1
|
Grivas N, Zachos I, Georgiadis G, Karavitakis M, Tzortzis V, Mamoulakis C. Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review. World J Urol 2021; 40:929-949. [PMID: 34480591 DOI: 10.1007/s00345-021-03815-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/17/2021] [Indexed: 12/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Nikolaos Grivas
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Ioannis Zachos
- Department of Urology, University Hospital of Larissa, University of Thessaly, Medical School, Larissa, Greece
| | - Georgios Georgiadis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Markos Karavitakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | - Vasilis Tzortzis
- Department of Urology, University Hospital of Larissa, University of Thessaly, Medical School, Larissa, Greece
| | - Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece.
| |
Collapse
|
2
|
The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair. J Robot Surg 2019; 14:205-210. [PMID: 31025244 DOI: 10.1007/s11701-019-00967-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/22/2019] [Indexed: 10/27/2022]
Abstract
While the majority of the literature written concerning minimally invasive hiatal hernia repair involves laparoscopy, little has been written concerning the transition to a robotic technique. We present our experience, with a transparent analysis of data, with regard to the introduction of robotic paraesophageal hernia (PEH) repair by an experienced laparoscopic surgeon. We reviewed our first 30 consecutive patients who underwent robotic PEH over a 2-year period after the introduction of robotic surgery at our institution. Patients were divided into two groups: the early experience group (procedures performed within the first year of introduction of robotic technique, n = 13) and a late experience group (procedures performed in the second year, n = 17). All procedures were performed by a single experienced foregut surgeon. The mean operative time for the early group was significantly greater than for the late group, 184 min versus 142 min, respectively (p < 0.01). Four patients in the early group required conversion to open, while zero patients in the late group required conversion (p = 0.03). Patient demographics and complications did not differ significantly between the two patient populations. The early robotic hiatal hernia repair experience can be more difficult than expected, even in the hands of an experienced laparoscopic team. We identify several areas of improvement including patient positioning, operating room team training, and technical experience. This data can help other surgeons prepare for the transition to robotic foregut surgery.
Collapse
|
3
|
Sivaraman A, Sanchez-Salas R, Prapotnich D, Yu K, Olivier F, Secin FP, Barret E, Galiano M, Rozet F, Cathelineau X. Learning curve of minimally invasive radical prostatectomy: Comprehensive evaluation and cumulative summation analysis of oncological outcomes. Urol Oncol 2017; 35:149.e1-149.e6. [DOI: 10.1016/j.urolonc.2016.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 08/08/2016] [Accepted: 10/23/2016] [Indexed: 12/30/2022]
|
4
|
Chang Y, Qu M, Wang L, Yang B, Chen R, Zhu F, Wang H, Wang Y, Lu X, Ma C, Shi Z, Dong Z, Chen H, Xu C, Sun Y, Gao X. Robotic-assisted Laparoscopic Radical Prostatectomy From a Single Chinese Center: A Learning Curve Analysis. Urology 2016; 93:104-11. [PMID: 27045710 DOI: 10.1016/j.urology.2016.03.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/09/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the learning curve of robotic-assisted laparoscopic radical prostatectomy (RALP) and analyze whether a surgeon's prior surgical experience has effects on the surgery. PATIENTS AND METHODS From April 2012 to August 2015, 3 surgeons performed RALP on 355 consecutive patients with prostate cancer. Among these cases, 184 were by surgeon A with prior open experiences, 92 by surgeon B with both open and laparoscopic experiences, and 79 by surgeon C with laparoscopic experiences only. Perioperative, oncological, and functional outcomes were evaluated and compared between surgeons. Learning curve patterns were evaluated to determine the number of cases to reach plateau. RESULTS Marked difference was observed in operative time among the 3 groups (all P <.05). Length of hospital stay was also statistically significant (all P <.001), except for that between Group B and Group C (P = .739). Continence at 1-year and 6-month postoperatively was better in Groups B and C compared with Group A (P <.001). Intraoperative blood loss, pathologic stage, positive surgical margin, biochemical recurrence-free rate, and other pathological findings showed no statistical significance between the groups. The number of cases required to reach plateau may vary for surgeons with different surgical experiences. CONCLUSION Different early surgical background may affect the perioperative parameters of novice RALP surgeons. Previous laparoscopic experiences may provide additional advantage in learning curve parameters compared with surgeons with open experiences only. A better overall continence for laparoscopic surgeons requires further validation.
