(UroToday.com) Tuesday morning's plenary session at the 2024 World Congress of Endourology and Uro-Technology Conference ignited a compelling debate on whether open surgery training is essential in an era dominated by robotic surgical techniques.
Dr. Chandru Sundaram, MD, who moderated the session, set the stage by highlighting a critical shift in surgical practice. He noted that over 90% of radical prostatectomies are now performed using a robotic approach. In his own institution, Indiana University, less than 15% of partial nephrectomies are conducted through open surgery. In contradistinction, Dr. Sundaram presented a challenging case involving a 25-year-old man with testicular cancer, where a large retroperitoneal mass necessitated aortic and vena cava replacement—a procedure that could only be performed using open surgery. This case raised the pivotal question: Is open surgery training still necessary for today’s urologists?
Dr. John Davis, MD, argued affirmatively, stressing the continued relevance of open surgery training. Drawing on over 20 years of experience, Dr. Davis identified two key differences between expert and novice surgeons. He emphasized that experts possess an in-depth understanding of ideal surgical exposure and can rapidly rectify issues that might impede progress. Experts also have the ability to visualize the anatomy before reaching it surgically, requiring minimal feedback to proceed. He argued that training in open surgery is essential to develop these skills that can be applied in any surgical procedure.
Dr. Davis supported his argument with evidence from our general surgery colleagues. He referenced a study where surgical interns initially underwent a robotic skills test, followed by a year of open and laparoscopic training. Remarkably, their robotic skills showed significant improvement after the year of open training. Another systematic review highlighted that surgeons with open surgical training could acquire robotic skills more rapidly than those without. Dr. Davis likened open surgical skills to navigating a road trip by car, suggesting that these skills allow surgeons to adapt and solve problems effectively. In contrast, those trained solely in robotics might progress step by step, but without the flexibility to adapt as challenges arise.
The Argument Against Open Surgery TrainingOn the opposing side, Dr. Philipp Mandel contended that open surgery training is not necessary in the robotic era. He began by questioning the clinical need for open prostatectomy, pointing out that 70-100% of prostatectomies in institutions equipped with robots are performed robotically. Dr. Mandel asserted that robotic prostatectomy offers several advantages, including lower transfusion rates, shorter hospital stays, fewer postoperative complications, and reduced positive margins and mortality rates.
Dr. Mandel further argued that open prostatectomy does not provide significant benefits for specific patient groups, such as elderly men, obese individuals, transplant patients, locally advanced disease patients or those undergoing salvage prostatectomy. He also highlighted the extremely low conversion rate from robotic to open surgery, which he estimated at 1 in 200 or 1 in 300 cases.
From a financial perspective, Dr. Mandel noted that as the volume of robotic procedures increases, the cost of robotic prostatectomy decreases, making it more economically viable. He raised concerns about the feasibility of training all surgeons in open prostatectomy, given the dwindling number of open cases. He concluded that the learning curve for open surgery is considerably steeper than for robotic surgery.
In his closing remarks, Dr. Mandel affirmed that open surgical training is not necessary in the era of robotics. He did acknowledge that while robotic surgeries yield better outcomes and meet patient demand, it might still be prudent to have one experienced open surgeon in each department as an emergency backup.
ConclusionThe debate underscored the evolving landscape of surgical education and practice. As robotic surgery continues to gain prominence, the necessity of open surgery training remains a contentious issue. The discussion highlighted the importance of balancing technological advancements with traditional surgical skills, ensuring that future surgeons are equipped to handle a wide range of clinical scenarios.
Presented by:
Moderator: Chandru P. Sundaram, MD, MBA, FRCS. Dr. Norbert M. Welch, Sr. and Louise A. Welch Professor of Urology and Program Director and Director of Minimally Invasive Surgery, Department of Urology, Indiana University
YES – John W. Davis, MD. Professor and Director of Urosurgical Prostate Program, Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
NO – Philipp Mandel, MD, PhD. Professor, Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt, Germany
Written by: Bruce Gao, MD, FRCSC, Endourology Fellow, Department of Urology, University of California Irvine, @b_gao on Twitter during the 2024 World Congress of Endourology and Uro-Technology: August 12 -16, 2024, Seoul, South Korea