1
|
Tetlow N, Dewar A, Arina P, Tan M, Sridhar AN, Kelly JD, Arulkumaran N, Stephens RC, Martin DS, Moonesinghe SR, Whittle J. Preoperative aerobic fitness and perioperative outcomes in patients undergoing cystectomy before and after implementation of a national lockdown. BJA Open 2024; 9:100255. [PMID: 38298206 PMCID: PMC10828563 DOI: 10.1016/j.bjao.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/16/2023] [Indexed: 02/02/2024]
Abstract
Background Lower fitness is a predictor of adverse outcomes after radical cystectomy. Lockdown measures during the COVID-19 pandemic affected daily physical activity. We hypothesised that lockdown during the pandemic was associated with a reduction in preoperative aerobic fitness and an increase in postoperative complications in patients undergoing radical cystectomy. Methods We reviewed routine preoperative cardiopulmonary exercise testing (CPET) data collected prior to the pandemic (September 2018 to March 2020) and after lockdown (March 2020 to July 2021) in patients undergoing radical cystectomy. Differences in CPET variables, Postoperative Morbidity Survey (POMS) data, and length of hospital stay were compared. Results We identified 267 patients (85 pre-lockdown and 83 during lockdown) who underwent CPET and radical cystectomy. Patients undergoing radical cystectomy throughout lockdown had lower ventilatory anaerobic threshold (9.0 [7.9-10.9] vs 10.3 [9.1-12.3] ml kg-1 min-1; P=0.0002), peak oxygen uptake (15.5 [12.9-19.1] vs 17.5 [14.4-21.0] ml kg-1 min-1; P=0.015), and higher ventilatory equivalents for carbon dioxide (34.7 [31.4-38.5] vs 33.4 [30.5-36.5]; P=0.030) compared with pre-lockdown. Changes were more pronounced in males and those aged >65 yr. Patients undergoing radical cystectomy throughout lockdown had a higher proportion of day 5 POMS-defined morbidity (89% vs 75%, odds ratio [OR] 2.698, 95% confidence interval [CI] 1.143-6.653; P=0.019), specifically related to pulmonary complications (30% vs 13%, OR 2.900, 95% CI 1.368-6.194; P=0.007) and pain (27% vs 9%, OR 3.471, 95% CI 1.427-7.960; P=0.004), compared with pre-lockdown on univariate analysis. Conclusions Lockdown measures in response to the COVID-19 pandemic were associated with a reduction in fitness and an increase in postoperative morbidity among patients undergoing radical cystectomy.
Collapse
Affiliation(s)
- Nicholas Tetlow
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Amy Dewar
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Pietro Arina
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
| | - Melanie Tan
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ashwin N. Sridhar
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - John D. Kelly
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nishkantha Arulkumaran
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
| | - Robert C.M. Stephens
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Suneetha R. Moonesinghe
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - John Whittle
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| |
Collapse
|
2
|
Sehmbi AS, Sridhar AN, Sahadevan K, Rai BP, Nwangwu P, Mohammed A, Freeman A, Mottrie A, Olsson MJ, Wiklund NP, Nathan MS, Briggs TP, Kelly JD, Rajan P. Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study. Journal of Clinical Urology 2021. [DOI: 10.1177/2051415820938176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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
Collapse
Affiliation(s)
- Arjan S Sehmbi
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
| | - Ashwin N Sridhar
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | | | - Bhavan P Rai
- Department of Urology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Pamela Nwangwu
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Anna Mohammed
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, UK
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium
- Division of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Mats J Olsson
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Icahn School of Medicine at Mount Sinai Health System, New York, USA
| | - M Senthil Nathan
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Timothy P Briggs
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - John D Kelly
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Division of Surgery and Interventional Sciences, University College London, UK
| | - Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Department of Urology, Barts Health NHS Trust, London, UK
| |
Collapse
|
3
|
