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Editorial: What is the optimal length of time for SNM testing?

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The authors are to be commended for their unique investigation of an extended stage 1 SNM test period. To our knowledge, no other series has included a minimum 4-week duration and microbiologic testing. Optimal duration for the test phase has not been elucidated and initial responses are likely compounded by a short-term placebo effect that may dissipate after time. Knowledge of when maximal improvement occurs would define a population of true responders and reduce implant failure rates. This series shows the feasibility of an extended test phase in a small cohort, but does not identify the optimal length of time for testing.

One must question how many responders are in the 2- to -4 week interval and if such patients would do as well with earlier implantation. Current testing with permanent leads and externalized hardware is cumbersome and not always convenient for activities of daily living, especially showering. Furthermore, knowing the sampling interval used by the authors to assess response and the time at which the majority of patients reached the established implant criteria could clarify the time needed for maximal response. In this small cohort, however, the difference would fail to show significance.

As the authors note, a low stage 2 failure rate is important in an era with rising concern over health care expenditure, but it generates questions on what to do for responders
who have symptomatic improvement >50% but <70%. Do we risk not helping an individual who has 50% improvement in order to reduce stage 2 failures, and how do we justify making this quality-of-life decision? The low stage 2 failure rate in this study may have resulted from the strict criteria for stage 1 success, specifically a 70% or greater response, and not necessarily the prolonged test phase.

Notably, there were no infections in this series despite an extended stage 1 test phase. This is considerably lower than the 5–7% infection rate reported in the literature (Urology, Eur Urol). Perhaps the degree of hygiene and antibiotic regimen contributed to the lack of infectious complications, but concern remains that such results are not generalizable. Infectious events not captured in this series may become evident with a larger sample size and surely the rate will be greater than zero. Granted, the results of this study add to our knowledge of SNM, it is not conclusive that the outcomes can be applied to the population at large, and further evidence from randomized trials are needed to identify the balance between benefits and risks associated with an extended test phase.

Brian K. Marks and Sandip P. Vasavada
Center for Female Urology and Reconstructive Pelvic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

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Article of the week: Nerve sparing during RARP: Watch the weaker hand

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Pathological confirmation of nerve-sparing types performed during robot-assisted radical prostatectomy (RARP)

Woo Jin Ko, Gregory W. Hruby*, Andrew T. Turk†, Jaime Landman‡ and Ketan K. Badani*

Department of Urology, National Health Insurance Corporation Ilsan Hospital, Goyang, South Korea; Departments of *Urology and †Pathology, Columbia University Medical Center, New York, NY, and ‡Department of Urology, University of California Irvine, Irvine, Orange, CA, USA

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OBJECTIVES

• To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens.

• To aid the novice robotic surgeon to develop the skills of RARP.

PATIENTS AND METHODS

• Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated.

• Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15° intervals (3–9 o’clock position), measured as the distance between the outermost prostate gland and surgical margin.

• The slides were reviewed by an experienced uropathologist who was ‘blinded’ to the NST.

RESULTS

• In all, 93 men were included. The overall mean (SD) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001).

• FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW.

• Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon’s right-hand dominance.

• Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively.

• To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required.

CONCLUSIONS

• The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right.

• The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF.

 

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Editorial: Specimen fascia width reflects nerve-sparing technique

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The authors have reported a pathological analysis showing that various levels of nerve-sparing technique were reflected in the radical prostatectomy (RP) specimen. Intriguingly, the authors found that the fascia width on the left side was much wider than the right side in the RP specimen with the interfascial nerve-sparing technique. This is important information for robotic surgeons. Looking at the literature, almost twice as many positive surgical margins have been reported on the left side in patients treated with laparoscopic RP and robot-assisted RP (RARP). Secin et al. also reported similar results, which revealed the tendency for left-side dominance of positive surgical margins. These results seem to be in large part due to the left side being more technically challenging, resulting in less precise dissection.

For lymph node dissection, our own unpublished data of 1005 patients who underwent RARP indicates that the mean lymph node yield is higher on the left side (7.5 vs 7.1, P = 0.004), while the author’s previous study found a higher lymph node yield on the right side. Although, we could not establish which factors contributed to the contrary results, it seems that side preference also exists when performing robotic lymph node dissection.

