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Moschovas MC, Loy D, Patel E, Sandri M, Moser D, Patel V. Comparison between intra- and postoperative outcomes of the da Vinci SP and da Vinci Xi robotic platforms in patients undergoing radical prostatectomy. J Robot Surg 2023; 17:1341-1347. [PMID: 36930424 DOI: 10.1007/s11701-023-01563-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
The new SP robot incorporates a single trocar that houses a flexible camera and three bi-articulated arms, which minimize the number of incisions needed to assess the surgical site, allowing for a less invasive procedure. To compare the postoperative pain scale and outcomes in patients with similar demographic characteristics undergoing robotic-assisted radical prostatectomy (RARP) with SP and Xi robots, One-hundred consecutive patients undergoing RARP with the SP robot were matched, using a propensity score (PS), with 100 patients from a cohort of 1757 who were operated on with the da Vinci Xi from June 2019 to January 2021. We described and compared the perioperative pain scores and outcomes of both groups. The SP group had less blood loss (50 cc vs. 62.5 cc, P < 0.001) and longer operative time (114 min. vs. 94 min, P < 0.001). The only period we could show a difference in postoperative pain scores was 6 h after surgery, with a small advantage for the SP (2 vs. 2.5, P < 0.001). Both groups had satisfactory postoperative continence recovery, 91% vs. 90% for the SP and Xi, respectively. The groups had a mean follow-up of 24.5 and 22 months for SP and Xi, respectively. The tumor stage and percentage of positive surgical margins were similar between groups (15% vs. 15%, P = 1). Patients undergoing RARP with the SP had longer operative times with less blood loss than the Xi. However, despite the lower number of abdominal incisions on the SP, the groups had similar intraoperative performance, and we were unable to demonstrate clinically significant differences in postoperative pain scores between the groups 6, 12, and 18 h after surgery.
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Affiliation(s)
- Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, 380 Celebration Place Suite # 410, Celebration, FL, 34747, USA.
- University of Central Florida (UCF), Orlando, FL, USA.
| | - David Loy
- AdventHealth Global Robotics Institute, 380 Celebration Place Suite # 410, Celebration, FL, 34747, USA
| | - Evan Patel
- AdventHealth Global Robotics Institute, 380 Celebration Place Suite # 410, Celebration, FL, 34747, USA
| | - Marco Sandri
- Big and Open Data Innovation Laboratory (BODaI-Lab) and Data Methods and Systems Statistical, Brescia, Italy
| | - Daniel Moser
- Hospital e Maternidade Brasil, Santo Andre, Brazil
| | - Vipul Patel
- AdventHealth Global Robotics Institute, 380 Celebration Place Suite # 410, Celebration, FL, 34747, USA
- University of Central Florida (UCF), Orlando, FL, USA
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Valsamis EM, Collins GS, Pinedo-Villanueva R, Whitehouse MR, Rangan A, Sayers A, Rees JL. Association between surgeon volume and patient outcomes after elective shoulder replacement surgery using data from the National Joint Registry and Hospital Episode Statistics for England: population based cohort study. BMJ 2023; 381:e075355. [PMID: 37343999 DOI: 10.1136/bmj-2023-075355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVE To investigate the association between surgeon volume and patient outcomes after elective shoulder replacement surgery to improve patient outcomes and inform future resource planning for joint replacement surgery. DESIGN Prospective cohort study. SETTING Public and private hospitals in the United Kingdom, 2012-20. PARTICIPANTS Adults aged 18 years or older who had shoulder replacement surgery, identified in the National Joint Registry, with linkage of participants in England to Hospital Episode Statistics data. MAIN OUTCOME MEASURES The main outcome measure was revision surgery. Secondary outcome measures were reoperation within 12 months, serious adverse events, and prolonged hospital stay (>3 nights) after shoulder replacement surgery. RESULTS 39 281 shoulder replacement procedures undertaken by 638 consultant surgeons at 416 surgical units met the inclusion criteria and were available for analysis. Multilevel mixed effects models and restricted cubic splines were fit to examine the association between a surgeon's mean annual volume and risk of adverse patient outcomes, with a minimum volume threshold of 10.4 procedures yearly identified. Below this threshold the risk of revision surgery was significantly increased, as much as twice that of surgeons with the lowest risk (hazard ratio 1.94, 95% confidence interval 1.27 to 2.97). A greater mean annual surgical volume was also associated with a significantly lower risk of reoperations, fewer serious adverse events, and shorter hospital stay, with no thresholds identified. Annual variation in surgeon volume was not associated with any of the outcomes assessed. CONCLUSIONS In the healthcare system represented by these registry data, an association was found between surgeons who averaged more than 10.4 shoulder replacements yearly and lower rates of revision surgery and reoperation, lower risk of serious adverse events, and shorter hospital stays. These findings should inform resource planning for surgical services and joint replacement surgery waiting lists and improve patient outcomes after shoulder replacement surgery.
