multimodal training programme for laparoscopic
radical prostatectomy (LRP). Eur Urol 2007;51:133240.
[6] Boom-Saad Z, Langenecker SA, Bieliauskas LA, et al. Surgeons
outperform normative controls on neuropsychologic tests, but
age-related decay of skills persists. Am J Surg 2008;195:2059.
DOI: 10.1016/j.eururo.2008.09.047
DOI of original article: 10.1016/j.eururo.2008.09.045