While the da Vinci Surgical System® has been shown to eliminate innate hand dominance, the observed findings were of novice robotic surgeons and meticulous dissection of the neurovascular bundle is usually performed using a dominant hand even in experienced robotic surgeons. Moreover, differences in robot instruments of both arms and assistant positioning may also play a role in different outcomes by laterality. Nevertheless, the da Vinci Surgical System provides surgeons with magnified three-dimensional vision equally on both sides and promotes meticulous lateral dissection. We think that the imprecision of surgery on the left side could be overcome if surgeons are aware of the potential difference in laterality. Finally, we congratulate Ko et al. for their novel work. A follow-up study with multiple surgeons and analysis that reflects the effect of the surgeon’s learning curve on the outcomes would also be informative.

Kwang Hyun Kim and Koon Ho Rha
Department of Urology, Yonsei University College of Medicine, Seoul, Korea

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Article of the week: Centralized simulation training combines technical and non-technical skills

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity

Mohammad Shamim Khan, Kamran Ahmed, Andrea Gavazzi, Rishma Gohil, Libby Thomas*, Johan Poulsen†, Munir Ahmed, Peter Jaye* and Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital , *Simulation and Interactive Learning (SaIL) Centre, Guy’s & St Thomas NHS Foundation Trust , and †Department of Urology, Aalborg Denmark and King’s College Hospital, London, UK

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OBJECTIVES

• To establish the feasibility and acceptability of a centralized, simulation-based training-programme.

• Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills.

MATERIALS AND METHODS

• For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme.

• The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA] , Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills.

• The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales.

RESULTS

• In total 33, three specialist registrars of different grades and five urological nurses participated in the present study.

• Construct-validity between junior and senior trainees was signifi cant. Of the participants, 90% rated the training models as being realistic and easy to use.

• In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized.

• A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills.

CONCLUSIONS

• A centralized simulation programme that provides training in both technical and non-technical skills is feasible.

• It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

 

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Editorial: The need to devise a better means of training

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There is increasing concern that current UK trainees at the end of their training are less experienced than their previous counterparts and continue to require more education, skills and support when they assume their consultant posts in the form of mentoring.

It is generally accepted that the numbers of hours required to become an ‘expert’ is 10 000–30 000 and currently in the UK our trainees experience =6000 h of training. Much of this is due to the impact of the European Working Time Directive (EWTD) and the government ‘New Deal’ initiative on junior doctors contracts introduced in 2003. The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD. Skills training has therefore been seen as the mechanism to resolve the situation, encompassing the acquisition of both technical and non-technical skills. The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them.

Contemporary urology training is moving out of clinical practice and simulation is increasingly used to provide a safe and supportive learning environment for learning and maintaining skills. However, this needs the following criteria:

• An agreed curriculum

• Agreed set of standards

• A validated form of assessment

• The availability of local and national skills centres

• Educators and trainers

The problem is that traditionally the UK has few training centres, together with a lack of trained manpower and funding. However, controversy still remains over the efficacy of simulation for training and those who are able to fund such projects comment on the paucity of available data in relation to the predictability of future outcomes and patient safety.

Projects such as the Simulation and Technology enhanced Learning Initiative (STeLI) initiative documented in this paper are important contributors to the evidence base. The programme aims to establish the feasibility and acceptability of a centralised, simulation-based system incorporating both skills and non-technical skills aspects of training. The latter involving crisis resource management using the SimMan model to teach team-working, decision-making, and communication skills in various settings between senior and junior trainees. Not surprisingly senior trainees scored significantly better on virtual reality simulators, bench-top box trainers and the European wet-lab training facility, as well as in human patient simulation training in crisis resource management (CRM) using SimMan, than junior trainees. The interesting point raised in this paper is that the trainees’ behaviour shows the value of inclusion of the CRM training and the interplay between technical and non-technical skills. Non-technical skills have often been sidelined in courses focusing on technical skills acquisition and this paper highlights the importance and added-value of incorporating such a skill set into future course content and curricula.