Thompson JE, Sridhar AN, Shaw G, Rajan P, Mohammed A, Briggs TP, Nathan S, Kelly JD, Sooriakumaran P. Peri-operative, functional and early oncologic outcomes of salvage robotic-assisted radical prostatectomy after high-intensity focused ultrasound partial ablation. BMC Urol 2020; 20:81. [PMID: 32611411 PMCID: PMC7329479 DOI: 10.1186/s12894-020-00656-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Partial ablation of the prostate using high-intensity focussed ultrasound (HIFU-PA) is a treatment option for localised prostate cancer. When local recurrence occurs, salvage robot-assisted radical prostatectomy is a treatment option for selected patients, but there is a paucity of data on the peri-operative safety, functional and oncologic outcomes of sRARP.. The objective of this study was therefore to describe peri-operative safety, functional and early oncologic outcomes following salvage robot-assisted radical prostatectomy (sRARP) for local recurrence after HIFU-PA. METHODS Retrospective analysis of a prospective database of 53 consecutive men who underwent sRARP after HIFU-PA from 2012 to 2018. Continence and erectile-function were reported pre-HIFU, pre-sRARP, 3-months post-sRARP and 12-months post-sRARP. Complications, PSMs and need for subsequent ADT/radiotherapy were assessed. RESULTS 45 men were suitable for inclusion and had sufficient data for analyses. Median duration from HIFU to sRARP was 30.0 months and median follow-up post-sRARP was 17.7 months. Median age, PSA and ISUP group were 63.0 yrs., 7.2 ng/mL and 2; 88.9% were cT2. Median operative-console time, blood loss and hospital stay were 140 min, 200 ml and 1 day respectively. Clavien-Dindo grade 1, 2 and 3 complications < 90 days occurred in 8.9, 6.7 and 2.2%; late (>90d) complications occurred in 13.2%. At sRARP pathology, ISUP 3-5 occurred in 51.1%, pT3a/b in 64.5%, and PSMs in 44.4% (37.5% for pT2, 48.3% for pT3). Of men with > 3-months follow-up after sRARP, 26.3% underwent adjuvant radiotherapy/ADT for residual disease or adverse pathologic features; 5.3% experienced BCR requiring salvage ADT/radiotherapy. Freedom from ADT/radiotherapy was 66.7% at 12-months. Pad-free rates were 100% pre-HIFU, 95.3% post-HIFU, 29.4% 3-months post-sRARP, and 65.5% 12-months post-sRARP. Median IIEF-5 scores pre-HIFU, post-HIFU, 3- and 12-months post-sRARP were 23.5, 16, 5 and 5, respectively. Potency rates were 81.8, 65.5, 0 and 0%, respectively. Bilateral/unilateral nerve sparing were feasible in 7%/22%. CONCLUSION Salvage RARP was safe with acceptable but sub-optimal continence and poor sexual-function and poor oncologic outcomes. One in three men required additional treatment within 12-months. This information may aid men and urologists with treatment selection and counselling regarding primary HIFU-PA vs primary RARP and when considering salvage RARP.
Collapse
Affiliation(s)
- James E Thompson
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK. .,Faculty of Medicine, University of New South Wales, Kensington, Australia.
| | - Ashwin N Sridhar
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Division of Surgery & Interventional Sciences, University College London, London, UK
| | - Greg Shaw
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Division of Surgery & Interventional Sciences, University College London, London, UK
| | - Prabhakar Rajan
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Centre for Molecular Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Anna Mohammed
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK
| | - Timothy P Briggs
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK
| | - Senthil Nathan
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Division of Surgery & Interventional Sciences, University College London, London, UK
| | - John D Kelly
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Division of Surgery & Interventional Sciences, University College London, London, UK
| | - Prasanna Sooriakumaran
- Department of Uro-oncology, University College London Hospital, London, W1G 8PH, UK.,Division of Surgery & Interventional Sciences, University College London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
4
|
Sridhar AN, Abozaid M, Rajan P, Sooriakumaran P, Shaw G, Nathan S, Kelly JD, Briggs TP. Surgical Techniques to Optimize Early Urinary Continence Recovery Post Robot Assisted Radical Prostatectomy for Prostate Cancer. Curr Urol Rep 2018; 18:71. [PMID: 28718165 PMCID: PMC5514172 DOI: 10.1007/s11934-017-0717-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Purpose of Review A variety of different surgical techniques are thought to impact on urinary continence (UC) recovery in patients undergoing robot assisted radical prostatectomy (RARP) for prostate cancer. Herein, we review current evidence and propose a composite evidence-based technique to optimize UC recovery after RARP. Recent Findings A literature search on studies reporting on surgical techniques to improve early continence recovery post robotic prostatectomy was conducted on PubMed and EMBASE. The available data from studies ranging from randomized control trials to retrospective cohort studies suggest that minimizing damage to the internal and external urinary sphincters and their neural supply, maximal sparing of urethral length, creating a secure vesicourethral anastomosis, and providing anterior and posterior myo- fascio-ligamentous support to the anastomosis can improve early UC recovery post RARP. Summary A composite evidence-based surgical technique incorporating the above principles could optimize early UC recovery post RARP. Evidence from randomized studies is required to prove benefit.
