Evaluating the Learning Curve of Experienced Laparoscopic Surgeons in Robot-Assisted Radical Prostatectomy

Objective performance indicators during specific steps of robotic right colectomy can differentiate surgeon expertise

BACKGROUND

Current surgical assessment tools are subjective and nonscalable. Objective performance indicators, calculated from robotic systems data, provide automated data regarding surgeon movements and robotic arm kinematics. We identified objective performance indicators that significantly differed among expert and trainee surgeons during specific steps of robotic right colectomy.

METHODS

Endoscopic videos were annotated to delineate surgical steps during robotic right colectomies. Objective performance indicators were compared during mesenteric dissection, ascending colon mobilization, hepatic flexure mobilization, and bowel preparation for transection.

RESULTS

Twenty-five robotic right colectomy procedures (461 total surgical steps) performed by 2 experts and 8 trainees were analyzed. Experts exhibited faster camera acceleration and jerk during all steps, as well as faster dominant and nondominant arm acceleration and dominant arm jerk during all steps except distal bowel preparation. During mesenteric dissection, experts used faster camera and dominant arm velocity. During medial-to-lateral ascending colon mobilization, experts used less-dominant wrist yaw and pitch, faster nondominant arm velocity, shorter dominant arm path length, and shorter moving times for camera, dominant arm, and nondominant arm. During lateral-to-medial ascending colon mobilization, experts had faster dominant and nondominant arm velocity and third-arm acceleration. During hepatic flexure mobilization, experts exhibited more camera movements, greater velocity for camera, dominant and nondominant arms, and faster third-arm acceleration. During distal bowel preparation, experts used greater dominant wrist articulation, faster camera velocity, and longer nondominant arm path length. During proximal bowel preparation, experts demonstrated faster nondominant arm velocity.

CONCLUSION

Objective performance indicators can differentiate experts from trainees during distinct steps of robotic right colectomy. These automated, objective and scalable metrics can provide personalized feedback for trainees.

A Clinical Evaluation of Robotic-assisted Radical Prostatectomy (RARP) in Located Prostate Cancer: A Systematic Review and Network Meta-analysis

Prostate cancer (PCa) is a prevalent malignant tumor affecting the male reproductive system and there are mainly three widely accepted PCa surgery types in current clinical treatment: open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). Here, we aimed to evaluate the clinical effect of RARP for PCa patients compared with ORP and LRP based on the context of PCa encompass two dimensions: oncological outcomes (biochemical recurrence (BCR) and positive surgical margin (PSM)) and functional outcomes (urinary continence and recovery of erectile function) in this network meta-analysis (NMA). PubMed, Embase and Cochrane databases were systematically searched in January 7, 2024. 4 randomized controlled trials (RCTs) and 72 non-RCTs were included. RARP displayed significant positive effect on lower BCR and better recovery of erectile function but no significant differences existed among three surgery types for PSM and urinary continence.

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.

Retzius-sparing robot-assisted radical prostatectomy in a medium size oncological center holds adequate oncological and functional outcomes

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has emerged as a surgical option for patients with prostatic cancer in high-volume centers. The objective is to assess oncological and functional outcomes when implementing RS-RARP in a medium-volume center without previous experience of robotic surgery. This is a prospective observational single-center study. Patients operated between July 2017 and April 2020 were divided into two consecutive groups, A and B, each with 104 patients. The surgeons had prior experience in laparoscopic surgery and underwent robotic training. Positive surgical margin (PSM) status, urinary continence, and erectile function projected by Kaplan-Meier curves, together with patient reported quality of life outcomes at 12 months post-surgery were documented. Median patient age was 63 years (IQR = 59-67), overall PSM rate were 33%, 28% for pT2 disease. Pre-operative values showed no significant difference between both groups. The rate of urinary continence dropped from 81 to 78% (SE = 5.7) (Group A) and from 90 to 72% (SE = 6.3) (Group B) using the International Consultation on Incontinence Questionnaire-Short Form. Baseline sexual function was regained in 41% (Group A) and 47% (Group B) of patients. The median Expanded Prostate Index Composite-26 total score decreased from 86 to 82. These outcomes relate favorably to prior reports. There was a clinically significant decrease in median operative time in the successive groups with post-operative complications occurring in less than 2% of surgical procedures overall. A 12-month follow-up suggests that RS-RARP may be safely introduced in a medium-volume center without previous experience of robotic surgery.

Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy

INTRODUCTION AND OBJECTIVE

The most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival.

PATIENTS AND METHOD

Prospective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p).

RESULTS

Cohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance.

CONCLUSIONS

The surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

The transferability of laparoscopic and open surgical skills to robotic surgery

BACKGROUND

Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.

METHODS

Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).

RESULTS

The mean leak pressure of bowel anastomosis was 36.25 (7.62-64.89) mmHg in the laparoscopic training group and 69.01 (28.02-109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96-141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37-19.04) in the laparoscopic training group, 18.14 (14.70-21.58) in the open surgery group, and 22.04 (19.29-24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.

CONCLUSION

In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.

Robotic-assisted radical prostatectomy with preceptor's assistance: the training experience and outcomes in South America

Prostate cancer is currently the second leading cause of cancer deaths in Brazilian men. In 2020, sixty-five thousand new prostate cancer cases were expected in Brazil, and almost 30% of these patients are estimated to be from the northeast region. However, from 75 robotic platforms available in the country, only one is accessible in the state of Ceará since 2015. This study reports the intraoperative, functional, and oncological outcomes of patients who underwent radical prostatectomy for prostate cancer performed by robotic surgeons during a training period supervised by a proctor. We also compared these results with the literature reporting the experience of different Brazilian centers. We retrospectively analyzed prospectively collected data of 58 initial cases of robotic-assisted radical prostatectomy at a private Brazilian hospital in Fortaleza, Ceará. The surgeries were performed by two robotic surgeons during the training period under proctor supervision. We reported the epidemiological and intraoperative data, complications, pathological report, functional and oncological outcomes. The median operative time was 180 min. None of the patients needed conversion or blood transfusion. The pathology report described 21.81% of positive surgical margins (16.27% of all pT2 and 45.45% of all pT3 patients). The median follow-up was 40 months. Biochemical recurrence occurred in 21.73%, continence in 92%, and potency in 79.54%. No major complications (Clavien grades III-V) were reported. In our experience, robotic-assisted radical prostatectomy performed by surgeons training with proctor's assistance is feasible and safe. The operative time, complication rates, functional and oncological outcomes were satisfactory and compatible with the literature.

Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: A retrospective cohort study

OBJECTIVE

We compared the learning curve and pathologic and functional outcomes of retropubic radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RARP) performed during the same time period by a novice to identify how the two surgical types affect each other.

METHODS

We retrospectively reviewed 480 men who underwent RRP or RARP for prostate cancer between January 2008 and December 2012. Operation time, estimated blood loss (EBL), positive surgical margin (PSM) rate, urinary continence and potency recovery, and complications were compared. Scatter-graphs were drawn using locally weighted scatterplot smoothing (LOWESS).

RESULTS

Operation time reached the lowest point in the 90th case in RRP and the 200th case in RARP. EBL showed a similar pattern, reaching the lowest point in the 95th case in RRP and the 230th case in RARP. The lowest points for both operation time and EBL took about 3 years to reach for both surgical types. PSM rate was not significantly different (P = 0.807). No pads were required at 6 and 12 months in 55.6% and 66.9% of patients in RRP, respectively, but in 79.6% and 88.4% of patients in RARP. The potency recovery rates were 59.1% in RRP and 70.9% in RARP at 12 months.

CONCLUSIONS

When RRP and RARP were begun contemporaneously by a novice, they showed similar learning curve patterns. The direct tactile feedback in RRP and the magnified field of view and detailed techniques in RARP help improve surgical skills complementarily to attain proficiency in both surgical types.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Laparoscopic radical prostatectomy versus robot-assisted radical prostatectomy: comparison of oncological outcomes at a single center

Purpose

The aim of the present study was to evaluate the pathological and oncological outcomes of laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) performed by one surgeon at a single center.

