Learning curve of minimally invasive radical prostatectomy: Comprehensive evaluation and cumulative summation analysis of oncological outcomes

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.

The Surgical Learning Curve for Biochemical Recurrence After Robot-assisted Radical Prostatectomy

BACKGROUND

Improved cancer control with increasing surgical experience-the learning curve-was demonstrated for open and laparoscopic prostatectomy. In a prior single-center study, we found that this might not be the case for robot-assisted radical prostatectomy (RARP).

OBJECTIVE

To investigate the relationship between prior experience of a surgeon and biochemical recurrence (BCR) after RARP.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed the data of 8101 patients with prostate cancer treated with RARP by 46 surgeons at nine institutions between 2003 and 2021. Surgical experience was coded as the total number of robotic prostatectomies performed by the surgeon before the patient operation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We evaluated the relationship of prior surgeon experience with the probability of BCR adjusting for preoperative prostate-specific antigen, pathologic stage, grade, lymph-node involvement, and year of surgery.

RESULTS AND LIMITATIONS

Overall, 1047 patients had BCR. The median follow-up for patients without BCR was 33 mo (interquartile range: 14, 61). After adjusting for case mix, the relationship between surgical experience and the risk of BCR after surgery was not statistically significant (p = 0.2). The 5-yr BCR-free survival rates for a patient treated by a surgeon with prior 10, 250, and 1000 procedures performed were, respectively, 82.0%, 82.7%, and 84.8% (absolute difference between 10 and 1000 prior procedures: 1.6% [95% confidence interval: 0.4%, 3.3%). Results were robust to a number of sensitivity analyses.

CONCLUSIONS

These findings suggest that, as opposed to open and laparoscopic radical prostatectomy, surgeons performing RARP achieve adequate cancer control in the early phase of their career. Further research should explore why the learning curve for robotic surgery differs from prior findings for open and laparoscopic radical prostatectomy. We hypothesize that surgical education, including simulation training and the adoption of objective performance metrics, is an important mechanism for flattening the learning curve.

PATIENT SUMMARY

We investigated the relationship between biochemical recurrence after robot-assisted radical prostatectomy and surgeon's experience. Surgeons at an early stage of their career had similar outcomes to those of more experienced surgeons, and we hypothesized that surgical education in robotics might be an important determinant of such a finding.

Learning curve in pipeline embolization device: results from the pipeline embolization device in China post-market multicentre registry study

BACKGROUND

Intracranial aneurysms pose a significant health issue, affecting 3-5% of the adult population. The pipeline embolization device (PED) has emerged as a promising treatment for these lesions. This study aimed to investigate the impact of operator experience on complication and poor outcome rates, as well as the learning curve for PED.

METHODS

A total of 217 patients were consecutively enroled from four eligible centres and divided into three groups based on the number of procedures performed: group 1 (first 10 procedures), group 2 (11-20 procedures), and group 3(>20 procedures). Major complications include operation-related ischaemic or haemorrhagic events and mass effect deterioration. Poor outcome was defined as a modified Rankin Scale score greater than 2 at discharge. Cumulative summation (CUSUM) analysis was generated to assess the learning curve according to major complications and poor outcome.

RESULTS

The study found that major complications and poor outcomes occurred in 5.1% and 2.3% of cases, respectively. The rate of major complications decreased from 10.0% in group 1 to 2.9% in group 3 ( P =0.053), while the rate of poor outcomes decreased from 7.5% in group 1 to 0.7% in group 3 ( P =0.015). Multivariable regression analysis adjusted for covariates showed that operator experience was associated with a lower rate of poor outcomes ( P =0.034). CUSUM analysis demonstrated that the learning curve for avoiding major complications and poor outcomes required 27 (mean=13) and 40 (mean=20) cases, respectively.

CONCLUSIONS

These findings suggest that PED treatment requires a learning curve of 40 cases to achieve reproducibility regarding complications and functional results. Additionally, major complications and poor outcomes significantly decreases after the first 20 procedures. CUSUM analysis can serve as a useful tool for monitoring and assessing surgical performance.

Outcomes over 20 years performing robot-assisted laparoscopic prostatectomy: a single-surgeon experience

OBJECTIVE

To evaluate a single surgeon's 20-year experience with robotic radical prostatectomy.

