Making A New Training Model For Laparoscopic Urethrovesical Anastomosis And Its Application Research

Background:Since the first cases of retroperitoneal laparoscopic nephrectomy was performed and reported by Clayman and colleagues in1900, this technology had experienced a rapid development, and results in a revolutionary change in the field of surgery, which almost take the place of traditional surgery. Nowadays, minimally invasive surgery represented by laparoscopic technology has become a main trend in the development of surgery, which almost be the necessary course for every surgeon. The laparoscopic technique, which has gradually involved every corner of traditional surgery and became the main theme of the development of the surgery, has raised the revolutionary progress in the field of surgical department. According to the statistics, almost more than90%cases of the operation can be accomplished by minimally invasive operation, and achieved the similar effect as the original open operation, less than10%of that has to resort to the traditional operation.The laparoscopic radical prostatectomy, a represent of the most successful surgery in the minimally invasive fields, had an extreme requirement for the surgeon endoscopic skills, for its difficult and complex operating.Hence, the first case of laparoscopic radical prostatectomy was reported by Schuessler until the1997, in his research, no advantages had been showed in the laparoscopic operation. Now, with the laparoscopy technology development and relevant auxiliary technical progress, laparoscopic radical prostatectomy, which shows the superiority of few trauma, less bleeding, clear vision and quick postoperative recovery, has became the gold standard for the treatment of localized prostate cancer. For the reason of enable patients to minimize the operation pain, more and more patients with early stage of prostate cancer are eager to laparoscopic operation, and urologists wish to master the techniques at the same time. Although the operation has gradually became the best choose for the early stage patients, this technology is still a big bottleneck for our urologic surgeon, lie in than it’s too difficult to operate in a short term for most surgeon. In our country, only few large hospitals have the ability to perform this operation, it has not been widely conducted in the most hospital.As the most research shown, the urethrovesical anastomosis(UVA), one of the most time wasting, energy consuming and difficult applying steps during the laparoscopic radical prostatectomy (LRP) for prostate cancer, is the main reasons to restrict the development of this new technology. On the one hand, it’s for the reason that the long and complicated surgery progress makes the surgeon too fatigue to conduct this step with full of energy; on the other hand, the narrow pelvic space aggravate the difficulty for this operation. Although the robot assisted LRP solved this problem successfully, the costly equipment configuration and expensive operation expenditure restricted its extensive use and only few hospitals own the equipments to carry out the technology and smaller quantity of people are capable of affording the huge expenditure, in this way, the general hospital almost hardly attempt to got this facilities to develop the technique.For these reason, improving the UVA is crucial for popularized the LRP. Research has indicated that the model training has an important practical value to enhance operation skills, and operation skills mastered during the training can also be transformed into actual operation application, but ideal model has not been reported by domestic or foreign researches to simulate the laparoscopic urethrovesical anastomosis progress. Therefore, the establishment of training models can contribute to the grasping of laparoscopic urethrovesical anastomosis technique and promote the development of LRP, providing a shortcut to grasp the LRP for the young doctors at the same time, and we hope that this outcome can be able to obtain a remarkable promotion in the fields of our laparoscopic level.The model training has been more and more popular in foreign countries, which has been employed by various laparoscopic agencies to cultivate the beginner with standardization, in order to shorten the laparoscopic learning curve. In the west, some reported models made with chicken skin or intestinal or something else has been applied to improve the laparoscopic skills of the young surgeon, while in domestic, these models have not be popularized and fewer laparoscopic institutes train the young surgeons as this way. We analyze the reasons and find that the shortcoming of these models restricted its wide spread. On the one hand, it is intractable and time consuming to made the chicken skin model, on the other hand, the simple circle anastomosis hardly reflects the progress of tricky operate circumstance. Therefore, conducting a practical model that vividly reflected the process of the UVA is significant for us to grasp and shorten the learning curve of LRP.We own the largest laparoscopic training center-the clinical skill experimental teaching center in the southern of our country, which equipped with virtual laparoscopic training system, basic training, and animal laboratory teaching experiment, and have the infrastructure for the laparoscopic experimental training; all of this enabled us to carry out the research.In our experiment, we make full use of existing resources and equipment, through training the participates on our new-making urethrovesical anastomosis model to improve their level of laparoscopic operation; at the same time, we evaluate the practicability of this model with the quality of anastomosis, to explore the new best ways for UVA through repeat practices and different ways for anastomosis and complish the operation during shorter time with lower leakage. We hope to realize the goal of promoting the develop of LRP eventually.Purpose:(1) To conduct a new and simple pig bladder-intestine training model for simulating laparoscopic urethrovesical anastomosis (L-UVA) that can vividly simulate the specific process during LRP.