The learning curve for laparoscopic radical prostatectomy: an international multicenter study

Creation of a Prototype Cochlear Training Model

OBJECTIVE

Creation of a novel 3D-printed physical cochlear model that demonstrated the feasibility of creating the model, and impact of a Graphical User Interface (GUI) system on training insertion metrics.

STUDY DESIGN

Feasibility study with a pilot prospective data collection.

SETTING

Tertiary academic center.

METHODS

The study was IRB exempt. Five resident trainees (PGY1-PGY5) practiced electrode insertions in cadaveric temporal bones before using the simulator. Nine students were educated on how to hold the electrodes and position them, and then allowed to use the simulator. All trainees were instructed that slower insertions were favorable. One cochlear implant (CI) surgeon used the simulator. The GUI captured the real video feed, but also provided distance, trajectory, and velocity measurements. The program is designed to plot the real-time depth of insertion and speed of insertion of the electrode; the user is also provided real-time occurrence of any kinks and back-outs.

RESULTS

A total of 14 trainees and 1 CI surgeon inserted the electrode at least 5 times without the use of the GUI (before) and then at least 5 times with the use of the GUI (after). Average Speed before and after (100.84 and 53.23 mm/s); Average minimum speed before and after (59.34 and 9.65 mm/s); and Average maximum speed before and after (416 and 285.81 mm/s). Statistically significant improvements were noted in all the measured speeds of insertion (P < .001). The other variables improved but not to a statistical significance.

CONCLUSIONS

Real-time training using the 3D-printed model and GUI for cochlear implantation can help improve surgical resident training and comfort levels with electrode insertion for surgical trainees. The advantage of this model is that surgeons/trainees can use it as many times as they like, as the whole set-up is easy, economical, and reusable. The real time graphical user interface enhances training and retention of the practiced skills.

Improved early continence following laparoscopic radical prostatectomy: the urethral hammock technique

PURPOSE

To introduce and illustrate a novel urethral reconstruction technique-the 'urethral hammock-technique'-and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP).

METHODS

119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant.

RESULTS

Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13-0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12-0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27-1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05).

CONCLUSIONS

The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Robot-Assisted Laparoscopic Prostatectomy Experience and Pathological Quality: Are They Always Linked?

Objective: We investigated whether pathological outcomes improved with experience and surgeon generation after robot-assisted laparoscopic prostatectomy (RALP). Materials and Methods: The study included 1338 patients who underwent RALP between February 2010 and April 2020. We created learning curves for pelvic lymph node dissection (PLND), number of lymph nodes (LNs) removed, and positive surgical margin (PSM) after adjustment for confounders. We compared the outcomes between the first and second generation of surgeons in regression models. Results: The learning curve regarding PLND indications showed a significant increase with experience for the first generation, whereas the second generation had a learning curve that remained flat at a higher level (92.3%) and significantly better than the first generation (p < 0.001). Similarly, the number of LN removed showed a significant increase with experience in both generations, but the overall median number of LN removed was significantly higher in the second generation compared with the first generation (12 vs 10, p < 0.001). However, the learning curve for PSM remained flat at ∼20% after adjustment and did not show improvement with experience in both generations of surgeons (p = 0.794). Conclusions: Surgeons showed improvement with experience and education with RALP with respect to the indications for PLND and number of LNs removed. However, there was no improvement over time and generations for PSM. Experience based solely on the number of patients operated on is not an intrinsic factor in the pathological quality of RALP. Factors other than experience may also play a role in oncologic improvement.

Learning Curve of Laparoscopic Gastrectomy: A Multicenter Study

OBJECTIVE

To evaluate the learning curve of laparoscopic gastrectomy (LG) after an implementation program.

BACKGROUND

Although LG is increasingly being performed worldwide, little is known about the learning curve.

METHODS

Consecutive patients who underwent elective LG for gastric adenocarcinoma with curative intent in each of the 5 highest-volume centers in the Netherlands were enrolled. Generalized additive models and a 2-piece model with a break point were used to determine the learning curve length. Analyses were corrected for casemix and were performed for LG and for the subgroups distal gastrectomy (LDG) and total gastrectomy (LTG). The learning curve effect was assessed for (1) anastomotic leakage; and (2) the occurrence of postoperative complications, conversions to open surgery, and short-term oncological parameters.

RESULTS

In total 540 patients were included for analysis, 108 patients from each center; 268 patients underwent LDG and 272 underwent LTG. First, for LG, no learning effect regarding anastomotic leakage could be identified: the rate of anastomotic leakage initially increased, then reached a plateau after 36 cases at 10% anastomotic leakage. Second, the level of overall complications reached a plateau after 20 cases, at 38% overall complications, and at 5% conversions. For both LDG and LTG, each considered separately, fluctuations in secondary outcomes and anastomotic leakage followed fluctuations in casemix.

CONCLUSION

On the basis of our study of the first 108 procedures of LG in 5 high-volume centers with well-trained surgeons, no learning curve effect could be identified regarding anastomotic leakage. A learning curve effect was found with respect to overall complications and conversion rate.

Do Skills Naturally Transfer Between Multiport and Single-Port Robotic Platforms? A Comparative Study in a Simulated Environment