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Affiliation(s)
- Epaminondas Markos Valsamis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gary S Collins
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
- Health Sciences and Medical School, University of York, York, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
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Jung J, Bae GH, Kim JH, Kim J. Outcomes of prostate cancer patients after robot-assisted radical prostatectomy compared with open radical prostatectomy in Korea. Sci Rep 2023; 13:7851. [PMID: 37188739 DOI: 10.1038/s41598-023-34864-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/09/2023] [Indexed: 05/17/2023] Open
Abstract
Limited evidence exists regarding the value of robot-assisted radical prostatectomy (RARP) in promoting health outcomes in patients with prostate cancer (PCa) in Korea, prompting a study to determine its clinical impact. The study included 15,501 patients with PCa who underwent RARP (n = 12,268) or radical prostatectomy (RP) (n = 3,233) between 2009 and 2017. The outcomes were compared using a Cox proportional hazards model after propensity score matching. Hazard ratios of all-cause overall mortality after RARP compared to that after RP within 3 and 12 months were (6.72, 2.00-22.63, p = 0.002) and (5.55, 3.31-9.31, p < 0.0001), respectively. The RARP group in four hospitals with the largest PCa surgery volume during the study period had worse percentile deaths than the total RARP patients within 3- (1.6% vs. 0.63%) and 12-month post-op (6.76% vs. 2.92%). The RARP group showed specific surgical complications, like pneumonia and renal failure, more than the RP group. A significantly higher short-term mortality and only modestly lower surgical complications occurred in RARP than RP group. RARP performance status may not be superior to that of RP as previously reported and perceived, possibly due to increased robotic surgery in the elderly. More meticulous measures are needed for robotic surgery in the elderly.
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Affiliation(s)
- Jaehun Jung
- Department of Preventive Medicine, Gachon University College of Medicine, Incheon, South Korea
- Artificial Intelligence and Big-Data Convergence Center, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Gi Hwan Bae
- Artificial Intelligence and Big-Data Convergence Center, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Hospital, Soonchunhyang University Medical College, Seoul, South Korea
- Urological Biomedicine Research Institute, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Jaehong Kim
- Department of Biochemistry, College of Medicine, Gachon University, Incheon, 21999, Republic of Korea.
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Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries. Eur Urol 2023; 83:393-401. [PMID: 36639296 DOI: 10.1016/j.eururo.2022.12.031] [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: 09/19/2022] [Revised: 11/30/2022] [Accepted: 12/26/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation "Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available. OBJECTIVE To assess current ADT use before prostate cancer surgery in Europe. DESIGN, SETTING, AND PARTICIPANTS This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence. RESULTS AND LIMITATIONS We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated. CONCLUSIONS EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued. PATIENT SUMMARY Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.
