The impact of resident involvement in minimally-invasive urologic oncology procedures

Abstract

Introduction: Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database. Methods: Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005Files ( -2011, we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates. Results: A total of 5459 minimally-invasive radical prostatectomies, 1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic). Conclusions:Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

Resident Involvement in Radical Inguinal Orchiectomy for Testicular Cancer Does Not Adversely Impact Perioperative Outcomes - A Retrospective Study

“…These findings corroborate previous reports that found RI to be significantly associated with pOT regardless of training status [16,17] . A significant association between RI and pOT was also found in more complex urological procedures as described by Ruhotina et al [17] .…”

“…Allard et al [16] showed that RI has no impact on overall complications or reoperation rates in endoscopic prostate surgeries and transurethral resection of bladder tumors, while readmission rates as quality of care measures were significantly higher in cases with RI. Along the same lines, 2 other studies focusing on RI in urological procedures reported no adverse outcomes following RI in reconstructive or minimally invasive procedures [17,24] .…”

“…Due to an increased interest in outcome-based quality metrics and under consideration of increased patient-safety concerns, the simultaneous provision of excellent patient care and adequate resident teaching has been subject to controversy [13,14] . Although RI during major oncological procedures tends to be correlated with increased risk of immediate perioperative complications [15] , most data about the impact of RI on outcomes in urology are restricted to endoscopic procedures [16,17] . On the basis of these considerations, we hypothesized that RI was not correlated with unfavorable perioperative outcomes after radical orchiectomy for testicular cancer and we aimed to demonstrate such an assumption by analyzing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.…”

The impact of teaching on the duration of common urological operations

“…The involvement of residents (including junior, senior, and chief residents) significantly increased the risk of an operative time >75 th percentile for minimally invasive partial and radical nephrectomies, as well minimally invasive radical prostatectomy. 4 Similarly, there was a twofold higher chance of a prolonged operative time (defined as >75% percentile) when urology residents were involved with transurethral surgery. 5 Among basic general surgery procedures (laparoscopic cholecystectomy or appendectomy, or open inguinal hernia repair, all of which tended to take approximately an hour), skin-to-skin operative time increased by 12-20 minutes with the involvement of both junior or senior residents, compared to the attending surgeon operating alone.…”

“…While non-teaching-based hospitals exist primarily to deliver patient care, academic hospitals have the additional demands of clinical research and the training and education of medical and nursing students, allied health professionals, and postgraduate physicians (interns, residents, and fellows). The inclusion of medical residents in surgical procedures performed in the U.S. has been shown to increase the risk of a prolonged operation for specific urological procedures (such as laparoscopic urological oncology procedures 4 and transurethral surgery 5 ), as well as in other surgical specialities (such as gynecology 6 and general surgery 7 ). The increase in operative duration associated with training future medical professionals inherently increases the operating room cost of procedures at academic hospitals and is not currently accounted for in many activity-based funding models.…”