1
|
Walker RJB, Stukel TA, de Mestral C, Nathens A, Breau RH, Hanna WC, Hopkins L, Schlachta CM, Jackson TD, Shayegan B, Pautler SE, Karanicolas PJ. Hospital learning curves for robot-assisted surgeries: a population-based analysis. Surg Endosc 2024; 38:1367-1378. [PMID: 38127120 DOI: 10.1007/s00464-023-10625-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures. STUDY DESIGN This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level. RESULTS A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87). CONCLUSION Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency.
Collapse
Affiliation(s)
- Richard J B Walker
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Charles de Mestral
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Avery Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rodney H Breau
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Waël C Hanna
- Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Laura Hopkins
- Division of Oncology, Saskatchewan Cancer Agency, Saskatoon, Canada
| | | | - Timothy D Jackson
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Bobby Shayegan
- Juravinski Cancer Centre, McMaster University, Hamilton, Canada
| | - Stephen E Pautler
- Divisions of Urology and Surgical Oncology, Departments of Surgery and Oncology, Western University, London, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 16, Toronto, ON, M4N 3M5, Canada.
| |
Collapse
|
2
|
Bertolo R, Carilli M, Antonucci M, Maiorino F, Bove P, Vittori M. "Single-Surgeon" versus "Dual-Surgeon" Robot-Assisted Radical Prostatectomy and Pelvic Lymph-nodes Dissection: Comparative Analysis of Perioperative Outcomes. Int Braz J Urol 2023; 49:732-739. [PMID: 37903007 PMCID: PMC10947625 DOI: 10.1590/s1677-5538.ibju.2023.0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/13/2023] [Indexed: 11/01/2023] Open
Abstract
PURPOSE To compare the perioperative outcomes of robot-assisted radical prostatectomy (RARP) with pelvic lymph-nodes dissection (PLND) when the same surgeon performs RARP and PLND versus one surgeon performs RARP and another surgeon performs PLND. MATERIALS AND METHODS From January 2022 to March 2023, data of consecutive patients who underwent RARP with PLND were prospectively collected. The surgeries were performed by two "young" surgeons with detailed profile. Specifically for the study purpose, one surgeon performed RARP, and the other surgeon performed PLND. A set of surgeries performed according to the standard setup (i.e., the same surgeon performing both RARP and PLND) was retrieved from the institutional database and used as comparator arm. To test the study hypothesis, patients were divided into two groups: "dual-surgeon" versus "single-surgeon". RESULTS Fifty patients underwent RARP and PLND performed according to dual-surgeon setup and were compared to the last 50 procedures performed according to the standard single-surgeon setup. Patients in the groups had comparable baseline characteristics. Dual-surgeon interventions had significantly shorter median total operative (194 [IQR 178-215] versus 174 [IQR 146-195] minutes, p<0.001) and console time (173 [IQR 158-194] versus 154 [IQR 129-170] minutes, p<0.001). No significant differences were found in terms of blood loss, intraoperative complications, postoperative outcomes, and final pathology results. CONCLUSIONS The present analysis found that when RARP and PLND are split onto two surgeons, the operative time is shorter by 20 minutes compared to when a single surgeon performs RARP and PLND. This is an interesting finding that could sponsor further studies.
Collapse
Affiliation(s)
- Riccardo Bertolo
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
| | - Marco Carilli
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
| | - Michele Antonucci
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
| | - Francesco Maiorino
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
| | - Pierluigi Bove
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
- Tor Vergata University of RomeDepartment of SurgeryUrology UnitRomeItalyUrology Unit, Department of Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Matteo Vittori
- San Carlo di Nancy HospitalDepartment of UrologyRomeItalyDepartment of Urology, San Carlo di Nancy Hospital, Rome, Italy;
| |
Collapse
|
3
|
Lin PL, Zheng F, Shin M, Liu X, Oh D, D'Attilio D. CUSUM learning curves: what they can and can't tell us. Surg Endosc 2023; 37:7991-7999. [PMID: 37460815 PMCID: PMC10520215 DOI: 10.1007/s00464-023-10252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION There has been increased interest in assessing the surgeon learning curve for new skill acquisition. While there is no consensus around the best methodology, one of the most frequently used learning curve assessments in the surgical literature is the cumulative sum curve (CUSUM) of operative time. To demonstrate the limitations of this methodology, we assessed the CUSUM of console time across cohorts of surgeons with differing case acquisition rates while varying the total number of cases used to calculate the CUSUM. METHODS We compared the CUSUM curves of the average console times of surgeons who completed their first 20 robotic-assisted (RAS) cases in 13, 26, 39, and 52 weeks, respectively, for their first 50 and 100 cases, respectively. This analysis was performed for prostatectomy (1094 surgeons), malignant hysterectomy (737 surgeons), and inguinal hernia (1486 surgeons). RESULTS In all procedures, the CUSUM curve of the cohort of surgeons who completed their first 20 procedures in 13 weeks demonstrated a lower slope than cohorts of surgeons with slower case acquisition rates. The case number at which the peak of the CUSUM curve occurs uniformly increases when the total number of cases used in generation of the CUSUM chart changes from 50 to 100 cases. CONCLUSION The CUSUM analyses of these three procedures suggests that surgeons with fast initial case acquisition rates have less variability in their operative times over the course of their learning curve. The peak of the CUSUM curve, which is often used in surgical learning curve literature to denote "proficiency" is predictably influenced by the total number of procedures evaluated, suggesting that defining the peak as the point at which a surgeon has overcome the learning curve is subject to routine bias. The CUSUM peak, by itself, is an insufficient measure of "conquering the learning curve."