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Day EK, Galbraith NJ, Ward HJT, Roxburgh CS. Volume-outcome relationship in intra-abdominal robotic-assisted surgery: a systematic review. J Robot Surg 2022; 17:811-826. [PMID: 36315379 DOI: 10.1007/s11701-022-01461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/02/2022] [Indexed: 11/07/2022]
Abstract
As robotic-assisted surgery (RAS) expands to smaller centres, platforms are shared between specialities. Healthcare providers must consider case volume and mix required to maintain quality and cost-effectiveness. This can be informed, in-part, by the volume-outcome relationship. We perform a systematic review to describe the volume-outcome relationship in intra-abdominal robotic-assisted surgery to report on suggested minimum volumes standards. A literature search of Medline, NICE Evidence Search, Health Technology Assessment Database and Cochrane Library using the terms: "robot*", "surgery", "volume" and "outcome" was performed. The included procedures were gynecological: hysterectomy, urological: partial and radical nephrectomy, cystectomy, prostatectomy, and general surgical: colectomy, esophagectomy. Hospital and surgeon volume measures and all reported outcomes were analysed. 41 studies, including 983,149 procedures, met the inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale and the retrieved data was synthesised in a narrative review. Significant volume-outcome relationships were described in relation to key outcome measures, including operative time, complications, positive margins, lymph node yield and cost. Annual surgeon and hospital volume thresholds were described. We concluded that in centres with an annual volume of fewer than 10 cases of a given procedure, having multiple surgeons performing these procedures led to worse outcomes and, therefore, opportunities should be sought to perform other complimentary robotic procedures or undertake joint cases.
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Affiliation(s)
- Elizabeth K Day
- Urology Department, University College London Hospital, Westmoreland Street, London, UK.
| | - Norman J Galbraith
- School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Hester J T Ward
- Public Health Scotland, Gyle Square, Gyle Crescent, Edinburgh, UK
| | - Campbell S Roxburgh
- School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Aning J. The pursuit of excellence. Scand J Urol 2022; 56:351-352. [PMID: 36281500 DOI: 10.1080/21681805.2022.2137231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Jonathan Aning
- Consultant Urological Surgeon and Honorary Associate Professor, Bristol Urological Institute, Bristol, United Kingdom
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Arnsrud Godtman R, Persson E, Bergengren O, Carlsson S, Johansson E, Robinsson D, Hugosson J, Stattin P. Surgeon volume and patient-reported urinary incontinence after radical prostatectomy. Population-based register study in Sweden. Scand J Urol 2022; 56:343-350. [PMID: 36068973 DOI: 10.1080/21681805.2022.2119270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate the association between surgeon volume and urinary incontinence after radical prostatectomy. METHODS A total of 8326 men in The National Prostate Cancer Register of Sweden (NPCR) underwent robot-assisted radical prostatectomy (RARP) between 2017 and 2019 of whom 56% (4668/8 326) had responded to a questionnaire one year after RARP. The questionnaire included the question: 'How much urine leakage do you experience?' with the response alternatives 'Not at all', 'A little', defined as continence and 'Moderately', 'Much/Very much' as incontinence. Association between incontinence and mean number of RARPs/year/surgeon was analysed with multivariable logistic regression including age, Charlson Comorbidity Index (CCI), PSA, prostate volume, number of biopsy cores with cancer, cT stage, Gleason score, lymph node dissection, nerve sparing intent and response rate to the questionnaire. RESULTS 14% (659/4 668) of the men were incontinent one year after RARP. There was no statistically significant association between surgeon volume and incontinence. Older age (>75 years vs. < 65 years, OR 2.29 [95% CI 1.48-3.53]), higher CCI (CCI 2+ vs. CCI 0, OR 1.37 [95% CI 1.04-1.80]) and no nerve sparing intent (no vs. yes OR 1.53 [95% CI 1.26-1.85]) increased risk of incontinence. There were large differences in the proportion of incontinent men between surgeons with similar annual volumes, which remained after adjustment. CONCLUSIONS The lack of association between surgeon volume and incontinence and the wide range in outcome between surgeons with similar volumes underline the importance of individual feedback to surgeons on functional results.
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Affiliation(s)
- Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Erik Persson
- Regional Cancer Center Mid Sweden, Uppsala, Sweden
| | - Oskar Bergengren
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Stefan Carlsson
- Department of Urology, Karolinska University Hospital, Solna, Sweden.,Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Eva Johansson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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