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"apellidos" => "Ahmed" "email" => array:1 [ 0 => "Kamran.ahmed@kcl.ac.uk" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "MRC Centre for Transplantation, King's College London, Department of Urology, Guy's and St. Thomas’ NHS Foundation Trust, King's Health Partners, London, United Kingdom" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Urology, East Surrey Hospital, United Kingdom" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Urology, King's College Hospital, London, United Kingdom" "etiqueta" => "c" "identificador" => "aff0020" ] 3 => array:3 [ "entidad" => "Department of Urology, Medway Maritime Hospital, United Kingdom" "etiqueta" => "d" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3624 "Ancho" => 2500 "Tamanyo" => 765248 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">LRN process map.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoscopic radical nephrectomy (LRN) remains a cornerstone in the management of renal tumours and small renal masses where nephron sparing surgery is not possible.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Outcomes are comparable to those of open radical nephrectomy and it is more cost effective than open or robot-assisted methods.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,3</span></a> Thus, LRN is an important procedure to master in order that the benefits of the minimally invasive technique is maximized.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Modern surgical training faces numerous challenges. There has been a rise in the prevalence of litigation against urologists and an increased awareness of factors affecting patient safety within the operating room.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4–6</span></a> Yet although the importance of safe practice and good outcomes is being increasingly recognized, surgeons face reduced training opportunities. Measures including the European Working Time Directive have lessened the hours doctors are to work.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Improved diagnostic technologies, surveillance, and alternative treatments mean that pathologies are identified at an earlier stage and fewer patients require the major surgery that was once the norm. Nonetheless, there is still the expectation to attain equal, if not greater, levels of competence through surgical training.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As a consequence of the aforementioned changes, training must be effective and safe, so that surgeons attain the relevant skills whilst protecting patients and maintaining outcomes. The WHO surgical safety checklist is widely employed in operating rooms as a team approach to augment safety and reduce the incidence of never-events. It was developed following publication of guidelines by the WHO identifying practice that was recommended for improvement in safety of surgical patients.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> The WHO checklist has been associated with significant difference in patient outcomes across the globe. It is logical, therefore, that by ensuring that surgeons are competent in performing steps of a procedure that has previously been identified as “hazardous” surgical outcomes can be optimized. Failure Mode and Effect Analysis is a systematic approach to risk assessment originally developed for use in the manufacturing and aviation industries.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> It has since been utilized in the medical profession (Healthcare Failure Mode and Effect Analysis (HFMEA)) in anaesthetics and prescribing as well as to train urologists in Robot-Assisted Radical Prostatectomy (RARP).<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9–11</span></a> Global rating scales to assess surgeons’ technical laparoscopy skills exist. However, these are generic, non-specific tools, and as yet there are no safety-based assessment tools for use in LRN.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aimed to systematically develop a tool for use in training and assessing surgeons in LRN and validate the developed tool for use by trainee urologists in terms of content validity.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study comprised a prospective, longitudinal, multi-institutional design and was undertaken between September 2014 and June 2015. HFMEA was utilized for the development phase where experts were consulted and procedures observed before constructing the assessment tool. These surgeons were elected based on their operating experience in case volume, complexity, and tutor experience. This was followed by the validation phase where the assessment tool was distributed to five specialists to ensure content validity.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Development</span><p id="par0030" class="elsevierStylePara elsevierViewall">HFMEA was employed in the development of the LRN Assessment Tool as a means of detecting the steps of the procedure most likely to fail due to technical error (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Four expert surgeons were observed in their operating rooms to ensure a multi-institutional approach. The hand-assisted, transperitoneal, and retroperitoneal approaches were all considered. The steps undertaken were used to construct a process map as a visual representation of the operation. Hazard analysis was then undertaken where each step was evaluated to identify failure modes (how a step could fail) and failure mode effects (the consequence of step failure). Multi-institutional hazard analysis then attributed probability and severity scores to each (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Steps of hazard score ≥4 from hazard analysis and single point weaknesses were taken forward for inclusion in the LRN Assessment Tool. “Single point weaknesses” refer to steps where failure will result in system failure and are critical to the integrity of the process.