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Ilias D, Passerotti CC, Pontes Junior J, Fakhouri F, Faria STDR, Maximiano LF, Otoch JP, DA-Cruz JAS. Learning curve of semi-rigid ureteroscopy for small calculi: how many cases are necessary? Rev Col Bras Cir 2022; 49:e20222693. [PMID: 36228197 PMCID: PMC10578800 DOI: 10.1590/0100-6991e-20222693-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/04/2022] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION semi-rigid ureteroscopy is the procedure of choice for the treatment of ureterolithiasis, but it requires a learning curve to be performed safely. OBJECTIVE To describe an estimate of the learning curve for performing semi-rigid ureterorenolithotripsy in patients with small-sized ureterolithiasis and to estimate the minimum number of procedures necessary to safely perform the surgical procedure. METHODS this is a prospective study evaluating the learning curve of a resident of urology in the first 60 semirigid ureteroscopies in patients with ureterolithiasis up to 1cm. The patients were divided into three groups: Group I one to twenty surgeries, Group II twenty one to forty surgeries and Group III forty one to sixty surgeries. The surgeries were recorded and analyzed by two urologists experienced in endourology. A qualitative analysis was performed based on a previously validated tool and a quantitative analysis. RESULTS all qualitative variables had significant variation between Groups I and II (p<0.001), and between Groups I and III (p<0.001). There was a difference in time to access the ureter, passage of a double J catheter and total operative time between Groups I and II (p<0.001) and Groups I and III (p<0.001). CONCLUSION after 40 cases there seems to be little increase in both quantitative as well as qualitative evaluation in surgical performance for performing semi-rigid ureterolithotripsy safely in calculations up to 1cm.
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Affiliation(s)
- Daniel Ilias
- - Hospital Alemão Oswaldo Cruz, Centro Especializado em Urologia - São Paulo - SP - Brasil
| | | | - José Pontes Junior
- - Hospital Alemão Oswaldo Cruz, Centro Especializado em Urologia - São Paulo - SP - Brasil
| | - Felipe Fakhouri
- - Hospital Alemão Oswaldo Cruz, Centro Especializado em Urologia - São Paulo - SP - Brasil
| | - Sabrina Thalita Dos Reis Faria
- - Faculdade de Medicina da Universidade de São Paulo, Departamento de Técnica Cirúrgica e Cirurgia Experimental - São Paulo - SP - Brasil
| | - Linda Ferreira Maximiano
- - Faculdade de Medicina da Universidade de São Paulo, Departamento de Técnica Cirúrgica e Cirurgia Experimental - São Paulo - SP - Brasil
- - Universidade de São Paulo, Hospital Universitário - São Paulo - SP - Brasil
| | - José Pinhata Otoch
- - Faculdade de Medicina da Universidade de São Paulo, Departamento de Técnica Cirúrgica e Cirurgia Experimental - São Paulo - SP - Brasil
- - Universidade de São Paulo, Hospital Universitário - São Paulo - SP - Brasil
| | - Jose Arnaldo Shiomi DA-Cruz
- - Hospital Alemão Oswaldo Cruz, Centro Especializado em Urologia - São Paulo - SP - Brasil
- - Faculdade de Medicina da Universidade de São Paulo, Departamento de Técnica Cirúrgica e Cirurgia Experimental - São Paulo - SP - Brasil
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d’Altilia N, Mancini V, Falagario UG, Martino L, Di Nauta M, Calò B, Del Giudice F, Basran S, Chung BI, Porreca A, Bianchi L, Schiavina R, Brunocilla E, Busetto GM, Bettocchi C, Annese P, Cormio L, Carrieri G. A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques. Cancers (Basel) 2022; 14:cancers14184350. [PMID: 36139511 PMCID: PMC9496957 DOI: 10.3390/cancers14184350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.
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Affiliation(s)
- Nicola d’Altilia
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Vito Mancini
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Ugo Giovanni Falagario
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Leonardo Martino
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Michele Di Nauta
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Beppe Calò
- Department of Urology, Bonomo Teaching Hospital, 76123 Andria, Italy
| | | | - Satvir Basran
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Benjamin I. Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Angelo Porreca
- Oncological Urology, Veneto Institute of Oncology (IOV), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 37138 Padua, Italy
| | - Lorenzo Bianchi
- Department of Urology, University of Bologna, 40126 Bologna, Italy
| | | | | | - Gian Maria Busetto
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
- Correspondence: ; Tel.: +39-0881-733856
| | - Carlo Bettocchi
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Pasquale Annese
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
| | - Luigi Cormio
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
- Department of Urology, Bonomo Teaching Hospital, 76123 Andria, Italy
| | - Giuseppe Carrieri
- Department of Urology and Renal Transplantation, Policlinico Riuniti di Foggia, University of Foggia, 71122 Foggia, Italy
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ILIAS DANIEL, PASSEROTTI CARLOCAMARGO, PONTES JUNIOR JOSÉ, FAKHOURI FELIPE, FARIA SABRINATHALITADOSREIS, MAXIMIANO LINDAFERREIRA, OTOCH JOSÉPINHATA, DA-CRUZ JOSEARNALDOSHIOMI. Curva de aprendizado em ureteroscopia semi-rígida em cálculos de pequenas dimensões: quantos casos são necessários? Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20222693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
RESUMO Introdução: ureteroscopia semi-rígida é o procedimento de escolha para o tratamento da ureterolitíase, mas necessita de uma curva de aprendizado para ser executada com segurança. Objetivo: descrever uma estimativa da curva de aprendizado para realização da ureterorrenolitotripsia semi-rígida em pacientes com ureterolitíase de pequena dimensão e estimar o número mínimo de procedimentos necessários para realizar o procedimento cirúrgico com segurança. Métodos: trata-se de um estudo prospectivo avaliando a curva de aprendizado de um residente de urologia nas primeiras 60 ureteroscopias semi-rígidas em pacientes com ureterolitíase até 1cm. Os pacientes foram divididos em três grupos: Grupo I uma a vinte cirurgias, Grupo II vinte e uma a quarenta cirurgias e Grupo III quarenta e uma a sessenta cirurgias. As cirurgias foram gravadas e analisadas por dois urologistas experientes em endourologia. Foi feita uma análise qualitativa baseada em uma ferramenta previamente validada e uma análise quantitativa. Resultados: todas as variáveis qualitativas tiveram variação significativa entre os Grupos I e II (p<0.001), e entre os Grupos I e III (p<0.001). Houve diferença no tempo para acesso ao ureter, passagem de cateter duplo J e tempo operatório total entre os Grupos I e II (p<0.001) e nos Grupos I e III (p<0.001). Conclusão: após 40 casos parece haver pouco incremento tanto na avaliação quantitativa bem como na avaliação qualitativa em performance cirúrgica para a realização de ureterolitotripsia semi-rígida com segurança em cálculos de até 1cm.
