Survey of Urologic Laparoscopic Practice Patterns in Saudi Arabia

Introduction

M any years ago, first reports were published describing the technique and results of laparoscopic surgery in urology. Despite the advantages of the technique, no widespread use followed the initial reports. ^1,2 Laparoscopic pelvic lymph node dissection was the first urologic procedure to get wide acceptance among urologists in Europe and North America. Moreover, during the early 1990s, it was the most commonly performed laparoscopic urologic procedure. Yet, later in the mid-1990s, the interest in laparoscopic surgical staging of prostate cancer diminished after the widespread implementation of nonsurgical staging using prostate-specific antigen combined with Gleason grade and physical examination. ^3,4

Many urologists published their work on the beneficial aspects of laparoscopic renal surgery, particularly in terms of reducing the postoperative pain analgesia requirements, hospital stays, and time to full convalescence. Later, laparoscopic renal surgery became much more accepted, and now urologists worldwide consider laparoscopy as the technique of choice for such procedures. ^{5 –7} In addition, in 1998, the interest in laparoscopy among urologists was further enhanced by the pioneering work of Drs. Vallancien and Guillonneau in radical prostatectomy. ^8,9

The extent to which laparoscopy is applied in urologic practice at present in Saudi Arabia is unknown; where the technique has been applied recently is also unknown. To gain a wide view of the current laparoscopic surgical practice patterns among urologists in Saudi Arabia, the division of urology at King Khalid University Hospital performed a detailed survey among urologists in different regions of Saudi Arabia.

Materials and Methods

In March 2009, surveys were delivered to 352 urologists who were working in Saudi Arabia. All recipients were registered by the Saudi Council of Health Specialities. Most surveys were received by hand; others were delivered by mail or e-mail. The questionnaire was anonymous, self-prepared, and accompanied by an introductory cover letter. In its 21 questions, all subjective and objective concerns about practice patterns of urologic laparoscopy were considered, with concentration on the volume of laparoscopic surgery performed regularly. The survey contained questions pertinent to age, time in practice, type of practice, practice setting, country of residency training, and academic affiliation. Two months were given for the survey to be returned. The study was approved by the Institutional Review Board.

The results of the completed questionnaires were entered into a computer database and processed using SPSS (version 12) software. Results were expressed in absolute numbers and percentages, chi square test was used for testing the significance of qualitative data, t test and F test were used for quantitative data. For testing correlations, the Spearman correlation coefficient was used.

Results

A total of 352 surveys were distributed, of which 148 were returned, for a response rate of 42%. Forty-three (29.3%) of the respondents did not complete their residency program; they were excluded from the analysis. The final sample comprised 105 certified urologists. Nearly two-thirds (65.1%) were Saudi and 34.9% were non-Saudi. Most (87%) were in the age group of 31 to 50 years. More than half (55.7%) were practicing in Riyadh city, the capital of Saudi Arabia, 21.5% were in Jeddah, and 22.8% were working in the other kingdom provinces and cities.

The current study revealed that 21% of the respondents never performed laparoscopy, and 24.8% used less than 5% of their surgery time in performing laparoscopy. Of urologists in Saudi Arabia, however, 53% devoted at least 5% of their practice time to laparoscopic surgery. The volume of laparoscopic surgery was inversely related to both age and time in practice (r = −0.45, P = 0.001) (Table 1). No significant difference was detected between Saudi and non-Saudi or between regions with regard to laparoscopic use (P < 0.05).

Only 27% of urologists mentioned that they had enough training during residency to practice laparoscopy; most of them had been trained in North America and Europe. Table 2 illustrates the distribution of urologists according to different health facilities and percentage of operative time devoted to laparoscopic surgery by practice type. Of the urologists in academic settings, 11.8% performed no laparoscopy, whereas 70.6% devoted more than 5% of practice volume to laparoscopic surgery. On the other hand, in Ministry of Health hospitals, the percentage of those who performed no laparoscopy was higher (29.4%), and only 35% devoted at least 5% of their practice time to laparoscopy. The difference between the two groups was significantly different (P = 0.001).