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Validation</span><p id="par0035" class="elsevierStylePara elsevierViewall">Expert opinion supported the content of the checklist and was continuously throughout the development phase of the study, though HFMEA, and thereafter. Five expert urologists and their operating teams were approached for participation. Feedback and constructive criticism were requested on mapping the process to ascertain that the relevant, important steps had not been overlooked. They undertook hazard analysis individually and results were collated and compared with the median score taken as the overall hazard score, determining whether a step warranted inclusion in the assessment tool. The final draft of the LRN Assessment Tool was circulated within the operating teams to confirm content validity; their evaluations were observed and changes made to the LRN Assessment Tool accordingly to create the most authentic educational resource.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">On concluding the development and content validation of the LRN Assessment Tool, it comprised four phases, 17 processes, and 41 sub-processes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Development</span><p id="par0045" class="elsevierStylePara elsevierViewall">Laparoscopic radical nephrectomy was identified as the operation to be evaluated by HFMEA. Given the variety of operating methods available, hand-assisted, trans-peritoneal and retro-peritoneal approaches were all examined. Four surgeons and their operating teams were observed across four hospitals for a total of 19.5<span class="elsevierStyleHsp" style=""></span>h in a range of case complexity and nephrectomy on both sides to achieve content validity (5.75<span class="elsevierStyleHsp" style=""></span>h hand-assisted, 8.75<span class="elsevierStyleHsp" style=""></span>h trans-peritoneal, 5<span class="elsevierStyleHsp" style=""></span>h retro-peritoneal). Following observation, a process map was created (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Given that all three approaches to LRN are characterized by several fundamental, common steps, these were collated into one process map (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). LRN was then divided into four operative phases comprising numerous processes and sub processes according to the operative technique employed (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The map was the basis of hazard analysis which was undertaken for each of the three operative modalities. Steps of hazard score ≥4 and single point weaknesses were included in the LRN Assessment Tool and steps with existing control measures or detectable failure modes were excluded. “Existing control measures” referred to steps where a hazard has previously been identified and action taken to alert or prevent its occurrence. “Detectable failure modes” are those where the hazard is so obvious and readily apparent that a control measure is not required.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">From the results of hazard analysis, three checklists were constructed. Those for hand-assisted LRN and transperitoneal LRN both contained four phases, 20 processes, and 33 sub-processes and that for retroperitoneal LRN contained four phases, 20 processes, and 30 sub-processes (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). These were merged to form one assessment tool with a scoring scale of 1–5 and space to enter patient parameters. The final result was a four phase LRN Assessment Tool with 17 processes and 41 sub-processes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Validation</span><p id="par0055" class="elsevierStylePara elsevierViewall">Multi-institutional, multi-disciplinary expert opinion was sought, involving anaesthetists, nursing staff, OR technicians and surgeons. At various stages of development, input was received and relevant adaptations made accordingly to improve the content validity of the developed assessment tool (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Four surgeons and their operating teams were observed and participated in mapping the LRN process. The map was distributed among five expert surgeons and their teams to form the final product (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Hazard analysis was independently completed by four experts. Use of median hazard score ensured that the steps most likely to endanger patient safety or the integrity of the operation were taken for inclusion in the final LRN Assessment Tool. The final LARN Assessment Tool was re-circulated for further content validation as a means of ascertaining that no critical steps had been overlooked. Surgeons demonstrated and reported different surgical techniques and a requirement for flexibility according to patient parameters and surgeons’ preferences. In recognition of this fact some sub-steps were noted as “optional”, for example “adhesiolysis” or reflection of adjacent anatomical structures. Additionally, a column delineating the level of difficulty of a step as agreed by the expert cohort was included along with the scoring scale and space for patient details to aid in training surgeons in LRN.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All participants were in agreement that the final LRN Assessment Tool included the steps most pertinent to the operation and which trainees must master in their learning.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This prospective, observational, longitudinal, multi-institutional study employed a systematic methodology to the development and validation of a safety-based training and assessment tool for use in LRN (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). HFMEA was followed in the development phase and validation was undertaken as a continuous process to increase content validity. This resulted in the LRN Assessment Tool comprising four phases, 17 processes and 41 sub-processes. With its foundations based on strategic risk analysis, this tool encourages surgeons to focus on the technical skills required to safely perform the most hazardous steps of the operation; those that are most likely to endanger patient safety and result in adverse outcomes.</p><p id="par0080" class="elsevierStylePara elsevierViewall">A multi-disciplinary, multi-institutional approach ascertained that the LRN Assessment Tool contained the steps most important to the integrity of the procedure. Expert opinion is vital in ensuring that assessments measure the relevant domains. This is especially pertinent given the requirement for effective, valid and efficient surgical training strategies in the modern era.</p><p id="par0085" class="elsevierStylePara elsevierViewall">As Lund et al. mention, it is imperative that modular training programmes and curricula have valid assessments available both as a means of evaluating surgical skill and also to ensure the educational impact of the teaching methods.