RARP checklist assesses, evaluates surgeon progress

Taipei, Taiwan-A new checklist-based assessment tool could prove to be useful for surgeons learning robot-assisted radical prostatectomy (RARP).

An international team headed by specialists in the urology department of King's College, London has been studying the learning processes that lead to proficiency in RARP and other urologic procedures for several years and has produced a number of studies on these subjects. At the World Congress of Endourology and SWL, the authors presented a study that deconstructs the procedure into constituent phases and gives each activity within a phase a difficulty rating that reflects the steepness of the learning curve required for competency. This most recent work created and subsequently validated a checklist that evaluates a surgeon's progress in acquiring proficiency with phases within the procedure and the procedure in its entirety.

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"Essentially, the study had three aims. The first was to create a means of mapping the entire surgical procedure. The second is to create a training document for specific aspects of the procedure, and the third is to create a tool that will assess an individual's performance and provide feedback that has value," senior author Kamran Ahmed, PhD, MBBS, MRCS, special registrar in urology at King's College, told Urology Times.

The authors broke the procedure into 41 steps spanning 17 stages. In addition to defining each stage and step in the procedure, the study identified 84 "failure modes," 46 of which had a hazard score of 8 or greater, indicating that the failure could lead to significant adverse clinical events.

The study derived its approach to the procedure from the principles of the Failure Mode and Effect Analysis, a proactive system created by the military to identify potential failures and their causes, and to take preventive action.

The effort can be described as labor intensive. Key robotic prostatectomy steps were identified by watching five surgeons who logged 42 hours on the robot console.

Next: Diverse team reviews process

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Diverse team reviews process

Once the process was mapped in detail, it was reviewed by specialists from the UK, Europe, and the U.S. Dr. Ahmed explained that the diversity on the reviewing team was deliberate.

"There are so many techniques. I suspect there is a technique for each and every surgeon. That is why we wanted a range of surgeons-to ensure that we captured every aspect of the procedure," he told Urology Times.

A checklist of definitive tasks within each stage of the procedure was created, allowing each task to be evaluated by an observer as it was performed. Evaluations ranged from 1 (unacceptable) to 5 (excellent). This tool was then used to evaluate the progress of 17 surgical fellows from Europe, Asia, and Australia.

"There are characteristics of every education tool. It should be valid, reliable, feasible, acceptable, and should have an educational impact," said Dr. Ahmed. He added that he felt all these ends were accomplished in the tool he and his team created.

The observational data collected also allowed learning curves to be assigned to each phase of RARP, he noted.

"Most of the learning curves to date have been evaluations based on patient outcomes. It has never before been done this way because it can be a very tedious process," Dr. Ahmed said. The learning curve data allows focus to be placed on the more challenging aspects of RARP.

The authors noted that the steps involved in patient preparation were among the easier aspects of the procedure. nerve sparing and vesico-urethral anastomosis were among the more challenging, Dr. Ahmed said.

The study was funded by the Royal College of Surgeons of England.

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