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Ou YC, Lu CH, Lin YS, Huang LH, Weng WC, Hsu CY, Tung MC. Complications of robotic-assisted laparoscopic radical prostatectomy: Experience Sharing from 2000 cases involving a single surgeon. UROLOGICAL SCIENCE 2022. [DOI: 10.4103/uros.uros_173_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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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.
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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.
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van der Merwe A, Ebinger Mundorf NN, van Heerden H, Bonkat G, van Deventer H, Mantica G, Keyser Z, Bachmann A. Evaluating the differences in the early laparoscopic donor nephrectomy learning curves of a Swiss high volume transplant program and a South African low volume transplant program after knowledge transfer. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To describe the retroperitoneoscopic donor nephrectomy learning curve differences between a high volume (training) hospital in Basel, Switzerland, and a low volume (trainee) hospital in Cape Town, South Africa, after knowledge transfer. The South African hospital is resource constraint in hospital and training equipment. Techniques for performing the surgery were near identical.
Methods
Both units maintained prospective databases. Comparisons were made of the first 74 cases in each database: Basel’s series were from 19 January 2001 until 28 June 2004, while the Cape Town Hospital were from 8 April 2008 until 15 July 2008. Four surgeons operated in the Basel group, while only one surgeon operated in the Cape Town group. Variables compared include operating time (first skin incision until kidney was extracted), warm ischaemic time (renal arterial occlusion until cold bench reperfusion), blood loss, graft function, and hospital stay. We also analysed the first and last 25 cases of each series. Subgroup analysis of a single Basel surgeon was conducted.
Results
Donor age (means: Basel vs. Cape Town 54 vs. 33 p < 0.0001) and gender (males vs. females Cape Town 57% male and Basel 31% male) differed widely. The Basel group did more left-sided operations (72% vs. 58%). Operative times, blood loss and donor creatinine did not differ. Warm ischaemic time was significantly shorter in the Basel group (Cape Town mean 204 s Basel mean 130 s P = 0.0023). There was double the number of early graft failures in the South African group (six vs. three)—not related to donor surgery. Both groups showed a decline in operating times, plateauing at 30–34 cases.
Conclusions
There are statistically significant differences in some aspects of the learning curves of the Swiss (training) and South African (trainee) hospitals. These differences are clinically not pronounced, and the knowledge transfer was worth the effort.
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Francavilla S, Veccia A, Dobbs RW, Zattoni F, Vigneswaran HT, Antonelli A, Dal Moro F, Autorino R, Simeone C, Crivellaro S. Radical prostatectomy technique in the robotic evolution: from da Vinci standard to single port-a single surgeon pathway. J Robot Surg 2021; 16:21-27. [PMID: 33554284 PMCID: PMC8863749 DOI: 10.1007/s11701-021-01194-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/15/2021] [Indexed: 12/02/2022]
Abstract
To describe perioperative outcomes following robot-assisted prostatectomy performed by a single surgeon during transitions between da Vinci standard/Si/Xi and the single port. Perioperative data were retrospectively evaluated of the first 40 consecutive robot-assisted radical prostatectomies performed by a single surgeon using the da Vinci standard, Si, Xi and single port. A total of 160 patients were included. We matched standard vs Si (Match 1), Si vs Xi (Match 2) and Xi vs single port (Match 3) cohort. Mann–Whitney and Fisher’s tests were used to test the difference among the groups. Univariate and multivariate logistic regression analyses were adopted to evaluate the predictors of overall and major complications. Single-port procedures in Match 3 showed significant shorter median operative time than Xi. Both Si and single-port groups showed significantly less median blood loss, a shorter median length of stay, respectively, than standard group in Match 1 and than Xi group in Match 3. 1 standard group patient required conversion to open surgery for an unsolvable conflict of the robotic arms. No other intraoperative complications were noted. On univariate and multivariate analyses, the da Vinci platform model was not a predicting factor of major complications (Clavien–Dindo ≥ 3). We described how technological progress impacted peri and postoperative outcomes during transitions between robotic surgical platforms for radical prostatectomy. In particular, the technological improvements associated to the increased surgeon’s expertise made the transition to the single port safe and effective when compared with previous platforms.
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Affiliation(s)
- Simone Francavilla
- Department of Urology, College of Medicine, University of Illinois at Chicago, 820 S Wood Street, Chicago, IL, 60612, USA.
- Urology Unit, Department of Medical and Surgical Specialties, Radiological Science, and Public Health, ASST Spedali Civili Hospital, University of Brescia, Brescia, Italy.
