Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery

Ureteral Ligation During Robotic-Assisted Laparoscopic Prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical standard of care for patients with localized prostate cancer. Although uncommon, the procedure involves a potential risk of injury to adjacent anatomical structures. We report on a unique case of iatrogenic ureteral injury during RALP that required subsequent robotic-assisted laparoscopic ureteral reimplantation for definitive repair. A 57-year-old male underwent RALP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA). The procedure was unremarkable and a 20 French Foley catheter was placed with plans for removal after one week following a negative cystogram. On postoperative day two, his creatinine level elevated to 2.69 mg/dL from a baseline of 1.40 mg/dL, left-sided flank pain increased, and non-contrast CT imaging revealed moderate left proximal hydroureteronephrosis and no other abnormalities. Aside from mild nausea on postoperative day one, he had no other symptoms. An integrated stent was unable to be placed by urology at this time. Subsequently, a left percutaneous nephrostomy tube was placed under fluoroscopic guidance. After this intervention, the patient's symptoms improved and the decision was made not to proceed with operative re-exploration at this time to attempt identification of the obstruction. Three weeks later, the patient underwent cystoscopy with attempted left retrograde ureteropyelography and left ureteroscopy due to suspected distal obstruction. This revealed complete obstruction of the intramural portion of the ureter, presumed to be secondary to suture ligation at the time of the vesicourethral anastomosis. Seven weeks postoperatively, the patient underwent robotic-assisted laparoscopic left ureteral reimplantation. Thereafter, the patient had a resolution of his left hydroureteronephrosis and acute kidney injury. This case describes an intravesical ureteral ligation during RALP. An iatrogenic intravesical ureteral ligation has far less guiding literature than a more common ureteral transection. Additionally, ureteral transection is often identified and managed intraoperatively, while the ureteral ligation presented in this case is far less likely to be apparent during surgery. Early identification will allow for rapid reoperation to manage the injury. We hypothesize that during the vesicourethral anastomosis, the left intramural ureter was ligated. Importantly, with the use of a 3-0 V-Loc stitch for the vesicourethral anastomosis, its barbed nature would not facilitate simple surgical removal. In conclusion, when performing RALP, the depth of the bladder-sided vesicourethral anastomotic stitch should be carefully considered to avoid a similar injury.

Diagnostic performance of photodynamic diagnosis with oral 5-aminolevulinic acid for upper tract- and bladder urothelial carcinoma: a single-centre, retrospective analysis

PURPOSE

To compare the diagnostic performance of photodynamic diagnosis (PDD) enhanced with oral 5-aminolaevulinic acid between the suspected upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) cases.

METHODS

This retrospective study included 18 patients with suspected UTUC who underwent ureteroscopy (URS) with oral 5-ALA in the PDD-URS cohort between June 2018 and January 2019; and 110 patients with suspected BUC who underwent transurethral resection of bladder tumour (TURBT) in the PDD-TURBT cohort between January 2019 and March 2023. Sixty-three and 708 biopsy samples were collected during diagnostic URS and TURBT, respectively. The diagnostic accuracy of white light (WL) and PDD in the two cohorts was evaluated, and false PDD-positive samples were pathologically re-evaluated.

RESULTS

The area under the receiver operating characteristic curve (AUC) of PDD was significantly superior to that of WL in both cohorts. The per biopsy sensitivity, specificity, and positive and negative predictive values of PDD in patients in the PDD-URS and PDD-TURBT cohorts were 91.2 vs. 71.4, 75.9 vs. 75.3, 81.6 vs. 66.3, and 88.0 vs. 79.4%, respectively. The PDD-URS cohort exhibited a higher AUC than did the PDD-TURBT cohort (0.84 vs. 0.73). Seven of four false PDD-positive samples (57.1%) in the PDD-URS cohort showed potential precancerous findings compared with eight of 101 (7.9%) in the PDD-TURBT cohort.