(2) Evaluating the practical and exploring the application of the model through the outcome of the participants’training experiment, and through exploring the different ways for anastomosis to improve the techniques for this operation.(3) To improve the theoretical knowledge and basic skills about laparoscopic operation of the participants, enhance their level of laparoscopic surgery and explore the way to as soon as possible to grasp the method of LUVA, one of the most time wasting, energy consuming and difficult applying steps during LRP, wish to solve the key technical problems of urethrovesical anastomosis, and realize the goal of shorten the operation time, improve the efficacy of surgery, reduce complications in LRP, through the development and popularization of the training model to indirectly promote the minimally invasive technique of prostate cancer.Methods:(1) Learning the basic theory and conducting the basic training:To learn the theory knowledge of laparoscopic surgery, master the working principle and the using methods of laparoscopic equipment systematically. To train the participants with the equipment in our training center for two hours in a consecutive week, the specific training contents are as follows:the ability of laparoscopic lens gathered, bean transfer, shearing gauze and suturing on the meat plate model; through these training, to make the trainer master the necessary for laparoscopic operation as a serious of3D spatial perception, hand eye separation, bimanual coordination operate and positioning, shear suture, knotted, basic operation, etc.(2) Model designing:The appropriate pig bladder and urethera were selected to instead of the bladder and urethra of human, with the anastomosis site clipped trim for uniform diameter, about2.0cm in diameter, and combined with the chicken truck to construct the visceral pelvic environment, to simulate the laparoscopic urethrovesical anastomosis with this new model.(3) The UVA Training:All the20participants, who were training in our laparoscopic training center without experience in laparoscopic technology, achieved to the level of our training course required firstly, then training on the new UVA model we constructed for thirty times.There was no significant difference among people in each group with regard to the competency as knot quality, suture speed and handling of instruments during the exercise before the operation. Each new trainer performed the laparoscopic anastomosis of this model in twenty times. Outcome measures were defined as operation time and volume of leakage from the anastomosis stoma. The leakage was assessed and recorded by an experienced laparoscopic doctor; time refers to the operate time from the beginning of the anastomosis to the total task completed, recorded by the personnels.(4) Statistical Analysis:Through the statistical analysis to detect the performance differences before and after suturing on the new mode. The correlation analysis was proceeded between operate time and leakage. The data was compared with independent samples t test and the outcome were divided by SPSS13.0software (P<0.05is the difference has statistical significance). Regression analysis proceeded with linear regression method (the coefficient of determination R2>0.3deemed to be statistically significant).Result:(1) All the participants reached the goal of transferring more than fifteen beans in three minutes(average17±1.32), suturing more than six stitches on the10cm incision in less ten minutes(average9±0.95min), with the splits less than two during the process of suturing.(2) All trainers completed the L-UVA with our pig bladder-intestine model for thirty times, a significant improvement in time and accuracy of performance skill was identified during the training (operation time was68.42±8.10min in the first time versus25.21±1.88min in the last time, p<0.05). There was significant statistical difference in the volume of leakage (14.82±4.08ml in the first time in contrast to1.47±0.65ml in the last time, p<0.01). All the trainers had a significant improvement in the anastomosis speed and quality after all the period.Correlation analysis showed positive correlation between suture time and leakage (R2=0.73, F=263.64, P<0.01), hinting that the quality of anastomosis improved with the operation times. Confirming the model training process has a significant effect on improvement of the laparoscopic urethrovesical anastomosis. Conclusion:(1) All the participants familiar with the basic theoretical knowledge of laparoscopic surgical operation through training and study. Finally, we achieved the goal that to make all the participant familiar with the various instruments of laparoscopic operation and master the basic skills of laparoscopic operation, such as cutting, suturing and knotting.(2) Through training on the new UVA model, the trainees not only master the basic circular anastomosis method and skill, but also can be able to adapt to the special position of the pelvic narrow space. This may contribute to enhancing the ability of urethrovesical anastomosis and grasping the needle skills in the process, and improving the UVA quality.(3) The new urethrovesical anastomosis training model can effectively help our urologists master the laparoscopic urethrovesical anastomosis technique and improve the skills of laparoscopic suture to shorten the learning cure of L-UVA.(4) The skilled laparoscopic suturing and knotting technique can be one of the key success factors to ensure a perfect operation, and may be the necessary skill for intraoperative hemostasis, suturing and knotting.(5) The reduction of operation time combined with postoperative leakage reflected the subjects’degree improvements on L-UVA. After about twenty-five operation, a rather good anastomosis could be achieved, which represented the the learning curve of L-UVA on the other hand. This cheap, real-life and readily constructed pig bladder-intestine model can be widely used to help trainees to develop skills in L-UVA.