| | - Alessandro Veccia
- Urology Unit, Department of Medical and Surgical Specialties, Radiological Science, and Public Health, ASST Spedali Civili Hospital, University of Brescia, Brescia, Italy
- Division of Urology, Department of Surgery, VCU Health System, Richmond, VA, USA
| | - Ryan W Dobbs
- Department of Urology, College of Medicine, University of Illinois at Chicago, 820 S Wood Street, Chicago, IL, 60612, USA
| | - Fabio Zattoni
- Urology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Hari T Vigneswaran
- Department of Urology, College of Medicine, University of Illinois at Chicago, 820 S Wood Street, Chicago, IL, 60612, USA
| | - Alessandro Antonelli
- Urology Unit Azienda Ospedaliero Universitaria Integrata di Verona, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
| | - Fabrizio Dal Moro
- Urology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health System, Richmond, VA, USA
| | - Claudio Simeone
- Urology Unit, Department of Medical and Surgical Specialties, Radiological Science, and Public Health, ASST Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Simone Crivellaro
- Department of Urology, College of Medicine, University of Illinois at Chicago, 820 S Wood Street, Chicago, IL, 60612, USA
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Bonet X, Moschovas MC, Onol FF, Bhat KR, Rogers T, Ogaya-Pinies G, Rocco B, Sighinolfi MC, Woodlief T, Vigués F, Patel V. The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study. Minerva Urol Nephrol 2020; 73:600-609. [PMID: 33256361 DOI: 10.23736/s2724-6051.20.04077-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to report the overall results and the learning curve (LC) in salvage robot-assisted radical prostatectomy (sRARP) patients, in terms of morbidity, oncological and functional outcomes in a single surgeon tertiary-referral center. METHODS One hundred and twenty patients underwent sRARP by a single surgeon (V.P.) from 2008 to 2018. To assess the trends in the learning experience they were sub-divided in 4 groups of 30 consecutive patients based on date of surgery. The Kaplan-Meier method and regression models were used to identify survival estimations and predictors of potency, continence and biochemical failure (BCF) at 12 months. RESULTS As the learning experience for sRALP increased operative time (OT) was significantly shorter (from 139.5 to 121 minutes) and the amount of nerve-sparing (NS) undertaken increased (from 46% to 80%). While complications rate remained stable, estimated blood loss (EBL) and radiographic anastomotic leaks (RAL) decreased through the groups (from 124 to 69 ml and 40% to 16,7%, respectively). BCF and continence rates at 12 months after sRARP were similar among groups (23-36% and 36,7-50%, respectively) and chance of potency rates tended to increase (from 3.3% to 16-23%) but was not statistically significant. In a multivariate analysis, predictors for BCF were PSM and GS 8-10. Non-radiation primary treatment was the unique predictor of continence at 12 months after sRARP. CONCLUSIONS Our data may suggest a decreasing trend in terms of OT and EBL through the sRARP learning curve. While morbidity remained stable through the time, RAL trended towards a decline. A higher degree of NS was observed through the groups and there was a slight correlation trend between surgical expertise and potency recovery. PSM and GS 8-10 were predictors of BCF and non-radiation primary treatment predicted a better continence after sRARP.
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Affiliation(s)
- Xavier Bonet
- Bellvitge University Hospital, Barcelona, Spain - .,Advent Health Global Robotics Institute, Celebration, FL, USA -
| | | | - Fikret F Onol
- Advent Health Global Robotics Institute, Celebration, FL, USA
| | - Kulthe R Bhat
- Advent Health Global Robotics Institute, Celebration, FL, USA
| | - Travis Rogers
- Advent Health Global Robotics Institute, Celebration, FL, USA
| | - Gabriel Ogaya-Pinies
- Advent Health Global Robotics Institute, Celebration, FL, USA.,Rey Juan Carlos University Hospital, Madrid, Spain
| | - Bernardo Rocco
- Advent Health Global Robotics Institute, Celebration, FL, USA.,University of Modena and Reggio Emilia, Modena, Italy
| | | | - Tracey Woodlief
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | | | - Vipul Patel
- Advent Health Global Robotics Institute, Celebration, FL, USA
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Tamhankar A, Spencer N, Hampson A, Noel J, El-Taji O, Arianayagam R, McNicholas T, Boustead G, Lane T, Adshead J, Vasdev N. Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy. Ann R Coll Surg Engl 2020; 102:717-725. [PMID: 32538121 DOI: 10.1308/rcsann.2020.0139] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases. METHODS We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases. RESULTS A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins. CONCLUSIONS It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.
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Affiliation(s)
| | | | - A Hampson
- East and North Hertfordshire NHS Trust, UK
| | - J Noel
- East and North Hertfordshire NHS Trust, UK
| | - O El-Taji
- East and North Hertfordshire NHS Trust, UK
| | | | | | - G Boustead
- East and North Hertfordshire NHS Trust, UK
| | - T Lane
- East and North Hertfordshire NHS Trust, UK
| | - J Adshead
- East and North Hertfordshire NHS Trust, UK
| | - N Vasdev
- East and North Hertfordshire NHS Trust, UK.,University of Hertfordshire, UK
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10
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Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in robot-assisted radical prostatectomy. PLoS One 2020; 15:e0230290. [PMID: 32182262 PMCID: PMC7077845 DOI: 10.1371/journal.pone.0230290] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/25/2020] [Indexed: 11/19/2022] Open
Abstract
Background Previous researches have shown that anesthetic techniques may influence the patients’ outcomes after cancer surgery. Here, we studied the relationship between the type of anesthetic techniques and patients’ outcomes following elective robot-assisted radical prostatectomy. Methods This was a retrospective cohort study of patients who received elective, robot-assisted radical prostatectomy between January 2008 and December 2018. Patients were grouped according to the anesthesia they received, namely desflurane or propofol. A Kaplan–Meier analysis was conducted, and survival curves were presented from the date of surgery to death. Univariable and multivariable Cox regression models were used to compare hazard ratios for death after propensity matching. Subgroup analyses were performed for tumor-node-metastasis stage and disease progression. The primary outcome was overall survival, and the secondary outcome was postoperative biochemical recurrence. Results A total of 365 patients (24 deaths, 7.0%) under desflurane anesthesia, and 266 patients (2 deaths, 1.0%) under propofol anesthesia were included. The all-cause mortality rate was significantly lower in the propofol anesthesia than in the desflurane anesthesia during follow-up (P = 0.001). Two hundred sixty-four patients remained in each group after propensity matching. The propofol anesthesia was associated with improved overall survival (hazard ratio, 0.11; 95% confidence interval, 0.03–0.48; P = 0.003) in the matched analysis. Subgroup analyses showed that patients under propofol anesthesia had less postoperative biochemical recurrence than those under desflurane (hazard ratio, 0.20; 95% confidence interval, 0.05–0.91; P = 0.038) in the matched analysis. Conclusions Propofol anesthesia was associated with improved overall survival in robot-assisted radical prostatectomy compared with desflurane anesthesia. In addition, patients under propofol anesthesia had less postoperative biochemical recurrence.