METHODS

Patients who had undergone robot-assisted laparoscopic prostatectomy by a single surgeon were identified via an IRB approved prospectively maintained prostate cancer database. Patients were divided into 5-year cohorts (cohort A 2001-2005; cohort B 2006-2010; cohort C 2011-2015; cohort D 2016-2021) for analysis. Oncologic and quality of life outcomes were recorded at the time of follow-up visits. Continence was defined as 0-1 pad with occasional dribbling. Potency was defined as intercourse or an erection sufficient for intercourse within the last 4 weeks.

RESULTS

Three thousand one hundred fifty-two patients met criteria for inclusion. Clavien ≥ 3 complication rates decreased from 5.9% to 3.2%, p = 0.021. There was considerable Gleason grade group (GG) and stage migration to more advanced disease between cohort A (6.4% GG4 or GG5, 16.2% pT3 or pT4, 1.2% N1) and cohort D (17% GG4 or GG5, 45.5% pT3 or pT4, 14.4% N1; p < 0.001). Consistent with this, an increasing proportion of patients required salvage treatments over time (14.6% of cohort A vs 22.5% of cohort D, p < 0.001). 1-year continence rates improved from 74.8% to greater than 92.4%, p < 0.001. While baseline potency and use of intraoperative nerve spare decreased, for patients potent at baseline, there were no significant differences for potency at one year (p = 0.065).

CONCLUSIONS

In this 20-year review of our experience with robotic prostatectomy, complication rates and continence outcomes improved over time, and there was a migration to more advanced disease at the time of surgery.

Opening the Horizons of Functional Urology and Neurourology to Robot-assisted Surgery

Robot-assisted surgery is likely to become the new standard of care for functional urology and neurourology. It has the potential to fill the gap that has prevented the spread of laparoscopic surgery in these fields. With its many technical advantages, together with the potentially more efficient training of junior surgeons, robot-assisted surgery could finally bring more homogeneity to high-level surgical procedures in functional urology and neurourology worldwide.

Robotic-assisted radical prostatectomy: learning curves and outcomes from an Australian perspective

Background

Robot-assisted radical prostatectomy (RARP) has been a treatment for men who suffer from intermediated to high-risk prostate cancer in Australia since 2003. The primary outcomes in relation to learning curves in robotic surgery have been extensively researched in overseas populations, but there is no study from a cohort of Australian surgeons performing RARP. This study aims to highlight the effect of RARP learning curves on primary surgical outcomes in a high-volume Australian centre.

Methods

A retrospective audit of all RARP performed at Epworth Healthcare from 2016 to 2021 was performed. The primary outcome data collected included operating time (OT), estimated blood loss (EBL), and positive surgical margins (PSM). Exclusion criteria were applied. Positive outcomes were set at OT 240 min, blood loss 310 mL, and negative surgical margins.

Results

A total of 3969 cases were analysed for a cohort of 53 surgeons. Of these surgeons, 24 surgeons have performed >50 operations to be able to undergo learning curve analysis. The median OT was 229 min, the median blood loss was 353 mL, and most cases had negative surgical margins (>1 mm, n = 3681, 92.7%). The mean learning curve transition point was 65 cases. There was a significant difference in the EBL and rate of PSM for the higher volume cohort (p = 0.002 and <0.0001, respectively).

Conclusion

We perform a retrospective study of all RARP performed at a high-volume Australian centre. Higher volume surgeons demonstrate that primary outcomes improve with a higher caseload (EBL, PSM). Learning curve transition points for RARP are comparable to international high-volume surgeons. Learning curve data could form the benchmark for RARP training and skills development.

Effects of nerve-sparing procedures on surgical margins after robot-assisted radical prostatectomy

BACKGROUND

Nerve-sparing (NS) techniques could potentially increase positive surgical margins after robot-assisted radical prostatectomy (RARP). Nevertheless, the available studies have revealed ambiguous results among distinct groups. This study purposed to clarify the details of NS techniques to accurately estimate their influence on margin status.

METHODS

We studied RARPs performed by one surgeon from 2010 to 2018. Surgical margins were evaluated by the laterality and levels of NS techniques in site-specific prostate lobes. The multivariable analysis evaluated the effects of nerve-sparing procedures, combined with other covariate factors, on margin status.