Collapse
Affiliation(s)
- Yifan Chang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Min Qu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Linhui Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Chen
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Feng Zhu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haifeng Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xin Lu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chunfei Ma
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenkai Shi
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenyang Dong
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Huan Chen
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chuanliang Xu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yinghao Sun
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Xu Gao
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
5
|
Systematic review of learning curves for minimally invasive abdominal surgery: a review of the methodology of data collection, depiction of outcomes, and statistical analysis. Ann Surg 2014; 260:37-45. [PMID: 24670849 DOI: 10.1097/sla.0000000000000596] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine how minimally invasive surgical learning curves are assessed and define an ideal framework for this assessment. BACKGROUND Learning curves have implications for training and adoption of new procedures and devices. In 2000, a review of the learning curve literature was done by Ramsay et al and it called for improved reporting and statistical evaluation of learning curves. Since then, a body of literature is emerging on learning curves but the presentation and analysis vary. METHODS A systematic search was performed of MEDLINE, EMBASE, ISI Web of Science, ERIC, and the Cochrane Library from 1985 to August 2012. The inclusion criteria are minimally invasive abdominal surgery formally analyzing the learning curve and English language. 592 (11.1%) of the identified studies met the selection criteria. RESULTS Time is the most commonly used proxy for the learning curve (508, 86%). Intraoperative outcomes were used in 316 (53%) of the articles, postoperative outcomes in 306 (52%), technical skills in 102 (17%), and patient-oriented outcomes in 38 (6%) articles. Over time, there was evidence of an increase in the relative amount of laparoscopic and robotic studies (P < 0.001) without statistical evidence of a change in the complexity of analysis (P = 0.121). CONCLUSIONS Assessment of learning curves is needed to inform surgical training and evaluate new clinical procedures. An ideal analysis would account for the degree of complexity of individual cases and the inherent differences between surgeons. There is no single proxy that best represents the success of surgery, and hence multiple outcomes should be collected.
Collapse
|
6
|
Piegeler T, Dreessen P, Graber SM, Haile SR, Schmid DM, Beck-Schimmer B. Impact of intraoperative fluid administration on outcome in patients undergoing robotic-assisted laparoscopic prostatectomy--a retrospective analysis. BMC Anesthesiol 2014; 14:61. [PMID: 25100922 PMCID: PMC4123305 DOI: 10.1186/1471-2253-14-61] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/22/2014] [Indexed: 11/16/2022] Open
Abstract
Background Robotic-assisted laparoscopic prostatectomy (RALP) gained much popularity during the last decade. Although the influence of intraoperative fluid management on patients’ outcome has been largely discussed in general, its impact on perioperative complications and length of hospitalization in patients undergoing RALP has not been examined so far. We hypothesized that a more restrictive fluid management might lead to a shortened length of hospitalization and a decreased rate of complications in our patients. Methods Retrospective analysis of data of 182 patients undergoing RALP at an University Hospital (first series of RALP performed at the center). Results The amount of fluid administered was initially normalized for body mass index of the patient and the duration of the operation and additionally corrected for age and the interaction of these variables. The application of crystalloids (multiple linear regression model, estimate = -0.044, p = 0.734) had no effect on the length of hospitalization, whereas a negative effect was found for colloids (estimate = -8.317, p = 0.021). Additionally, a significant interaction term between age and the amount of colloid applied (estimate = 0.129, p = 0.028) was calculated. Evaluation of the influence of intraoperative fluid administration using multiple logistic regression models corrected for body mass index, duration of the surgery and additionally for age revealed a negative effect of crystalloids on the incidence of an anastomotic leak between bladder and urethra (estimate = -23.860, p = 0.017), with a significant interaction term between age and the amount of crystalloids (estimate = 0.396, p = 0.0134). Colloids had no significant effect on this particular complication (estimate = 1.887, p = 0.524). Intraoperative blood loss did not alter the incidence of an anastomotic leak (estimate = 0.001, p = 0.086), nor did it affect the length of hospitalization (estimate = 0.0001, p = 0.351). Conclusions In accordance to the findings of our study, we suggest that a standardized, more restrictive fluid management might be beneficial in patients undergoing RALP. In older patients this measure would be able to shorten the length of hospitalization and to decrease the incidence of anastomosis leakage as a major complication.