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11
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Chen H, Lian B, Dong Z, Wang Y, Qu M, Zhu F, Sun Y, Gao X. Experience of one single surgeon with the first 500 robot-assisted laparoscopic prostatectomy cases in mainland China. Asian J Urol 2019; 7:170-176. [PMID: 32257810 PMCID: PMC7096692 DOI: 10.1016/j.ajur.2019.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/14/2019] [Accepted: 11/04/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives To summarize the experience of the first 500 robot-assisted laparoscopic radical prostatectomy (RALP) cases by one surgeon and analyze the influencing factors of functional and oncological outcomes. Methods Between April 2012 and October 2017, 500 patients who underwent RALP were included and divided sequentially into five equal groups. Patients’ preoperative, perioperative and postoperative outcomes were analyzed and evaluated, and the Kruskal-Wallis test was used to analyze and compare the effect of surgeon experience by case. Results There is a statistically significant reduction in operative time, intraoperative estimated blood loss and postoperative hospital stay time (all p<0.001) with the increased experience. The results show that experience was the most important influencing factor in both operative time and blood loss. Pelvic lymph node dissection (PLND) might increase the operative time. The total positive surgical margin (PSM) rate was 21.8%. The PSM rate in pT3 tumors was significantly higher than that in pT2 tumors (12.0% vs. 37.1%, p<0.001). The 5-year biochemical recurrence (BCR)-free rate was 70.8%. The results of Cox regression showed that preoperative prostate-specific antigen (PSA), postoperative Gleason score (GS), and pathologic T stage were independent risk factors for BCR. Conclusion After approximately 200 cases, the surgeon reached a plateau for RALP, but the outcomes could still improve after more cases. The surgeon's experience was the most important influencing factor for both operative time and blood loss. PSM rate was mainly determined by tumor stage rather than by operation experience.
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Affiliation(s)
- Huan Chen
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bijun Lian
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenyang Dong
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Min Qu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Feng Zhu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yinghao Sun
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xu Gao
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Salwa P, Kielan W. Peri- and post-operative results of initial robot-assisted radical prostatectomies of a surgeon graduating from a structured fellowship. MEDICAL SCIENCE PULSE 2019. [DOI: 10.5604/01.3001.0013.0844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: No validated training curriculum for robotic surgery exists so far. International scientific societies
like ERUS (EAU Robotic Urology Section) seek to validate a structured training program for robotic surgeons.
In 2014, ERUS launched Pilot Study II, a 6-month structured training program to allow a surgeon without prior
robotic training to perform a complete RARP (robot-assisted radical prostatectomy) independently and effectively.
Aim of the study: Here we report the detailed courses and training materials, specific surgical activities and
perioperative efficacy and safety results of the first 52 RARP cases performed by a single surgeon after graduating
from Pilot Study II. The aim is to compare these results with the literature and show if this sophisticated
training helps patients undergoing this type of surgery achieve advantageous perioperative results.
Material and methods: The fellowship was conducted from January to June 2014 and consisted of lectures on
technical and non-technical skills, as well as e-learning, bedside assistance (at least 20), intensive training consisting
of laboratory training (i.e., virtual reality simulation, dry lab (plastic model), wet lab on animal cadavers
and living anaesthetized pigs) and dual-console live surgery followed by five months of modular training, where
the trainee performed different steps of the surgery at the host center. After passing the final evaluation (a full
recorded video of RARP evaluated blindly by robotic experts), the trainee was deemed capable of performing
efficiently and safely a full case of RARP. Here we retrospectively report the content of training and perioperative
results of the surgeon’s initial 52 RARPs performed from July 2014 to April 2015.
Results: After graduating from the fellowship, the surgeon performed 52 cases of RARP. The mean patient age
was 65.2 years, initial PSA 12.9 ng/ml, prostate volume 43.7 ml in TRUS, BMI 27.5, and 61% of patients had a
prior abdominal or pelvic surgery. Because of internal regulations, every patient had a pelvic lymphadenectomy
performed, three of whom had positive lymph nodes. The average estimated blood loss was 225.7 ml, and no
patient needed intraoperative blood transfusion. The average console time was 174.2 minutes. Final full-mount
pathology identified 23 patients (44.2%) with a locally advanced prostate cancer (T3 or T4). Positive surgical margins
were present in three cases. A further 29 patients (55.8%) had locally confined disease (T2). Positive surgical
margins were observed in 2 cases. Catheters were removed on the 5th postoperative day followed by a cystogram,
with no urine leakage observed in 96.2% of cases. The safety of the procedure was good with one major (Clavien
4) and 13 minor (Clavien 1 and 2, i.e., uncomplicated urinary infection, urinary retention) complications.
Conclusions: The study showed that graduating from an intensive and structured learning program in robotic
surgery resulted in a faster learning curve, allowing the trainee to reach high safety parameters in performed
surgeries. When compared with already published series, advantageous results could be observed. The study
was limited by its retrospective design, the moderate number of patients and variables such as individual motivation,
dexterity and attitude of the person in training. The advantages of such training should be further evaluated
in controlled, multi-center trials.
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Affiliation(s)
- Paweł Salwa
- Urology Department, Medicover Hospital, Warsaw, Poland
| | - Wojciech Kielan
- Second Department and Clinic of General and Oncological Surgery, Wroclaw Medical University, Poland
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Analysis of the Learning Curve of Surgeons without Previous Experience in Laparoscopy to Perform Robot-Assisted Radical Prostatectomy. Adv Urol 2018; 2018:9073807. [PMID: 30510573 PMCID: PMC6231378 DOI: 10.1155/2018/9073807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/26/2018] [Accepted: 10/11/2018] [Indexed: 11/24/2022] Open
Abstract
Objective To assess the learning curve in robot-assisted radical prostatectomy (RARP) performed by surgeons without previous experience in laparoscopic prostatectomy. Materials and Methods We analyzed 119 patients submitted to RARP performed by two surgeons without previous experience in laparoscopic prostatectomy, with emphasis on the relevant outcomes such as continence, erectile function, and oncologic control with a minimum follow-up of 24 months. We used Fisher's exact test and the chi-square test to investigate the existence of a relationship between the variables and analysis of variance (ANOVA) to verify possible statistically significant differences between groups, at the 5% level. Results The patients' age varied from 41 to 72 years (mean = 61.09), with 68 (57.14%) cases having intermediate or high risk. There was a consistent decline in operative time. Of the 119 patients, 80.67% were continent 6 months after surgery and 89.07% 12 months afterward, while 35.29% were potent 6 months after surgery and 60.50% 12 months following surgery. Twelve months after surgery, the trifecta outcome rate was 51.26% and the pentafecta rate was 31.09%. There was progressive postoperative improvement and maintenance of continence and sexual potency until the last patient was operated in our sample. Conclusions Robot-assisted radical prostatectomy does not require previous experience in laparoscopic radical prostatectomy, but the learning curve is not short to achieve the plateau.
