Effectiveness of postgraduate training for learning extraperitoneal access for robot-assisted radical prostatectomy

Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis

BACKGROUND

Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and efficacy between the two remain controversial. This study aimed to compare the perioperative, function, and positive surgical margin of extraperitoneal with transperitoneal approaches SP-RARP.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study is registered with PROSPERO (CRD 42023409667). We systematically searched databases including PubMed, Embase, Web of Science, and Cochrane Library to identify relevant studies published up to February 2023. Stata 15.1 software was used to analyze and calculate the risk ratio (RR) and weighted mean difference (WMD).

RESULTS

A total of five studies, including 833 participants, were included in this study. The SP-TPRP group is superior to the SP-EPRP group in intraoperative blood loss (WMD: - 43.92, 95% CI - 69.81, - 18.04; p = 0.001), the incidence of postoperative Clavien-Dindo grade II and above complications (RR: 0.55, 95% CI - 0.31, 0.99; p = 0.04), and postoperative continence recovery (RR: 1.23, 95% CI 1.05, 1.45; p = 0.04). Conversely, the hospitalization stays (WMD: 7.88, 95% confidence interval: 0.65, 15.1; p = 0.03) for the SP-EPRP group was shorter than that of the SP-TPRP group. However, there was no significant difference in operation time, postoperative pain score, total incidence of postoperative complications, and positive surgical margin (PSM) rates between the two groups (p > 0.05).

CONCLUSIONS

This study demonstrates that both extraperitoneal and extraperitoneal SP-RARP approaches are safe and effective. SP-TPRP is superior to SP-EPRP in postoperative blood loss, the incidence of postoperative Clavien-Dindo grade II and above complications, and postoperative continence recovery, but it is accompanied by longer hospital stays.

Learning curves in robot-assisted minimally invasive liver surgery at a high-volume center in Denmark: Report of the first 100 patients and review of literature

BACKGROUND AND OBJECTIVE

Minimally invasive liver surgery is evolving worldwide, and robot-assisted liver surgery (RLS) can deliver obvious benefits for patients. However, so far no large case series have documented the learning curve for RLS.

METHODS

We conducted a retrospective study for robotic liver surgery (RLS) from June 2019 to June 2022 where 100 patients underwent RLS by the same surgical team. Patients' variables, short-term follow-up, and the learning curve were analyzed. A review of the literature describing the learning curve in RLS was also conducted.

RESULTS

Mean patient age was 63.1 years. The median operating time was 246 min and median estimated blood loss was 100 mL. Thirty-two patients underwent subsegmentectomy, 18 monosegmentectomies, 25 bisegmentectomies, and 25 major hepatectomies. One patient (1.0%) required conversion to open surgery. Five patients (5%) experienced postoperative major complications, and no mortalities occurred. Median length of hospital stay was 3 days. R0 resection was achieved in 93.4% of the malignant cases. The learning curve consisted of three stages; there were no significant differences in operative time, transfusion rate, or complication rate among the three groups. Postoperative complications were similar in each group despite an increase in surgical difficulty scores. The learning effect was highlighted by significantly shorter hospital stays in cohorts I, II, and III, respectively. The included systematic review suggested that the learning curve for RLS is similar to, or shorter, than that of laparoscopic liver surgery.

CONCLUSIONS

In our experience, RLS has achieved good clinical results, albeit in the short term. Standardization of training leads to increasing proficiency in RLS with reduced blood loss and low complication rates even in more advanced liver resections. Our study suggests that a minimum of 30 low-to-moderate difficulty robotic procedures should be performed before proceeding to more difficult resections.

Extraperitoneal versus transperitoneal approach for robot-assisted radical prostatectomy: a contemporary systematic review and meta-analysis