Collapse
Affiliation(s)
- Tobias Piegeler
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Pamela Dreessen
- Surgical Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Sereina M Graber
- Institute of Physiology and Center for Integrative Human Physiology, University of Zurich, Winterthurerstrasse 190, 8057 Zurich, Switzerland
| | - Sarah R Haile
- Institute for Social and Preventive Medicine, Division of Biostatistics, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Daniel Max Schmid
- Department of Urology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland ; Institute of Physiology and Center for Integrative Human Physiology, University of Zurich, Winterthurerstrasse 190, 8057 Zurich, Switzerland
| |
Collapse
|
7
|
Yang CK, Chung SD, Hung SF, Wu WC, Ou YC, Huang CY, Pu YS. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: the Taiwan Robot Urological Surgery Team (TRUST) experience. World J Surg Oncol 2014; 12:219. [PMID: 25031072 PMCID: PMC4118608 DOI: 10.1186/1477-7819-12-219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/04/2014] [Indexed: 12/16/2022] Open
Abstract
Background To report Taiwan’s experience in robot-assisted laparoscopic nephroureterectomy (RANU) for upper tract urothelial carcinoma (UTUC). Methods Twenty patients with a diagnosis of renal pelvic or ureteral urothelial carcinoma underwent RANU at three medical centers. We performed RANU by re-docking the robot after the nephrectomy with or without repositioning for excision of the distal ureter and bladder cuff. Results From November 2010 to July 2013, a total of 20 patients with a mean age of 70.1 +/- 9.9 years (range 43 to 92 years) and mean body mass index (BMI) of 22.9 +/-3.8 kg/m2 underwent RANU for renal pelvic or ureteral urothelial carcinoma. Mean operative time was 251.6 +/- 126.7 minutes (range 110 to 540 minutes), estimated blood loss was 50.0 +/- 42.9 mL (range 10 to 200 mL), and mean length of hospital stay was 6.7 +/- 2.4 days (range 4 to 12 days). Pathology data revealed 19 high and one low-grade urothelial carcinoma and staged Ta for three, T1 for five, T2 for five and T3 for seven. With a mean follow-up of 14.7 months (range 2 to 34 months), three intravesical recurrences developed in the bladder, and four of them also developed metastatic disease. Conclusions The TRUST early experience showed that RANU is a safe and feasible minimally invasive procedure for UTUC.
Collapse
Affiliation(s)
| | | | | | | | - Yen-Chuan Ou
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard, Taichung 40705, Taiwan.
| | | | | |
Collapse
|
8
|
Chen CC, Yang CK, Hung SW, Wang J, Ou YC. Outcome of vesicourethral anastomosis after robot-assisted laparoscopic radical prostatectomy: A 6-year experience in Taiwan. J Formos Med Assoc 2014; 114:959-64. [PMID: 24491994 DOI: 10.1016/j.jfma.2013.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 12/23/2013] [Accepted: 12/29/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND/PURPOSE The use of a da Vinci robotic system may improve the outcome of urological surgery. This study reports 6 years of experience with vesicourethral anastomosis (VUA) following robot-assisted laparoscopic radical prostatectomy (RALP) performed in Taichung Veterans General Hospital, Taichung, Taiwan. METHODS A total of 350 patients who underwent RALP by a single surgeon were reviewed. We followed Dr Patel's RALP procedure with minor modifications. VUA was checked with 120 mL and 200 mL saline in sequence. The urinary bladder was then pressed with endoscopic instruments. If a VUA leak was detected, it was sutured immediately. An 18-French silicon Foley's catheter was inserted and removed 7-14 days after RALP. Preoperative characteristics and perioperative complications were assessed. RESULTS Overall, 332 (94.85%) patients were without any leakage in the first step of the challenge, eight of whom had leakage in the second step. After repair, all were free from leakage. The other 18 patients had leakage in the first step of the challenge (5.14%). After repair, 12 patients were without leakage in the second step. However, one patient had urine leakage postoperatively. The other six patients had leakage in the second step. After repair, two patients were free from leakage, but the remaining four suffered from persistent minor urine leakage postoperatively. The urine leakage rate after RALP was 1.43% (5/350). The potential urine leakage after bladder challenge and endoscopic instruments pressing could be minimized to 0.29% (1/346). CONCLUSION VUA leakage after RALP is rare. Intraoperative VUA challenge is simple and feasible compared to postoperative retrograde cystography.