RESULTS

Overall, 419 RARPs involving 838 prostate lobes were analyzed. Notably, 181 patients (43.4%) had pT2-stage, and 236 (56.6%) had pT3-stage cancer. The PSM rates for patients who underwent unilateral, bilateral, and non NS procedures were 30.3%, 28.8%, and 50%, respectively ( p = 0.233) or in stratification by pT2 ( p = 0.584) and pT3 ( p = 0.116) stage. The posterolateral PSM rates among site-specific prostate lobes were 10.9%, 22.4%, and 18.9% for complete, partial, and non NS techniques, respectively ( p = 0.001). The partial NS group revealed a significant increase in PSM rate compared with the complete NS (OR 2.187, 95% CI: 1.19-4.03) and non NS (OR 2.237, 95% CI: 1.01-4.93) groups in site-specific prostate lobes.

CONCLUSION

Partial NS procedures have a potential risk of increasing the positive surgical margins rate than complete and non NS procedures do. Therefore, correct case selection is required before performing partial NS techniques.

A multi-surgeon learning curve analysis of overall and site-specific positive surgical margins after RARP and implications for training

Robot-assisted radical prostatectomy (RARP) is the most adopted treatment for localized prostate cancer. The aim of this study was to explore the learning curves (LC) for overall and site-specific positive surgical margins (PSM) occurrence after RARP of multiple surgeons within a step-structured mentor-initiated training program. The study included consecutive patients undergoing RARP between January 2013 and March 2020, by three surgeons: a mentor and his two trainees. Prospectively collected patients' data were retrospectively analyzed. The cumulative summation (CUSUM) method was used to generate the LCs, with turning points indicating the number of cases to reach proficiency levels. Furthermore, the association between PSM and surgical experience was evaluated, adjusting for case mix. A total of 761 consecutive patients were included, 370 treated by the Mentor surgeon, 247 and 144 treated, respectively, by the two Trainees. Mentor and Trainees had similar PSM rates (31.6% vs 28.0% vs 31.3%, p = 0.6). CUSUM charts showed different LC shapes for different PSM locations (postero-lateral, bladder neck, apex, and multifocal/> 3 mm). Surgical experience was significantly associated with overall, postero-lateral, and multifocal/> 3 mm PSMs, in the Mentor series only. Trainees reached their turning points after far fewer cases then the Mentor, both for overall (12 and 31 vs 153), postero-lateral (24 and 30 vs 120), and multifocal/> 3 mm PSMs (9 and 31 vs 153). The achievement of stable SM proficiency takes involved different LCs depending on the prostatic location being considered. Monitoring site-specific LC can indicate the surgical steps for which there may be still room for further technical refinements, even when an apparent proficiency status seems achieved.

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.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

Videolaparoscopic prostatectomy in porcine model for training residents

Introduction:

Surgical training models prepare the resident for a more ethical surgical practice as well as providing a less steep learning curve. In urology, there are well-known models of pyeloplasty simulation, urethro-vesical anastomosis and nephrectomy, which have helped in the training of urology residents (1–3). Learning laparoscopic prostatectomy is a difficult surgery and requires advanced surgical skill from the surgeon (4), requires operate without a direct view of the surgical field in a two-dimensional space and with longer instruments (5).

Laparoscopic prostatectomy step by step makes the surgeon's learning curve less difficult, lead to less intraoperative complications, such as blood loss, while also enabling shorter operative time and less positive surgical margins (6).

The objective of surgical models is to simulate surgical procedures in a reliable way thus preparing the surgeon for his daily practice, surgical simulations in animal models have been described to compensate for inadequate clinical exposure (7).

The canine model of prostate cancer has many similarities with humans. Despite trying to develop a model that is as credible as possible, there are ethical issues in several countries, such as Brazil, that do not allow the use of live dogs for scientific experimentation and there is a difficulty in not standardizing the animals used (8, 9).

The swine surgical training model is widely known, accepted and used as a valuable tool in the teaching of new surgeons (10).

The porcine video laparoscopic prostatectomy model allows the urologist in training to exercise the skills required in a real surgical situation, practicing them in a single session (10). We will present an experimental model in pigs for training urology residents in laparoscopic radical prostatectomy with current techniques (11–13).

