An Objective Scoring System for Laparoscopic Nephrectomy

Background and Purpose: The current first-line recommended modality for nephrectomy is by the laparoscopic approach. This is one of the most frequent laparoscopic interventions conducted in urology. From a skills acquisition and delivery perspective in minimally invasive urologic surgery, there is a paucity of objective scoring systems for advanced laparoscopic urologic procedures. We developed a system of direct observation with structured criteria to evaluate the surgical conduction of laparoscopic nephrectomy (LN). We tested the application and preliminary validity of the scoring system. Methods: Sixty cases of prerecorded LN performed in four teaching hospitals were each analyzed by four mentors. Each mentor scored each case based on a 100-point scoring systemthat comprised 20 key steps for LN (each step ranging 0 to 5). Steps included port placement and safety checks in addition to the actual case. In addition, a negative marking system based on a 50-point index scoring system was deployed such that technically unsound techniques were penalized. The sum of the two resulted in the final score. The final scores independently submitted for each recorded case were analyzed and compared. The system was then used to predict the experience of a surgeon for 10 pilot cases. The cases included a mix of five fellows and five experienced laparoscopic urologic surgeons. The cases were blinded to the independent assessors. A further 20 cases involving 10 cases performed by a trainee who sufficiently completed training (as deemed by the recent award of a certificate of specialist training in urology) vs one who is not ready were reviewed. Results: There was no significant difference in the scores submitted by each of the four mentors for each of the cases observed. There was a strong correlation between overall score and seniority/experience of the performing surgeon of each case; ie, it was able to predict whether an experienced surgeon or laparoscopic fellow performed the case. It was able to predict accurately between a trainee who sufficiently completed training vs one who is "not ready." Conclusion: The scoring system was a reliable tool for assessing the performance of LN and accurately predicts the level of experience of the surgeon. This system could be a useful supplementary tool for assessing the baseline skill and progress of trainees.