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Chien CH, Chuang CK, Liu KL, Pang ST, Wu CT, Chang YH. Prostate cancer-specific anxiety and the resulting health-related quality of life in couples. J Adv Nurs 2018; 75:63-74. [DOI: 10.1111/jan.13828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/21/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Ching-Hui Chien
- College of Nursing; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
| | - Cheng-Keng Chuang
- Division of Urology; Department of Surgery; Chang Gung Memorial Hospital at Linkou; Taiwan
- College of Medicine; Chang Gung University; Tao-Yuan Taiwan
| | - Kuan-Lin Liu
- Division of Urology; Department of Surgery; Chang Gung Memorial Hospital at Linkou; Taiwan
| | - See-Tong Pang
- Division of Urology; Department of Surgery; Chang Gung Memorial Hospital at Linkou; Taiwan
- College of Medicine; Chang Gung University; Tao-Yuan Taiwan
| | - Chun-Te Wu
- College of Medicine; Chang Gung University; Tao-Yuan Taiwan
- Division of Urology; Department of Surgery; Chang Gung Memorial Hospital at Keelung; Taiwan
| | - Ying-Hsu Chang
- Division of Urology; Department of Surgery; Chang Gung Memorial Hospital at Linkou; Taiwan
- College of Medicine; Chang Gung University; Tao-Yuan Taiwan
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Shim JS, Noh TI, Kim JY, Pyun JH, Cho S, Oh MM, Kang SH, Cheon J, Lee JG, Kim JJ, Kang SG. Predictive Validation of a Robotic Virtual Reality Simulator: The Tube 3 module for Practicing Vesicourethral Anastomosis in Robot-Assisted Radical Prostatectomy. Urology 2018; 122:32-36. [PMID: 30144481 DOI: 10.1016/j.urology.2018.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To predict actual performance in real surgery when vesicourethral anastomosis (VUA) is performed in patients after Tube 3 module training of robot-naive surgeons. METHODS Forty-five patients were enrolled and divided into 3 groups according to chronological trends (each containing 15 patients). Three robot-naive surgeons in a single center completed VUA in robot-assisted radical prostatectomy (RARP) following robotic virtual reality simulator (RVRS) training. The practicing tool used in robotic virtual reality simulator was Tube 3, which was invented for the dV-Trainer that imitates a VUA in RARP. The effects of performance were investigated by analyzing the number of repetitions and the time required to complete the task until achieving the predetermined proficiency level. RESULTS The targeted time (predetermined proficiency level) for completing tasks of Tube 3 and the number of required task repetitions to achieve the proficiency level were 283.1 s and 36 times, respectively, whereas in actual VUA procedures, the number of required attempts was 24, with an average time of 14.9 minutes. The mean time for completing VUA in real surgery significantly decreased with serial cases among all surgeons (1-15 vs 16-30 vs 31-45 cases, P <.001), as well as comparisons between groups (P <.001). CONCLUSION The Tube 3 module can represent a valuable educational tool for procedure-specific robotic training by bridging the gap between safe acquisition of surgical skills and effective performance during actual VUA in RARP.
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Affiliation(s)
- Ji Sung Shim
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Tae Il Noh
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Jae Yoon Kim
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Jong Hyun Pyun
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Seok Cho
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Mi Mi Oh
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Seok Ho Kang
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Jun Cheon
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Jeong Gu Lee
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Je Jong Kim
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea
| | - Sung Gu Kang
- Department of Urology, Korea University Medical Center, Seoul, Republic of Korea.
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Chen PY, Chiang PH, Liu YY, Chuang YC, Cheng YT. Primary whole-gland ablation for localized prostate cancer with high-intensity focused ultrasound: The important predictors of biochemical recurrence. Int J Urol 2018; 25:615-620. [PMID: 29756298 DOI: 10.1111/iju.13581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 03/05/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To identify predictive factors of biochemical recurrence for patients undergoing high-intensity focused ultrasound treatment for localized prostate cancer. METHODS We retrospectively identified patients receiving whole-gland prostate ablation with high-intensity focused ultrasound for localized prostate cancer from 2009 to 2015. All the patients received pre-high-intensity focused ultrasound radical transurethral resection of the prostate. We included perioperative parameters as follows: age, preoperative prostate volume, stage of operation, initial prostate-specific antigen, T stage, postoperative prostate-specific antigen nadir, Gleason score, time to prostate-specific antigen nadir and the presence of prostate-specific antigen biochemical recurrence. Multivariable Cox regression and Kaplan-Meier analysis were used for investigating predictors of recurrence, and receiver operating characteristic analysis was used for the cut-off values of prostate-specific antigen nadir. RESULTS Among 182 patients, 26.9% had prostate-specific antigen biochemical recurrence after high-intensity focused ultrasound during the median follow-up period of 32.21 months. Gleason score ≥7 (Gleason score 7, hazard ratio 2.877, P = 0.027), stage ≥T2b (T2b, hazard ratio 3.16, P = 0.027) and prostate-specific antigen nadir (hazard ratio 1.11, P < 0.001) were statistically significant, whereas there was no significance in prostate volume and initial prostate-specific antigen. We posit that a cut-off level of prostate-specific antigen nadir 0.43 ng/mL might be considered as an independent predictive factor for prostate-specific antigen biochemical recurrence in high-intensity focused ultrasound patients in multivariate analysis (P < 0.001, hazard ratio 7.39, 95% confidence interval 3.56-15.37), and created a new nadir-related prediction model for biochemical recurrence prediction. CONCLUSIONS Postoperative prostate-specific antigen nadir of 0.43 ng/mL can be considered an important predictive factor for biochemical recurrence in primary whole-prostate gland high-intensity focused ultrasound treatment, and the nadir-related prediction model might provide a reference for early salvage treatment. Furthermore, Gleason score ≥7, stage ≥T2b might be associated with unfavorable outcomes, although prostate volume and higher initial prostate-specific antigen appear not to be associated with biochemical recurrence for the high-intensity focused ultrasound treatment.