Thus, there is no doubt that some surgical skills can be learned in the laboratory and although this will never be a substitute for operative experience, the first steps of training can be accelerated with potential reduction of risk to patients. Increasingly data from sources such as the STeLI project underline a better appreciation of the importance of the training in non-technical skills, which equip surgeons in working under stress and more importantly working as a team player. However, the ultimate test for simulation is whether the model and content is able to reduce surgical errors, improve patient safety and reduce operative time and costs. To try and answer these questions BAUS in conjunction with the Specialist Advisory Committee (SAC) in Urology have recognised that the technology is there but there is a need to identify trainers keen to train, with the nomination of a national lead for simulation to develop a national strategy to deliver a viable programme aligned to the curriculum to try and answer the important question: ‘Does simulation enhance real-life performance of a surgical technique?’.

Adrian D. Joyce
St James’ University Hospital, Leeds LS9 7TF, UK

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Article of the week: Prostate cancer treatments: How much do you want to spend?

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Matthew Cooperberg discussing his paper.

If you only have time to read one article this week, it should be this one.

Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis

Matthew R. Cooperberg, Naren R. Ramakrishna†, Steven B. Duff*, Kathleen E. Hughes‡, Sara Sadownik‡, Joseph A. Smith§ and Ashutosh K. Tewari

Departments of Urology and Epidemiology and Biostatistics, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, *Veritas Health Economics Consulting, Inc., Carlsbad, CA, †Department of Radiation Oncology, MD Anderson Cancer Center, Orlando, FL, ‡Avalere Health LLC, Washington, DC, §Department of Urologic Surgery, Vanderbilt University, Nashville, TN, and Department of Urology, Cornell University, New York, NY, USA

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OBJECTIVE

• To characterise the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (RT: dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy, or combination), using a comprehensive, lifetime decision analytical model.

PATIENTS AND METHODS

• A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications.

• In each Markov cycle, patients could have remission, recurrence, salvage treatment, metastasis, death from prostate cancer, and death from other causes.

• Utilities for each health state were determined, and disutilities were applied for complications and toxicities of treatment.

• Costs were determined from the USA payer perspective, with incorporation of patient costs in a sensitivity analysis.

RESULTS

• Differences across treatments in quality-adjusted life years across methods were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6–10.5 for intermediate-risk patients and 7.8–9.3 for high-risk patients.

• There were no statistically significant differences among surgical methods, which tended to be more effective than RT methods, with the exception of combined external beam + brachytherapy for high-risk disease.

• RT methods were consistently more expensive than surgical methods; costs ranged from $19 901 (robot-assisted prostatectomy for low-risk disease) to $50 276 (combined RT for high-risk disease).

• These findings were robust to an extensive set of sensitivity analyses.

CONCLUSIONS

• Our analysis found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives.

• These findings may inform future policy discussions about strategies to improve efficiency of treatment selection for localised prostate cancer.

 

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Editorial: Valuing interventions for localised prostate cancer

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Robert Pickard and Luke Vale

Governments of all nations struggle to work out how best to use the limited resources available for health care. One key area of uncertainty is long term conditions with multiple therapeutic options including no active treatment, where relative merits of different treatments are unclear and there is associated unexplained variation in use of often expensive interventions such as surgery. The management of localised prostate cancer typifies this situation. The problem is how to decide the relative worth of options especially as this judgement might differ between patients, clinicians, providers and funders. The best way is to perform well designed randomised trials between competing interventions with sufficient follow-up to identify any differences. For localised prostate cancer the ProTect trial is due to report in 2014. In the meantime, health care agencies commission Health Technology Assessments (HTA) to comparatively value interventions usually on the basis of the monetary cost of the added benefit they give in terms of better outcomes. This is commonly measured as the extra cost of each additional quality-adjusted life year (QALY) they give. The well laid out paper by Cooperberg et al. certainly adds to previous similar work  that is available on relevant health agency websites (HTA 2003, CADTH 2011, HTA 2011, HTA 2012), but was interestingly funded by an industrial stakeholder, Intuitive Surgical. Given its perspective focusing predominantly on Medicare tariffs, it is perhaps most relevant to the US Government who pays these rates, but careful reading by all will at the very least give a flavour of the use of predictive statistical and economic modelling of the possible benefits to patients, and costs to funders of the treatments advised by clinicians.

