although great enthusiasm exists for developing skills in laparoscopic urology in the united kingdom , training opportunities are limited .
this is primarily due to a lack of approved urology / laparoscopy fellowships , as exist in the united states .
it is an unfortunate fact that many interested urologists do not progress beyond the initial courses stage and indeed a number of urologists who have attended animal laboratory training as well have not proceeded to regular urological laparoscopic practice .
fellowship , enabling supervised training so that interested urologists could become comfortable and competent with laparoscopic urology .
the fellowship program is available to those who have completed the 2 initial training steps , ie , basic / advanced training courses and an animal laboratory course .
prior practice on simulators using laparoscopic instruments is encouraged to enable the trainees to get the most out of their time spent with the mentor in the clinical setting .
basic training is centered on the development of familiarity with the safe handling of laparoscopic instrumentation and stereoscopic skills in the dry laboratory setting .
advanced training involves a series of formal lectures followed by practice sessions in the animal laboratory ; attendees are also shown live surgery via video links .
skills training is assessed by the mentor in these phases by objectively marking the achievement of various predetermined parameters that evaluate safe acquisition of laparoscopic skills like clipping and suturing .
the fellowship program steps are broadly similar thereafter , but individual variations may occur , depending on the distance that the trainee has to travel and availability of the mentor .
an honorary contract is raised for the trainee at the mentor hospital ; the trainee then observes the mentor perform 4 or 5 laparoscopic renal procedures and may assist with the same by acting as the camera driver for these cases .
if possible , trainees then refer cases suitable for laparoscopic surgery to the mentor ; this helps gestate the necessary workload .
the first 4 cases that are performed by the trainee are usually hand - assisted simple or radical nephrectomies , and the aim is to perform at least a case a week at a dedicated theater session with the possibility of adding in more cases as appropriate .
the trainee then goes on to perform conventional laparoscopic cases , again under mentor supervision , with the mentor initially acting as camera driver .
this program duration varies but is approximately 4 to 5 months , primarily due to the paucity of clinical material available in any one unit at a time , and secondly , to fit in with other work commitments .
mentors are then awarded an honorary contract at the trainees ' hospital to supervise the trainees during their first few cases therein .
trainees schedule simple cases initially and gradually increase the level of difficulty as their skills and confidence improve .
six of them are in independent laparoscopic urological practice , and the others are in phase 6 or above .
trainee one started this program in september 2000 and observed 4 simple nephrectomies and 1 radical nephrectomy before proceeding to phase 6 .
because of the distance involved , the mentor condensed stages 4 and 5 and performed 12 cases with the trainee at the trainee 's hospital before the trainee entered independent practice . since then , he has performed 14 unsupervised laparoscopic urological procedures .
trainee two started the program in may 2001 and has performed 10 procedures with the mentor ; he was fortunate to obtain further hands - on training abroad , which helped shorten his training .
trainee three , four , five , and six started the program in may 2002 and performed 10 procedures each with the mentor , before commencing unsupervised practice .
trainees seven , eight , and nine are making steady progress , currently performing hand - assisted procedures with the mentor who is offering support and advice without actually being scrubbed in for the procedure .
it is anticipated that over the next few months trainees seven , eight , and nine will adopt independent practice .
skills development in all cases was steady , with a progressive increase in dexterity and improvement in spatial orientation .
for the neophyte laparoscopist , it is indeed a great leap of faith that has to be taken from the animal laboratory to the human arena ; we perceive the main stumbling block to be a lack of direct mentor / trainee supervision .
this program was designed to allow skill and confidence building under the direct supervision and guidance of experienced laparoscopic urologists , as initially suggested by shalhav . in effect , this reduces the conversion rate and complications that otherwise could be a major issue ; therefore , the transition to independent urological practice appears to be smoother .
we also believe that the selective use of hand assistance early in the program helps build confidence and aids in development of 3-dimensional spatial orientation ; secondly , the ability to directly apply digital pressure exists in case of unexpected vascular injury .
once trainees are facile with hand - assisted laparoscopic practice , they are then encouraged to move on towards pure laparoscopic and retroperitoneoscopic procedures ; all trainees agreed that the initial phase helped them make the transition more easily .
the case load at one particular hospital may not be enough to enable concentrated dissemination of laparoscopic skills . as a result ,
sometimes trainees have had to spend up to 4 weeks on occasion without performing a single laparoscopic case ; this in turn has a bearing on the length of the fellowship program .
it is not easy to put a finite number onto the number of mentored cases that would have to be performed by trainees before proceeding to independent practice because this appears to depend on innate skills , but 10 cases would seem to approximate an acceptable mean .
some trainees have had to forfeit other obligations for the duration of the fellowship , which they could not have done without support from their colleagues and the management in their respective hospitals .
we acknowledge unstinting support from anaesthetic colleagues , given the fact that anaesthetic / procedure time needs to be acceptable ; this has obviously not always been the case when a new trainee joins the fellowship program .
this program seeks to help safely relocate the teaching of laparoscopy from the lecture hall and animal laboratory to the clinical setting , and , in doing so , we hope to accelerate the training of interested , qualified urologists over the next few years . residents and fellows are being trained in laparoscopic urology now ; as a result , this fellowship may be phased out in the future ; until this noticeable lacuna in training is filled , we would wish to continue to offer this training to interested consultant urologists .
a one - on - one fellowship program enables rapid , safe , and effective laparoscopic skills acquisition by established urologists .
 objectives : a fellowship training model in laparoscopic urological surgery has been established for interested urologists to help them proceed from the pelvic trainer/ animal laboratory environment to safe clinical practice . 
 the objective of the model is to provide trainees with clinical experience under direct mentor supervision before embarking on independent laparoscopic urological surgery at their own base hospitals.methods:the fellowship model incorporates 9 fluid phases : phase 1 to complete basic and advanced training courses . 
 phase 2 to practice at home or in the office using pelvic trainers . 
 phase 3 to proceed to an animal laboratory course . 
 phase 4 to visit centers of international repute to observe high - volume laparoscopic urology . 
 phase 5 to observe the mentor perform several major renal laparoscopic cases . 
 phase 6 to perform several hand - assisted renal procedures under direct mentor guidance at the mentor hospital . 
 phase 7 to perform several laparoscopic or retroperitoneoscopic renal procedures , or both , under direct mentor guidance at the mentor hospital . 
 phase 8 to mentor assisted trainees to start laparoscopic surgery at their own hospitals . 
 phase 9 to practice laparoscopic urology independently.results:so far , 9 trainees have participated in the fellowship . 
 six have reached phase 9 with independent practice , 2 others are in phase 8 , and 1 is in phase 7 . 
 skills development has been steady , with progressive acquisition of surgical dexterity and spatial orientation.conclusion:this fluid fellowship model provides urologists with clinically applicable teaching experience to learn a relatively new surgical concept safely and effectively , thereby promoting clinical governance . it may be possible for other centers to establish similar fluid  mini  fellowships to help disseminate laparoscopic surgical skills . 