A decade of robot-assisted radical prostatectomy training: Time-based metrics and qualitative grading for fellows and residents

Measures of performance and proficiency in robotic assisted surgery: a systematic review

Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.

Determining the component-based operative time learning curve for robotic-assisted radical prostatectomy

Objectives

To determine the learning curve (LC) of total operative time and the discrete components of the robotic-assisted radical prostatectomy (RARP) for a recent robotic fellowship-trained urologic surgeon.

Materials and methods

We performed a retrospective analysis of RARP procedures performed by a single new attending surgeon from August 2015 to April 2019. Patients' demographics and operative details were assessed. Total operative time was divided and prospectively recorded in 7 parts: (a) docking robot, (b) dissecting seminal vesicles (SVs) (c) dissecting endopelvic fascia (EPF), (d) incising bladder neck (BN), (e) completing the dissection, (f) lymph node dissection, and (g) urethrovesical anastomosis (UVA) and robot undocking. Cumulative sum analysis was used to ascertain the LC for total operative time and the 7 parts of the procedure.

Results

One hundred twenty consecutive RARPs were performed. The LC was overcome at 25 cases for total operative time, 13 cases for docking the robot, 33 cases for dissecting SVs, 31 cases for dissecting EPF, 46 cases for incising BN, 38 cases for prostate dissection, 25 cases for lymph node dissection, and 52 cases for UVA. Total operative time was decreased 22.8% (p < 0.0001) and time for robot docking, dissecting SVs, dissecting EPF, incising BN, completing prostate dissection, lymph node dissection, and UVA were decreased 16.7%, 30.5%, 29.5%, 36.2%, 37.3%, 32.2%, and 26.9%, respectively (all p < 0.05).

Conclusions

We observed a 25-case LC for a fellowship-trained urologist to achieve stable operative performance of RARP surgery. Procedural components demonstrated variable LCs including the UVA that required upward of 52 cases.

More than surgical tools: a systematic review of robots as didactic tools for the education of professionals in health sciences

Within the field of robots in medical education, most of the work done during the last years has focused on surgeon training in robotic surgery, practicing surgery procedures through simulators. Apart from surgical education, robots have also been widely employed in assistive and rehabilitation procedures, where education has traditionally focused in the patient. Therefore, there has been extensive review bibliography in the field of medical robotics focused on surgical and rehabilitation and assistive robots, but there is a lack of survey papers that explore the potential of robotics in the education of healthcare students and professionals beyond their training in the use of the robotic system. The scope of the current review are works in which robots are used as didactic tools for the education of professionals in health sciences, investigating the enablers and barriers that affect the use of robots as learning facilitators. Systematic literature searches were conducted in WOS and Scopus, yielding a total of 3812 candidate papers. After removing duplicates, inclusion criteria were defined and applied, resulting in 171 papers. An in-depth quality assessment was then performed leading to 26 papers for qualitative synthesis. Results show that robots in health sciences education are still developed with a roboticist mindset, without clearly incorporating aspects of the teaching/learning process. However, they have proven potential to be used in health sciences as they allow to parameterize procedures, autonomously guide learners to achieve greater engagement, or enable collective learning including patients and instructors "in the loop". Although there exist documented added-value benefits, further research and efforts needs to be done to foster the inclusion of robots as didactic tools in the curricula of health sciences professionals. On the one hand, by analyzing how robotic technology should be developed to become more flexible and usable to support both teaching and learning processes in health sciences education, as final users are not necessarily well-versed in how to use it. On the other, there continues to be a need to develop effective and standard robotic enhanced learning evaluation tools, as well good quality studies that describe effective evaluation of robotic enhanced education for professionals in health sciences. As happens with other technologies when applied to the health sciences field, studies often fail to provide sufficient detail to support transferability or direct future robotic health care education programs.

Validation of standardized training system for robot-assisted radical prostatectomy: comparison of perioperative and surgical outcomes between experienced surgeons and novice surgeons at a low-volume institute in Japan

INTRODUCTION

Although robot-assisted radical prostatectomy (RARP) has become a standard treatment modality in patients with prostate cancer (PCa), RARP is a complicated and difficult surgical procedure due to the risk of serious surgery-related complications. This study aimed to evaluate the validation of a standardized training system for RARP in patients with PCa at a single institute.

MATERIAL AND METHODS

We retrospectively reviewed the clinical and pathological records of 155 patients with PCa who underwent RARP at Gifu University between August 2018 and April 2021. We developed an institutional program for new surgeons based on the separation of the RARP procedure into six checkpoints. The primary endpoints were surgical outcomes and perioperative complications among three groups (expert, trainer, and novice surgeon groups).

RESULTS

The console time was significantly longer in the novice surgeon group than in the other groups. Regarding bladder neck dissection, ligation of lateral pedicles, and vesicourethral anastomosis, the operative time was significantly shorter in the expert group than in the other groups. Surgery-related complications occurred in 15 patients (9.7%).

CONCLUSIONS

Our training system for RARP might help reduce the influence of the learning curve on surgical outcomes and ensure that the surgeries performed at low-volume institutions are safe and effective.

Does YouTube include high-quality resources for training on laparoscopic and robotic radical prostatectomy?

PURPOSE

Our aim was to assess the educational quality of the YouTube video content related to laparoscopic and robotic radical prostatectomy (RP).

METHODS

An objective scoring tool named as Prostatectomy Assessment and Competency Evaluation (PACE) score was used to measure and quantify seven critical steps in RP including bladder drop, preparation of the prostate, bladder neck dissection, posterior/seminal vesicle dissection, neurovascular bundle preservation, apical dissection, and urethro-vesical anastomosis. A five-point scale was used for grading the seven steps, where a score of 1 and 5 represented the lowest and ideal performance, respectively. Additionally, descriptive statistics including the upload time, video length, view count, number of comments, likes, and dislikes were all recorded.

RESULTS

Of the 1688 videos (551 from laparoscopic RP, 567 from robotic RP, and 570 from robot-assisted RP), 226 videos were analyzed after excluding duplicate and irrelevant videos. Robotic/robot-assisted RP videos were found to be statistically longer than laparoscopic RP videos (p = 0.016). The PACE score of urethro-vesical anastomosis step in robotic RP videos was statistically higher than laparoscopic RP videos (p = 0.021). A weak but significant positive correlation between the video length and total PACE score (rho: 0.51; p = 0.04 for laparoscopic RP and rho: 0.43; p = 0.03 for robotic/robot-assisted RP) was found. A weak but positive correlation was also determined between number of likes and total PACE score (rho: 0.39; p = 0.02) for robotic/robot-assisted RP videos.

CONCLUSIONS

Although YouTube website includes high-quality videos for both laparoscopic and robotic/robot-assisted RP, there is no objective parameter to predict the educational quality of the videos.