Collapse
Affiliation(s)
- Cheng-Che Chen
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Siu-Wan Hung
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - John Wang
- Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yen-Chuan Ou
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC; Institute of Medicine, Chung Sang Medical University, Taichung, Taiwan, ROC; Graduate Institute of Biomedicine and Biomedical Technology, Department of Applied Chemistry, National Chi-Nan University, Nantou, Taiwan, ROC.
| |
Collapse
|
9
|
Measuring competence development for performing high flow extracranial-to-intracranial bypass. J Clin Neurosci 2013; 20:1083-8. [DOI: 10.1016/j.jocn.2012.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 10/05/2012] [Accepted: 10/07/2012] [Indexed: 11/19/2022]
|
10
|
Jiménez-Rodríguez RM, Díaz-Pavón JM, de la Portilla de Juan F, Prendes-Sillero E, Dussort HC, Padillo J. Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Colorectal Dis 2013; 28:815-21. [PMID: 23242270 DOI: 10.1007/s00384-012-1620-6] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2012] [Indexed: 02/04/2023]
Abstract
INTRODUCTION One of the main uses of robotic assisted abdominal surgery is the mesorectal excision in patients with rectal cancer. The aim of the present study is to analyse the learning curve for robotic assisted laparoscopic resection of rectal cancer. PATIENTS AND METHODS We included in our study 43 consecutive rectal cancer resections (16 females and 27 males) performed from January 2008 through December 2010. Mean age of patients was 66 ± 9.0 years. Surgical procedures included both abdomino-perineal and anterior resections. We analysed the following parameters: demographic data of the patients included in the study, intra- and postoperative data, time taking to set up the robot for operations (set-up or docking time), operative time, intra- and postoperative complications, conversion rates and pathological specimen features. The learning curve was analysed using cumulative sum (CUSUM) methodology. RESULTS The procedures understudied included seven abdomino-perineal resections and 36 anterior resections. In our series of patients, mean robotic set-up time was 62.9 ± 24.6 min, and the mean operative time was 197.4 ± 44.3 min. Once we applied CUSUM methodology, we obtained two graphs for CUSUM values (operating time and success), both of them showing three well-differentiated phases: phase 1 (the initial 9-11 cases), phase 2 (the middle 12 cases) and phase 3 (the remaining 20-22 cases). Phase 1 represents initial learning; phase 2 plateau represents increased competence in the use of the robotic system, and finally, phase 3 represents the period of highest skill or mastery with a reduction in docking time (p = 0.000), but a slight increase in operative time (p = 0.007). CONCLUSION The CUSUM curve shows three phases in the learning and use of robotic assisted rectal cancer surgery which correspond to the phases of initial learning of the technique, consolidation and higher expertise or mastery. The data obtained suggest that the estimated learning curve for robotic assisted rectal cancer surgery is achieved after 21-23 cases.
Collapse
Affiliation(s)
- Rosa M Jiménez-Rodríguez
- Department of General Surgery, University Hospital Virgen del Rocío, C/Jándula 2, Bl-3, P-3, 4º2, 41013, Sevilla, Spain.
| | | | | | | | | | | |
Collapse
|
11
|
Current world literature. Curr Opin Urol 2012. [PMID: 23202289 DOI: 10.1097/mou.0b013e32835bb149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|