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EDITORIAL COMMENT

This article, more than any other to date, puts laparoscopic urology in a clear perspective. The authors have pooled their vast experience to report on almost 2,500 laparoscopic procedures a t their institu- tions and the resulting complication rate. Practical and philosophical lessons can be derived from this article. On a practical level the authors provide several insights. The more difficult the procedure, the higher the complication rate. As one progresses from the simplest to the most difficult procedures, complications increase 9-fold. How- ever, as experience grows, the incidence of complications decreases markedly and after 100 cases it decreases 4-fold. Experience encom- passes not only greater familiarity with obtaining a pneumoperito- neum and laparoscopic dissection techniques, but also greater knowledge in the use of the instrumentation. In this respect monopo- lar electrosurgical current is attributed with the greatest number of instrument related mishaps. The authors cite several methods to decrease problems with monopolar electrosurgical current. These suggestions, if adapted in entirety, can all but eliminate problems with this most powerful and efficient means of dissection and coag- ulation.

However, of far greater importance is what the authors have written from a philosophical standpoint. The training of urologists in laparoscopic surgery is critical and to this end the authors have devised a 4-part didactic and laboratory training course. I believe this program is excellent and hope that a similar series of courses will be initiated in the United States. It is becoming more and more evident that laparoscopy is not a technique that one can learn during a single 2 or 3-day procedure oriented course. The approach of a graduated 4-part series seems prudent and may well lead t o a far greater number of urologists being comfortable enough to initiate and continue doing laparoscopic procedures following this type of training than have done so following the isolated 2 or 3-day course.

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COMPLICATIONS OF LAPAROSCOPIC PROCEDURES 77 1

At the 1999 meeting of the American Urological Association uro- logical laparoscopy came into its own. Several reports on laparo- scopic radical nephrectomy were presented for the first time at the oncology poster sessions and were well received. Additional studies, comprising large numbers of patients, were presented on laparo- scopic donor nephrectomy and laparoscopic pyeloplasty. Laparoscopy is likely to grow significantly during the coming years. However, growth will not be in the realm of simpler procedures, such as varicocelectomy or pelvic node dissection, but in the realm of the more difficult procedures which largely relate to urological oncology, reconstructive surgery and renal transplantation.

It is essential to the future well-being of urology that we train ourselves and our residents in laparoscopic surgery. In residency programs it will be important for laparoscopy to become a part of the training program. To this end the Residency Review Committee and the American Board of Urology need to mandate that laparoscopic

training be included in the curriculum of all residency programs. Thus, each training program will require an individual or individu- als skilled in laparoscopic techniques. At a post-residency level a 4-part series of graduated courses should enable all urologists to learn laparoscopic techniques in an unhumed and organized man- ner. Following this initiation appropriate mentoring and proctoring should allow each urologist so inclined to become facile a t all levels of laparoscopic surgery. If we do not take it upon ourselves to obtain and maintain the latest in operative skills, there is little doubt that we will lose our open surgical responsibilities to other specialists more motivated and better trained than we.

Ralph V. Clayman Department of Urology Washington University School of Medicine St. Louis, Missouri