Robotic radical prostatectomy in 93 cases: Outcomes of the first ERUS robotic urology curriculum trained surgeon in Turkey

Current Standards for Training in Robot-assisted Surgery and Endourology: A Systematic Review

BACKGROUND AND OBJECTIVE

Different training programs have been developed to improve trainee outcomes in urology. However, evidence on the optimal training methodology is sparse. Our aim was to provide a comprehensive description of the training programs available for urological robotic surgery and endourology, assess their validity, and highlight the fundamental elements of future training pathways.

METHODS

We systematically reviewed the literature using PubMed/Medline, Embase, and Web of Science databases. The validity of each training model was assessed. The methodological quality of studies on metrics and curricula was graded using the MERSQI scale. The level of evidence (LoE) and level of recommendation for surgical curricula were awarded using the educational Oxford Centre for Evidence-Based Medicine classification.

KEY FINDINGS AND LIMITATIONS

A total of 75 studies were identified. Many simulators have been developed to aid trainees in mastering skills required for both robotic and endourology procedures, but only four demonstrated predictive validity. For assessment of trainee proficiency, we identified 18 in robotics training and six in endourology training; however, the majority are Likert-type scales. Although proficiency-based progression (PBP) curricula demonstrated superior outcomes to traditional training in preclinical settings, only four of six (67%) in robotics and three of nine (33%) in endourology are PBP-based. Among these, the Fundamentals of Robotic Surgery and the SIMULATE curricula have the highest LoE (level 1b). The lack of a quantitative synthesis is the main limitation of our study.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Training curricula that integrate simulators and PBP methodology have been introduced to standardize trainee outcomes in robotics and endourology. However, evidence regarding their educational impact remains restricted to preclinical studies. Efforts should be made to expand these training programs to different surgical procedures and assess their clinical impact.

How Safe Are the Laparoscopic and Robotic Graspers? Evaluation of the Novel Avatera Robotic Surgical System: An Acute In Vivo Study on a Porcine Model

OBJECTIVE

To evaluate the tissue injury caused by the force applied by the roboticassisted graspers of avatera robotic surgical system on bowel tissue.

METHODS

An experimental in vivo porcine model with 1 pig was conducted. After a standard transperitoneal setup of the avatera robotic surgical system, different laparoscopic and robotic graspers were used on the bowel with maximum force applied each time. Robotic atraumatic grasper, laparoscopic right angle grasper, laparoscopic curved grasper, and laparoscopic atraumatic grasper were used. After using all graspers, the pig was sacrificed. The bowel segments were resected and sent for histological analysis.

RESULTS

The pathologist reported that all the graspers caused signs of acute inflammation without any irreversible damage or signs compatible with ischemia of the tissue. No significant difference in histology was observed between the graspers.

CONCLUSION

No permanent damage was caused by graspers, except for acute, reversible inflammation. Concluding, the avatera grasper could be safe to use on bowel segments, independent of the applied pressure.

Current practises and the future of robotic surgical training

INTRODUCTION

This study reviews the current state of robotic surgery training for surgeons, including the various curricula, training methods, and tools available, as well as the challenges and limitations of these.

METHODS

The authors carried out a literature search across PubMed, MEDLINE, and Google Scholar using keywords related to 'robotic surgery', 'computer-assisted surgery', 'simulation', 'virtual reality', 'surgical training', and 'surgical education'. Full text analysis was performed on 112 articles.

TRAINING PROGRAMMES

The training program for robotic surgery should focus on proficiency, deliberation, and distribution principles. The curricula can be broadly split up into pre-console and console-side training. Pre-Console and Console-Side Training: Simulation training is an important aspect of robotic surgery training to improve technical skill acquisition and reduce mental workload, which helps prepare trainees for live procedures.

OPERATIVE PERFORMANCE ASSESSMENT

The study also discusses the various validated assessment tools used for operative performance assessments.

FUTURE ADVANCES

Finally, the authors propose potential future directions for robotic surgery training, including the use of emerging technologies such as AI and machine learning for real-time feedback, remote mentoring, and augmented reality platforms like Proximie to reduce costs and overcome geographic limitations.

CONCLUSION

Standardisation in trainee performance assessment is needed. Each of the robotic curricula and platforms has strengths and weaknesses. The ERUS Robotic Curriculum represents an evidence-based example of how to implement training from novice to expert. Remote mentoring and augmented reality platforms can overcome the challenges of high equipment costs and limited access to experts. Emerging technologies offer promising advancements for real-time feedback and immersive training environments, improving patient outcomes.

The relationship between adjuvant chemotherapy and thiol-disulfide compounds

Aim

Thiols are the organic compounds of the antioxidant system. There is limited data in the literature concerning chemotherapy (CT) in cancer and thiol balance. In this study, we aimed to evaluate the possible changes of thiol/disulfide levels with the recurrent CT cycles and type of cancer.

Materials and Methods

The 40 healthy individuals and 40 patients who had been newly diagnosed with early-stage breast, ovary and endometrium cancer receiving adjuvant CT. Blood samples were taken from all patients three times as basal and after the first and second CT sessions.

Results

We compared preadjuvant treatment levels of thiol and disulfide parameters in the patients group with the control group. The median of native thiol and total thiol was found to be higher in the control group than in the study group (P < 0.001). In addition, disulfide/native thiol and disulfide/total thiol rates were found to be higher in the patient group (P = 0.001). When we look at the comparison before and after CT in the patient group, disulfide/native thiol and disulfide/total thiol rates, which represent increased oxidative stress (OS) levels were found to be higher after CT than before CT measurement (P < 0.016).

Discussion

This is the first study, which has researched the relationship between cancer type and thiol compounds and changes of thiol compounds during CT therapy, by using the method designed by Erel and Neşelioğlu. In this study, we found that pre-CT thiol disulfide balance in cancer patients shifted toward disulfide direction and OS levels may increase after repetitive CT sessions.

Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study

Objective:

Technical skills in robot-assisted radical prostatectomy (RARP) are not mandated by the Intercollegiate Surgical Curriculum Programme. The European Association of Urology Robotic Urology Section (ERUS) developed a structured curriculum; however, surgeons’ outcomes data from subsequent independent practice are limited. We describe the initial post-ERUS curriculum RARP outcomes for a United Kingdom (UK)-based surgeon.

Patients and methods:

This was a prospective single surgeon cohort study of 272 patients who underwent RARP between February 2016 and October 2019 in a high-volume UK centre and who were followed up at approximately 3 and 12 months. Positive surgical margins (PSMs), and 3- and 12-month continence rates were obtained and used to generate learning curves, with point of plateau estimated from logarithmic trendlines.

Results:

Overall (⩾3 mm) PSM rate for pT2 was 14.9% (5.4%) and pT3 was 22.6% (3.2%). Where data were available, 70.5% (of n=251) and 95.5% (of n=154) patients achieved social continence (0–1 pads) at 3 and 12 months, respectively. PSM and 3-month social continence rates plateaued at ~175 and ~100 cases, respectively.

Conclusion:

Following completion of the ERUS RARP curriculum, early oncological and functional outcomes consistent with published standards are rapidly achievable in independent practice. These data exemplify the potential value of a standardised RARP training curriculum to mitigate possible compromises in outcomes.

Level of evidence:

IV

The safety of urologic robotic surgery depends on the skills of the surgeon

PURPOSE

To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

METHODS

A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

RESULTS

Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

CONCLUSION

To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.