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Affiliation(s)
- Po Yen Chen
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po Hui Chiang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi Yang Liu
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao Chi Chuang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yuan Tso Cheng
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Toh JWT, Phan K, Kim SH. Robotic colorectal surgery: more than a fantastic toy? Innov Surg Sci 2018; 3:65-68. [PMID: 31579767 PMCID: PMC6754041 DOI: 10.1515/iss-2017-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/06/2018] [Indexed: 01/26/2023] Open
Abstract
There has been a rapid rise in the number of robotic colorectal procedures worldwide since the da Vinci Surgical System robotic technology was approved for surgical procedures in the year 2000. Several recent meta-analyses and systematic reviews have shown a significant difference in outcomes between robotic and laparoscopic rectal cancer surgery. However, these results from pooled data have not been supported by the initial results reported from the Robotic assisted versus laparoscopic assisted resection for rectal cancer trial. In this article, we examine the current evidence for robotic colorectal surgery, assess its features and functionality, evaluate its learning curve and provide our perspective on its future.
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Affiliation(s)
- James W T Toh
- International Visiting Colorectal Surgeon, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Westmead Hospital, The University of Sydney Westmead Clinical School, Sydney, NSW, Australia
| | - Kevin Phan
- Division of Colorectal Surgery, Department of Surgery, Westmead Hospital, The University of Sydney Westmead Clinical School, Sydney, NSW, Australia
| | - Seon-Hahn Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 02841, Inchon-ro 73, Seongbuk-gu,Seoul, Korea
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[Ablative therapy in urology: Good practice and perspective]. Prog Urol 2017; 27:994-1014. [PMID: 28958771 DOI: 10.1016/j.purol.2017.08.008] [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: 07/26/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/23/2022]
Abstract
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.
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Calio B, Sidana A, Sugano D, Gaur S, Jain A, Maruf M, Xu S, Yan P, Kruecker J, Merino M, Choyke P, Turkbey B, Wood B, Pinto P. Changes in prostate cancer detection rate of MRI-TRUS fusion vs systematic biopsy over time: evidence of a learning curve. Prostate Cancer Prostatic Dis 2017; 20:436-441. [PMID: 28762373 DOI: 10.1038/pcan.2017.34] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/04/2017] [Accepted: 06/10/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND To determine the effect of urologist and radiologist learning curves and changes in MRI-TRUS fusion platform during 9 years of NCI's experience with multiparametric magnetic resonance imaging (mpMRI)/TRUS fusion biopsy. METHODS A prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007 to 2016 was reviewed. The patients were stratified based on the timing of first biopsy. Cohort 1 (7/2007-12/2010) accounted for learning curve. Cohort 2 (1/2011-5/2013) and cohort 3 (5/2013-4/2016) included patients biopsied prior to and after debut of a new software platform, respectively. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. McNemar's test compared cancer detection rates (CDRs) of Sbx and Fbx between time periods. RESULTS 1528 patients were included in the study with 230, 537 and 761 patients included in three respective cohorts. Median age (interquartile range) was 61.0 (±9.0), 62.0 (±7.3), and 64.0 (±11.0) years in three cohorts, respectively (P<0.001). Fbx and Sbx had comparable CS CDR in cohort 1 (24.8 vs 22.2%, P=0.377). Fbx detected significantly more CS disease compared to Sbx in the following two periods (cohort 2: 31.5 vs 25.0%, P=0.001; cohort 3: 36.4 vs 30.3%, P<0.001) and detected significantly less low risk disease in the same period (cohort 2: 14.5 vs 19.6%, P<0.001; cohort 3: 12.6 vs 16.7%, P<0.001). Even after multivariate adjustment with age, PSA, race, clinical stage and MRI suspicion score, Fbx CS cancer detection increased in successive cohorts (cohort 2: OR 2.23, P=0.043; cohort 3: OR 2.92, P=0.007). CONCLUSIONS In the past 9 years, there has been significant improvement in the accuracy of Fbx. Our results show that after an early learning period, Fbx detected higher rates of CS cancer and lower rates of clinically insignificant cancer than Sbx. Software advances allowed for even greater detection of CS disease.
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Affiliation(s)
- B Calio
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - A Sidana
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - D Sugano
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - S Gaur
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - A Jain
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - M Maruf
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - S Xu
- Center for Interventional Oncology, National Cancer Institute and Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - P Yan
- Center for Interventional Oncology, National Cancer Institute and Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - J Kruecker
- Center for Interventional Oncology, National Cancer Institute and Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - M Merino
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - P Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - B Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - B Wood
- Center for Interventional Oncology, National Cancer Institute and Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - P Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Wang L, Wang B, Ai Q, Zhang Y, Lv X, Li H, Ma X, Zhang X. Long-term cancer control outcomes of robot-assisted radical prostatectomy for prostate cancer treatment: a meta-analysis. Int Urol Nephrol 2017; 49:995-1005. [DOI: 10.1007/s11255-017-1552-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/21/2017] [Indexed: 01/11/2023]
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Evolving treatment of prostate diseases – A never ending journey. UROLOGICAL SCIENCE 2016. [DOI: 10.1016/j.urols.2016.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Standardized procedure of robotic assisted laparoscopic radical prostatectomy from case 1 to case 1200. UROLOGICAL SCIENCE 2016. [DOI: 10.1016/j.urols.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Goonewardene SS, Cahill D. Salvage robotic prostatectomy and high risk disease: what else can we do? J Robot Surg 2016; 12:197-198. [PMID: 27456693 DOI: 10.1007/s11701-016-0628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 07/17/2016] [Indexed: 11/26/2022]
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Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised? J Robot Surg 2016; 11:69-74. [PMID: 27350553 DOI: 10.1007/s11701-016-0615-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
This study evaluates whether a new staff surgeon early in the learning curve can be integrated into a high-volume robotic practice with an established robotic team and mentorship without compromising robot-assisted radical prostatectomy (RARP) outcomes of the practice. We analyzed outcomes of 3064 patients who underwent RARP from 2007 to 2012 at a high-volume tertiary center by a robotic practice comprising three experienced robotic surgeons (2846 patients) and a newly hired surgeon (218 patients) immediately out of training (residency and oncology fellowship with 2 years of RARP exposure). The new surgeon performed RARP with intraoperative mentorship by the senior surgeons during the first year. Complications, biochemical recurrence (BCR), positive surgical margins rate (PSM), operating time (OR time), estimated blood loss (EBL) for the new and senior surgeons were compared. Multivariable linear, logistic and exact logistic regression adjusting for disease and patient characteristics were performed. On regression analyses, case number was the most significant predictor of decrease in probability of major complications (p = 0.025) and BCR (p = 0.004) for the new surgeon. Increasing case number was not associated with decrease in minor complications, PSM, OR time, or EBL (p > 0.05). Inclusion of the new surgeon's outcomes did not adversely impact outcomes of the practice. In conclusion, a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice. Our results may be relevant for programs hiring newly trained staff to join an established robotic practice.