Introduction and Objective: With introduction of the da Vinci single-port (SP) system, we evaluated which multiport (MP) robotic skills are naturally transferable to the SP platform. Methods: Three groups of urologists: Group 1 (5 inexperienced in MP and SP), Group 2 (5 experienced in MP without SP experience), and Group 3 (2 experienced in both MP and SP) were recruited to complete a validated urethrovesical anastomosis simulation using MP followed by SP robots. Performance was graded using both GEARS and RACE scales. Subjective cognitive load measurements (Surg-TLX and difficulty ratings [/20] of instrument collisions camera and EndoWrist movement) were collected. Results: GEARS and RACE scores for Groups 1 and 3 were maintained on switching from MP to SP (Group 3 scored significantly higher on both systems). Surg-TLX and difficulty scores were also maintained for both groups on switching from MP and SP except for a significant increase in SP camera movement (+7.2, p = 0.03) in Group 1 compared to Group 3 that maintained low scores on both. Group 2 demonstrated significant lower GEARS (-2.9, p = 0.047) and RACE (-5.1, p = 0.011) scores on SP vs MP. On subanalysis, GEARS subscores for force sensitivity and robotic control (-0.7, p = 0.04; -0.9, p = 0.02) and RACE subscores for needle entry, needle driving, and tissue approximation (-0.9, p = 0.01; -1.0, p = 0.02; -1.0, p < 0.01) significantly decreased. GEARS (depth perception, bimanual dexterity, and efficiency) and RACE subscores (needle positioning and suture placement) were maintained. All participants scored significantly lower in knot tying on the SP robot (-1.0, p = 0.03; -1.2, p = 0.02, respectively). Group 2 reported higher Surg-TLX (+13 pts, p = 0.015) and difficulty ratings on SP vs MP (+11.8, p < 0.01; +13.6, p < 0.01; +14 pts, p < 0.01). Conclusions: The partial skill transference across robots raises the question regarding SP-specific training for urologists proficient in MP. Novices maintained difficulty scores and cognitive load across platforms, suggesting that concurrent SP and MP training may be preferred.

LAPAROSCOPIC RADICAL PROSTATECTOMY: SINGLE CENTER CASE SERIES

Laparoscopic radical prostatectomy (LRP) is traditionally characterized as a technically difficult procedure with a long learning curve but it is successfully performed worldwide. The aim of this paper was to assess the initial learning curve and clinical outcomes for LRP in our center. We performed a retrospective study including 63 LRP cases, in the course of 22 months, performed by 2 urologists, with no previous LRP experience. All patients were previously assessed by a multidisciplinary team and were selected on the basis of low and intermediate risk disease attributes according to the classification of prostate cancer risk groups of the European Association of Urology. The main outcomes of follow-up are procedure duration, estimated blood loss, complications, positive surgical margins, biochemical relapse and urinary continence. The median follow-up was 19.6 months. The median procedure duration was 196.8 minutes and median blood loss 257.1 mL. Significant decrease in both outcomes was observed when comparing first and last cases in the series. There were 5 (7.9%) Clavien Dindo grade II complications. Undetectable prostate specific antigen (PSA) was observed in 59 (93.6%) patients, and fifty-five patients (87.3%) were continent. Following a methodical learning approach, LRP can be safely mastered with favorable outcomes.

Versatility of 3D laproscopy for radical prostatectomy: A single tertiary cancer center experience

Objective

The objective of this study is to compare our institutional outcomes of 3D laparoscopic when compared with open radical prostatectomy in terms of functional and oncological outcomes.

Methods

This is a retrospective study of patients who underwent radical prostatectomy during the period January 2016 to September 2019 at our institute. Out of 49 patients who underwent radical prostatectomy, 23 were done by open approach and 25 were operated by 3D laparoscopy. One patient was lost to follow-up and was excluded from the study. Data were collected from medical records, and functional evaluation was done by telephonic interview. Data analysis was done by SPSS software to calculate overall and disease-free survival.

Results

Laparoscopic arm patients had lesser blood loss, postoperative pain, hospital stay and wound-related issues although they had a longer operating time. Functional outcomes in terms of erectile dysfunction and incontinence were almost similar in both open and 3D laparoscopic approach. No statistically significant difference was observed for overall survival or disease-free survival. All shortcomings with the laparoscopic arm were improved as our experience increased with 3D laparoscopic prostatectomy. The outcomes of 3D laparoscopic radical prostatectomy were comparable to previously published data of robotic radical prostatectomy.

Conclusions

3D LRP is a feasible technique with similar oncological or functional outcomes and better perioperative outcomes as compared to ORP. Being cost-effective and with comparable outcomes it is a suitable alternative to RRP in resource-limited settings.

Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review

BACKGROUND

There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP.

METHODS

A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers.

RESULTS

We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012).

CONCLUSION

The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review

PURPOSE

To perform a systematic search and review of the available literature on the learning curves (LCs) in laparoscopic and robot-assisted prostate surgery.

METHODS

Medline was systematically searched from 1946 to January 2021 to detect all studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, reporting on the LC in laparoscopic radical prostatectomy (LRP), laparoscopic simple prostatectomy (LSP), robot-assisted radical prostatectomy (RARP) and robot-assisted simple prostatectomy (RSP).

RESULTS

In total, 47 studies were included for qualitative synthesis evaluating a single technique (LRP, RARP, LSP, RSP; 45 studies) or two techniques (LRP and RARP; 2 studies). All studies evaluated outcomes on real patients. RARP was the most widely investigated technique (30 studies), followed by LRP (17 studies), LSP (1 study), and RSP (1 study). In LRP, the reported LC based on operative time; estimated blood loss; length of hospital stay; positive surgical margin; biochemical recurrence; overall complication rate; and urinary continence rate ranged 40-250, 80-250, 58-200, 50-350, 110-350, 55-250, 70-350 cases, respectively. In RARP, the corresponding ranges were 16-300, 20-300, 25-200, 50-400, 40-100, 20-250, 30-200, while LC for potency rates was 80-90 cases.

CONCLUSIONS

The definition of LC for laparoscopic and robot-assisted prostate surgery is not well defined with various metrics used among studies. Nevertheless, LCs appear to be steep and continuous. Implementation of training programs/standardization of the techniques is necessary to improve outcomes.