Collapse
Affiliation(s)
- Peng-Lin Lin
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA.
| | - Feibi Zheng
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Minkyung Shin
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Xi Liu
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Daniel Oh
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| | - Daniel D'Attilio
- Intuitive Surgical, 1020 Kifer Road, Sunnyvale, CA, 94086-5304, USA
| |
Collapse
|
4
|
Altaylouni T, Gebert P, Elezkurtaj S, Rossner F, Ralla B, Weinberger S, Moldovan D, Schlomm T, Guillonneau B. Robot-Assisted Laparoscopic Prostatectomy Experience and Pathological Quality: Are They Always Linked? J Endourol 2023; 37:995-1000. [PMID: 37387397 DOI: 10.1089/end.2023.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Turki Altaylouni
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pimrapat Gebert
- Department of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sefer Elezkurtaj
- Department of Pathology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Florian Rossner
- Department of Pathology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernhard Ralla
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sarah Weinberger
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Diana Moldovan
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thorsten Schlomm
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bertrand Guillonneau
- Department of Urology, Charité-Universitätsmedizin and Hospital, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
5
|
Lee MR, Li WM, Li CC, Chou YH, Wu WJ, Juan YS, Ke HL, Wen SC, Lee HY, Chien TM. Cumulative sum analysis of the learning curve of laparoendoscopic single-site robot-assisted radical prostatectomy. Asian J Surg 2023; 46:3614-3619. [PMID: 36813677 DOI: 10.1016/j.asjsur.2023.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Radical prostatectomy has become the gold standard for treating localized prostate cancer. Improvement in the single-site technique and surgeon's skill reduces not only the hospital duration but also the number of wounds. Realizing the learning curve for a new procedure can prevent unnecessary mistakes. OBJECTIVE To analyze the learning curve of extraperitoneal laparoendoscopic single-site robot-assisted radical prostatectomy (LESS-RaRP). METHODS We retrospectively evaluated 160 patients diagnosed with prostate cancer during June 2016 to December 2020 who underwent extraperitoneal LESS-RaRP. Calculated cumulative sum analysis (CUSUM) was used to evaluate the learning curves for the extraperitoneal setting time, robotic console time, total operation time, and blood loss. The operative and functional outcomes were also assessed. RESULTS The learning curve of the total operation time was observed in 79 cases. For the extraperitoneal setting and robotic console times, the learning curve was observed in 87 and 76 cases, respectively. The learning curve for blood loss was observed in 36 cases. No in-hospital mortality or respiratory failure was observed. CONCLUSION Extraperitoneal LESS-RaRP using the da Vinci Si system is safe and feasible. Approximately 80 patients are required to achieve a stable and consistent operative time. A learning curve for blood loss was observed after 36 cases.
Collapse
Affiliation(s)
- Ming-Ru Lee
- Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Wei-Ming Li
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, Ministry of Health and Welfare, Pingtung Hospital, Pingtung, Taiwan.
| | - Ching-Chia Li
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Yii-Her Chou
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Wen-Jeng Wu
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Yung-Shun Juan
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Hung-Lung Ke
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.