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> To date, there has been no procedure-specific educational tool developed for use in LRN. While simulation models exist and are able to provide feedback on individual performance, there has been nothing to evaluate surgical performance in the operating room.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">13–16</span></a> Enciso et al. describe the efficacy of dry and wet-lab simulation for LRN but there remains a requirement for educational resources to support the transition from simulation to the operating room. The LRN Assessment Tool can be employed in both simulated and real-time settings. This flexibility can allow mentors to score their trainees and plot their acquisition of the technical skills relevant to the operation. This has been done in previous studies, namely with the RARP Assessment Score.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> By this means, individuals can track their improvements. Similarly, senior proctors can evaluate when specific steps have been mastered in a simulated setting and thus when it is safe to move their trainees to performing that step in the operating room. Adopting a modular approach to surgical education can benefit patients and surgeons alike and uptake is increasing, for example for laparoscopic urological training within individual institutions and within the ERUS robotic curriculum.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">During the development phase of the LRN Assessment Tool, it was recognized that surgeons can adopt one of several approaches; hand-assisted, trans-peritoneal or retroperitoneal. All three are widely employed, having advantages and disadvantages, according to surgeons preference and patient parameters.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> There exists an element of skill-transfer between operating techniques with many sub-processes being common to the three approaches to nephrectomy.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Incorporating aspects of each modality into the LRN Assessment Tool which was constructed based on nephrectomies performed on both left and right sides and from a range of case complexities, enables flexibility for trainees and mentors to use the technique most appropriate to the clinical or simulated scenario. This flexibility suggests the tool may also be used to train surgeons in skills that can be utilized in other laparoscopic procedures including pyeloplasty and adrenalectomy.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Within the development and validation of the LRN Assessment Tool, several limitations were encountered. Firstly, the relatively small number of surgeons observed may have narrowed the mapping process and caused other important procedural sub-steps to be omitted from the final product. This was accounted for by ensuring a multi-disciplinary approach. Members of the operating room team will frequently work with several surgeons whose operating was not observed directly but whose variability in surgical technique will have been taken into account by the multi-disciplinary team during validation.</p><p id="par0100" class="elsevierStylePara elsevierViewall">A further limitation is the lack of guidance in the scoring scale; what may be “good” to one mentor might only be “satisfactory” to another. Thus, there is a need to develop a more objective method of describing each score as a means of increasing the reliability and utility of the training tool. Before full use in wider clinical practice, the LRN tool must undergo validation to evaluate its inter-rater and test–test reliability and a pilot study must be undertaken to ascertain its perceived feasibility, acceptability and educational impact.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Finally, the LRN Assessment Score was developed with the view to assess real-time operating as opposed to simulated practice. In order to be used in a simulated environment, full validation of the simulation model would have to be undertaken, as with all simulation models in surgical training.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Future work must be done to ascertain the full validity and reliability of the assessment tool before wider implementation in clinical practice. This is best undertaken at a multi-institutional, international level through a pilot study including a large cohort of trainees or laparoscopic fellows and their mentors. This will allow more thorough analysis of its educational impact and construct validity. Once this has been completed, learning curves for individual sub-processes can be analyzed by following trainees through their practice and plotting the score obtained for any given sub-step against time on a graph. Such details can provide information regarding how much training is required to attain competence in specific steps and guide modular pathways within curricula. Comparison can then be made with learning curves obtained from other procedure-specific assessment tools (such as those for robot assisted radical prostatectomy and partial nephrectomy) to evaluate the transfer of skills between laparoscopic and robot-assisted surgical techniques.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">Laparoscopic radical nephrectomy is an indexed procedure within urology and there exist several different approaches to the operation. Given pressures on surgeons to develop competence in the necessary skill domains while having reduced training time available to them, it is imperative that the efficiency of surgical education is optimized. Effective teaching requires valid and reliable training and assessment tools to be available and utilized to maximize patient safety.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The LRN Assessment Tool was developed with this in mind. Development using HFMEA risk analysis ensured the most hazardous procedural sub-steps were identified for inclusion. Extensive involvement of experts throughout the project ascertained content validity – that is that the important processes had not been overlooked for hand-assisted, trans-peritoneal, or retroperitoneal approaches. The result was a four-phase scoring tool pertaining 17 processes and 41 sub-processes. For full application within curricula, using modular training validation of the assessment through a pilot study must be undertaken. Thereafter, full implementation in both simulated and real operating practice to enable evaluation of the learning curves associated with the procedure may be conducted.