Tumor Biological Feature and Its Association with Positive Surgical Margins and Apical Margins after Radical Prostatectomy in Non-Metastasis Prostate Cancer

Purpose: We assessed clinical and tumor biological features and evaluated their association with positive surgical margins (PSMs) and positive apical margins (PAMs) variability after radical prostatectomy (RP) in men with non-metastasis prostate cancer (nmPCa) in our institute. Patients and methods: During the period from January 2013 to December 2017, clinical and pathological data were collected in 200 patients with nmPCa undergoing RP in the Urological department of Peking University Cancer Hospital & Institute. Surgical and apical margins were stated negative and positive, separately. A dichotomous logistic regression model was used to assess clinical and tumor biological features including age, total prostate volume (TPV), biopsy positive cores (BPC), D’Amico risk grade, tumor clinical stage, International Society of Urologic Pathology (ISUP) grade, tPSA, f/t and pelvic lymph nodes (PLN) invasion, and their association with PSMs and PAMs was evaluated. Results: Overall, men with nmPCa in this study had a high ISUP grade (58.5% grade 3–5), high risk grade (89.4%) and high clinical T stage (56% cT3-4). PSMs were detected in 106 patients; the rate of PSMs was 53%. Among patients with PSMs, 83% were PAMs; the overall rate of PAMs was 44%. Among patients with PSMs, high risk (OR, 1.439; p = 0.023), cT3a (OR, 1.737; p = 0.045), cT3b (OR, 5.286; p < 0.001), cT4 (OR, 6.12; p < 0.001), ISUP Grade 4 (OR, 2; p = 0.034) and Grade 5 (OR, 6.167; p < 0.001) and PLN invasion (OR, 6; p = 0.019) were strongly associated with PSMs using a dichotomous logistic regression univariable model, and high risk (OR, 6; p = 0.019), cT3a (OR, 5.116; p = 0.048), cT3b (OR, 9.194; p = 0.008), cT4 (OR, 4.58; p = 0.01), ISUP Grade 4 (OR, 7.04; p = 0.035), Grade 5 (OR, 16.514; p = 0.002) and PLN invasion (OR, 5.516; p = 0.03) were independently associated with PSMs by using multivariable analysis. Among patients with PAMs, cT3b (OR, 2.667; p = 0.004), cT4 (OR, 3; p = 0.034) and proportion of BPC (OR, 4.594; p = 0.027) were strongly associated with PAMs by using a dichotomous logistic regression univariable model, and cT3b (OR, 3.899; p = 0.02), cT4 (OR, 2.8; p = 0.041) and proportion of BPC (OR, 5.247; p = 0.04) were independently associated with PSMs by using multivariable analysis. Conclusions: Patients with nmPCa in our institute had high risk, high ISUP grade and high clinical stage. Tumor biological factors were strongly associated with PSMs and PAMs, and PLN invasion was independently associated with PSMs. The risk factors influenced the status of surgical margins, and apical margins were different.

Laparoscopic radical prostatectomy: a single surgeon’s experience in 80 cases after 2 years of formal training

Background

To assess the learning curve in laparoscopic radical prostatectomy (LRP) performed by a single surgeon who had a healthcare career as a surgical first assistant for 2 years in high-volume centers treating > 150 cases per year.

Methods

The records of 80 LRP cases performed between October 2017 and August 2018 by a single surgeon were consecutively divided into four groups (groups A = first 20 cases, B = second 20 cases, C = third 20 cases, and D = last 20 cases). The groups were compared in terms of surgical and functional outcomes with a minimum follow-up of 6 months.

Results

Clinical and surgical stages of the four groups were similar between groups. The operative time (126.8 ± 5.48 min; P = 0.001) and time of removal of the drain (1.65 ± 0.93 days; P = 0.029) were significantly lower in group D; however, hospitalization, catheterization time, and blood loss were similar between groups. The complication rate was low. No patient had a visceral injury, and there were no procedures needed to open conversion. The positive surgical margin (PSM) rates were similar between groups. In terms of continence and potency, all groups were similar at the 6th-month follow-up after surgery.

Conclusions

Our results showed that prior experience in laparoscopic surgery as a surgical first assistant in a high-volume center improves the learning curve and oncological and functional outcomes, and helps to minimize the complication rate

3D laparoscopic prostatectomy: A prospective single-surgeon learning curve in the first 200 cases with oncologic and functional results

BACKGROUND

Studies for 3D-laparoscopic prostatectomy (3D-LRP) learning curve and surgical results are lacking. Combining 3D vision to LRP attenuates differences compared to Robotic assisted laparoscopic prostatectomy (RALP) with similar mini-invasiveness but lower costs.

MATERIALS AND METHODS

Two hundred consecutive men with localized prostate cancer underwent 3D-LRP at Seinäjoki central hospital between 2013 and 2018. Oncological and functional results were documented. Long-term functional evaluation was done using EPIC-26 survey. Clavien-Dindo classification was used to assess complications during first 3 months. All operations were performed by a single surgeon (M.R.) with no experience of LRP or 3D-LRP. The learning curve was assessed by evaluating urethral anastomosis- and total operative time. Perioperative and postoperative data was collected prospectively during surgery and at subsequent control visits up to minimum of 1 year.

RESULTS

A plateau in anastomosis time was reached after 30 cases and in operative time after 60 cases. Median operative time was 114 min (78-258 min) and median time for anastomosis was 25 min (11-90 min). Median blood loss was 150 ml (10-800 ml); 93.5% of the patients were discharged within the first 3 days. Clavien-Dindo ≥3a complications occurred in 6.5%. Positive surgical margins occurred in 23%. One-year after the operation, 93.3% had PSA ≤ 0.1; 91.9% of the patients were dry or used one daytime pad. EPIC-26 scores were as follows: Urinary incontinence 79.25 (14.5-100), urinary irritative/obstructive 93.75 (31.25-100), bowel 100 (33.33-100), sexual 36.17 (0-100) and hormonal 95 (37.5-100).

CONCLUSION

The learning curve for 3D laparoscopic prostatectomy is comparable to RALP, which makes it a cost-effective alternative with comparable oncological and functional results.

The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study

BACKGROUND

The aim of this study was to report the overall results and the learning curve (LC) in salvage robot-assisted radical prostatectomy (sRARP) patients, in terms of morbidity, oncological and functional outcomes in a single surgeon tertiary-referral center.

METHODS

One hundred and twenty patients underwent sRARP by a single surgeon (V.P.) from 2008 to 2018. To assess the trends in the learning experience they were sub-divided in 4 groups of 30 consecutive patients based on date of surgery. The Kaplan-Meier method and regression models were used to identify survival estimations and predictors of potency, continence and biochemical failure (BCF) at 12 months.

