Innovation and surgical clinical trials

Randomized Controlled Feasibility Trial of Robot-assisted Versus Conventional Open Partial Nephrectomy: The ROBOCOP II Study

BACKGROUND

There is no evidence from randomized controlled trials (RCTs) comparing robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN).

OBJECTIVE

To assess the feasibility of trial recruitment and to compare surgical outcomes between RAPN and OPN.

DESIGN, SETTING, AND PARTICIPANTS

ROBOCOP II was designed as single-center, open-label, feasibility RCT. Patients with suspected localized renal cell carcinoma referred for PN were randomized at a 1:1 ratio to either RAPN or OPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the feasibility of recruitment, assessed as the accrual rate. Secondary outcomes included perioperative and postoperative data. Data were analyzed descriptively in a modified intention-to-treat population consisting of randomized patients who underwent surgery.

RESULTS AND LIMITATIONS

A total of 50 patients underwent RAPN or OPN (accrual rate 65%). In comparison to OPN, RAPN had lower blood loss (OPN 361 ml, standard deviation [SD] 238; RAPN 149 ml, SD 122; difference 212 ml, 95% confidence interval [CI] 105-320; p < 0.001), less need for opioids (OPN 46%; RAPN 16%; difference 30%, 95% CI 5-54; p = 0.024), and fewer complications according to the mean Comprehensive Complication Index (OPN 14, SD 16; RAPN 5, SD 15; difference 9, 95% CI 0-18; p = 0.008). OPN has a shorter operative time (OPN 112 min, SD 29; RAPN 130 min, SD 32; difference -18 min, 95% CI -35 to -1; p = 0.046) and warm ischemia time (OPN 8.7 min, SD 7.1; RAPN 15.4 min, SD 7.0; difference 6.7 min, 95% CI -10.7 to -2.7; p = 0.001). There were no differences between RAPN and OPN regarding postoperative kidney function.

CONCLUSIONS

This first RCT comparing OPN and RAPN met the primary outcome of the feasibility of recruitment; however, the window for future RCTs is closing. Each approach has advantages over the other, and both remain safe and effective options.

PATIENT SUMMARY

For patients with a kidney tumor, open surgery and robot-assisted keyhole surgery are both feasible and safe approaches for partial removal of the affected kidney. Each approach has known advantages. Long-term follow-up will explore differences in quality of life and cancer control outcomes.

To Robot or Not To Robot: The Use of Robotics in Benign Gynecologic Surgery

The use of robotic-assisted laparoscopic surgery has continued to grow since the Food and Drug Administration approval for robotic-assisted gynecologic surgery in 2005. However, despite this growth in utilization, the data supporting its use in benign gynecologic surgery has not strongly supported its advantages over conventional laparoscopy. Controversy exists between supporters of robotic-assisted laparoscopic surgery and conventional laparoscopy. This article discusses the current literature regarding the use of robotic-assisted surgery in benign gynecologic surgery.

Prostatectomies for localized prostate cancer: a mixed comparison network and cumulative meta-analysis

No consensus has been attained regarding the utility of open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) for localized prostate cancer (PCa). We carried out a network meta-analysis and cumulative meta-analysis comparing RRP, LRP and RALRP on peri-operative and functional outcome measures. Electronic databases were searched for either randomized clinical trials or cohort studies comparing RALRP either with LRP or RRP in patients with localized PCa. Outcome measures were as follows: overall, pT2 and pT3-positive surgical margins (PSMs); biochemical recurrence (BCR); complication rates; estimated blood loss; blood transfusion rate; continence and potency rates; duration of catheterization and hospital stay. Publication bias, risk of bias and inconsistency were assessed. Inverse heterogeneity model was used for analysis. A total of 45 studies were included for the final analysis. We observed that RALRP and LRP did not differ significantly from RRP with regard to the following outcomes: overall PSM; pT2 and pT3 PSMs; OT; complication rate; continence and potency rates; total blood loss and hospital stay. Duration of catheterization was significantly shorter in RALRP than LRP and RRP while significant reductions in the need for blood transfusion and BCR were observed for both RALRP and LRP in comparison with RRP. To conclude, similar functional, operative and oncologic outcomes were observed for both RALRP and LRP compared to RRP.