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">Financial support was received from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy's &St Thomas’ NHS Foundation Trust in partnership with King's College London and King's College Hospital NHS.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">P.D. acknowledges financial support from the <span class="elsevierStyleItalic">National Institute for Health Research</span> (NIHR) <span class="elsevierStyleItalic">Biomedical Research Centre</span> based at <span class="elsevierStyleItalic">Guy's</span> and <span class="elsevierStyleItalic">St Thomas’ NHS Foundation Trust</span> and <span class="elsevierStyleItalic">King's College London</span>. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the <span class="elsevierStyleItalic">Department of Health</span>. P.D. also acknowledges the support of the <span class="elsevierStyleItalic">MRC Centre for Transplantation, London Deanery, London School of Surgery, GSTT Charity, EU, Vattikuti Foundation</span> and <span class="elsevierStyleItalic">Olympus</span>. P.D., K.A., N.R. acknowledge funding for the SIMULATE project from the <span class="elsevierStyleItalic">Urology Foundation</span> (TUF) and the BAUS. CL, EB, KA and PD acknowledge educational funding from the <span class="elsevierStyleItalic">Royal College of Surgeons of England</span>.</p><p id="par0135" class="elsevierStylePara elsevierViewall">There are no further disclosures from Matin Sferiff, Abhay Rane, Christian Brown nor Shahid Khan.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1050026" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1001049" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1050027" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1001048" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Development" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Validation" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Development" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Validation" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-08" "fechaAceptado" => "2017-10-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1001049" "palabras" => array:5 [ 0 => "Training" 1 => "Assessment" 2 => "Laparoscopy" 3 => "Urology" 4 => "Nephrectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1001048" "palabras" => array:5 [ 0 => "Formación" 1 => "Evaluación" 2 => "Laparoscopia" 3 => "Urología" 4 => "Nefrectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic radical nephrectomy (LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This prospective, longitudinal, multi-institutional study was undertaken from September 2014–June 2015. Healthcare Failure Mode and Effect Analysis was utilized for development and followed by validation where the assessment tool was distributed to five specialists to increase content validity. Four experts were observed as a multi-institutional approach. Hand-assisted, transperitoneal and retroperitoneal approaches were considered.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The LRN Assessment Tool comprised four phases, 17 processes, 41 sub-processes. Four surgeons and operating teams were observed across four hospitals for 19.5<span class="elsevierStyleHsp" style=""></span>h (5.75<span class="elsevierStyleHsp" style=""></span>h hand-assisted, 8.75<span class="elsevierStyleHsp" style=""></span>h trans-peritoneal, 5<span class="elsevierStyleHsp" style=""></span>h retro-peritoneal). After hazard analysis, three checklists were constructed. Those for hand-assisted LRN and transperitoneal LRN contained four phases, 20 processes, 33 sub-processes and that for retroperitoneal LRN contained four phases, 20 processes, 30 sub-processes. These were merged to form one assessment tool. The final result was a four phase LRN Assessment Tool with 17 processes, 41 sub-processes. All participants agreed the final LRN Assessment Tool included pertinent steps.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The LRN Assessment Tool was developed using Healthcare Failure Mode and Effect Analysis risk analysis to ensure hazardous procedural sub-steps were included. Validation ascertained important processes were not overlooked. Full application through a pilot study must be undertaken.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La nefrectomía radical laparoscópica (NRL) es un pilar en el tratamiento del cáncer renal y las pequeñas masas renales. El entrenamiento quirúrgico del siglo XXI enfrenta desafíos, por lo tanto debe ser eficiente y seguro para que los cirujanos logren habilidades relevantes, protegiendo a los pacientes y los resultados operativos. Este estudio tuvo como objetivo desarrollar sistemáticamente una herramienta para capacitación y evaluación en NRL y validar la herramienta desarrollada para su uso por los urólogos en formación.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este estudio prospectivo, longitudinal y multiinstitucional se realizó entre septiembre de 2014 y junio de 2015. Se utilizó el Análisis Modal de Fallos y Efectos de Salud para el desarrollo y luego se validó, donde la herramienta de evaluación se distribuyó a cinco especialistas para aumentar la validez del contenido. Cuatro expertos fueron observados como un enfoque multiinstitucional. Se consideraron los abordajes asistidos por la mano, transperitoneales y retroperitoneales.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La herramienta de evaluación NRL constó de cuatro fases, 17 procesos, 41 subprocesos. Se observaron cuatro cirujanos y equipos operativos en cuatro hospitales durante 19,5 h (5,75<span class="elsevierStyleHsp" style=""></span>h asistidas por la mano, 8,75<span class="elsevierStyleHsp" style=""></span>h transperitoneales, 5<span class="elsevierStyleHsp" style=""></span>h retroperitoneales). Después del análisis de riesgos, se construyeron tres listas de verificación. Las de NRL asistida manualmente y NRL transperitoneal contenían cuatro fases, 20 procesos, 33 subprocesos y la de NRL retroperitoneal contenía cuatro fases, 20 procesos, 30 subprocesos. Estos se fusionaron para formar una herramienta de evaluación. El resultado final fue una herramienta de evaluación de NRL de cuatro fases con 17 procesos, 41 subprocesos. Todos los participantes estuvieron de acuerdo en que la herramienta final de evaluación de NRL incluía los pasos pertinentes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La herramienta de evaluación de NRL se desarrolló utilizando el análisis de riesgos Análisis Modal de Fallos y Efectos de Salud para garantizar que se incluyan los subpasos de procedimientos peligrosos. La validación aseguró que los procesos importantes no fueron pasados por alto. Se debe llevar a cabo una aplicación completa a través de un estudio piloto.