RESULTS

As the learning experience for sRALP increased operative time (OT) was significantly shorter (from 139.5 to 121 minutes) and the amount of nerve-sparing (NS) undertaken increased (from 46% to 80%). While complications rate remained stable, estimated blood loss (EBL) and radiographic anastomotic leaks (RAL) decreased through the groups (from 124 to 69 ml and 40% to 16,7%, respectively). BCF and continence rates at 12 months after sRARP were similar among groups (23-36% and 36,7-50%, respectively) and chance of potency rates tended to increase (from 3.3% to 16-23%) but was not statistically significant. In a multivariate analysis, predictors for BCF were PSM and GS 8-10. Non-radiation primary treatment was the unique predictor of continence at 12 months after sRARP.

CONCLUSIONS

Our data may suggest a decreasing trend in terms of OT and EBL through the sRARP learning curve. While morbidity remained stable through the time, RAL trended towards a decline. A higher degree of NS was observed through the groups and there was a slight correlation trend between surgical expertise and potency recovery. PSM and GS 8-10 were predictors of BCF and non-radiation primary treatment predicted a better continence after sRARP.

A Review of Training and Guidance Systems in Medical Surgery

In this paper, a map of the state of the art of recent medical simulators that provide evaluation and guidance for surgical procedures is performed. The systems are reviewed and compared from the viewpoint of the used technology, force feedback, learning evaluation, didactic and visual aid, guidance, data collection and storage, and type of solution (commercial or non-commercial). The works’ assessment was made to identify if—(1) current applications can provide assistance and track performance in training, and (2) virtual environments are more suitable for practicing than physical applications. Automatic analysis of the papers was performed to minimize subjective bias. It was found that some works limit themselves to recording the session data to evaluate them internally, while others assess it and provide immediate user feedback. However, it was found that few works are currently implementing guidance, aid during sessions, and assessment. Current trends suggest that the evaluation process’s automation could reduce the workload of experts and let them focus on improving the curriculum covered in medical education. Lastly, this paper also draws several conclusions, observations per area, and suggestions for future work.

[LAPAROSCOPIC RADICAL PROSTATECTOMY OF 926 PATIENTS AT THE HIROSHIMA ENDOUROLOGICAL ASSOCIATION]

(Objective) The aim of this study is to investigate the treatment outcome of laparoscopic radical prostatectomy (LRP). (Patients and methods) The study cohort consisted of 926 hormone-naïve patients with localized prostate cancer who underwent LRP at the Hiroshima Endourological Association from January 2007 to December 2016. (Results) The mean age was 69.4 years, the mean initial PSA was 9.1 ng/ml, and the mean follow-up period was 40.3 months. The D'Amico Risk Classification was Low: 232 cases, Intermediate: 344 cases, and High: 350 cases. Nerve preservation was performed bilaterally for 138 patients and unilaterally for 181 patients. The mean operative time was 181.0 minutes and the mean estimated blood loss was 360.7 ml. As the number of experienced cases increased, the operative time was significantly shorter and the estimated blood loss was significantly decreased. According to Clavien-Dindo classification, the ratio of perioperative complication degree IIIa or above was 4.0% (37 cases). The pathological results were Gleason score (GS) ≤6: 174 cases, GS7: 514 cases, GS ≥8: 232 cases, pT2≥: 704 cases, pT3a: 172 cases, pT3b: 47 cases, pT4: 3 cases, pN0: 917 cases, and pN1: 9 cases. Positive surgical margins were found in 278 cases (30.0%). The biochemical recurrence-free survival rate at 5 years was 78.1%. In multivariate analysis, age (≥70 yrs), initial PSA (≥10 ng/ml), biopsy GS (GS ≥8), cancer positive core ratio at biopsy (≥30%), pT (pT≥3), pathological GS (GS≥8), positive surgical margin and total number of patients in the facility were predictive factors of postoperative biochemical PSA recurrence. Younger age and nerve preservation were found to be predictive factors for the early recovery of urinary continence after surgery, with 88% regaining urinary continence at 12 months after surgery. (Conclusion) This study revealed the clinical outcome and appropriate candidates for LRP in Japanese patients.

Experience of one single surgeon with the first 500 robot-assisted laparoscopic prostatectomy cases in mainland China

Objectives

To summarize the experience of the first 500 robot-assisted laparoscopic radical prostatectomy (RALP) cases by one surgeon and analyze the influencing factors of functional and oncological outcomes.

Methods

Between April 2012 and October 2017, 500 patients who underwent RALP were included and divided sequentially into five equal groups. Patients’ preoperative, perioperative and postoperative outcomes were analyzed and evaluated, and the Kruskal-Wallis test was used to analyze and compare the effect of surgeon experience by case.

Results

There is a statistically significant reduction in operative time, intraoperative estimated blood loss and postoperative hospital stay time (all p<0.001) with the increased experience. The results show that experience was the most important influencing factor in both operative time and blood loss. Pelvic lymph node dissection (PLND) might increase the operative time. The total positive surgical margin (PSM) rate was 21.8%. The PSM rate in pT3 tumors was significantly higher than that in pT2 tumors (12.0% vs. 37.1%, p<0.001). The 5-year biochemical recurrence (BCR)-free rate was 70.8%. The results of Cox regression showed that preoperative prostate-specific antigen (PSA), postoperative Gleason score (GS), and pathologic T stage were independent risk factors for BCR.

Conclusion

After approximately 200 cases, the surgeon reached a plateau for RALP, but the outcomes could still improve after more cases. The surgeon's experience was the most important influencing factor for both operative time and blood loss. PSM rate was mainly determined by tumor stage rather than by operation experience.

Impact of positive surgical margins on secondary treatment, palliative radiotherapy and prostate cancer-specific mortality. A population-based study of 13 198 patients

BACKGROUND

The results of studies evaluating the impact of positive surgical margins on prostate cancer-specific mortality have been inconsistent. We, therefore, evaluated the impact of surgical margin status on subsequent secondary treatment, palliative radiotherapy, and prostate cancer-specific mortality.

METHODS

A total of 14 837 men treated with radical prostatectomy (RP) during the period 2001 to 2015 were identified from the Cancer Registry of Norway. Of those, 13 198 (89%) patients had complete data on the preoperative prostate-specific antigen level, pathological T-category, Gleason score in the prostatectomy specimen, and margin status. Multivariable Cox proportional hazards models were used to evaluate the risk, and flexible parametric models for the cumulative incidence were fitted to predict the probabilities of secondary treatment (salvage radiotherapy or prophylactic breast radiation), palliative radiotherapy, and prostate cancer-specific mortality.