Subjects

We evaluated 700 patients with localized prostate cancer (i.e., 250 received LRP and 450 received RARP) in the study. The clinicopathological outcomes, positive surgical margin (PSM) frequency, and biochemical recurrence (BCR)–free survival were compared between LRP and RARP.

Results

At diagnosis, the median patient age and level of prostate-specific antigsen in the serum for LRP were 68 years and 8.1 ng/ml, respectively, while those for RARP were 66 years and 7.7 ng/ml, respectively. In the LRP group, the overall PSM rate was 31.2% (11.1% for pT2a, 19.0% for pT2b, 25.0% for pT2c, 60.0% for pT3a, 64.3% for pT3b, and 50% for pT4). In the RARP group, the overall PSM rate was 20.7% (4.8% for pT2a, 15.9% for pT2b, 12.9% for pT2c, 36.9% for pT3a, 46.2% for pT3b, and 100% for pT4). The PSM rate was significantly lower for RARP in men with pT2c, pT3a, or pT3b disease (p = 0.006, p = 0.009, and p = 0.027, respectively). Based on the multivariate analysis, RARP reduced the risk of BCR (hazard ratio = 0.8, p = 0.014).

Conclusions

We compared the pathological findings and rates of BCR-free survival between patients who received LRP and those who received RARP at a single center. The rate of BCR-free survival was significantly higher in men classified as D'Amico high-risk patients who received RARP versus that reported in D'Amico high-risk patients who received LRP.

The role of laparoscopic experience on the learning curve of HoLEP surgery: A questionnaire-based study

OBJECTIVE

Holmium laser enucleation of the prostate (HoLEP) is an established method for treating benign prostatic obstruction. Nonetheless, its steep learning curve limits its wide distribution. The purpose of the present study was to demonstrate the impact of laparoscopic experience on HoLEP learning curve by evaluating the association between learning curves of surgeons performing both laparoscopy and HoLEP surgery.

MATERIAL AND METHODS

A questionnaire was prepared to identify surgeon's experience on laparoscopy and HoLEP, as well as their learning curves. This questionnaire was then distributed via e-mail to 110 urologists who are actively involved in endourology/laparoscopy.

RESULTS

Of the 110 urologists, 80 (72.7%) responded and completed the questionnaire. Of the 80 surgeons, 47 (58.8%) reported that they had completed the HoLEP learning curve with <20 cases. Moreover, 33 (41.2%) reported that they were able to complete the learning curve by performing >20 cases. Completion of the HoLEP learning curve in <20 cases was reached at 1.3%, 13.8%, and 43.8% by beginner, moderate skilled, and experienced laparoscopists, respectively (p<0.001).

CONCLUSION

Laparoscopic experience appears to be beneficial for surgeons while learning HoLEP. Highly experienced laparoscopic surgeons have a shorter HoLEP learning curve.

Does Previous Laparoscopic Experience Influence Basic Robotic Surgical Skills?

OBJECTIVE

Studies addressing the effect of laparoscopic experience on robotic skills have produced conflicting results. This study aimed to compare simulated robotic surgical tasks using the virtual reality simulator dV-Trainer between laparoscopically experienced surgeons and first-year surgical residents.

DESIGN

A cross-sectional study. Participants completed 4 trials of the following tasks on the dV-Trainer: Peg Board 2, Ring and Rail 1, and Suture Sponge 1. Performance was recorded using a computerized built-in scoring algorithm. Scores and metrics were compared between groups 1 and 2 and between the first and subsequent trials.

SETTING

Hospital de Clínicas, Porto Alegre, Brazil, a tertiary care teaching hospital.

PARTICIPANTS

Twenty laparoscopically experienced surgeons (group 1) and 20 first-year surgical residents (group 2). All participants completed the study.

