Role of robotics for prostate cancer:

Visual behaviour in robotic surgery-Demonstrating the validity of the simulated environment

BACKGROUND

Eye metrics provide insight into surgical behaviour allowing differentiation of performance, however have not been used in robotic surgery. This study explores eye metrics of robotic surgeons in training in simulated and real tissue environments.

METHODS

Following the Fundamentals of Robotic Surgery (FRS), training curriculum novice robotic surgeons were trained to expert-derived benchmark proficiency using real tissue on the da Vinci Si and the da Vinci skills simulator (dVSS) simulator. Surgeons eye metrics were recorded using eye-tracking glasses when both "novice" and "proficient" in both environments. Performance was assessed using Global Evaluative Assessment of Robotic skills (GEARS) and numeric psychomotor test score (NPMTS) scores.

RESULTS

Significant (P ≤ .05) correlations were seen between pupil size, rate of change and entropy, and associated GEARS/NPMTS in "novice" and "proficient" surgeons. Only number of blinks per minute was significantly different between pupilometrics in the simulated and real tissue environments.

CONCLUSIONS

This study illustrates the value of eye tracking as an objective physiological tool in the robotic setting. Pupilometrics significantly correlate with established assessment methods and could be incorporated into robotic surgery assessments.

Open versus minimally invasive surgical approaches in pediatric urology: Trends in utilization and complications

OBJECTIVE

Minimally invasive surgery (MIS) techniques are anecdotally reported to be increasingly used, but little objective data supports this. Our objective was to assess trends in MIS utilization across various procedures in pediatric urology and to compare postoperative complication rates between MIS and open procedures.

METHODS

We analyzed the 1998-2012 Nationwide Inpatient Sample. We identified children (<18 years old) undergoing open and MIS inpatient procedures and any in-hospital post-operative complications that occurred during that postoperative hospitalization. We utilized propensity score matching and multivariable logistic regression to adjust for confounding factors.

RESULTS

We identified 163,838 weighted encounters in the "overall cohort," 70,273 of which were at centers performing more than five MIS procedures over the years studied. Use of MIS techniques increased significantly over time for several procedures, most prominently for nephrectomy (Fig.). The overall rate of complications was lower in patients undergoing MIS compared with open surgery (6% vs. 11%, p < 0.001). Specialized centers had a significantly lower overall rate of complications than unspecialized centers (9% vs. 12%, p < 0.001). Within specialized centers, MIS had lower complication rates than open procedures (7% vs. 9%, p < 0.001); this finding was consistent even after adjusting for other factors (OR 0.71, p = 0.02).

DISCUSSION

Limitations include that these data may not be generalizable to encounters not in the sample pool. As a large, retrospective, administrative database, NIS may be affected by miscoding bias - rendering our analysis sensitive to the accuracy of procedure coding in NIS. Although the accuracy level of NIS is high for an administrative database, it is possible at least some portion of our cohort may be incorrectly coded. Further, the NSQIP complications we identified may represent associated comorbidities and not true postoperative complications, as NIS does not provide temporal relationships between different diagnosis codes. Despite these limitations, we note that the NIS database is rigorously monitored and audited for coding accuracy and, therefore, represents a reasonably reliable panorama of the characteristics of an inpatient surgical cohort. However, it is important to note that the choice of operative modality is, undoubtedly, multifactorial and patient/setting-specific.

CONCLUSIONS

There is increasing use of MIS for pediatric urology procedures, although utilization rates vary among procedures. MIS was associated with a lower postoperative complication rate than for open procedures. Higher-volume MIS centers have a lower complication rate than lower-volume centers.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty

The laparoscopic approach to the pyeloplasty procedure has proven to be safe and effective in the pediatric population. Multiple studies have revealed outcomes comparable to the open approach. However, a major drawback to laparoscopy is the technical challenge of precise suturing in the small working space in children. The advantages of robotic surgery when compared to conventional laparoscopy have been well established and include motion scaling, enhanced magnification, 3-dimensional stereoscopic vision, and improved instrument dexterity. As a result, surgeons with limited laparoscopic experience are able to more readily acquire robotic surgical skills. Limitations of the robotic platform include its high costs for acquisition and maintenance, as well as the need for additional robotic surgical training. In this article, we review the current status of the robot-assisted laparoscopic pyeloplasty, including a brief history, comparative outcomes, cost considerations, and training.

Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy

OBJECTIVE

To perform a contemporary comparative cost-analysis of robotic-assisted laparoscopic radical prostatectomy (RARP) and open radical retropubic prostatectomy (RRP).

METHODS

All patients undergoing RARP (n = 115) or RRP (n = 358) by 1 of 4 surgeons at a single institution during a 15-month period were retrospectively reviewed. The hospital length of stay (LOS), operative time, hospital charges, reimbursement, and direct and indirect hospital costs were analyzed and compared.