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lovegrove C, Bruce E, Raison N, Khan S, Brown C, Rane A, et al. Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica. Actas Urol Esp. 2018;42:396–405.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 1795 "Tamanyo" => 132042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hazard analysis within HFMEA.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4122 "Ancho" => 1883 "Tamanyo" => 904648 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">LRN assessment tool.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3624 "Ancho" => 2500 "Tamanyo" => 765248 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">LRN process map.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1556 "Ancho" => 2500 "Tamanyo" => 298301 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Phases of LRN.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1372 "Ancho" => 2333 "Tamanyo" => 276305 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ensuring content validity at each stage of HFMEA.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFMEA step \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1. Define the topic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2. Assemble the team \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3. Graphically describe the process \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4. Conduct hazard analysis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5. Actions and outcome measures \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Choose subject for analysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Establish a multi-disciplinary team to approach the HFMEA process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Construct a flowchart or process map \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Establish all potential failure modes for each step of the process<br>• Establish severity and probability of potential failure mode<br>• Establish hazard score for each potential failure mode (severity<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>probability)<br>• Identifying single point weaknesses, detectable failure modes and existing control measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Apply protective measure<br>• Appraise protective measure implemented \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Action Applied \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Robot Assisted Partial Nephrectomy (RAPN) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Multi-institutional, multidisciplinary team assembled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Flowchart constructed and circulated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• HFMEA hazard table formed<br>• Circulated among international experts<br>• Individual surgeons undertook hazard analysis<br>• Median value chosen as hazard score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Steps of hazard score ≥4 included in RAPN training tool<br>• Inclusion of single point weaknesses<br>• Exclusion of “detectable failure modes” and “existing control measures” \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1784179.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">HFMEA applied to LRN.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p>" ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Processes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sub-processes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Failure modes \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Hand-assisted LRN</td><td class="td" title="table-entry " align="left" valign="top">Preparation of operative field \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exposure of surgical plane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dissection and ligation of hilar structures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Finalizing and closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Trans-peritoneal LRN</td><td class="td" title="table-entry " align="left" valign="top">Preparation of operative field \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exposure of surgical plane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dissection and ligation of hilar structures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Finalizing and closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Retro-peritoneal LRN</td><td class="td" title="table-entry " align="left" valign="top">Preparation of operative field \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exposure of surgical plane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dissection and ligation of hilar structures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Finalizing and closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1784178.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Breakdown of LRN phases to be evaluated by HFMEA.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A critical analysis of the actual role of minimally invasive surgery and active surveillance for kidney cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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Original article
Development and validation of a training and assessment tool for laparoscopic radical nephrectomy
Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica
C. Lovegrovea, E. Brucea, N. Raisona, S. Khanb, C. Brownc, A. Raneb, M. Sheriffd, P. Dasguptaa, K. Ahmeda,
Corresponding author
a MRC Centre for Transplantation, King's College London, Department of Urology, Guy's and St. Thomas’ NHS Foundation Trust, King's Health Partners, London, United Kingdom
b Department of Urology, East Surrey Hospital, United Kingdom
c Department of Urology, King's College Hospital, London, United Kingdom
d Department of Urology, Medway Maritime Hospital, United Kingdom