CONCLUSION

The diagnostic performance of PDD in the PDD-URS cohort was at least equivalent to that in the PDD-TURBT cohort.

A Comprehensive Overview of Intraoperative Complications during Retzius-Sparing Robot-Assisted Radical Prostatectomy: Single Series from High-Volume Center

BACKGROUND

Intraoperative complications (ICs) are invariably underreported in urological surgery despite the recent endorsement of new classification systems. We aimed to provide a detailed overview of ICs during Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

METHODS

We prospectively collected data from 1891 patients who underwent RS-RARP at a single high-volume European center from January 2010 to December 2022. ICs were collected based on surgery reports and categorized according to the Intraoperative Adverse Incident Classification (EAUiaiC). The quality criteria for accurate and comprehensive reporting of intraoperative adverse events proposed by the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project were fulfilled. To better classify the role of the RS-RARP approach, ICs were classified into anesthesiologic and surgical ICs. Surgical ICs were further divided according to the timing of the complication in RARP-related ICs and ePNLD-related ICs.

RESULTS

Overall, 40 ICs were reported in 40 patients (2.1%). Ten out of thirteen ICARUS criteria were satisfied. According to EAUiaiC grading of ICs, 27 (67.5%), 7 (17.5%), 2 (5%), 2 (5%), and 2 (5%) patients experienced Grade 1, 2, 3, 4A, and 4B, respectively. When we classified the ICs, two cases (5%) were classified as anesthesiologic ICs. Among the 38 surgical ICs, 16 (42%) were ePNLD-related, and 22 (58%) were RARP-related. ICs led to seven (0.37%) post-operative sequelae (four non-permanent and three permanent). Patients who suffered ICs were significantly older (67 years vs. 65 years, p = 0.02) and had a higher median BMI (27.0 vs. 26.1, p = 0.01), but did not differ in terms of comorbidities or tumor characteristics (all p values ≥ 0.05).

CONCLUSIONS

Intraoperative complications during RS-RARP are relatively infrequent, but should not be underestimated. Patients suffering from ICs are older, have a higher body mass index, a higher rate of intraoperative blood transfusion, and a longer length of stay.

Lost Needle During Robot-Assisted Radical Prostatectomy: A Case Report and Literature Review

Laparoscopic or robotic radical prostatectomy and partial nephrectomy require needle suturing and manipulation. Although uncommon, if a needle is lost during laparoscopy, locating and removing it is challenging. Here, we report a case of needle loss during robot-assisted laparoscopic radical prostatectomy (RARP). A 51-year-old patient with localized prostate cancer underwent RARP. After vesicourethral anastomosis using a 3-0 Barbed Suture with two threads connected in the tail, the two threads were held with a needle holder. One needle was lost during removal through a 12 mm trocar. A thorough laparoscopic examination of the abdominal cavity identified a needle attached to the abdominal wall, which was successfully removed. Needle loss is uncommon, but familiarity with handling and preventing such cases helps surgeons address further deterioration. Stepwise and intensive exploration should be performed to confirm the needle location.

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies

BACKGROUND

Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND).

OBJECTIVE

To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers.

SURGICAL PROCEDURE

ONI was identified during PLND and managed according to the type of nerve injury.

RESULTS AND LIMITATIONS

The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction.

CONCLUSIONS

ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae.

PATIENT SUMMARY

We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.

Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience

Introduction

The role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.

Methods

Data of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.

Results

A total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) > 30 kg/m2, Prostate-Specific Antigen (PSA) > 20 ng/mL, PSA density >0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI >30 kg/m2, PSA >20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA >20 ng/mL, prostate volume <30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA >20 ng/mL significantly correlated with overall postoperative complications, while PSA > 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.

Conclusions

eRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

Deep Learning-Based Seminal Vesicle and Vas Deferens Recognition in the Posterior Approach of Robot-Assisted Radical Prostatectomy

OBJECTIVE

To develop a convolutional neural network to recognize the seminal vesicle and vas deferens (SV-VD) in the posterior approach of robot-assisted radical prostatectomy (RARP) and assess the performance of the convolutional neural network model under clinically relevant conditions.