RESULTS

After a median follow-up time of 5.2 years (3591 patients with ≥8 years of follow-up), positive surgical margins (PSMs) were independently predictive of secondary treatment (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 2.21-2.66) and palliative radiotherapy (HR = 1.45, 95% CI = 1.03-2.05). After 10 years, the absolute increased risk for palliative radiotherapy in patients with PSMs after RP varied between 0.1% in pT2 tumors with a Gleason score of 6, to 12% for pT3b tumors with a Gleason score of 9 to 10. PSMs were not independently associated with prostate cancer-specific mortality (HR = 1.14, 95% CI = 0.82-1.59).

CONCLUSION

PSMs were associated with increased application of secondary treatment and palliative radiotherapy but were not predictive of prostate cancer-specific mortality. As the use of palliative radiotherapy was only marginally increased in patients with PSMs and the lowest-risk disease characteristics, avoiding PSMs may be of greatest prognostic relevance in patients with higher-risk disease characteristics.

Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience

OBJECTIVE

The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management.

MATERIAL AND METHODS

A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed.

RESULTS

The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages.

CONCLUSION

A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.

Learning Curve and Associated Morbidity of Minimally Invasive Esophagectomy: A Retrospective Multicenter Study

OBJECTIVE

To investigate the morbidity that is associated with the learning curve of minimally invasive esophagectomy.

BACKGROUND

Although learning curves have been described, it is currently unknown how much extra morbidity is associated with the learning curve of technically challenging surgical procedures.

METHODS

Prospectively collected data were retrospectively analyzed of all consecutive patients undergoing minimally invasive Ivor Lewis esophagectomy in 4 European expert centers. The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were operative time and textbook outcome ("optimal outcome"). Learning curves were plotted using weighted moving average and CUSUM analysis was used to determine after how many cases the plateau was reached. Learning associated morbidity was calculated with area under the curve analysis.

RESULTS

This study included 646 patients. Three of the 4 hospitals reached the plateau of 8% anastomotic leakage. The length of the learning curve was 119 cases. The mean incidence of anastomotic leakage decreased from 18.8% during the learning phase to 4.5% after the plateau had been reached (P < 0.001). Thirty-six extra patients (10.1% of all patients operated on during the learning curve) experienced learning associated anastomotic leakage, that could have been avoided if patients were operated by surgeons who had completed the learning curve. The incidence of textbook outcome increased from 28% to 53% and the mean operative time decreased from 344 minutes to 270 minutes.

CONCLUSIONS

A considerable number of 36 extra patients (10.1%) experienced learning associated anastomotic leakage. More research is urgently needed to investigate how learning associated morbidity can be reduced to increase patient safety during learning curves.

Robot-assisted and laparoscopic vs open radical prostatectomy in clinically localized prostate cancer: perioperative, functional, and oncological outcomes: A Systematic review and meta-analysis

BACKGROUND

To perform a systematic review and meta-analysis evaluating the perioperative, functional, and oncological outcomes and cost of robot-assisted radical prostatectomy (RARP), or laparoscopic radical prostatectomy (LRP) comparing with open radical prostatectomy (ORP) in men with clinically localized prostate cancer through all prospective comparative studies.

METHODS

A comprehensive literature search was performed in August 2018 using the Pubmed, Medline, Embase, and Cochrane databases. Only randomized controlled trials (RCTs) and prospective studies including patients with clinically localized prostate cancer were eligible for study inclusion. Cumulative analysis was conducted using Review Manager v. 5.3 software.

RESULTS

Two RCTs and 9 prospective studies were included in this systematic review. There were no significant differences between RARP/LRP and ORP in overall complication rate, major complication rate, overall positive surgical margin (PSM) rate, ≤pT2 tumor PSM rate, ≥pT3 tumor PSM rate. Moreover, RARP/LRP and ORP showed similarity in biochemical recurrence (BCR) rate at 3, 12, 24 months postoperatively. Urinary continence and erectile function at 12 months postoperatively between RARP and ORP are also comparable. RARP/LRP were associated with significantly lower estimated blood loss [mean difference (MD) -749.67, 95% CI -1038.52 to -460.82, P = .001], lower transfusion rate (OR 0.17, 95% CI 0.10 to 0.30, P < .001) and less hospitalization duration (MD -1.18, 95% CI -2.18 to -0.19, P = .02). And RARP/LRP required more operative time (MD 50.02, 95% CI 6.50 to 93.55, P = .02) and cost.

CONCLUSION

RARP/LRP is associated with lower blood loss, transfusion rate and less hospitalization duration. The available data were insufficient to prove the superiority of any surgical approach in terms of postoperative complications, functional and oncologic outcomes.

Clinical utility of MRI in the decision-making process before radical prostatectomy: Systematic review and meta-analysis

Context

Magnetic resonance imaging (MRI) is currently the most accurate imaging modality to assess local prostate cancer stage. Despite a growing body of evidence, incorporation of MRI images into decision-making process concerning surgical template of radical prostatectomy, is complex and still poorly understood.

Objective

We sought to determine the value of MRI in preoperative planning before radical prostatectomy.

Materials and methods

Systematic search through electronic PubMed, EMBASE, and Cochrane databases from 2000 up to April 2018 was performed. Only studies that used preoperative MRI in decision-making process regarding extension of resection in patients with prostate cancer, in whom radical prostatectomy was an initial form of treatment were included into analysis. Their quality was scored by Risk Of Bias In Non-Randomized Studies of Interventions system. Meta-analysis was performed to calculate the weighted summary proportion under the fixed or random effects model as appropriate and pooled effects were depicted on forest plots.

Results

The results showed that the preoperative MRI led to the modification of initial surgical template in one third of cases (35%). This occurred increasingly with the rising prostate cancer-risk category: 28%, 33%, 52% in low-, intermediate- and high-risk group, respectively. Modification of neurovascular bundle-sparing surgery based on MRI appeared to have no impact on the positive surgical margin rate. The decision based on MRI was correct on average in 77% of cases and differed across prostate cancer-risk categories: 63%, 75% and 91% in low-, intermediate- and high-risk group, accordingly.