Robotic radical prostatectomy after aborted prostatectomy: still feasible? The experience from a tertiary care center

To describe the surgical management of patients who had radical prostatectomy previously attempted but aborted due to diverse causes. Patients who underwent an "aborted prostatectomy" were extracted from the institutional prostatectomy database. A description of the tailored robotic approach was reported for each case. Tips and tricks for the accomplishment of robotic prostatectomy after aborted prostatectomy were reported. Six clinical cases were analyzed. Three patients had aborted prostatectomy due to complicated dissection hindered by pelvic mesh and bowel adhesions; one prostatectomy was aborted due to anesthesiology/respiratory matters; one for narrow pelvis; one due to abnormal pelvic vascular anatomy. All patients successfully underwent robotic prostatectomy at our institution. In five patients, standard transperitoneal robotic approach was performed. In one patient, robotic transperineal approach was mandatory. Median operative time was 282 min (86-460). Median estimated blood loss was 325 mL (50-1000). Two patients had positive surgical margins. One patient was found with nodal metastasis at final pathology. Neither perioperative nor postoperative complications were reported. At last follow-up, PSA was undetectable in 5/6 patients. Even after previous aborted prostatectomy, robot-assisted prostatectomy is feasible, with acceptable results. The case-by-case tailoring of the technique is the key for a successful intervention.

Defining Innovation in Neurosurgery: Results from an International Survey

BACKGROUND

Innovation is a part of the daily practice of neurosurgery. However, a clear definition of what constitutes innovation is lacking and opinions vary from continent to continent, from hospital to hospital, and from surgeon to surgeon.

METHODS

In this study, we distributed an online survey to neurosurgeons from multiple countries to investigate what neurosurgeons consider innovative, by gathering opinions on several hypothetical cases. The anonymous survey consisted of 52 questions and took approximately 10 minutes to complete.

RESULTS

A total of 355 neurosurgeons across all continents excluding Antarctica completed the survey. Neurosurgeons achieved consensus (>75%) in considering specific cases to be innovative, including laser resection of meningioma, focused ultrasonography for tumor, oncolytic virus, deep brain stimulation for addiction, and photodynamic therapy for tumor. Although the new dura substitute case was not considered innovative, there was consensus among neurosurgeons indicating that institutional review board approval was still necessary to maintain ethical standards. Furthermore, although 90% of neurosurgeons considered an oncolytic virus for glioblastoma multiforme to be innovative, only 78% believed that institutional review board approval was necessary before treatment.

CONCLUSIONS

Our results indicate that innovation is a heterogeneous concept among neurosurgeons that necessitates standardization to ensure appropriate patient safety without stifling progress. We discuss both the ethical drawbacks of not having a clear definition of innovation and the challenges in achieving a unified understanding of innovation in neurosurgery and offer suggestions for uniting the field.

Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis

The inaugural robot-assisted urological procedure in a child was performed in 2002. This study aims to catalogue the impact of this technology by utilizing bibliographic data as a surrogate measure for global diffusion activity and to appraise the quality of evidence in this field. A systematic literature search was performed to retrieve all reported cases of paediatric robot-assisted urological surgery published between 2003 and 2016. The status of scientific community acceptance was determined using a newly developed analysis model named progressive scholarly acceptance. A total of 151 publications were identified that reported 3688 procedures in 3372 patients. The most reported procedures were pyeloplasty (n = 1923) and ureteral reimplantation (n = 1120). There were 16 countries and 48 institutions represented in the literature. On average, the total case volume reported in the literature more than doubled each year (mean value increase 236.6% per annum). The level of evidence for original studies remains limited to case reports, case series and retrospective comparative studies. Progressive Scholarly Acceptance charts indicate that robot-assisted techniques for pyeloplasty or ureteral reimplantation are yet to be accepted by the scientific community. Global adoption trends for robotic surgery in paediatric urology have been progressive but remain low volume. Pyeloplasty and ureteral reimplantation are dominant applications. Robot-assisted techniques for these procedures are not supported by high quality evidence at present. Next-generation robots are forecast to be smaller, cheaper, more advanced and customized for paediatric patients. Ongoing critical evaluation must occur simultaneously with expected technology evolution.