METHODS

Intraoperative videos of robot-assisted radical prostatectomy performed by the posterior approach from 3 institutions were obtained between 2019 and 2020. Using SV-VD dissection videos, semantic segmentation of the seminal vesicle-vas deferens area was performed using a convolutional neural network-based approach. The dataset was split into training and test data in a 10:3 ratio. The average time required by 6 novice urologists to correctly recognize the SV-VD was compared using intraoperative videos with and without segmentation masks generated by the convolutional neural network model, which was evaluated with the test data using the Dice similarity coefficient. Training and test datasets were compared using the Mann-Whitney U-test and chi-square test. Time required to recognize the SV-VD was evaluated using the Mann-Whitney U-test.

RESULTS

From 26 patient videos, 1 040 images were created (520 SV-VD annotated images and 520 SV-VD non-displayed images). The convolutional neural network model had a Dice similarity coefficient value of 0.73 in the test data. Compared with original videos, videos with the generated segmentation mask promoted significantly faster seminal vesicle and vas deferens recognition (P < .001).

CONCLUSION

The convolutional neural network model provides accurate recognition of the SV-VD in the posterior approach RARP, which may be helpful, especially for novice urologists.

The Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project: Development of Criteria for Reporting Adverse Events During Surgical Procedures and Evaluating Their Impact on the Postoperative Course

BACKGROUND

Intraoperative adverse events (iAEs) are surgical and anesthesiologic complications. Despite the availability of grading criteria, iAEs are infrequently reported in the surgical literature and in cases for which iAEs are reported, these events are described with significant heterogeneity.

OBJECTIVE

To develop Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration criteria to standardize the assessment, reporting, and grading of iAEs. The ultimate aim is to improve our understanding of the nature and frequency of iAEs and our ability to counsel patients regarding surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

The present study involved the following steps: (1) collecting criteria for assessing, reporting, and grading of iAEs via a comprehensive umbrella review; (2) collecting additional criteria via a survey of a panel of experienced surgeons (first round of a modified Delphi survey); (3) creating a comprehensive list of reporting criteria; (4) combining criteria acquired in the first two steps; and (5) establishing a consensus on clinical and quality assessment utility as determined in the second round of the Delphi survey.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Panel inter-rater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α.

RESULTS AND LIMITATIONS

The umbrella review led to nine common criteria for assessing, grading, and reporting iAEs, and review of iAE grading systems led to two additional criteria. In the first Delphi round, 35 surgeons responded and two criteria were added. In the second Delphi round, 13 common criteria met the threshold for final guideline inclusion. All 13 criteria achieved the consensus minimum of 70%, with agreement on the usefulness of the criteria for clinical and quality improvement ranging from 74% to 100%. The mean inter-rater agreement was 89.0% for clinical improvement and 88.6% for quality improvement.

CONCLUSIONS

The ICARUS Global Collaboration criteria might aid in identifying important criteria when reporting iAEs, which will support all those involved in patient care and scientific publishing.

PATIENT SUMMARY

We consulted a panel of experienced surgeons to develop a set of guidelines for academic surgeons to follow when publishing surgical studies. The surgeon panel proposed a list of 13 criteria that may improve global understanding of complications during specific procedures and thus improve the ability to counsel patients on surgical risk.

How to reduce the risk of organ injuries during surgical instrument insertion in laparoscopic surgery: Pushing/pressing force analysis using forceps with sensors

INTRODUCTION

In laparoscopic surgery, surgical instruments are inserted from a trocar to the target organ in a blind fashion, which carries a risk of organ injury. To clarify the risks associated with surgical instrument insertion, we measured grip strength and pushing/pressing force during surgical instrument insertion in laparoscopic surgery.