The limitations found are that the prostate has no limits as well defined as in humans, the urethra is long and coiled, the fat surrounding the pelvic organs is scarce and there is no postoperative follow-up for evaluating functionality after the procedure, as well as the effectiveness of the surgery with surgical margins. However, it is similar in surgical model presented, it is reproducible and can provide a realistic simulation environment to the beginner surgeon.

Material and Methods:

In this paper, according to the institutional protocol approved by the institutional ethics and research committee FMUSP n° 964/2017 and protocol was in accordance with current international regulations for the use of animals in Research: Reporting In Vivo Experiments (ARRIVE) guide. Ten male pigs weighing 20 to 22kg were used. The animals were anesthetized with a combination of Telazol (5mg/kg), Xylazine (1.5mg/kg), Cetamine (22mg/kg) and Atropine (0.04mg/kg) for orotracheal intubation followed by Isoflurane (2%). Animals were euthanized at the end of the procedure with a lethal dose of KCl (2mEq/kg). The trocar insertion points were marked using the epigastric vessels and umbilical region as reference points. Initially, urethral catheterization was performed using a hydrophilic Nitinol guidewire, followed by a perineal incision to dissect the tortuous urethra of the porcine model. A malleable urethral catheter 8Fr was inserted into their bladder. The animal was placed in the Trendelenburg position inserted and 12mm trocars were inserted in its umbilical region, utilizing 10mm in the surgeon's dominant hand, 5mm in his non-dominant hand of the surgeon, and 5mm in the first assistant's trocar.

The surgeon replicates the steps performed in a laparoscopic radical prostatectomy in humans, including the bladder catheterization, dissection of the anterior bladder plane, the vesicular and prostatic dissection, the suture of the dorsal venous plexus, a prostatectomy, an urethral vesical anast omosis, as well as the waterproof test, even including the performing of surgical steps using current concepts of anterior urethral suspension as the reconstruction of the posterior plane of the rhabdosphincter.

Results:

All steps of surgery could be reproduced in all ten porcine cases. No significant bleeding was observed and the surgical time was gradually reduced fifty percent from case one to last cases.

Conclusions:

The porcine model allowed the surgeon to replicate all the steps usually performed in a laparoscopic radical prostatectomy. The junior surgeons are better prepared to such difficult surgery. However, further studies will be necessary to prove the impact of the animal model presented in urological clinical practice.

Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

Development and validation of non-guided bladder-neck and neurovascular-bundle dissection modules of the RobotiX-Mentor® full-procedure robotic-assisted radical prostatectomy virtual reality simulation

Background

Full‐procedure virtual reality (VR) simulator training in robotic‐assisted radical prostatectomy (RARP) is a new tool in surgical education.

Methods

Description of the development of a VR RARP simulation model, (RobotiX‐Mentor®) including non‐guided bladder neck (ngBND) and neurovascular bundle dissection (ngNVBD) modules, and assessment of face, content, and construct validation of the ngBND and ngNVBD modules by robotic surgeons with different experience levels.

Results

Simulator and ngBND/ngNVBD modules were rated highly by all surgeons for realism and usability as training tool. In the ngBND‐task construct, validation was not achieved in task‐specific performance metrics. In the ngNVBD, task‐specific performance of the expert/intermediately experienced surgeons was significantly better than that of novices.

Conclusions

We proved face and content validity of simulator and both modules, and construct validity for generic metrics of the ngBND module and for generic and task‐specific metrics of the ngNVBD module.

Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial

Objectives

To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot‐assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP.

Patients and Methods

Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non‐randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon‐specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP.

Results

Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate.

Conclusions

There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.