It is important to highlight that the methods of meta-analysis of the existing literature used by Cooperberg et al. are unclear – this makes it hard to critique whether the best data have been used in the model. Furthermore, the data analyses are unusual. A more typical presentation would have been to explore the likelihood that each treatment would be considered cost-effective. The method used does not really illustrate whether the conclusion should be that there are no differences between treatments or whether there is insufficient evidence to determine whether there are differences. Furthermore, although baseline characteristics of patients included in the meta-analysis are not given it is likely that some would differ between men undergoing surgery or radiotherapy leading to bias in outcome. The linear Markov model used is also perhaps an inadequate reflection of reality since it does not appear to calculate QALYs for repeated transit through further cancer treatment/remission/recurrence states and between incontinent/continent and sexual dysfunction/no sexual dysfunction states which men would value specifically and independently. In terms of costs the have included costs of patient recovery time. Arguably recovery should be captured within the QALY measure and to include it again under costs might be an element of double counting. In addition they showed that the results were sensitive to certain assumptions that may be questioned such as the four year shorter time to metastasis after biochemical recurrence for radiotherapy.

Cooperberg et al. have certainly provided a useful example of how different treatments supervised by clinicians may be valued by those that pay the bills. A parting thought is if only clinicians of differing specialties could collaborate on large definitive RCTs we would not need to rely on predictive models based on imperfect data.

 

Robert Pickard is a Professor of Urology at the Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]

Luke Vale is Health Foundation Chair in Health Economics at the Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]

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Video: Dr Cooperberg’s article commentary on prostate cancer treatment

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Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis

Matthew R. Cooperberg, Naren R. Ramakrishna†, Steven B. Duff*, Kathleen E. Hughes‡, Sara Sadownik‡, Joseph A. Smith§ and Ashutosh K. Tewari

Departments of Urology and Epidemiology and Biostatistics, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, *Veritas Health Economics Consulting, Inc., Carlsbad, CA, †Department of Radiation Oncology, MD Anderson Cancer Center, Orlando, FL, ‡Avalere Health LLC, Washington, DC, §Department of Urologic Surgery, Vanderbilt University, Nashville, TN, and Department of Urology, Cornell University, New York, NY, USA

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OBJECTIVE

• To characterise the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (RT: dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy, or combination), using a comprehensive, lifetime decision analytical model.

PATIENTS AND METHODS

• A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications.

• In each Markov cycle, patients could have remission, recurrence, salvage treatment, metastasis, death from prostate cancer, and death from other causes.

• Utilities for each health state were determined, and disutilities were applied for complications and toxicities of treatment.

• Costs were determined from the USA payer perspective, with incorporation of patient costs in a sensitivity analysis.

RESULTS

• Differences across treatments in quality-adjusted life years across methods were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6–10.5 for intermediate-risk patients and 7.8–9.3 for high-risk patients.

• There were no statistically significant differences among surgical methods, which tended to be more effective than RT methods, with the exception of combined external beam + brachytherapy for high-risk disease.

• RT methods were consistently more expensive than surgical methods; costs ranged from $19 901 (robot-assisted prostatectomy for low-risk disease) to $50 276 (combined RT for high-risk disease).

• These findings were robust to an extensive set of sensitivity analyses.

CONCLUSIONS

• Our analysis found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives.

• These findings may inform future policy discussions about strategies to improve efficiency of treatment selection for localised prostate cancer.

Article of the week: Reality check: simulators are effective training tools for robotic surgery

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Current status of validation for robotic surgery simulators – a systematic review

Hamid Abboudi, Mohammed S. Khan, Omar Aboumarzouk*, Khurshid A. Guru†, Ben Challacombe, Prokar Dasgupta and Kamran Ahmed

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, *Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK, and †Department of Urology, Roswell Park Center for Robotic Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA

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To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE®, EMBASE® and PsycINFO® databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; ‘expert’ and ‘novice’. Experts ranged in experience from 21–2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer®, ProMIS®, SimSurgery Educational Platform® (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial.Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

 

 

 

 

 

 

 

 

 

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Editorial: VR simulators can improve patient safety

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You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

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