METHODS

Using forceps with sensors inside a trocar, 10 urologists performed a laparoscopic procedure in pigs, in which they were asked to touch the abdominal wall. The surgeons closed their eyes during the procedure and stopped moving the forceps when they felt them come into contact with the abdominal wall. They were ordered to grip the forceps strongly or softly and to move them rapidly or slowly during the procedure. Grip strength and the pushing/pressing force when the forceps hit the abdominal wall were measured and analyzed.

RESULTS

The mean pushing/pressing force when the surgeons gripped the forceps strongly and moved them rapidly (strong/rapid), strongly/slowly, softly/rapidly, and softly/slowly were 2.8, 2.0, 1.7, and 1.1 N, respectively. The pushing/pressing force was significantly greater when the surgeons gripped the forceps strongly, regardless of the forceps speed (P < .001). The pushing/pressing force was significantly greater when the surgeons moved the forceps rapidly, regardless of grip strength (P < .001).

CONCLUSIONS

When surgeons insert laparoscopic instruments through trocars, the instruments should be gripped softly and moved slowly to avoid organ injuries.

Urine leak after robotic radical prostatectomy: not all urine leaks come from the anastomosis

Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.

Detection of adverse events leading to inadvertent injury during laparoscopic cholecystectomy using convolutional neural networks

Uncontrolled movements of laparoscopic instruments can lead to inadvertent injury of adjacent structures. The risk becomes evident when the dissecting instrument is located outside the field of view of the laparoscopic camera. Technical solutions to ensure patient safety are appreciated. The present work evaluated the feasibility of an automated binary classification of laparoscopic image data using Convolutional Neural Networks (CNN) to determine whether the dissecting instrument is located within the laparoscopic image section. A unique record of images was generated from six laparoscopic cholecystectomies in a surgical training environment to configure and train the CNN. By using a temporary version of the neural network, the annotation of the training image files could be automated and accelerated. A combination of oversampling and selective data augmentation was used to enlarge the fully labeled image data set and prevent loss of accuracy due to imbalanced class volumes. Subsequently the same approach was applied to the comprehensive, fully annotated Cholec80 database. The described process led to the generation of extensive and balanced training image data sets. The performance of the CNN-based binary classifiers was evaluated on separate test records from both databases. On our recorded data, an accuracy of 0.88 with regard to the safety-relevant classification was achieved. The subsequent evaluation on the Cholec80 data set yielded an accuracy of 0.84. The presented results demonstrate the feasibility of a binary classification of laparoscopic image data for the detection of adverse events in a surgical training environment using a specifically configured CNN architecture.

Incorporation and validation of clinically relevant performance metrics of simulation (CRPMS) into a novel full-immersion simulation platform for nerve-sparing robot-assisted radical prostatectomy (NS-RARP) utilizing three-dimensional printing and hydrogel casting technology

OBJECTIVES

To incorporate and validate clinically relevant performance metrics of simulation (CRPMS) into a hydrogel model for nerve-sparing robot-assisted radical prostatectomy (NS-RARP).

MATERIALS AND METHODS

Anatomically accurate models of the human pelvis, bladder, prostate, urethra, neurovascular bundle (NVB) and relevant adjacent structures were created from patient MRI by injecting polyvinyl alcohol (PVA) hydrogels into three-dimensionally printed injection molds. The following steps of NS-RARP were simulated: bladder neck dissection; seminal vesicle mobilization; NVB dissection; and urethrovesical anastomosis (UVA). Five experts (caseload >500) and nine novices (caseload <50) completed the simulation. Force applied to the NVB during the dissection was quantified by a novel tension wire sensor system fabricated into the NVB. Post-simulation margin status (assessed by induction of chemiluminescent reaction with fluorescent dye mixed into the prostate PVA) and UVA weathertightness (via a standard 180-mL leak test) were also assessed. Objective scoring, using Global Evaluative Assessment of Robotic Skills (GEARS) and Robotic Anastomosis Competency Evaluation (RACE), was performed by two blinded surgeons. GEARS scores were correlated with forces applied to the NVB, and RACE scores were correlated with UVA leak rates.