We aim to evaluate the differences in peri-operative characteristics, surgical complications, and oncological and functional control between the extraperitoneal RARP (EP-RARP) and transperitoneal RARP (TP-RARP). A comprehensive database search was performed up to March 2021 for eligible studies comparing outcomes between EP-RARP versus TP-RARP. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO. A leave-one-out sensitivity analysis was performed to control for heterogeneity and risk of bias. A total of 16 studies were included with 3897 patients, including 2201 (56.5%) EP-RARPs and 1696 (43.5%) TP-RARPs. When compared to TP-RARP, EP-RARP offers faster operative time (MD - 14.4 min; 95% CI - 26.3, - 2.3), decreased length of post-operative stay (MD - 0.9 days, 95% CI - 1.3, - 0.4), and decreased rates of post-operative ileus (RR 0.2, 95% CI 0.1, 0.7) and inguinal hernia formation (RR 0.2, 95% CI 0.1, 0.5). There were no significant differences in total complications, estimated blood loss, positive surgical margins, or continence at 6 months. In this review, EP-RARP delivered similar oncological and functional outcomes, while also offering faster operative time, decreased length of post-operative stay, and decreased rates of post-operative ileus and inguinal hernia formation when compared to TP-RARP. These findings provide evidence-based data for surgical approach optimization and prompts future research to examine whether these findings hold true with recent advances in single-port RARP and outpatient RARP.

Training Modalities in Robot-assisted Urologic Surgery: A Systematic Review

CONTEXT

Novel surgical techniques demand that surgical training adapts to the need for technical and nontechnical skills.

OBJECTIVE

To identify training methods available for robot-assisted surgical (RAS) training in urology, evaluate their effectiveness in terms of validation, educational impact, acceptability, and cost effectiveness, and assess their effect on learning curves (LCs).

EVIDENCE ACQUISITION

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines searched Ovid Medline, Embase, PsycINFO, and the Cochrane Library. Results were screened to include appropriate studies. Quality was evaluated. Each method was evaluated, and conclusions were drawn regarding LCs.

EVIDENCE SYNTHESIS

Of 359 records, 24 were included (521 participants). Training methods included dry-lab training (n=7), wet-lab training (n=7), mentored training (n=7), and nonstructured pathways (n=5). Dry-lab training demonstrated educational impact by reducing console time and was acceptable in a study; 100% of participants confirmed face validity. Wet-lab training principally uses human cadaveric material; effectiveness is well rated, although dry-lab training and observation were rated as equally useful. Mentored programmes combine lectures, tutorials, observation, simulation, and proctoring. Minifellowships were linked to greater practice of RAS 1 yr later. LCs vary according to experience. One study found that surgeons from robot-related fellowships demonstrated fewer positive surgical margins than surgeons from laparoscopic-related fellowships (24% vs 34.6%; p=0.05) and reduced time (132 vs 152min; p=0.0003). Five studies examined nonstructured training pathways (clinical practice). Experience correlated with fewer complications (p=0.007), improved continence (p=0.049), and reduced time (p=0.002).

CONCLUSIONS

RAS training methods include dry and wet lab, mentored training, and nonstructured pathways. Limited available evidence suggests that they affect LCs differently and are rarely used alone. The different methods of training appear effective when combined. Their benefits must be explored to facilitate validated acceptable training with educational impact.

PATIENT SUMMARY

Robot-assisted training encompasses several methods used in combination, but more evidence is required to gain the greatest benefit and formulate future training pathways.

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection

OBJECTIVE

To determine an accurate incidence of lymphocele formation and its sequela after robot-assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort.

PATIENTS AND METHOD

Consecutive patients who underwent RARP and eLND and had a minimum follow-up of 3 months were included. All surgeries were performed by one surgeon via a transperitoneal approach, with patients uniformly receiving low-molecular-weight heparin. Patients were followed with serial ultrasonography (US) based on a predetermined schedule for lymphocele surveillance. Incidence and sequelae of lymphoceles were retrospectively assessed.

RESULTS

In all, 521 patients were analysed. The mean (sd) follow-up was 33.5 (22.8) months. Lymphocele developed in 9% and became symptomatic in 2.5%. All except one were detected at the 1-month postoperative US; however, 76% regressed by the 3-month US. If lymphocele persisted at 3 months, 64% developed symptoms associated with infection and required drainage. Having diabetes mellitus was significantly associated with a higher risk of developing an infected lymphocele. Other symptoms related to lymphocele were rare. Comparisons of patient characteristics between patients with and without lymphoceles did not show any significant prognostic indicators to predict the occurrence of lymphocele in neither univariate nor multivariate analysis in the present cohort.

CONCLUSION

The incidence of symptomatic lymphocele after transperitoneal RARP and eLND is rare. However, during follow-up, US imaging at 3 months after surgery appears advisable. If a lymphocele is detected at the 3-month follow-up US discussing percutaneous external drainage with the patient appears to be wise, as it may prevent the development of a symptomatic lymphocele in two-thirds of such patients.