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Hung CF, Yang CK, Ou YC. Urologic cancer in Taiwan. Jpn J Clin Oncol 2016; 46:605-9. [PMID: 27052114 DOI: 10.1093/jjco/hyw038] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/16/2016] [Indexed: 11/14/2022] Open
Abstract
For the past three decades, cancer is the number one cause of death in Taiwan. An increasing trend in the incidence of urologic cancers has also been noticed since 1979. In 2012, urologic cancer accounted for 10.0% of all the new malignant cases. Prostate, bladder and kidney cancers are the most common types. Metastatic prostate cancer still accounted for nearly 30% of new cases in Taiwan between 2004 and 2012. There are several specifically noticeable characteristics of urothelial carcinoma in Taiwan, associated with arseniasis and aristolochic acid. The diagnosis and treatment of urologic cancer mainly follows the current international guidelines. The development of minimal invasive surgery, especially DaVinci robotic surgical system, has made a marked change in the surgical treatment of urologic cancer. Meanwhile, newer systemic agents also commence and improve our standard of care. However, treatment decisions are greatly influenced by the National Health Insurance coverage. The current national cancer registry system should be renovated more comprehensively in order to gain better insight into specific features of urologic cancer in Taiwan.
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Affiliation(s)
- Chi-Feng Hung
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung
| | - Yen-Chuan Ou
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
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Chang Y, Qu M, Wang L, Yang B, Chen R, Zhu F, Wang H, Wang Y, Lu X, Ma C, Shi Z, Dong Z, Chen H, Xu C, Sun Y, Gao X. Robotic-assisted Laparoscopic Radical Prostatectomy From a Single Chinese Center: A Learning Curve Analysis. Urology 2016; 93:104-11. [PMID: 27045710 DOI: 10.1016/j.urology.2016.03.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/09/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the learning curve of robotic-assisted laparoscopic radical prostatectomy (RALP) and analyze whether a surgeon's prior surgical experience has effects on the surgery. PATIENTS AND METHODS From April 2012 to August 2015, 3 surgeons performed RALP on 355 consecutive patients with prostate cancer. Among these cases, 184 were by surgeon A with prior open experiences, 92 by surgeon B with both open and laparoscopic experiences, and 79 by surgeon C with laparoscopic experiences only. Perioperative, oncological, and functional outcomes were evaluated and compared between surgeons. Learning curve patterns were evaluated to determine the number of cases to reach plateau. RESULTS Marked difference was observed in operative time among the 3 groups (all P <.05). Length of hospital stay was also statistically significant (all P <.001), except for that between Group B and Group C (P = .739). Continence at 1-year and 6-month postoperatively was better in Groups B and C compared with Group A (P <.001). Intraoperative blood loss, pathologic stage, positive surgical margin, biochemical recurrence-free rate, and other pathological findings showed no statistical significance between the groups. The number of cases required to reach plateau may vary for surgeons with different surgical experiences. CONCLUSION Different early surgical background may affect the perioperative parameters of novice RALP surgeons. Previous laparoscopic experiences may provide additional advantage in learning curve parameters compared with surgeons with open experiences only. A better overall continence for laparoscopic surgeons requires further validation.
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Affiliation(s)
- Yifan Chang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Min Qu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Linhui Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Chen
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Feng Zhu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haifeng Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xin Lu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chunfei Ma
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenkai Shi
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenyang Dong
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Huan Chen
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chuanliang Xu
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yinghao Sun
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Xu Gao
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Yu CC, Yang CK, Ou YC. Three Types of Intravesical Hem-o-Lok Clip Migration After Laparoscopic Radical Prostatectomy. J Laparoendosc Adv Surg Tech A 2015; 25:1005-8. [PMID: 26566082 DOI: 10.1089/lap.2015.0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hem-o-Lok® clips (HOLCs) (Weck® Surgical Instruments, Teleflex Medical, Durham, NC) are widely used for controlling the lateral pedicles in laparoscopic radical prostatectomy, but intravesical HOLC migrations have been reported in more and more studies. This study aimed to summarize clinical presentations, management, and outcomes of these patients. MATERIALS AND METHODS Six patients with intravesical HOLC migration were retrospectively identified from 750 consecutive patients who underwent robot-assisted laparoscopic prostatectomy between 2005 and 2014 performed by a single surgeon. The PubMed database was also searched for Hem-o-Lok clip migration after laparoscopic prostatectomy. RESULTS The incidence of intravesical HOLC migration in this study was 0.8% (6/750). In total, 22 patients were reported, including six from the current series. Three types of migrations were classified: Type I migration resulted in obstructive lower urinary tract symptoms 2-8 months after prostatectomy, whereas Type II migration led to stone formation, gross hematuria, or bladder spasm; in Type III migration, patients had spontaneous expulsion of the HOLC weeks after surgery. CONCLUSIONS Although the incidence of intravesical HOLC migration is relatively low, Type I migration with long-term sequelae remains a concern. The use of HOLCs adjacent to anastomosis should be minimized, and any loose clip must be retrieved to reduce complications.