The analysis, which included the proportion of urologists who devoted at least 5% of their operative log to laparoscopy, revealed that the rationale for performing laparoscopy was—in order— a faster recovery period, reduced patient morbidity, patient-driven request, and for the research interest (Table 3). Questions 15 and 16 were about hand-assisted laparoscopy. Only 21.2% of urologists who can perform laparoscopy cited that they performed hand-assisted laparoscopy, and only 14.6% of them used the hand-assisted approach as a means of becoming more familiar with urologic laparoscopic techniques.

Depending on the answers of the respondents, we calculated the main laparoscopic cases according to the percent of performing surgeons: Varicocelectomy, 38%; simple nephrectomy, 27%; renal cyst decortications, 23%; adrenalectomy, 20%; radical nephrectomy, 20%; pyeloplasty, 18%; and orchidopexy, 17%.

Discussion

Many laparoscopic procedures, such as radical and simple nephrectomy, donor nephrectomy, and adrenalectomy, have become a technique of choice. ^10,11 Although other reconstructive procedures, such as laparoscopic pyeloplasty and radical prostatectomy, are still performed at some centers, the interest of minimal access surgeons is skewed now toward robot-assisted laparoscopy. We sought to assess the urologic practice patterns among urologists in Saudi Arabia.

It was interesting that there was a higher prevalence of laparoscopic practice than we expected; nonetheless, as we did with ureteroscopy and percutaneous surgery, continued efforts are mandatory to implement more laparoscopic practice in our local residency and fellowship training programs.

Our survey revealed that 21% of urologists performed no laparoscopy, whereas 54.3% devoted at least 5% of their practice time to laparoscopy. Comparative figures were reported from two different studies in 2002 and 2004. The study in California (2002) reported lower figures; 54% of urologists who completed the questionnaire performed no laparoscopy, and only 12% performed a significant amount of laparoscopy. ¹² On the other hand, the survey of urologists in the American Midwest (2004) showed that 49% of respondents performed no laparoscopy at all, and 21% devoted 5% or more of their practice time to laparoscopy. ¹³ Considering the time difference between the current survey and theirs, our figures are promising and encouraging.

The majority of the urologists (73%) believed that they were inadequately trained during residency to perform laparoscopy. Only 27% reported that they had adequate training in laparoscopic surgery during residency; most had their training in North America and Europe. Only a small percentage who trained in a local residency program believed that their training was enough to perform laparoscopy. It is obvious that the high percentage of urologists who have the capability to perform laparoscopy is not related to the fashion of our current local residency training (the Saudi Board of Urology), but it is affected by those who had trained abroad. A survey of urologists concluded that those who had received formal laparoscopic training were more likely to incorporate these techniques in their practice. ¹⁴

In accordance with similar international surveys, the vast majority of laparoscopic urologic procedures were performed by younger urologists and by those who are fewer than 5 years in practice. ^12,13 Those who received no training rely mainly on postgraduate courses and seminars to become acquainted with the new techniques. Our survey indicated that those in academics tended to devote more of their operative time to laparoscopy, because academics are actively interested in learning new techniques, which is important to their academic future.

Although the role of laparoscopic varicocelectomy is still controversial, we found it on the top of the laparoscopic procedures list performed by our urologists, followed, respectively, by simple nephrectomy, cyst decortication, radical nephrectomy, and adrenalectomy. Other procedures, such as radical prostatectomy and pyeloplasty, were at the bottom. We believe that with the rising numbers of published series in robot-assisted laparoscopy, more urologists in Saudi Arabia will be interested in performing reconstructive urologic procedures using minimal access surgery.

Conclusion

Urologic laparoscopic practice patterns in Saudi Arabia are still in early stages. Our urologists must have the enthusiasm to provide their patients with the most updated healthcare. Obviously, it is a matter of training and exposure, as laparoscopic instruments and technology are available in most hospitals in the country. Continued efforts are necessary to incorporate laparoscopy further into the urologic community. Increasing the number of laparoscopic training courses can provide the solution.