The Use of Cumulative Sum Analysis to Derive Institutional and Surgeon-Specific Learning Curves for Robot-Assisted Radical Prostatectomy

Purpose: The cumulative sum (CUSUM) approach has been adopted to evaluate surgical competence in various contexts. The CUSUM method comprises sequential monitoring of cumulative differences from a target level in performance quality over time, allowing the detection of deviations from the target. We use the CUSUM method in this study to derive both institutional and surgeon-specific learning curves for robot-assisted radical prostatectomy (RARP). Patients and Methods: We reviewed 540 patients diagnosed with localized prostate cancer (pathologic stage T2) who underwent RARP at our institution between September 2011 and December 2017. The CUSUM method was used to construct both institutional and individual-surgeon learning curves; the outcome was assessed based on whether a positive surgical margin (PSM) was present. The target PSM rate was 20%. Of seven surgeons performing robot-assisted resections for this period, four who performed ≥60 resections were assessed separately. Results: Of 540 patients, 74 (14%) had PSMs. The institutional CUSUM chart exhibited a downward trend for the first 54 cases and an upward trend thereafter. The CUSUM chart for the earliest adopter was similar to that for the institution; that is, learning was complete at 45 cases. Two adopters did not undergo a learning curve as they consistently performed well. The last adopter required 10 cases for initial learning. However, his CUSUM chart trend became negative at 46 cases and remained so afterward. Conclusions: CUSUM charts are useful for monitoring surgical quality. Long-term monitoring of the PSM rate of a surgeon who has become independent allows an attending surgeon to intervene if necessary; thus, long-term quality control is assured.

Contemporary Comparison of Open to Robotic Prostatectomy at a Veteran's Affairs Hospital

INTRODUCTION

Among veterans, prostate cancer is the most common malignancy and has a higher incidence compared to the rest of the nation. No study has compared the effectiveness of Robotic-assisted-laparoscopic radical prostatectomy (RALP) vs. open radical prostatectomy (ORP) in the Veteran's Affairs (VA) hospital setting during the adoption of RALP.

METHODS

Institutional Review Board approval was obtained. Retrospective review was completed on Veterans with prostate cancer who underwent ORP or RALP from March 2011 to January 2017 during the introduction of RALP at one VA hospital. Perioperative and functional outcomes between ORP and RALP were compared as well as between the initial 50 and final 53 RALPs.

RESULTS

Among 91 ORPs and 153 RALPs, RALP had significant reductions in blood transfusions [2(1.3%) vs. 44(40%), p < 0.001], length of stay [2 days(1-2) vs. 3 days(2-4), p < 0.001], Clavien grade >2 complications [1(0.7%) vs. 20 (22.0%), p < 0.001], urine leak [2(1.3%) vs. 11 (12.1%), p < 0.001], and ICU readmissions [0(0%) vs. 3(3.3%), p < 0.001]. There were no significant differences in positive margin status or functional outcomes. Compared to the first 50 cases, the last 53 RALPs demonstrated a shorter operative time (349 vs. 292 min, p < 0.001), lower EBL (300 vs. 150 mL, p < 0.001), more frequent 1-day length of stay (34% vs. 60%, p = 0.02), and fewer composite adverse events (82% vs. 51%, p = 0.004). Operative time for the final 53 RALPs (292 minutes) was shorter than that of ORP (325 minutes, p = 0.013).

CONCLUSIONS

During the introduction of RALP at one VA hospital, RALP was associated with several improved parameters compared to ORP and similar operative times were noted after the first 100 cases of RALPs. RALP is safe to introduce in a VA setting without compromising outcomes.

Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study

INTRODUCTION

Robot-assisted radical prostatectomy (RARP) is a standard of care primary treatment for men with clinically localized prostate cancer (CLPC). The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for surgical performance. To date, no study has examined whether Canadian surgeons are achieving these benchmarks. We determined the proportion of University of Alberta (UA) urologic surgeons achieving the CUA surgical quality performance outcome (SQPO) benchmarks.

METHODS

A retrospective quality assurance analysis of prospectively collected data from the PROstate Cancer Urosurgery Repository of Edmonton (PROCURE) was performed. Men who underwent RARP for CLPC between September 2007 and May 2018 by one of seven surgeons were analyzed. SQPO were an unadjusted pT2-R1 resection rate <25%, blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. Descriptive statistics were used to determine the proportion of surgeons achieving the benchmarks.

RESULTS

Data were evaluable for 2821 men. Seven of seven (100%) surgeons achieved a blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. However, only six of seven surgeons achieved an unadjusted pT2-R1 resection rate <25%; one surgeon had an unadjusted pT2-R1 resection rate of 27.9%. Limitations include the lack of centralized pathology review for surgical margin status by a dedicated genitourinary pathologist.