RESULTS

The mean LOS between patients undergoing RARP (1.2 ± 0.6 days) and RRP (1.4 ± 0.8 days) was not significantly different. The operating room supply costs per case were almost 7 times greater for RARP ($2852 ± $528) than for RRP ($417 ± $59; P < .05). The ancillary, cardiology, imaging, administrative, laboratory, and pharmacy costs were not significantly different between the 2 approaches. The mean total costs per case for RARP exceeded the total costs for RRP by 62% ($14 006 ± $1641 vs $8686 ± $1989; P < .05). Payment to the hospital from all sources was nearly equivalent: $10 011 for RRP and $9993 for RARP. Therefore, the average profit for each RRP was $1325 and each RARP lost $4013.

CONCLUSION

In the present single-institution analysis, the total actual costs associated with RARP were significantly greater than those for RRP and were attributable to the robotic equipment and supplies.

Laparo-endoscopic single-site radical prostatectomy: Feasibility and technique

Background

As laparoscopy becomes a standard approach in many urological procedures, researchers strive to make minimally invasive surgery less invasive. Our objective was to apply recent innovations in equipment and surgical approaches to develop the technique and perform laparo-endoscopic single site radical prostatectomy (LESS-RP).

Methods

The technique for LESS-RP was derived by combining existing techniques of standard laparoscopic RP and developing techniques of urological LESS. This incorporated newly available low-profile trocars, flexible instruments and a flexible-tip laparoscope. The procedure was performed through a single 3-cm transverse infra-umbilical incision. LESS-RP was completed successfully via a single operative site without auxiliary needles or trocars. Perioperative variables and postoperative outcomes were recorded and measured.

Results

The operative time was 424 min and the hospital stay was 10 days because of a vesicourethral leak and ileus. The anastomotic leak resolved and the urethral catheter was removed at 4 weeks after surgery. The final pathology showed negative margins and Gleason 3 + 4 pT2c prostatic adenocarcinoma.

Conclusions

LESS-RP is feasible by replicating laparoscopic RP techniques and incorporating the LESS technique with the advent of flexible-tip laparoscopes and flexible instruments. After a learning curve has been overcome, this should be further tested prospectively to compare oncological and functional outcomes with laparoscopic and robotic-assisted RP.

Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer

BACKGROUND

Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking.

OBJECTIVE

To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP).

DESIGN, SETTING, AND PARTICIPANTS

The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008.

MEASUREMENTS

Direct and component costs were compared. Costs were adjusted for changes over the time of the study.

RESULTS AND LIMITATIONS

Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283-7369]; LRP: $5687 [IQR: $4941-5905]; RRP: $4437 [IQR: $3989-5141]; p<0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p<0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year.

CONCLUSIONS

RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.

The effect of the approach to radical prostatectomy on the profitability of hospitals and surgeons

OBJECTIVE

To evaluate the profit margins for radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP), and the effect on the reimbursement to the urologist, as there has been a dramatic increase in use of RALP, with the cost of the robot borne by hospitals.

METHODS

Data on costs and payments to hospital and surgeon from 2003 to 2008 for RRP, LRP and RALP were obtained from the hospital and urology department. We determined the profit based on the difference between payments received and total cost.

RESULTS

Between 2000 and 2008, 1279 RPs were performed at our private hospital. The introduction of RALP increased total number of RPs and replaced most RRPs. RRP represents the only procedure where payments exceed total costs. For RRP there was a significantly higher profit for patients with comorbidities. The type of payer had a large effect on profit. Medicare provides a small profit for RRP but a significant loss of >US$4000 for RALP. While all insurance companies resulted in losses for LRP and RALP, there was variability of almost $600/case for LRP and >$1400/case for RALP. RALP provided the highest reimbursement for the surgeon due to additional reimbursement for the S2900 code (use of robot).

CONCLUSIONS

The introduction of RALP has increased the case volume at our hospital and improved profits for the surgeon. The hospital loses money on each LRP and RALP case compared with RRP, which provides a small profit.

Robotic-Assisted Laparoscopic Surgery in Pediatric Urology: An Update

Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyeloplasty and orchiopexy, have proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for this procedure because of technical difficulties of suturing and anastomosis. More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. RAS has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimentional view. These features render RAS ideal for complex reconstructive surgery in a pediatric urological population. This review discusses the role of RAS in pediatric urology, and provides some technical aspects of RAS and a critical summary of current knowledge on its indications and out-come. Almost all operations that are classically performed as open or conventional laparoscopic reconstructive surgery for children with urological anomalies could be replaced by RAS, which may be established as an alternative minimally invasive surgery in the future.