“By three methods we may learn wisdom: First by reflection, which is noblest; Second, by imitation, which is easiest; and Third by experience, which is the bitterest.” –Confucius

As surgeons, most of us love to give presentations about the procedures that we perform. We boldly stride to the podium as the lecture hall darkens. The audience falls silent while we confidently set our Power Point® display to presentation mode. And then the magic starts and the images appear. Fifteen feet tall, cropped and color corrected, these high definition beauties and the accompanying discussion leave no doubt whatsoever that we are fully in command of these complex procedures, and offer little room for speculation that there are times when the surgery doesn’t go as presented.

But what about those occasions when our surgeries don’t go as planned? When the tissue planes don’t reveal themselves, exposure is poor, bleeding is profuse or the postoperative results fall short of patient expectations? How can we turn clinical catastrophes into useful lessons that will help others avoid these pitfalls?

Although attending surgical lectures and watching videos where everything “goes right” are important learning opportunities, it can be equally valuable to review cases where things did not go as planned. For decades, NASA, all branches of the U.S. military and performance improvement teams in both medical and industrial settings have demonstrated the critical importance of “debriefing” after an adverse event in order to learn what led to the poor outcome and, more importantly, what can be done to prevent this outcome in the future. By participating in such exercises, participants have been shown to absorb and retain key learning points very efficiently without having to experience the actual events themselves. As Otto von Bismarck bluntly stated: “Fools say that they learn by experience. I prefer to profit by others’ experience.”

The U.S. Army described this process in US Army Training Circular 25-20, September 30, 1993: “An after-action review (AAR) is a professional discussion of an event, focused on performance standards, that enables soldiers to discover for themselves what happened, why it happened, and how to sustain strengths and improve on weaknesses.” A former high-ranking military leader summarized it thus: “If you don’t conduct AARs after each event, you are rolling the dice with each mission thereafter. Dice is 100% a game of chance.”

The use of the AAR, or medical debriefing, has become one of the most powerful tools in clinical quality improvement. The Agency for Healthcare Research and Quality defines the medical debriefing as “a dialogue between two or more people; its goals are to discuss the actions and thought processes involved in a particular patient care situation, encourage reflection on those actions and thought processes, and incorporate improvement into future performance”.

In order to learn from the kind of clinical experiences many providers only encounter in their worst dreams, we asked highly respected urological surgeons from a number of subspecialties to bring us their worst. We wanted to explore the kind of outcomes that wake you up in the middle of the night in a cold sweat. Outcomes that would chill the heart of the most resolute urologist and offer plaintiff attorneys the chance to retire in style. In short, we wanted to know what to do “When Disaster Strikes!”

The urological surgeons listed below answered the call and will be presenting complications related to their areas of clinical expertise. Each of our faculty members would certainly be on a short list of urologists that one would call to help prevent or manage calamities such as these. During their presentations, each speaker will describe the case and its outcome. They will then share teaching points such as identifying procedural, training or system-based factors that may have contributed to the outcome along with preventive strategies to address these factors. Management of the complication will also be addressed, and each member of our faculty will discuss two primary learning points or recommendations for those who attend the session to take home with them.

Faculty and Topic for Discussion:

1. Randall Meacham, MD, University of Colorado School of Medicine, Aurora, Colorado: Moderator.
2. Michael Ferrandino, MD, Duke University School of Medicine, Durham, North Carolina: Ligation of the superior mesenteric artery during robotic radical nephrectomy.
3. Run Wang, MD, University of TexasMcGovern Medical School and MD Anderson Cancer Center, Houston, Texas: Patient that is dissatisfied with penile length and SST deformity following surgery.
4. Evangelos Listsikos, MD, University of Patras, Patras Greece: Subcapsular hematoma following ureteroscopy.
5. Craig Comiter, MD, Stanford University School of Medicine, Palo Alto, California: Urinary incontinence following robot-assisted laparoscopic prostatectomy.
6. Kevin Pranikoff, MD, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York: Death related to urosepsis in a frail, elderly nursing home patient.

We encourage everyone to attend “When Disaster Strikes: Preventing and Managing Nightmares in Urology.” It promises to be a lively, fast-paced session that will send chills down your spine while helping to prevent these nightmares from becoming a reality in your own clinical practice.