Stesura Seveso 371Archivio Italiano di Urologia e Andrologia 2022; 94, 3 LETTER TO EDITOR No conflict of interest declared. Submitted 3 July 2022; Accepted 9 July 2022 To the Editor, Good surgical training is essential for the formation of excellent surgeons, consequently providing the best possible care for our patients in the future. Considering the increase in surgeon shortage over the last two decades (1, 2) (estimated between 14,300 and 23,400 by the year 2032 only in the US) (3), it is important for filling the national health system's needs as well. Finally, respectable surgical training will allow preservation of residency programs by annually attracting more and more new candidates. Every country has its' own structure of surgical training, and it differs immensely between states, sometimes even with- in the same country (4). In recent years, several issues were raised regarding inadequacy of surgical training in some of the most developed coun- tries (5). Resident-directed surveys, done primarily in Italy, Spain and Germany, evaluating urological training in partic- ular, revealed a lot of training-related concerns such as residents' low exposure to major surgeries and a lack of their active participation during them (4-10). Reasons for this trend might be multiple, starting from the administrative work over- load, increasing medico-legal assessments and lawsuits, development of the new, high-tech devices that do not allow both mentor and trainee working simultaneously (e.g. single-console robotic systems and novel laser techniques) and neo-spe- cialists still in learning curve. Although we have training centers with simulators dedicated to resolving these issues, con- cerns such as poor understanding of the skill-retention, possibility of the skill decay and scarce evidence about simula- tors improving clinical outcomes are often discussed (11, 12). As if that was not enough, a significant reduction in elective procedures occurred during the COVID-19 pandemic. This has had a huge impact on surgical activity and residents, with 50% reduction in procedures with them as primary surgeons (13- 15). Furthermore, the reality of many residents is a lack of time they can dedicate to simulators at their disposal (4). So, can this be mediated? What are the questions we are frequently asking our residents and ourselves? What are the most important skills a surgeon should possess before stepping in the OR? A good base of the surgical anatomy, familiarity with dif- ferent organ tissues, textures and resistances as well as proficiency in various methods of suturing and knot-tying. Although residents have access to a lot of learning material (e.g. recordings of the operations) that might help improving their knowledge about surgical anatomy, it does not provide any practical training nor tactile experience. In some centers, residents have access to simulators or, in other cases where they do not, tutorials on how to build your own, low-cost training models1 (6, 17) are available. Unfortunately, they often do not reproduce truthfully the real-life tissue consistencies. Further, programs that offer training on the cadaveric models are also available (18, 20). The major problems with cadav- eric models are firstly, the availability of them, secondly, they are expensive, and lastly, but maybe the most importantly, the ceased circulation, low temperature and electrolytic imbalances alter organs. So, in the end, even cadaveric models are not able to faithfully reproduce the real-life medical procedures. Now, if we do not teach young surgeons today, we will not have any surgeons, or at least not capable surgeons, tomor- row, so these issues need to be addressed as soon as possible. In addition, Italy is facing yet another challenge considering that, a few years back, EPAteam (national association for liver transplant patients) predicted shortage of transplant surgeons (21) and availability to harvest organs at late night hours. All in all, we are in a desperate need of better surgical training and in a serious need of (transplant) surgeons. One must wonder, couldn't we simply involve surgical residents in organ harvesting as a mandatory structured program during the first two years of their training? Instead of two transplant surgeons, organs could be harvested (and transplanted for that matter) by one transplant surgeon and one trainee or, even, by two senior supervised trainees. Why should we use cadav- eric models if we have access to a living body? Could this be a win-win solution? Simply, it seems a nearly perfect answer to all of our problems: surgical anatomy can be mastered very well and quite Organ harvesting as a mandatory training step of all PGY1 and PGY2 surgical residents Rafaela Malinaric 1, 2, Guglielmo Mantica 1-3, Carlo Terrone 1, 2 1 Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy; 2 Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; 3 European Society of Residents in Urology (ESRU), Arnhem, The Netherlands. DOI: 10.4081/aiua.2022.3.371 Archivio Italiano di Urologia e Andrologia 2022; 94, 3 R. Malinaric, G. Mantica, C. Terrone 372 quickly, novices could become more acquainted with organ structures, connections and textures as well as learning how to manipulate various organs without creating too much damage. Moreover, during arterial or venous graft harvesting and abdominal wall closure residents could practice various types of knot-tying and improve their knowledge about suture materials, suture size, and the components of the surgical needle. The major pitfall of this proposal is the fact that not all training-centers have transplant programs. But how many surgi- cal residency programs already include rotations in other departments or hospitals? So, couldn't this principle simply be applied to here-proposed organ-harvesting program? This would provide both, better education for the residents and could help greatly our transplant teams. It would mean night hours, and some training programs do not allow or sim- ply do not encourage them, but this rotation could have only a three to four months duration. Of course, this is just an idea that needs furnishing, thought, elaborated and structured plan, but surely worthwhile con- sidering, at least for a discussion. REFERENCES 1. Stringer B, et al. Trouble on the horizon: an evaluation of the general surgeon shortage in rural and frontier counties. Am Surg. 2020; 86:76-78. 2.Van Way CW Jr. Is there a surgeon shortage? Mo Med. 2010; 107:309-12. 3. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. 4. Carrion DM et al. Current status of urology surgical training in Europe: an ESRU-ESU-ESUT collaborative study World J Urol. 2020; 38:239-246. 5. Mattar SG, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors Ann Surg. 2013; 258:440-449. 6. Borgmann H, Arnold HK, Meyer CP, et al. Training, research, and working conditions for urology residents in Germany: a contemporary sur- vey. Eur Urol Focus. 2018; 4:455-460. 7. Rodríguez-Socarrás ME, et al. Medical-surgical activity and the current state of training of urology residents in Spain: results of a national survey' Actas Urol Esp. 41:391-399. 8. Mantica G, Chierigo F, Gallo F; Italian Residents Association of the Italian Urology Association Study Group. Patients' perceptions of quality of care delivery by urology residents: A nationwide study. BJU Int. 2022. doi: 10.1111/bju.15768. 9. Almannie R, et al. Exposure of Urology residents to the management of urethral strictures in Saudi Arabia: should the program for postgrad- uates be customized? Res Rep Urol. 2020; 12:367-372. 10. Aslam AU, Philipraj J, Jaffrey S, Buchholz N. A global snapshot of endourology residency training. Arch Ital Urol Androl. 2020; 92:219-229. 11. Stefanidis D, et al. Simulation in surgery what’s needed next?' Ann Surg. 2015; 261:846-53. 12. Kozan AA, Chan LH, Biyani CS. Current status of simulation training in urology: a non-systematic review. Res Rep Urol. 2020; 12:111-128. 13. Joint Committee of Surgical Training, Association of Surgeons in Training, British Orthopaedics Trainees’ Association, Confederation of Postgraduate Schools of Surgery. Maximising training: making the most of every training opportunity. 2021. https://www.jcst.org/key-documents/. 14. Coleman JR, Abdelsattar JM, Glocker RJ. RAS-ACS COVID-19 Task Force. COVID-19 pandemic and the lived experience of surgical resi- dents, fellows, and early-career surgeons in the American College of Surgeons. J Am Coll Surg. 2021; 232:119-135.e20. 15. Mantica G, et al. The TOMATO model. Urology. 2021; 157:280-281; 16. Leonardi R, Bellinzoni P, Broglia L, et al. Hospital care in Departments defined as COVID-free: A proposal for a safe hospitalization pro- tecting healthcare professionals and patients not affected by COVID-19. Arch Ital Urol Androl. 2020; 92:67-72. 17. Soriero D, et al. 'Development and validation of a homemade, low-cost laparoscopic simulator for resident surgeons (LABOT)' Int J Environ Res Public Health. 2020; 17:323. 18. Huri E, et al. The novel laparoscopic training 3D model in urology with surgical anatomic remarks: Fresh-frozen cadaveric tissue' Turk J Urol. 2016; 42:224-229. 19. Mantica G, Leonardi R, Diaz R. CACTUS group. Reporting ChAracteristics of cadaver training and sUrgical studies: The CACTUS guide- lines. Int J Surg. 2022; 101:106619. 20. Mantica G, Pini G, De Marchi D, et al. Intensive simulation training on urological mini-invasive procedures using Thiel-embalmed cadav- ers: The IAMSurgery experience. Arch Ital Urol Androl. 2020; 92:93-96. 21. https://www.repubblica.it/salute/medicina-e-ricerca/2019/02/21/news/15mila_trapianti_di_fegato_nei_prossimi_10_anni_ma_mancheran- no_i_chirurghi-219733589/ Correspondence Rafaela Malinaric, MD (Corresponding Author) rafaela.malinaric@gmail.com San Martino Hospital, University of Genoa, Genoa, Italy Guglielmo Mantica, MD guglielmo.mantica@gmail.com Carlo Terrone, MD carlo.terrone@med.uniupo.it