RESULTS

The expert group achieved faster task-specific times for nerve-sparing (P = 0.007) and superior surgical margin results (P = 0.011). Nerve forces applied were significantly lower for the expert group with regard to maximum force (P = 0.011), average force (P = 0.011), peak frequency (P = 0.027) and total energy (P = 0.003). Higher force sensitivity (subcategory of GEARS score) and total GEARS score correlated with lower nerve forces (total energy in Joules) applied to NVB during the simulation with a correlation coefficient (r value) of -0.66 (P = 0.019) and -0.87 (P = 0.000), respectively. Both total and force sensitivity GEARS scores were significantly higher in the expert group compared to the novice group (P = 0.003). UVA leak rate highly correlated with total RACE score r value = -0.86 (P = 0.000). Mean RACE scores were also significantly different between novices and experts (P = 0.003).

CONCLUSION

We present a realistic, feedback-driven, full-immersion simulation platform for the development and evaluation of surgical skills pertinent to NS-RARP. The correlation of validated objective metrics (GEARS and RACE) with our CRPMS suggests their application as a novel method for real-time assessment and feedback during robotic surgery training. Further work is required to assess the ability to predict live surgical outcomes.

Training in robotic surgery, replicating the airline industry. How far have we come?

Introduction

As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. We aim to compare current robotic training curricula with training in aviation, to evaluate current similarities and to provide insight into how healthcare can further learn from replicating initiatives in aviation training.

Methods

A systematic literature review of the current evidence was conducted online and relevant publications and information were identified. Evaluation and comparison between training in robotic surgery and the aviation industry was performed.

Results

There are significant similarities between modern robotic training curricula and pilot training. Both undergo basic training before proceeding to advanced training. Aviation training methods include classroom instruction, e-learning and practical training, in both the aircraft and flight simulation training devices. Both surgeon and pilot training include technical and procedural instruction as well as training in non-technical skills such as crisis management, decision making, leadership and communication. However, there is more regulation in aviation, with international standards for training curricula, simulation devices and instructors/trainers that are legally binding. Continuous learning with re-qualification with benchmarked high stakes tests are also mandatory throughout a pilot’s and instructor’s career.

Conclusion

Robotic surgeons and pilots roles have many fundamental similarities. Both work with expensive and complex technology requiring high levels of skills, within working environments with high physiological and psychological stress levels. Whilst many initiatives in aviation training have already been replicated in surgical training there remain considerable differences in regulation. Adopting established and proven aviation methods of assessment and regulation could help robotic surgical training become more efficient, more effective and ultimately safer.

Robotic versus laparoscopic urological surgery: incidence of reoperation and complications

Objective: To report the introduction of minimum invasive surgery in Denmark with focus on the reoperation and complication rates. Materials and methods: Data were prospectively collected at the national UroLap database. The database was established in 2003 in Denmark to register all laparoscopic urological procedures as well as their peri- and post-operative outcomes. In the period from 2009-2014, 10,843 patients were registered with the database, of which 10,546 (97%) had a complete Clavien-Dindo score within the first 30 postoperative days. Results: The mean age of patients was 60.5 years (S.D. = 16.2), and 415 patients (4%) were under the age of 17 years. The male-to-female ratio was 4:1. At the end of 2010, 25% of surgeries used the robotic technique, but the frequency of robotic surgeries increased to 56% in 2014. No complications were reported in 74.6% of the urological procedures. The mortality rate was reported at only 0.27% of all patients. Patients who underwent a urological procedure performed by consultant urologists had a lower rate of complication compared to procedures performed by trainees (p = 0.03) but not staff doctors (p = 0.9). There were no significant differences in complication rates between staff doctors and trainee (p = 0.2). Conclusion: Robotic and laparoscopic urological procedures are associated with low serious complication rates. Postoperative complications were more common among surgeries performed by trainees. The robotic approach is associated with a shorter L.O.S. compared to the laparoscopic approach and linked to lower reoperation rates.