Conclusions

In summary, MRI has a considerable impact on the decision-making process regarding the extent of resection during radical prostatectomy. Adaptation of MRI images by operating surgeons has at worst no significant impact on surgical margin status, however its ability to decrease the positive surgical margin rates remains unconfirmed.

Analysis of the Learning Curve of Surgeons without Previous Experience in Laparoscopy to Perform Robot-Assisted Radical Prostatectomy

Objective

To assess the learning curve in robot-assisted radical prostatectomy (RARP) performed by surgeons without previous experience in laparoscopic prostatectomy.

Materials and Methods

We analyzed 119 patients submitted to RARP performed by two surgeons without previous experience in laparoscopic prostatectomy, with emphasis on the relevant outcomes such as continence, erectile function, and oncologic control with a minimum follow-up of 24 months. We used Fisher's exact test and the chi-square test to investigate the existence of a relationship between the variables and analysis of variance (ANOVA) to verify possible statistically significant differences between groups, at the 5% level.

Results

The patients' age varied from 41 to 72 years (mean = 61.09), with 68 (57.14%) cases having intermediate or high risk. There was a consistent decline in operative time. Of the 119 patients, 80.67% were continent 6 months after surgery and 89.07% 12 months afterward, while 35.29% were potent 6 months after surgery and 60.50% 12 months following surgery. Twelve months after surgery, the trifecta outcome rate was 51.26% and the pentafecta rate was 31.09%. There was progressive postoperative improvement and maintenance of continence and sexual potency until the last patient was operated in our sample.

Conclusions

Robot-assisted radical prostatectomy does not require previous experience in laparoscopic radical prostatectomy, but the learning curve is not short to achieve the plateau.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy)

PURPOSE

The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery.

MATERIALS AND METHODS

A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor.

RESULTS

In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor´s group. No conversion to open surgery was performed.

CONCLUSIONS

The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

Level of invasion into fibromuscular band is an independent factor for positive surgical margin and biochemical recurrence in men with organ confined prostate cancer

Background

This study aimed investigate the effect of the level of invasion into fibromuscular band (FMB) of prostate on the positive surgical margin (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) in patients with organ-confined (pT2) prostate cancer.

Methods

The clinical and pathological data of 461 consecutive patients with pT2 prostate cancer were evaluated regarding the level of invasion into FMB. The relationship between levels of invasion into FMB and PSM / BCR was assessed.

Results

The rate of PSM at an FMB level of at 2 was 18.8%, which was significantly greater than the rates at levels 0 (5.4%) and 1 (7.8%). The level of FMB (p = 0.007) and percentage of tumor volume (p = 0.012) were identified as independent factors predictive of a positive surgical margin in a multivariate analysis. The 5-year BCR-free survival rates for a level 0–1 FMB with negative surgical margin, level 0–1 FMB with positive surgical margin, level 2 FMB with negative surgical margin, and level 2 FMB with positive surgical margin were 96.6%, 86.4%, 85.6%, and 72.9%, respectively (p <  0.001). A level 2 FMB (p = 0.050), positive surgical margin (p = 0.001), and surgical Gleason score (p = 0.001) were identified as independent predictors of a BCR of pT2 prostate cancer.

Conclusions

Among patients with negative surgical margins, the surgical Gleason score and level of FMB independently affected the incidence of a BCR of pT2 prostate cancer. The level of FMB was an independent predictor of both a positive surgical margin and a BCR of pT2 disease. Accordingly, the level of FMB might help to further stratify the prognosis of patients with pT2 disease.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy

Introduction:

This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP.

Patients and Methods:

110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used.

Results:

The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad).

Conclusions:

The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

Systematic Review of Studies Reporting Positive Surgical Margins After Bladder Neck Sparing Radical Prostatectomy

PURPOSE OF REVIEW

Bladder neck preservation (BNP) during radical prostatectomy (RP) has been proposed as a method to improve early recovery of urinary continence after radical prostatectomy. However, there is concern over a possible increase in the risk of positive surgical margins and prostate cancer recurrence rate. A recent systematic review and meta-analysis reported improved early recovery and overall long-term urinary continence without compromising oncologic control. The aim of our study was to perform a critical review of the literature to assess the impact on bladder neck and base margins after bladder neck sparing radical prostatectomy.

EVIDENCE ACQUISITION

We carried out a systematic review of the literature using Pubmed, Scopus and Cochrane library databases in May 2017 using medical subject headings and free-text protocol according to PRISMA guidelines. We used the following search terms: bladder neck preservation, prostate cancer, radical prostatectomy and surgical margins. Studies focusing on positive surgical margins (PSM) in bladder neck sparing RP pertinent to the objective of this review were included.

EVIDENCE SYNTHESIS

Overall, we found 15 relevant studies reporting overall and site-specific positive surgical margins rate after bladder neck sparing radical prostatectomy. This included two RCTs, seven prospective comparative studies, two retrospective comparative studies and four case series. All studies were published between 1993 and 2015 with sample sizes ranging between 50 and 1067. Surgical approaches included open, laparoscopic and robot-assisted radical prostatectomy. The overall and base-specific PSM rates ranged between 7-36% and 0-16.3%, respectively. Mean base PSM was 4.9% in those patients where bladder neck sparing was performed, but only 1.85% in those without sparing. Bladder neck preservation during radical prostatectomy may increase base-positive margins. Further studies are needed to better investigate the impact of this technique on oncological outcomes. A future paradigm could include modification of intended approach to bladder neck dissection when anterior base lesions are identified on pre-operative MRI.

Improving postoperative radiotherapy following radical prostatectomy

INTRODUCTION

Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.

Establishing a teaching unit in laparoscopic radical prostatectomy: An Australian experience

Objective:

The aim of this project was to examine the role of surgical mentorship on the perioperative and oncological outcomes of patients undergoing laparoscopic radical prostatectomy (LRP) performed by two urologists inexperienced in the procedure.