RESULTS

The overall scores for Peg Board 2 (738.04 ± 267.83 vs 730.39 ± 225.31; p  = 0.57), Ring and Rail 1 (919.03 ± 242.69 vs 965.84 ± 222.96; p  =  0.13), and Suture Sponge 1 (563.62 ± 185.50 vs 560.99 ± 152.71; p = 0.67) did not differ significantly between groups 1 and 2. Group 1 had better results for master workspace range in Peg Board 2 and Ring and Rail 1. Group 2 had higher scores for economy of motion in Peg Board 2 and Ring and Rail 1 and for excessive instrument force in Ring and Rail 1. In both groups, the overall scores in the third and fourth trials were significantly higher than those in the first trial.

CONCLUSIONS

There are no significant differences in the performance of simulated robotic surgical tasks between laparoscopically experienced surgeons and laparoscopically naïve surgical residents. Some slight differences were observed in specific metrics, but these differences were not sufficient to change the final results. We may assume that laparoscopic experience should not be an essential step in the initial learning curve of robotic surgery.

Getting ready for the first robotic prostatectomy, from basics to real practice

PURPOSE OF REVIEW

Robot-assisted radical prostatectomy (RARP) has been embraced by urologists and has become a treatment standard in many countries already. Learning how to perform a RARP is challenging and has not yet been standardized. The current review summarizes the latest concepts regarding the most effective way of training for RARP.

RECENT FINDINGS

The strategy to learn RARP should comprise didactic activities, skills lab training, participating in surgeries and mentorship. Skills lab and virtual simulators are valuable tools to develop manual abilities and to overcome the initial technical learning curve. Participating in surgeries is crucial for familiarization with the robot installation, steps of the surgical procedure and is essential for troubleshooting. Mentorship improves learning and is the safest way to initiate real practice. Innate and individual background variances were suggested to influence the learning process; however, there is paucity of robust evidence correlating previous surgical experience and, for example videogame playing with faster learning of RARP. Structured curricula were proposed to orient the training for robotic surgery; currently, only one is focused exclusively on urology.

SUMMARY

Systematic training is the most effective way to learn and surpass the possibly intense learning curve of RARP. Training activities should focus on developing cognitive and manual abilities. The existing curricula for robotic surgery training still require constant refinement; however, they offer good and structured guidance to train for RARP.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy

Introduction:

This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP.

Patients and Methods:

110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used.

Results:

The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad).

Conclusions:

The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

INTRODUCTION

Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience.

METHODS

We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1-Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4).

RESULTS

The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period.

CONCLUSIONS

Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

[Ablative therapy in urology: Good practice and perspective]

INTRODUCTION

To expose the main point of discussion from present ablative therapies' guidelines and propose global perspectives.

MATERIALS AND METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com/) using different associations of keywords "ablative therapy" ; "prostate cancer"; "kidney cancer"; "guidelines"; "hybrid operating room". Publications obtained were selected based on methodology, language and relevance.

RESULTS

Present guidelines on ablative therapies in urology are, considering authors and organs, either particularly prudent (EAU guidelines for prostate and kidney) or relatively optimistic (CIRSE guidelines). This discrepancy is related to a low level of proof. So, a new approach is mandatory: more homogeneous in methodology, and especially more open to a new organization sparing economic efficiency. The objective will be to get multifunctional and multidisciplinaries platforms, in facts and in minds. It will induce, in the future, a deep reflection about training and boundaries' specialties.

CONCLUSION

Ablative therapies represent a crucial stake for urology and a clear example of medicosurgical evolution in future, based on new technologies (energy, robotic, imaging). A serious and deep reflection is necessary to prepare it and be deeply involved in.

Robot-assisted radical prostatectomy has lower biochemical recurrence than laparoscopic radical prostatectomy: Systematic review and meta-analysis

Purpose

To assess the effectiveness and safety of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer.

Materials and Methods

Existing systematic reviews were updated to investigate the effectiveness and safety of RARP. Electronic databases, including Ovid MEDLINE, Ovid Embase, the Cochrane Library, KoreaMed, Kmbase, and others, were searched through July 2014. The quality of the selected systematic reviews was assessed by using the revised assessment of multiple systematic reviews (R-Amstar) and the Cochrane Risk of Bias tool. Meta-analysis was performed by using Revman 5.2 (Cochrane Community) and Comprehensive Meta-Analysis 2.0 (CMA; Biostat). Cochrane Q and I2 statistics were used to assess heterogeneity.