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Affiliation(s)
- Chih-Chin Yu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital , Taichung, Taiwan, Republic of China
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital , Taichung, Taiwan, Republic of China
| | - Yen-Chuan Ou
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital , Taichung, Taiwan, Republic of China
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Robot-Assisted Laparoscopic Nephroureterectomy versus Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma: A Matched Comparison Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:918486. [PMID: 26539538 PMCID: PMC4619898 DOI: 10.1155/2015/918486] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/17/2015] [Accepted: 08/02/2015] [Indexed: 12/20/2022]
Abstract
Objectives. To investigate the perioperative and oncological outcomes of hand-assisted laparoscopic nephroureterectomy (HANU) and robotic-assisted nephroureterectomy (RANU). Methods. Patients who underwent RANU were matched by sex, age (±5 years), and tumor location to those who underwent HANU; 18 matched pairs were included. Results. Each group consisted of five men and 13 women. The mean age was 70.4 years in RANU group and 69.6 years in HANU group (p = 0.646). Each group contained 10 patients with tumor location in the renal pelvis, five in the ureter, and three in both sites. The median follow-up time was 6.1 months for the RANU group and 47.8 months for the HANU group. The demographic and pathological data did not differ significantly. The RANU group had significantly less blood loss (p < 0.001), resumed oral intake earlier (p = 0.043), and had shorter hospital stays (p = 0.014) but higher pain scores associated with their wounds (p = 0.043). The oncological outcomes were comparable with those of the HANU group. Conclusions. Our results show that the RANU and HANU groups have comparable operative, early postoperative, and functional outcomes. A longer follow-up period would be needed for final comparison of oncological outcome.
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Alvin LWX, Gee SH, Hong HH, Christopher CWS, Henry HSS, Weber LKO, Hoon TP, Shiong LL. Oncological outcomes following robotic-assisted radical prostatectomy in a multiracial Asian population. J Robot Surg 2015; 9:201-9. [PMID: 26531200 DOI: 10.1007/s11701-015-0516-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/02/2015] [Indexed: 11/26/2022]
Abstract
This study evaluates the oncological outcomes of RARP in a multiracial Asian population from a single institution. All suitable patients from 1st January 2003-30th June 2013 were identified from a prospectively maintained cancer registry. Peri-operative and oncological outcomes were analysed. Significance was defined as p < 0.05. There were n = 725 patients identified with a mean follow-up duration 28 months. The mean operative time, EBL and LOS were 186 min, 215 ml and 3 days, respectively. The pathological stage was pT2 in 68.6% (n = 497/725), pT3 in 31.3% (n = 227/725) and n = 1 patient with pT4 disease. The pathological Gleason scores (GS) were 6 in 27.9% (n = 202/725), GS 7 in 63.6% (n = 461/725) and GS ≥ 8 in 8.0 % (n = 58/725). The node positivity rate was 5.8% (n = 21/360). The positive margin rates were 31.0% (n = 154/497) and 70.9% (n = 161/227) for pT2 and pT3, respectively, and decreasing PSM rates are observed with surgical maturity. The biochemical recurrence rates were 9.7% (n = 48/497) and 34.2% (n = 78/228) for pT2 and pT3/T4, respectively. On multivariate analysis, independent predictors of BCR were pathological T stage and pathological Gleason score. Post-operatively, 78.5% (n = 569/725) of patients had no complications and 17.7% (n = 128/725) had minor (Clavien grade I-II) complications. This series, representing the largest from Southeast Asia, suggests that RARP can be a safe and oncologically feasible treatment for localised prostate cancer in an institution with moderate workload.
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Affiliation(s)
- Low Wei Xiang Alvin
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Sim Hong Gee
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore
| | - Huang Hong Hong
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore
| | - Cheng Wai Sam Christopher
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore
| | - Ho Sien Sun Henry
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore
| | - Lau Kam On Weber
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore
| | - Tan Puay Hoon
- Department of Pathology, Singapore General Hospital, Singapore, 169856, Singapore
| | - Lee Lui Shiong
- Department of Urology, Singapore General Hospital, Level 5, The Academia, 20 College Road, Singapore, 169856, Singapore.
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Lott FM, Favorito LA. Is previous experience in laparoscopic necessary to perform robotic radical prostatectomy? A comparative study with robotic and the classic open procedure in patients with prostate cancer. Acta Cir Bras 2015; 30:229-34. [DOI: 10.1590/s0102-8650201500300000011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/18/2015] [Indexed: 11/22/2022] Open
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Zhou J, Shi Y, Qian F, Tang B, Hao Y, Zhao Y, Yu P. Cumulative summation analysis of learning curve for robot-assisted gastrectomy in gastric cancer. J Surg Oncol 2015; 111:760-7. [PMID: 25580709 DOI: 10.1002/jso.23876] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 12/02/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND The purpose of this study was to determine the learning curve for robot-assisted gastrectomy using the Cumulative Summation (CUSUM) technique. METHODS Two series of consecutive robotic gastrectomy were retrospective analyzed. Patient demographics, surgical performance, and short-term outcomes were examined and data of operation time were abstracted for the learning curve analysis. RESULTS Similar processes occurred in the two surgeons. Each of their learning curves of robotic gastrectomy was best modeled as a third-order polynomial, with equation CUSUMOT in minutes equal to 0.0495 case number (3) - 4.217 case number(2) + 91.206 case number 100.11(R(2) = .8731) for surgeon A and 0.0314 case number (3) - 2.4106 case number(2) + 33.682 case number + 315.28(R(2) = 0.8816) for surgeon B. They both included three unique phases: an initial phase, a well-developed phase, and a mastery phase after the accumulation of additional experience. CONCLUSION The CUSUM method is a useful tool for objective evaluation of practical skills for surgeons during the learning phase of robotic surgery training. The robotic gastrectomy is found to have a short learning curve for experienced laparoscopic surgeons and the popularity of this new technology won't reduce because of its difficulty to learn.
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Affiliation(s)
- Junfeng Zhou
- Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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