Methods:

Forty-one (41) consecutive LRP cases were performed for clinically localised prostate cancer between December 2006 and June 2008 at a single centre. The surgical mentor approach was used with an experienced LRP surgeon being present for all cases that were performed by two urologists training in LRP. Data was retrospectively reviewed to assess morbidity and oncological outcomes of patients undergoing LRP by the team of trainees.

Results:

No LRP cases were converted to open and no major intraoperative complications were noted. Mean intraoperative blood loss was 493 ml (range 150–1000 ml) with the mean operative time being 220 minutes (range 100–315 minutes). The overall positive margin rate was only 12% (five out of 41 cases).

Conclusion:

LRP teaching units can be established with appropriate mentor supervision and can result in good oncological outcomes and minimal morbidity that compares favourably to robotic-assisted radical prostatectomy (RARP).

Impact of prior abdominal surgery on the outcomes after robotic - assisted laparoscopic radical prostatectomy: single center experience

Purpose:

To evaluate the influence of prior abdominal surgery on the outcomes after robotic-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods:

We retrospectively analyzed patients with prostate cancer who underwent RALP between June 2012 and February 2015 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery while considering the mean total operating, console, and port-insertion times; mean estimated blood loss; positive surgical margin rate; mean duration of catheterization; and rate of complications.

Results:

A total of 203 patients who underwent RALP during the study period were included in this study. In all, 65 patients (32%) had a prior history of abdominal surgery, whereas 138 patients (68%) had no prior history. The total operating, console, and port-insertion times were 328 and 308 (P=0.06), 252 and 242 (P=0.28), and 22 and 17 minutes (P=0.01), respectively, for patients with prior and no prior surgery. The estimated blood losses, positive surgical margin rates, mean durations of catheterization, and complication rates were 197 and 170 mL (P=0.29), 26.2% and 20.2% (P=0.32), 7.1 and 6.8 days (P=0.74), and 12.3% and 8.7% (P=0.42), respectively. Furthermore, whether prior abdominal surgery was performed above or below the umbilicus or whether single or multiple surgeries were performed did not further affect the perioperative outcomes.

Conclusions:

Our results suggest that RALP can be performed safely in patients with prior abdominal surgery, without increasing the risk of complications.

4-Ports endoscopic extraperitoneal radical prostatectomy: preliminary and learning curve results

INTRODUCTION

There is a lack of studies in our national scenario regarding the results obtained by laparoscopic radical prostatectomy technique (LRP). Except for a few series, there are no consistent data on oncological, functional, and perioperative results on LRP held in Brazil. As for the LRP technique performed by extraperitoneal access (ELRP), when performed by a single surgeon, the results are even scarcer.

OBJECTIVE

To analyze the early perioperative and oncologic results obtained with the ELRP, throughout the technical evolution of a single surgeon.

PATIENTS AND METHODS

A non-randomized retrospective study was held in a Brazilian hospital of reference. In the 5-year period, 115 patients underwent the ELRP procedure. Patients were divided into two groups, the first 57 cases (Group 1) and the following 58 cases, (Group 2). A comparative analysis between the groups of efficacy results and ELRP safety was carried out.

RESULTS

The average age of patients was 62.8 year-old and the PSA of 6.9ng/dl. The total surgery time was 135.8 minutes on average, and the urethral-bladder anastomosis was 21.9 min (23.3 min versus 20.7 min). The positive surgical margins (PSM) rate was 17.1%, showing no difference between groups (16.4% versus 17.9%; p=0.835). There was statistical difference between the groups in relation to the anastomosis time, estimated blood loss and the withdrawal time of the urinary catheter.

CONCLUSION

The ELRP technique proved to be a safe and effective procedure in the treatment of prostate cancer, with low morbidity.

Laparoscopic radical prostatectomy outcome data: how should surgeon's performance be reported? A retrospective learning curve analysis of two surgeons

Objective

To document the learning curve for the laparoscopic radical prostatectomy (LRP) procedure and discuss the optimal usage of prospectively documented outcome data for reporting a surgeon’s performance.

Materials and methods

Using prospectively collected data from the first series of patients to undergo LRP by two surgeons in the same institution, linear and logistic regression multivariate analyses per 25 patients were carried out to graphically represent the surgical learning curve for operative time, blood loss, complications, length of stay (LOS), and positive margins. Surgeon A carried out 275 operations between 2003–2009; Surgeon B carried out 225 between 2008–2012.

Results

Learning curves showing continuous improvement of each of the above outcomes were demonstrated for both cohorts. For surgeon A, a plateau was observed for LOS and T2 positive margins after 100 and 150 surgeries respectively. No such plateau was observed for surgeon B.

Conclusion

On documenting these learning curves and discussion of the reporting methods used, we concluded that the most informative outcome measure, with the least potential observer bias was T2 positive margins. Whether as a single measure or in combination with others, this has potential for use as an objective outcome representative of improvement in a surgeon’s skill over time.

Are you now a good surgeon? T2 positive margin status as a quality outcome measure following radical prostatectomy

Objective

To assess potential biases, such as the reporting pathologist, that may affect objectivity of T2 positive margin rates as a quality outcome measure following radical prostatectomy.

Patients and methods

Prospective data on 183 consecutive LRP patients with pT2 disease, operated on by a single surgeon (2003–2009), were studied. Outcomes were grouped as pre-, peri-, and post-operative and included: age, ethnicity, Gleason score, reporting pathologist, percentage of positive cores, operative time, blood loss, nerve-sparing status, hospital stay and prostate weight. Descriptive analysis and logistic regression analysis were carried out to compare these variables by positive margin status.

Results

A total of 30 (16.4 %) positive surgical margins (PSMs) were reported. Surgical stage, earlier date of surgery, and lower prostatic weight showed statistically significant associations with PSM status in both univariate and multivariate analysis. The reporting pathologist was not found to be predictive of PSMs (P = 0.855).

Conclusion

We showed that the reporting pathologist does not influence T2 positive margin status, in contrast to tumour characteristics and surgeon experience. T2 positive margin assessment therefore appears to be an objective quality outcome measure.

A Systematic Review of Economic Evaluations of the Use of Robotic Assisted Laparoscopy in Surgery Compared with Open or Laparoscopic Surgery

BACKGROUND

Robot assisted laparoscopic (RAL) surgery developed to overcome the limitations of laparoscopy to assist in surgical procedures, has high capital and operating costs. Systematically assembled evidence demonstrating its clinical and cost effectiveness would be helpful for its adoption by decision makers.