CONCLUSIONS

UA surgeons are achieving the CUA SQPO benchmarks for blood transfusion, rectal injury, and perioperative mortality. However, not all UA urologists are achieving a pT2-R1 resection rate <25%. Surgical quality performance initiatives designed to improve cancer control may be warranted.

Systematic review of learning curves in robot-assisted surgery

Background

Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery.

Methods

MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients.

Results

Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology.

Conclusion

Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.

The safety of urologic robotic surgery depends on the skills of the surgeon

PURPOSE

To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

METHODS

A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

RESULTS

Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

CONCLUSION

To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.

The Impact of Experience on the Risk of Surgical Margins and Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Learning Curve Study

PURPOSE

Improved cancer control with increasing surgical experience (the learning curve) has been demonstrated for open and laparoscopic prostatectomy. We assessed the relationship between surgical experience and oncologic outcomes of robot-assisted radical prostatectomy.

MATERIALS AND METHODS

We analyzed the records of 1,827 patients in whom prostate cancer was treated with robot-assisted radical prostatectomy. Surgical experience was coded as the total number of robotic prostatectomies performed by the surgeon before the patient operation. We evaluated the relationship of prior surgeon experience to the probability of positive margins and biochemical recurrence in regression models adjusting for stage, grade and prostate specific antigen.

RESULTS

After adjusting for case mix, greater surgeon experience was associated with a lower probability of positive surgical margins (p = 0.035). The risk of positive margins decreased from 16.7% to 9.6% in patients treated by a surgeon with 10 and 250 prior procedures, respectively (risk difference 7.1%, 95% CI 1.7-12.2). In patients with nonorgan confined disease the predicted probability of positive margins was 38.4% in those treated by surgeons with 10 prior operations and 24.9% in those treated by surgeons with 250 prior operations (absolute risk reduction 13.5%, 95% CI -3.4-22.5). The relationship between surgical experience and the risk of biochemical recurrence after surgery was not significant (p = 0.8).

CONCLUSIONS

Specific techniques used by experienced surgeons which are associated with improved margin rates need further research. The impact of experience on cancer control after robotic prostatectomy differed from that in the prior literature on open and laparoscopic radical prostatectomy, and should be investigated in larger multi-institutional studies.

Improving patient safety during introduction of novel medical devices through cumulative summation analysis

OBJECTIVE The aim of this study was to implement cumulative summation (CUSUM) analysis as an early-warning detection and quality assurance system for preclinical testing of the iSYS1 novel robotic trajectory guidance system. METHODS Anatomically accurate 3D-printed skull phantoms were created for 3 patients who underwent implantation of 21 stereoelectroencephalography electrodes by surgeons using the current standard of care (frameless technique). Implantation schema were recreated using the iSYS1 system, and paired accuracy measures were compared with the previous frameless implantations. Entry point, target point, and implantation angle accuracy were measured on postimplantation CT scans. CUSUM analysis was undertaken prospectively. RESULTS The iSYS1 trajectory guidance system significantly improved electrode entry point accuracies from 1.90 ± 0.96 mm (mean ± SD) to 0.76 ± 0.57 mm (mean ± SD) without increasing implantation risk. CUSUM analysis was successful as a continuous measure of surgical performance and acted as an early-warning detection system. The surgical learning curve, although minimal, showed improvement after insertion of the eighth electrode. CONCLUSIONS The iSYS1 trajectory guidance system did not show any increased risk during phantom preclinical testing when used by neurosurgeons who had no experience with its use. CUSUM analysis is a simple technique that can be applied to all stages of the IDEAL (idea, development, exploration, assessment) framework as an extra patient safety mechanism. Further clinical trials are required to prove the efficacy of the device.

Risk of biochemical recurrence based on extent and location of positive surgical margins after robot-assisted laparoscopic radical prostatectomy

Background

There are no published studies on the simultaneous effect of extent and location of positive surgical margins (PSMs) on biochemical recurrence (BCR) after robot-assisted laparoscopic prostatectomy (RALP). The aim was to report the incidence, extent, and location of PSMs over the inclusion period as well as the rates of BCR and cancer-related mortality, and determine if BCR is associated with PSM extent and/or location.

Methods

Retrospective review of 530 consecutive patients who underwent RALP between 2003 and 2012. Kaplan-Meier (KM) survival analyses and Cox regressions were performed to determine variables associated with BCR.