Development of novel force-limiting grasping forceps with a simple mechanism

OBJECTIVES

In endoscopic surgery, fragile tissues may be damaged by the application of excessive force. Thus, we developed novel endoscopic forceps with a simple force-limiting mechanism.

METHODS

The novel forceps were constructed with a leaf spring, and the spring thickness determines grasping pressure. We established an evaluation system (maximum score is 11 points) for lung tissue damage leading to complications. We tested the conventional forceps (186.8 kPa) and 3 novel spring forceps with the following thicknesses: 1.3 mm (53.0 kPa), 2.2 mm (187.7 kPa) and 2.8 mm (369.2 kPa). After grasping, peripheral canine lung tissues were microscopically examined for acute- and late-phase damages.

RESULTS

In the acute phase (20 sites), the novel forceps caused capillary congestion and haemorrhage in the subpleural tissue, whereas the conventional forceps caused deep tissue and pleural damages. In the late phase (30 sites), both forceps caused fibroblast formation and interstitial thickening, which progressed to the deeper tissues as grasping pressure increased. In the acute phase, the median scores were 2.0 and 6.0 for the novel and conventional forceps, respectively (P = 0.003). In the late phase, the median scores were 2.0, 2.5 and 5.0 for 1.3-, 2.2- and 2.8-mm thick forceps, respectively, and 5.0 for the conventional forceps (P < 0.001). In both phases, the novel forceps with grasping pressure set below 187.7 kPa (2.2 mm) caused significantly less lung tissue damage than the conventional forceps.

CONCLUSIONS

The novel endoscopic forceps are able to regulate the tissue-grasping pressure and induce less damage in lung tissues than conventional forceps.

Minimally invasive management of ureteral strictures: a 5-year retrospective study

Introduction

Ureteric strictures are well-documented complications related to surgery or radiation therapy. Minimally invasive treatment using endoscopic dilatation or laser incision is the standard practice. There are no existing guidelines on which techniques to use in the treatment of different stricture types and a paucity of data regarding long-term results.

Purpose

Our study aimed to retrospectively assess the long-term efficacy of minimally invasive treatment in benign and malignant ureteric strictures.

Materials and methods

Over a 5-year period, 2007–2012, we analyzed the data of 59 consecutive patients undergoing minimally invasive treatment for symptomatic ureteric strictures. We excluded 16 patients from final analysis due to failed access or loss to follow-up. All patients but one were treated with antegrade, retrograde balloon or catheter dilatations. Successful outcome was defined as an asymptomatic, completely catheter free patient, with stable renal function.

Results

43 patients were eligible for retrospective final analysis. The largest proportion of strictures occurred following surgery combined with radiotherapy 8/43 (19%). Preoperative decompression was required in 30/43 (70%). We identified 32/43 (75%) balloon dilatations, 10/43 (23%) catheter dilatations and 1/43 (2%) laser incision. Overall success rate was 31/43 (72%). All 6 recurrences occurred within 36 months, 4 within the first 12 months. 3/6 patients were successfully re-dilated.

Conclusion

Minimally invasive treatment is a worthwhile alternative in strictures due to previous radiation and/or surgical treatment of malignancies. Most recurrences occurred within the first year. However, late recurrences arise; therefore, patients should be subject to long-term follow-up. Moreover, re-dilatation may be required.

Needle lost in minimally invasive surgery: management proposal and literature review

The reported incidence of intraoperative retained instruments, such as needles, hangs around 0.06-0.11%. Leaving a needle inside the abdominal cavity can have significant medical and legal consequences. In addition, the retrieval can be hampered due to the limited visualization of the scope during minimally invasive surgery. Factors associated with an increased probability for NL have been described. Prevention for this situation includes: having one needle at a time inside the cavity, effective communication between all personnel in the operating room, evaluation of the strength of the suture-needle connection, avoid parking of needles intraoperatively, and a proper needle withdrawal. Notwithstanding, no agreement has been made regarding NL management. Herein, we present a literature review, and a management proposal in which through a series of systematic steps, the surgical team can efficiently locate and retrieve a lost needle such as: examination of the surgical field, trocar visualization, trocar disassembly, and revision of the suction device. Finally, intraoperative or postoperative imaging can be utilized.