| | - Sheng-Chen Wen
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Hsiang-Ying Lee
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Tsu-Ming Chien
- Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| |
Collapse
|
6
|
Vasdev N, Charlesworth P, Slack M, Adshead J. Preclinical evaluation of the Versius surgical system: A next‐generation surgical robot for use in minimal access prostate surgery. BJUI COMPASS 2023. [DOI: 10.1002/bco2.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Affiliation(s)
- Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre Lister Hospital Stevenage UK
- School of Life and Medical Sciences University of Hertfordshire Hertfordshire UK
| | | | | | - Jim Adshead
- Hertfordshire and Bedfordshire Urological Cancer Centre Lister Hospital Stevenage UK
| |
Collapse
|
7
|
Robotic-assisted radical prostatectomy: learning curves and outcomes from an Australian perspective. Prostate Int 2023; 11:51-57. [PMID: 36910896 PMCID: PMC9995681 DOI: 10.1016/j.prnil.2022.10.002] [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: 07/25/2022] [Revised: 10/02/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Robot-assisted radical prostatectomy (RARP) has been a treatment for men who suffer from intermediated to high-risk prostate cancer in Australia since 2003. The primary outcomes in relation to learning curves in robotic surgery have been extensively researched in overseas populations, but there is no study from a cohort of Australian surgeons performing RARP. This study aims to highlight the effect of RARP learning curves on primary surgical outcomes in a high-volume Australian centre. Methods A retrospective audit of all RARP performed at Epworth Healthcare from 2016 to 2021 was performed. The primary outcome data collected included operating time (OT), estimated blood loss (EBL), and positive surgical margins (PSM). Exclusion criteria were applied. Positive outcomes were set at OT 240 min, blood loss 310 mL, and negative surgical margins. Results A total of 3969 cases were analysed for a cohort of 53 surgeons. Of these surgeons, 24 surgeons have performed >50 operations to be able to undergo learning curve analysis. The median OT was 229 min, the median blood loss was 353 mL, and most cases had negative surgical margins (>1 mm, n = 3681, 92.7%). The mean learning curve transition point was 65 cases. There was a significant difference in the EBL and rate of PSM for the higher volume cohort (p = 0.002 and <0.0001, respectively). Conclusion We perform a retrospective study of all RARP performed at a high-volume Australian centre. Higher volume surgeons demonstrate that primary outcomes improve with a higher caseload (EBL, PSM). Learning curve transition points for RARP are comparable to international high-volume surgeons. Learning curve data could form the benchmark for RARP training and skills development.
Collapse
|
8
|
Furrer MA, Costello DM, Thomas BC, Peters JS, Costello AJ, Dundee P. Robotics in Australian urology contemporary practice and future perspectives. ANZ J Surg 2021; 91:2241-2245. [PMID: 34766679 DOI: 10.1111/ans.17161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/27/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Marc A Furrer
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia.,The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Daniel M Costello
- The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin C Thomas
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia.,The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Prostate Cancer Centre, North Melbourne, Victoria, Australia
| | - Justin S Peters
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia.,The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Prostate Cancer Centre, North Melbourne, Victoria, Australia
| | - Anthony J Costello
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia.,The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Prostate Cancer Centre, North Melbourne, Victoria, Australia
| | - Philip Dundee
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia.,The Australian Medical Robotics Academy, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian Prostate Cancer Centre, North Melbourne, Victoria, Australia
| |
Collapse
|
9
|
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
|
10
|
A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education. J Robot Surg 2021; 16:749-763. [PMID: 34480323 PMCID: PMC8415702 DOI: 10.1007/s11701-021-01302-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022]
Abstract
We conducted a comprehensive review of surgical simulation models used in robotic surgery education. We present an assessment of the validity and cost-effectiveness of virtual and augmented reality simulation, animal, cadaver and synthetic organ models. Face, content, construct, concurrent and predictive validity criteria were applied to each simulation model. There are six major commercial simulation machines available for robot-assisted surgery. The validity of virtual reality (VR) simulation curricula for psychomotor assessment and skill acquisition for the early phase of robotic surgery training has been demonstrated. The widespread adoption of VR simulation has been limited by the high cost of these machines. Live animal and cadavers have been the accepted standard for robotic surgical simulation since it began in the early 2000s. Our review found that there is a lack of evidence in the literature to support the use of animal and cadaver for robotic surgery training. The effectiveness of these models as a training tool is limited by logistical, ethical, financial and infection control issues. The latest evolution in synthetic organ model training for robotic surgery has been driven by new 3D-printing technology. Validated and cost-effective high-fidelity procedural models exist for robotic surgery training in urology. The development of synthetic models for the other specialties is not as mature. Expansion into multiple surgical disciplines and the widespread adoption of synthetic organ models for robotic simulation training will require the ability to engineer scalability for mass production. This would enable a transition in robotic surgical education where digital and synthetic organ models could be used in place of live animals and cadaver training to achieve robotic surgery competency.
Collapse
|
11
|
Yang CW, Wang HH, Hassouna MF, Chand M, Huang WJS, Chung HJ. Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy. Sci Rep 2021; 11:14329. [PMID: 34253832 PMCID: PMC8275750 DOI: 10.1038/s41598-021-93860-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.
Collapse
Affiliation(s)
- Ching-Wei Yang
- Department of Urology, Cheng-Hsin General Hospital, No. 45, Cheng-Hsin St., Beitou Dist., Taipei, 112, Taiwan
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
| | - Hsiao-Hsien Wang
- Department of Urology, Cheng-Hsin General Hospital, No. 45, Cheng-Hsin St., Beitou Dist., Taipei, 112, Taiwan
| | - Mohamed Fayez Hassouna
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
- Division of Surgical and Interventional Sciences, Charles Bell House, 43-45 Foley St, Fitzrovia, London, W1W 7TY, UK
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
- Department of Colorectal Surgery, University College London Hospital, 250 Euston Road, London, NW1 2BU, UK
| | - William J S Huang
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan
- Department of Urology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Beitou Dist., Taipei, 112, Taiwan
| | - Hsiao-Jen Chung
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan.
- Department of Urology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Beitou Dist., Taipei, 112, Taiwan.
| |
Collapse
|