Results

For the 530 operated patients, evaluated at a median of 92 months (IQR, 87–99), PSMs were observed in 156 (29%), of which 24% were focal. Out of 172 PSMs, 126 (73%) were focal and 46 (27%) were extensive. The KM survival using BCR as endpoint was 0.81 (CI, 0.78–0.85) at 5 years and was 0.67 (CI, 0.61–0.72) at 10 years; and using cancer-related mortality as endpoint was 0.99 (CI, 0.99–1.00) at 5 years and 0.95 (CI, 0.92–0.98) at 10 years. Multi-variable analysis revealed the strongest predictors of BCR to be Gleason score ≥ 8 (HR = 7.97; CI, 4.38–14.51) and 4 + 3 (HR = 3.88; CI, 2.12–7.07), lymph nodes invasion (HR = 3.42; CI, 1.70–6.91), pT stage 3b or 4 (HR = 3.07; CI, 1.93–4.90), and extensive apical PSMs (HR = 2.62; CI, 1.40–4.90) but not focal apical PSMs (HR = 0.86; CI, 0.49–1.50; p = 0.586).

Conclusion

Extensive apical PSMs significantly increased the risk of BCR, independently from pT stage, Gleason score and lymph nodes invasion, while focal apical PSMs had no significant effect on BCR.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5229-1) contains supplementary material, which is available to authorized users.

Unintended consequences of decreased PSA-based prostate cancer screening

BACKGROUND

In May 2012, the US Preventive Services Task Force issued a grade D recommendation against PSA-based prostate cancer screening. Epidemiologists have concerns that an unintended consequence is a problematic increase in high-risk disease and subsequent prostate cancer-specific mortality.

MATERIALS AND METHODS

To assess the effect of decreased PSA screening on the presentation of high-risk prostate cancer post-radical prostatectomy (RP). Nine high-volume referral centers throughout the United States (n = 19,602) from October 2008 through September 2016 were assessed and absolute number of men presenting with GS ≥ 8, seminal vesicle and lymph node invasion were compared with propensity score matching.

RESULTS

Compared to the 4-year average pre-(Oct. 2008-Sept. 2012) versus post-(Oct. 2012-Sept. 2016) recommendation, a 22.6% reduction in surgical volume and increases in median PSA (5.1-5.8 ng/mL) and mean age (60.8-62.0 years) were observed. The proportion of low-grade GS 3 + 3 cancers decreased significantly (30.2-17.1%) while high-grade GS 8 + cancers increased (8.4-13.5%). There was a 24% increase in absolute numbers of GS 8+ cancers. One-year biochemical recurrence rose from 6.2 to 17.5%. To discern whether increases in high-risk disease were due to referral patterns, propensity score matching was performed. Forest plots of odds ratios adjusted for age and PSA showed significant increases in pathologic stage, grade, and lymph node involvement.

CONCLUSIONS

All centers experienced consistent decreases of low-grade disease and absolute increases in intermediate and high-risk cancer. For any given age and PSA, propensity matching demonstrates more aggressive disease in the post-recommendation era.

Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy

OBJECTIVES

To compare perioperative outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RSP) for benign prostatic hypertrophy (BPH).

METHODS

Patient demographics and perioperative outcomes were compared between 600 patients undergoing HoLEP and 32 patients undergoing RSP at two separate academic institutions between 2008 and 2015.

RESULTS

Patients undergoing HoLEP and RSP had comparable ages (71 vs 71, p = 0.96) and baseline American Urological Association Symptom Scores (20 vs 24, p = 0.21). There was no difference in mean specimen weight (96 g vs 110 g, p = 0.15). Mean operative time was reduced in the HoLEP cohort (103 minutes vs 274 minutes, p < 0.001). Patients undergoing HoLEP had lesser decreases in hemoglobin, decreased transfusions rates, shorter hospital stays, and decreased mean duration of catheterization. There was no difference in the rate of complications Clavien grade 3 or greater (p = 0.33).

CONCLUSIONS

HoLEP and RSP are both efficacious treatments for large gland BPH. In expert hands, HoLEP appears to have a favorable perioperative profile. Further studies are necessary to compare long-term efficacy, cost, and learning curve influences, especially as minimally invasive approaches become more widespread.