OBJECTIVE

To summarise the evidence on the cost-effectiveness of robot-assisted laparoscopic (RAL) surgery compared with relevant alternatives. Methods and results of identified studies were assessed to identify the deficiencies in evidence and areas for further research.

METHODS

Studies reporting both costs and outcomes for comparisons of RAL with laparoscopy and/or open surgery were systematically identified. Searches were conducted in February 2015 on MEDLINE, EMBASE and NHS EED. Quality of the included studies was assessed against a standard checklist for economic analyses. Length of hospital stay and operating time (determinants of cost), cost of intervention, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were extracted. To aid comparison, costs were converted into a common currency and price year (2014 US dollars).

RESULTS

Forty-seven eligible studies were identified (full economic evaluation n = 6 and cost analysis n = 41). Economic models were used in 11 (23%) studies. Only three studies used a model considered representative of the disease and clinical pathway with a time-horizon allowing capture of relevant differences in outcomes across strategies. The cost of RAL varied substantially between uses, ranging from US$7011 for hysterectomy to over US$30,000 for radical cystectomy. The majority of estimates were between US$15,000 and US$25,000 per person. In part this difference is explained by the difference between studies in which costs were included. It was also identified to have higher costs than the alternatives it was compared against. Incremental cost per QALY for RAL radical prostatectomy was US$28,801-$31,763 over a 10-year period assuming 200 cases per annum.

CONCLUSION

The clinical evidence available for RAL overall and used within included studies is limited. RAL surgery costs were consistently higher than open and laparoscopic surgery. Therefore, in adopting the robotic technology decision makers need to take into account the cost effectiveness within their own systems. Economic models generated and published for radical prostatectomy and hysterectomy may be adapted to other health systems if the care pathway is similar to provide locally relevant data.

[Positive surgical margin status after minimally invasive radical prostatectomy: a multicenter study]

UNLABELLED: The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50-150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage.

MATERIALS AND METHODS

We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques.

RESULTS

We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs.

CONCLUSIONS

In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients' selection can be a possible explanation.

Patient Safety Risks of Basic Urological Procedures Performed by Junior and Senior Residents

OBJECTIVE

To investigate the current performance of urological residents regarding basic urological procedures in relation to patient safety issues and the identification of specific training needs.

DESIGN

Observational data of 146 urethrocystoscopies (UCSs), 27 transrectal ultrasounds of the prostate (TRUSs), 38 transrectal ultrasound-guided prostatic biopsies (TRUSPs), and 30 transurethral resections of bladder tumor (TURBTs) were collected. Performance was evaluated using scoring lists including details on completeness of procedural steps, level of independence, time, and the incidence of unintended events. The causal factors contributing to the unintended events were identified by 2 expert urologists and classified according to the recognized PRISMA method.

SETTING

This study was performed in 5 teaching hospitals in the Netherlands.

PARTICIPANTS

We included 11 junior residents and 5 senior residents in urology in the final study cohort.

RESULTS

Senior residents showed a lower degree of completeness in material usage than junior residents did during UCS (p < 0.01) and in preparation, material usage, and procedure during TRUSP (all p < 0.05). In UCS and TURBT, senior residents received significantly less feedback than junior residents did (both p < 0.01). Incidence of unintended events for junior vs senior residents was 11% and 4% in UCS, 0% and 7% in transrectal ultrasound of the prostate, 36% and 62% in TRUSP, and 41% and 23% in TURBT, respectively. Overall, unintended events were mainly caused by human factors, in particular, verification and skills-based issues.

CONCLUSION

Present performance of basic urological procedures involves a high percentage of unintended events, especially in TRUSP and TURBT, which are mainly caused by human factors and are a potential threat for patient safety. Junior residents are less independent but more thorough in the performance of UCS and TRUSP than senior residents are. Targeted skills training including assessment should be implemented before privileges for independent practice are granted to reduce the incidence of unintended events and optimize patient safety.

Laparoscopic versus Robotic-Assisted Radical Prostatectomy for the Treatment of Localised Prostate Cancer: A Systematic Review

Background: Prostate cancer is a prominent form of cancer diagnosed in men living in developed countries, for which radical prostatectomy is a common frontline treatment. The aim of this systematic review was to determine whether robot-assisted laparoscopic radical prostatectomy (RALP) is more effective in the treatment of localised prostate cancer, compared to laparoscopic radical prostatectomy (LRP). Methods: An electronic search of Medline, Scopus, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (Central) was performed up until December 2014. Randomised controlled trials (RCTs) that offered a direct comparison of laparoscopic and robotic techniques were eligible for inclusion in this review. Results: A total of 93 articles were identified through the literature search, of which 2 were included in this review. Meta-analysis of 2 studies identified a significantly higher rate of return of erectile function in the RALP group (relative risk (RR) 1.51; 95% confidence interval (CI) 1.19, 1.92). A similar effect was observed with return to continence function (RR 1.14; 95% CI 1.04, 1.24). Conclusions: This systematic review offers the first evaluation of evidence from RCTs with respect to the effectiveness of RALP and LRP in the treatment of localised prostate cancer. Preliminary results suggest that RALP was more efficient at preserving the erectile function and continence in comparison to LRP.

A Generalized Assessment of the Impact of Regionalization and Provider Learning on Patient Outcomes

We present a generalized model to assess the impact of regionalization on patient care outcomes in the presence of heterogeneity in provider learning. The model characterizes best regionalization policies as optimal allocations of patients across providers with heterogeneous learning abilities. We explore issues that arise when solving for best regionalization, which depends on statistically estimated provider learning curves. We explain how to maintain the problem's tractability and reformulate it into a binary integer program problem to improve solvability. Using our model, best regionalization solutions can be computed within reasonable time using current-day computers. We apply the model to minimally invasive radical prostatectomy and estimate that, in comparison to current care delivery, within-state regionalization can shorten length of stay by at least 40.8%.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies

OBJECTIVES

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients.

RESULTS

The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation.

CONCLUSIONS

The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.