Robot-assisted laparoscopic radical prostatectomy using modular training programme in a private hospital

The aim of the study was to demonstrate an efficacious robotic fellowship model that balances safety of patients, time efficiency and adequate training, in a private hospital. Sixty-four patients underwent robot-assisted laparoscopic radical prostatectomy using a 13-step modular training programme in a single private institute. The patients were compared with 64 consecutive patients operated on by the mentoring surgeon immediately prior to the implementation of the programme. The main parameters analysed included console time, total operating time, blood loss, positive surgical margin rate and postoperative complications. There was a marginal difference in mean console time (92.67 vs. 90.41 min; p = 0.02). Statistical difference disappeared when comparing mean total operating time (136.09 vs. 134.14 min; p = 0.16), mean blood loss (165 vs. 172 ml; p = 0.96) and margin positivity (8 vs. 13; p = 0.34). The trainee was able to complete significant numbers of modular training steps whilst maintaining momentum of the operation from the commencement of the fellowship programme. This study demonstrates that a comprehensive modular training programme in complicated robotic procedures could be implemented without compromising patient safety or time efficiency.

Impact of trainee involvement with robotic-assisted radical prostatectomy

Robotic-assisted surgery has been rapidly adopted within urology practice. As a result, academic centers are challenged with the burden of how to effectively train residents and fellows to perform robotic-assisted surgery without compromising outcomes. We evaluated the perioperative outcomes of trainee involvement with robotic-assisted radical prostatectomy (RARP) within our healthcare organization. We retrospectively reviewed RARP cases performed at our institution between September 2008 and December 2010 using a single da Vinci robotic platform. Trainees consisted of urology residents and fellows who operated with staff surgeons on select operating days, whereas two staff surgeon teams performed RARP on alternate days. We compared clinicopathologic variables including operating time, estimated blood loss, surgical margin rates, and complication rates between the trainee and staff-only surgeon groups. Overall, 1,019 RARP surgeries were performed within the study period and trainees participated in 162 cases (16 %). Clinical characteristics were similar between men undergoing surgery with a trainee and those without. Positive surgical margin rates were lower for patients with pT2 disease for cases with trainee involvement (11 vs. 19 %, p = 0.02), although overall margin rates and margin rates for patients with pT3 disease were similar between the groups (p = 0.34). Surgical cases involving trainees were longer (241 vs. 200 min, p < 0.001) and resulted in higher estimated blood loss (190 vs. 120 mL, p < 0.001) than the two staff surgeon cases. However, transfusion rates as well as intraoperative and postoperative complication rates did not differ significantly between groups. In conclusion, surgical margin rates were lower in teaching cases for patients with pT2 disease. Importantly, trainee involvement in RARP is safe, with similar perioperative outcomes to staff-only surgical cases. This information may be useful for training and surgical planning.

Robot-assisted extended pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP): a video-based illustration of technique, results, and unmet patient selection needs

OBJECTIVE

• To describe the differences in technique and results between standard vs extended template pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) using a robot-assisted (RA) technique.

PATIENTS AND METHODS

• Using extended templates illustrated for the open surgical technique, a RA technique was developed to solve obstacles related to surgical exposure, identification of key landmarks, proper sequencing of operative steps, and prevention of complicationsshown in the accompanying video. • From May 2006 to October 2007, 261 patients underwent a standard PLND, and from November 2007 to November 2010, 670 underwent an extended PLND (E-PLND) by one surgeon.

RESULTS

• The lymph node (LN) yield increased from a median(interquartile range) of 8 (5-11) to 16 (11-21) with the extended technique (P < 0.001). • The ratio of positive LNs increased from 7% to 18%. Among E-PLND cases by risk group, positive LNs were found in 39%, 9%, and 3% of high-, intermediate-, and low-risk cases, and the later two groups strongly associated with upgrading and/or upstaging. • Extensive clipping appears necessary to avoid postoperative lymphoceles, and peritoneal fenestration for the extraperitoneal technique. • The median operative duration for E-PLND was 42 min, roughly double that of a standard PLND.

CONCLUSIONS

• E-PLND is feasible with a RA technique, and increases the LN yield and positive LN ratio;the latter especially in high-risk disease. • The procedure takes twice as long and requires several updates in technique shown in the video.