Results

Two systematic reviews and 16 additional studies were selected from a search performed of existing systematic reviews. These included 2 randomized controlled clinical trials and 28 nonrandomized comparative studies. The risk of complications, such as injury to organs by the Clavien-Dindo classification, was lower with RARP than with LRP (relative risk [RR], 0.44; 95% confidence interval [CI], 1.23–0.85; p=0.01). The risk of urinary incontinence was lower (RR, 0.43; 95% CI, 0.31–0.60; p<0.000001) and the potency rate was significantly higher with RARP than with LRP (RR, 1.38; 95% CI, 1.11–1.70; I²=78%; p=0.003). Regarding positive surgical margins, no significant difference in risk between the 2 groups was observed; however, the biochemical recurrence rate was lower after RARP than after LRP (RR, 0.59; 95% CI, 0.48–0.73; I²=21%; p<0.00001).

Conclusions

RARP appears to be a safe and effective technique compared with LRP with a lower complication rate, better potency, a higher continence rate, and a decreased rate of biochemical recurrence.

Comparison of perioperative, functional, and oncologic outcomes between standard laparoscopic and robotic-assisted radical prostatectomy: a systemic review and meta-analysis

BACKGROUND

Robotic surgery has been developed with an attempt to reduce the difficulty of complex laparoscopic procedures. The goal of this study was to perform a systemic review and meta-analysis to evaluate the perioperative, functional, and oncologic outcomes between laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RARP) through all relevant comparative studies.

METHODS

A literature search of EMBASE, MEDLINE, PubMed, and Cochrane Library databases was conducted. We selected randomized controlled trials (RCTs) and non-randomized comparative studies (including prospective and retrospective studies) comparing perioperative, functional, or oncologic outcomes of both LRP and RARP, and meta-analysis was applied using the Review Manager V5.3 software.

RESULTS

Twenty-four studies were identified in the literature search, including 2 RCTs, 7 prospective studies, and 15 retrospective studies. LRP and RARP showed similarity in the operative time, catheterization duration, in-hospital stay, and overall complication rate. However, blood loss [mean difference (MD) 75.94; p = 0.03] and transfusion rate [odds ratio (OR) 2.08; p = 0.001] were lower in RARP. Moreover, RARP was associated with significantly improved outcomes for continence and potency rates to those of LRP at 3, 6, and 12 months postoperatively. Overall positive surgical margin (PSM) rate (OR 0.88; p = 0.03) was lower in LRP. However, there was no significant differences in ≤pT2 (OR 0.94; p = 0.69) and ≥pT3 (OR 0.94; p = 0.73) PSM rates between LRP and RARP. Additionally, LRP and RARP owned similar biochemical recurrence (BCR) rate (OR 1.15; p = 0.90).

CONCLUSIONS

RARP was associated with lower blood loss and transfusion rate and much greater functional outcomes in contrast to LRP. However, there was no conclusive evidence that RARP was advantaged in terms of perioperative (except for blood loss and transfusion rate) and oncologic outcomes.

Complications of the first 500 extra-peritoneal robot-assisted radical prostatectomy (EP-RARP) cases in an Italian medium volume centre

OBJECTIVE

The aim of this study was to evaluate the prevalence and the predictors of postoperative complications in Extra-Peritoneal Robot Assisted Radical Prostatectomy (EP-RARP), and also to test the influence of the surgeons skills on perioperative variables and complications.

MATERIALS AND METHODS

Data from the first consecutive 500 patients who underwent EP-RARP were prospectively collected from December 2004 and June 2014. Mean follow-up was 55.7 months. Standardized criteria were used to report the procedural complications. Independent predictors of complications were examined through multivariate analysis using logistic regression models. The influence of the surgeons learning curves on perioperative variables was tested.

