The Private Practice Model

Between August 1995 and April 2004, 1092 advanced urologic laparoscopic procedures were performed by a single surgeon in a metropolitan area serving a population greater than three million people. Although these procedures took place in eight different facilities, more than 75% occurred at the same 450-bed hospital in order to simplify reproducibility. Because the early 1990s marked the infancy of modern urologic laparoscopy, no formal training was readily available. However, previous exposure included involvement in approximately 20 pure laparoscopic nephrectomies and various other less demanding laparoscopic procedures during residency training. Although only a small number of procedures were performed in the first year, the volume subsequently grew exponentially as a member of a four-physician group. During the third year, further growth occurred after merging with a large group totaling thirty urologists. However, partner referrals have only comprised between 15% and 40% of total laparo-scopic procedures performed annually. The low proportion of internal referrals reflects initial reluctance to embrace the technology, geographical logistics, increasing outside referrals, and improved laparoscopic skills of the other physicians within the group.

Extreme care was used to balance the difficulty of the procedure with the level of "expertise" at the time. The chief considerations were patient anatomy (e.g., body habitus, previous surgery), comorbid conditions, and complexity of the urologic condition. With time, the indications for laparoscopic management of common urologic disorders expanded widely. Table 1 depicts the variety of patient characteristics. With experience, seemingly challenging endeavors can be overcome. Although various types of

TABLE l ■ Patient Characteristics

Age

1 mo-96 yr

Body mass index

16-52

Largest renal tumor

14 cm

Extra/retroperitoneal

96%

Prostate size

18-166 g

With carefully planned strategies, advanced urologic laparoscopy in a community setting can yield results comparable to major academic centers. The importance of balancing the complexity of procedures with the experience of the surgeon cannot be overemphasized.

TABLE2 ■ Procedure Types

Procedure

Number

Nephrectomy

637

Radical

430

Simple

116

Partial

29

Nephroureterectomy

62

Prostatectomy

202

Pyeloplasty

93

Adrenalectomy

32

Miscellaneous

128

nephrectomy comprise the majority of cases, nearly half of the procedures represent a laparoscopic approach to a multitude of other urologic disorders (Tables 2 and 3).

Pure laparoscopic techniques were employed routinely, with the exception of 12 hand-assisted procedures. Almost 90% of cases were retroperitoneal or extraperi-toneal. This approach was a surgeon preference based on attempts to decrease operative time, decrease patient morbidity, and mimic open surgery (7,8).

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