Visceral and gastrointestinal complications in robotic urologic surgery

INTRODUCTION

with the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening.

OBJECTIVES

To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management.

ACQUISITION OF THE EVIDENCE

Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed.

SYNTHESIS OF THE EVIDENCE

Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation.

CONCLUSIONS

Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory.

Complications in robotic urological surgeries and how to avoid them: A systematic review

Objectives

To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues.

Methods

A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it.

Results

In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored.

Conclusions

Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.

Robotic Transnasal Endoscopic Skull Base Surgery: Systematic Review of the Literature and Report of a Novel Prototype for a Hybrid System (Brescia Endoscope Assistant Robotic Holder)

BACKGROUND

Although robotics has already been applied to several surgical fields, available systems are not designed for endoscopic skull base surgery (ESBS). New conception prototypes have been recently described for ESBS. The aim of this study was to provide a systematic literature review of robotics for ESBS and describe a novel prototype developed at the University of Brescia.

METHODS

PubMed and Scopus databases were searched using a combination of terms, including Robotics OR Robot and Surgery OR Otolaryngology OR Skull Base OR Holder. The retrieved papers were analyzed, recording the following features: interface, tools under robotic control, force feedback, safety systems, setup time, and operative time. A novel hybrid robotic system has been developed and tested in a preclinical setting at the University of Brescia, using an industrial manipulator and readily available off-the-shelf components.

RESULTS

A total of 11 robotic prototypes for ESBS were identified. Almost all prototypes present a difficult emergency management as one of the main limits. The Brescia Endoscope Assistant Robotic holder has proven the feasibility of an intuitive robotic movement, using the surgeon's head position: a 6 degree of freedom sensor was used and 2 light sources were added to glasses that were therefore recognized by a commercially available sensor.

CONCLUSIONS

Robotic system prototypes designed for ESBS and reported in the literature still present significant technical limitations. Hybrid robot assistance has a huge potential and might soon be feasible in ESBS.

Incidence of incisional hernia after minimally invasive and open radical prostatectomy: a population-based nationwide study

OBJECTIVE

Minimally invasive techniques (laparoscopic or robot-assisted laparoscopic) are gradually becoming the methods of choice for surgical treatment of prostate cancer. However, the impact of these techniques on the risk of developing incisional hernia has yet to be fully evaluated. The aim of this study was to compare the risk of incisional hernia after open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP).

MATERIALS AND METHODS

From the National Prostate Cancer Register of Sweden, all men who underwent radical prostatectomy for prostate cancer between 2004 and 2013 were identified. These data were linked with the National Patient Register to determine comorbidity and subsequent diagnosis of incisional hernia or surgery for incisional hernia. The endpoint was diagnosis of or surgery for incisional hernia. Multivariate proportional Cox hazard regression analyses were performed to analyze risk factors.

RESULTS

In total, 19,743 men underwent radical prostatectomy during the study period. The cumulative incidence of incisional hernia was 1.4% [95% confidence interval (CI) 1.2-1.7%] and 2.3% (CI 1.9-2.7%) 5 years after ORP and MIRP, respectively (p < .05). For men undergoing ORP, age above the median was associated with increased risk of incisional hernia (p < .001). For men undergoing MIRP, age above the median, prostate volume above the median and lymph-node dissection were associated with increased risk of incisional hernia (p < .05).

CONCLUSION

MIRP is associated with a significantly higher risk of developing an incisional hernia compared to ORP. Awareness of appropriate surgical technique may reduce this risk.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.