RESULTS

One hundred fifty (30%) patients experienced complications, with 104 medical complications in 95 (19%) patients and 89 surgical complications in 72 (14.4%) patients. There were 17 major (Clavien IIIa-b) surgical complications in 15 (3%) patients, with no mortality. Multivariate analysis showed that Charlson score [odds ratio: 1.514; 95% confidence interval (95% CI): 1.145-2.002; p = 0.0003] and gastroenteric diseases (odds ratio 1.108; 95% CI: 1.108-4.560; p = 0.003) were the best predictors of medical complications and cT1c/T2a stages (odds ratio: 2.697; 95% CI: 1.319-5.514; p&lt;0.0001) and blood transfusions (odds ratio: 3.328; 95% CI: 1.471-7.530; p&lt;0.0001) were strongly related to surgical complications. Finally, the statistical evaluation showed that all considered perioperative variables, except the complication rates, improved during the study period.

CONCLUSIONS

With a precise report of the morbidity related to EP-RARP, this study showed that complications were relatively frequent, but their severity was generally low.

Robotic-assisted radical prostatectomy learning curve for experienced laparoscopic surgeons: does it really exist?

Background

Robotic-assisted radical prostatectomy (RALP) is a minimally invasive procedure that could have a reduced learning curve for unfamiliar laparoscopic surgeon. However, there are no consensuses regarding the impact of previous laparoscopic experience on the learning curve of RALP. We report on a functional and perioperative outcome comparison between our initial 60 cases of RALP and last 60 cases of laparoscopic radical prostatectomy (LRP), performed by three experienced laparoscopic surgeons with a 200+LRP cases experience.

Materials and Methods

Between January 2010 and September 2013, a total of 60 consecutive patients who have undergone RALP were prospectively evaluated and compared to the last 60 cases of LRP. Data included demographic data, operative duration, blood loss, transfusion rate, positive surgical margins, hospital stay, complications and potency and continence rates.

Results

The mean operative time and blood loss were higher in RALP (236 versus 153 minutes, p<0.001 and 245.6 versus 202ml p<0.001). Potency rates at 6 months were higher in RALP (70% versus 50% p=0.02). Positive surgical margins were also higher in RALP (31.6% versus 12.5%, p=0.01). Continence rates at 6 months were similar (93.3% versus 89.3% p=0.43). Patient’s age, complication rates and length of hospital stay were similar for both groups.

Conclusions

Experienced laparoscopic surgeons (ELS) present a learning curve for RALP only demonstrated by longer operative time and clinically insignificant blood loss. Our initial results demonstrated similar perioperative and functional outcomes for both approaches. ELS were able to achieve satisfactory oncological and functional results during the learning curve period for RALP.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

A Generalized Assessment of the Impact of Regionalization and Provider Learning on Patient Outcomes

We present a generalized model to assess the impact of regionalization on patient care outcomes in the presence of heterogeneity in provider learning. The model characterizes best regionalization policies as optimal allocations of patients across providers with heterogeneous learning abilities. We explore issues that arise when solving for best regionalization, which depends on statistically estimated provider learning curves. We explain how to maintain the problem's tractability and reformulate it into a binary integer program problem to improve solvability. Using our model, best regionalization solutions can be computed within reasonable time using current-day computers. We apply the model to minimally invasive radical prostatectomy and estimate that, in comparison to current care delivery, within-state regionalization can shorten length of stay by at least 40.8%.

Robot-assisted laparoscopic total extraperitoneal hernia repair during prostatectomy: technique and initial experience

Introduction

To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes.

Material and methods

12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure.

Results

Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data.

Conclusions

Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

A Critical Analysis of the Learning Curve and Postlearning Curve Outcomes of Two Experience- and Volume-Matched Surgeons for Laparoscopic and Robot-Assisted Radical Prostatectomy

BACKGROUND AND PURPOSE

There remains equipoise with regard to whether laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) has any benefit over the other. Despite this, there is a trend for the increasing adoption of RARP at great cost to health services across the world. The aim was to critically analyze the learning curve and outcomes for LRP and RARP for two experience- and volume-matched surgeons who have completed the learning curve for LRP and RARP.