Collapse
Affiliation(s)
- Ashwin N. Sridhar
- Department of Urology, University College London Hospital, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Mohammed Abozaid
- Department of Urology, University College London Hospital, London, UK
| | - Prabhakar Rajan
- Department of Urology, University College London Hospital, London, UK
| | - Prasanna Sooriakumaran
- Department of Urology, University College London Hospital, London, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Greg Shaw
- Department of Urology, University College London Hospital, London, UK
| | - Senthil Nathan
- Department of Urology, University College London Hospital, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - John D. Kelly
- Department of Urology, University College London Hospital, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Tim P Briggs
- Department of Urology, University College London Hospital, London, UK
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW There has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon. RECENT FINDINGS A structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice. Robotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.
Collapse
Affiliation(s)
- Ashwin N. Sridhar
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Tim P. Briggs
- Department of Urology, University College London Hospital NHS Trust, London, UK
| | - John D. Kelly
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Senthil Nathan
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| |
Collapse
|
6
|
Sridhar AN, Zacharakis E, Dudderidge T, Kelly JD, Nathan S. Robot-assisted management of Zinner's syndrome: report of seminal vesicle sparing technique and review of literature. J Robot Surg 2014; 8:185-7. [PMID: 27637531 DOI: 10.1007/s11701-013-0430-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/29/2013] [Indexed: 11/25/2022]
Abstract
The range of urological procedures performed with robotic assistance has widened with increasing experience with the da Vinci robotic system. We describe the use of the da Vinci SI Surgical System for excision of a seminal vesicle cyst in a patient who had associated ipsilateral renal agenesis (Zinner's syndrome). The robotic platform afforded a minimally invasive procedure with precise dissection and no collateral damage to neighbouring vital anatomy.
Collapse
Affiliation(s)
- A N Sridhar
- Institute of Urology, University College London Hospital NHS Trust, London, UK.
| | - E Zacharakis
- Institute of Urology, University College London Hospital NHS Trust, London, UK
| | - T Dudderidge
- Institute of Urology, University College London Hospital NHS Trust, London, UK
| | - J D Kelly
- Institute of Urology, University College London Hospital NHS Trust, London, UK
| | - S Nathan
- Institute of Urology, University College London Hospital NHS Trust, London, UK
| |
Collapse
|
7
|
Sridhar AN, Andrikopoulou M, Clarke L, Ashley C, Mekhail P, Khan UA. Impact of the Increased Use of Preoperative Imaging and Laparoscopy on Appendicectomy Outcomes. Indian J Surg 2013; 77:356-60. [PMID: 26730025 DOI: 10.1007/s12262-013-0842-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 01/16/2013] [Indexed: 12/29/2022] Open
Abstract
The diagnosis of appendicitis is based on clinical picture. The aim of this retrospective study was to analyse variation of outcomes and impact of increasing use of radiological investigations and laparoscopy over a 5-year period. A retrospective audit of appendicectomies over the last 5 years (01 January 2007-31 December 2011) was conducted. The negative appendicectomy rate (NAR), perforation rate and complication rate were used as outcome endpoints. A statistical analysis was performed to evaluate the difference in outcomes with surgical approach and use of radiology. One thousand fifty-five appendicectomies were performed in this period. The NAR was 22.65 % (21 % for open and 28 % for laparoscopic) and perforation rate was 14 %. There was no statistically significant difference in NAR with the use of ultrasound (P 0.3814) but there was a significant reduction in NAR with the use of computed tomography (CT) (P <0.0001). Intra-abdominal abscess (2.3 %) and wound infection (1.4 %) were the common complications with the former being higher with laparoscopy and the latter with open appendicectomy. Over 5 years, there were no significant changes in appendicectomy outcomes. The impact of diagnostic imaging on NAR varies with age, gender and the use of CT. CT can significantly reduce the negative appendicectomy rate in equivocal presentations. Complication rates vary with surgical approach.
Collapse
Affiliation(s)
- A N Sridhar
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| | - M Andrikopoulou
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| | - L Clarke
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| | - C Ashley
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| | - P Mekhail
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| | - U A Khan
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Victoria road, Macclesfield, SK10 3BL Cheshire UK
| |
Collapse
|