Intraoperative Online Telementoring—Redefining Surgical Education in the Philippines Amidst the Pandemic

The COVID-19 pandemic presented a major challenge to not only health care centers around the world but also to institutions with residency training programs. Training took a hit, and the learning curves became steeper. Reconstructive surgery requires a high level of skill and training via repetition. Traditionally, to gain the capability of conducting these surgeries, fellows must train at high-volume centers abroad. Adaptation techniques in the form of virtual conferences, online courses and intraoperative telementoring were utilized to maintain a high standard of care. To our knowledge, this is the first reported case in the Philippines wherein intraoperative telementoring was utilized in order for a surgeon to remotely teach novel techniques in real time.

A 27-year-old male had a urethral injury and scrotal laceration secondary to a vehicular crash 6 months prior to his consultation. Upon the initial cystoscopic evaluation, he had a partial tear (40%) of the distal urethra, which was managed with an indwelling catheter for 1 month. At 3 months follow-up, the patient developed a poor urinary stream, which progressed to retention. Upon a retrograde urethrogram and voiding cystourethrogram, a 1 cm stricture was noted, with a 75% luminal obstruction, at the area of the fossa navicularis. The Q-max was 6 mL/min with >50% retention upon post-void ultrasound studies. At the operating theatre, three cameras were used to show the surgical field, operating room and another for the direct communication with the surgeons. The surgery was performed at East Avenue Medical Center, Philippines, with real-time guidance from the surgical innovator Dr. Dmitriy Nikolavsky from SUNY Upstate Medical University, New York, NY, USA. A transurethral ventral buccal mucosal graft inlay method was performed by the onsite surgeons.

Intraoperatively, the remote surgeon was able to guide and instruct the onsite surgeons with minimal difficulty (Figure 1). All the intraoperative issues were addressed in real time. The remote surgeon had a clear view of the operative field and was able to virtually scrub in from start to finish. The patient was discharged on the second post-operative day after an unremarkable stay in the wards. The indwelling urethral catheter was removed after one week, and the patient was noted to void freely with no difficulty. A standard post-operative follow-up was performed at 0-, 3- and 6-month intervals. A repeat voiding cystourethrogram was performed showing no narrowing at the prior stricture site. The uroflowmetry conducted at 3 months showed a Q-max of 21 mL/s with no residual urine. The LUTS symptom scoring was at 3, and an IIEF-5 score of 25 was documented at the 6-month follow-up.

Urology residency training was critically affected by the COVID-19 pandemic. With the massive deferral of non-emergent cases, there was a decrease in the surgical activities among urology residents [1,2].

Due to the nuances of learning a new surgical technique, mentoring by an experienced surgeon is necessary. There are several subclassifications of telemedicine, namely telementoring, teleproctoring, telesurgery and teleassistance [3]. With the use of telementoring, specifically teleproctoring, real-time guidance can be achieved despite the physical distance between the mentor and the mentee. As long as there is proper visualization of the surgical field, which includes arrangements for multiple viewpoints, the mentor is able to teach the mentee just as if they were standing side-by-side together in the operating theatre. Of course, high-definition cameras, stable tripods and a good internet connection are mandatory.

Performing a new reconstructive technique with no prior training is challenging, but adapting through real-time intraoperative guidance and pre-operative virtual conference discussion makes it feasible and safe [4]. With the global crisis making things less ideal, traditional learning has shifted to virtual courses and telementoring [1,2]. This can improve the intraoperative decision making and boost the surgeon’s confidence to overcome a steeper learning curve while maintaining a high standard of care, as demonstrated in our post-operative follow-up.