PATIENTS AND METHODS

Two experience- and volume-matched LRP and RARP surgeons who have completed the learning curve were compared with respect to their learning curve and outcomes for RARP and LRP. There were 531 RARP and 550 LRPs analyzed from April 2003 until January 2012 at two relatively high-volume United Kingdom centers. Outcome measures included operative time, blood loss, complication rate (Clavien-Dindo grade III), positive surgical margin (PSM) rate, and early continence rate.

RESULTS

Learning curves for blood loss, operative times, and complication rate were similar between groups. The overall PSM rate and pT2 PSM rate learning curves were longer for RARP compared with LRP but shorter for early continence. Apical PSM showed no learning curve for RARP; however, a long learning curve for LRP and the rate was lower for RARP than for LRP (P=<0.001).

CONCLUSIONS

This study of RARP and LRP identified that both modalities had long learning curves. Despite the long learning curve for RARP, significant benefits in lower PSM rates and better early continence in comparison with LRP exist. There are benefits to patients with RARP over LRP, especially those linked to better apical dissection (apical PSM and early continence).

Developing technical expertise in robot-assisted laparoscopic prostatectomy in a moderate-volume center through a proctor-based team approach

Our aim is to report our preliminary experience of a proctor-based team approach in robot-assisted laparoscopic prostatectomy (RALP) for the treatment of localized prostate cancer. Data was collected between December 2008 and February 2012. RALP was performed on 100 consecutive patients with prostate cancer by a team of five urologists proctored by two fellowship-trained surgeons from a single hospital. Clinical and pathological data of these patients were reviewed. The mean age of the patients was 66 years (range 48-76). Clinical stages were 82 % cT1c, 3 % cT1b, 13 % cT2a and 2 % cT3a disease. Preoperative mean prostate-specific antigen level was 11.33 ng/ml (SD 10.47). Mean operative time was 342 min and mean blood loss was 717 ml (SD 988). Mean hospital stay and duration of the indwelling catheter were 3.2 days (SD 1.8) and 12.6 days (SD 8.5), respectively. Pathological staging showed 65 patients with pT2a (65 %) disease and 33 patients with pT3a (33 %) disease. Thirty-five patients (35 %) had positive surgical margins. Eighteen patients underwent adjuvant radiotherapy. Overall postoperative complication rate was 14 %. There were six Clavien grade 1 complications, seven Clavien grade 2 complications and one Clavien grade 3 complication. At mean follow-up of 36 months, 100 % of patients remained free of biochemical recurrence with continence at 70 %. Our proctor-based team approach will continue to improve each surgeon's technical competency. He or she will continue to improve and gradually move on to achieving his or her outcomes learning curve.

Transurethral marking incision of the bladder neck: a helpful technique in robot-assisted laparoscopic radical prostatectomy involving post-transurethral resection of the prostate and cancers protruding into the bladder neck

Background

Bladder neck transection is one of the most difficult procedures for robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. To ensure negative surgical margins and safely preserve the ureteral orifices during bladder neck transection, we propose the use of the transurethral resectoscope for making the incision in the bladder neck before initiating RALP. Thus, we developed a technique for bladder neck transection to facilitate this operation in such patients.

Case presentation

Two Japanese men, aged 61 and 63 years, who were diagnosed with prostate cancer, received a transurethral marking incision of the bladder neck before starting RALP; prostate cancer developed in one patient after TUR-P and the other patient had cancer protruding into the bladder neck. A transurethral resectoscope was used to closely observe the ureteral orifices and bladder necks; the bladder necks were marked to indicate the depth from the mucosa to the muscular layer. During the RALP, the bladder necks were dissected to indicate the depth of the marking incision. The surgical margins were negative and perioperative complications did not occur. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed.

Conclusion

This technique, involving the use of an ordinary transurethral resectoscope, may be an easy procedure to ensure negative surgical margins, safely preserve the ureteral orifices, avoid increasing the bladder neck diameter, and achieve a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.