Silver nanoparticles enhanced enzyme-linked immunosorbent assay (ELISA) detection of cancer testis antigens (CTAs)

OBJECTIVE

The Enzyme-Linked Immunosorbent Assay (ELISA) has been a cornerstone technique in laboratory medicine for over 55 years, relying on the specific binding of antibodies to antigens. ELISA's widespread use stems from its ability to detect low concentrations, its specificity, reproducibility, and potential for high-throughput screening. However, its sensitivity has limitations, prompting the exploration of innovative methods to improve the limit of detection (LOD). Nanoparticles provide a promising platform for enhancing ELISA sensitivity. Due to their high surface-to-volume ratio, they offer increased binding sites for capture elements and reporting tags, leading to amplified analytical signals. Recent studies have demonstrated improved sensitivity in ELISA through nanoparticle application, yielding faster detection times and enhanced sensitivities. This study investigates the potential of 50 nm citrate-capped silver nanoparticles to enhance ELISA's performance in quantifying cancer testis antigens (CTAs).

PATIENTS AND METHODS

In our study, we used the Human NY-ESO-1 ELISA kit (for research purposes) to determine the concentration of CTAs in randomly selected samples from healthy (n=89) and oncological (n=80) subjects, aged 18-75. We employed 50 nm citrate-capped silver nanoparticles (AGCB50-1M, BioPure Silver Nanoparticles - bare citrate, nano-Composix, San Diego, CA, USA). ELISA reactions followed the manufacturer's instructions, and data processing aligned with the same guidelines. Absorbance (OD) measurements occurred at 450 nm, influencing nanoparticle selection. Each ELISA well contained 5 ml of nanoparticles' stock solution with specified concentrations. CTAs concentrations were derived from the standard curve through CurveExpert Basic software. Statistical analysis was performed using SPSS v. 27 software, with p-values indicating significance if <0.03. The study adhered to Helsinki Declaration principles and received ethical approval. Participants provided informed written consent.

RESULTS

The increased concentration values of CTAs for healthy individuals and cancer patients were determined in the case of the application of silver nanoparticles.

CONCLUSIONS

The usage of nanoparticles can enhance the sensitivity of the ELISA method and positively influence its specific detection limit.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis

CONTEXT

Radical cystectomy is considered a procedure of high complexity with a relative high complication rate.

OBJECTIVE

To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them.

EVIDENCE ACQUISITION

We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy.

EVIDENCE SYNTHESIS

A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates.

CONCLUSIONS

In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes.

PATIENT SUMMARY

Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.

Digital Tracking of Patients Undergoing Radical Cystectomy for Bladder Cancer: Daily Step Counts Before and After Surgery Within the iROC Randomised Controlled Trial

BACKGROUND

Efforts to improve recovery after radical cystectomy (RC) are needed.

OBJECTIVE

To investigate wrist-worn wearable activity trackers in RC participants.

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study was conducted within the iROC randomised trial.

INTERVENTION

Patients undergoing RC at nine cancer centres wore wrist-based trackers for 7 days (d) at intervals before and after surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Step counts were compared with participant and operative features, and recovery outcomes.

RESULTS AND LIMITATIONS

Of 308 participants, 284 (92.2%) returned digital activity data at baseline (median 17 d [interquartile range: 8-32] before RC), and postoperatively (5 [5-6] d) and at weeks 5 (43 [38-43] d), 12 (94 [87-106] d), and 26 (192 [181-205] d) after RC. Compliance was affected by the time from surgery and a coronavirus disease 2019 pandemic lockdown (return rates fell to 0-7%, chi-square p < 0.001). Step counts dropped after surgery (mean of 28% of baseline), before recovering at 5 weeks (wk) (71% of baseline) and 12 wk (95% of baseline; all analysis of variance [ANOVA] p < 0.001). Baseline step counts were not associated with postoperative recovery or death. Patients with extended hospital stays had reduced postoperative step counts, with a difference of 2.2 d (95% confidence interval: 0.856-3.482 d) between the lowest third and highest two-third tertiles (linear regression analysis; p < 0.001). Additionally, they spent less time out of the hospital within 90 d of RC (80.3 vs 74.3 d, p = 0.013). Lower step counts at 5, 12, and 26 wk were seen in those seeking medical help and needing readmission (ANOVA p ≤ 0.002).

CONCLUSIONS

Baseline step counts were not associated with recovery. Lower postoperative step counts were associated with longer length of stay at the hospital and postdischarge readmissions. Studies are required to determine whether low step counts can identify patients at a risk of developing complications.

PATIENT SUMMARY

Postoperative step counts appear to be a promising tool to identify patients in the community needing medical help or readmission. More work is needed to understand which measures are most useful and how best to collect these.

Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis

BACKGROUND

For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques.

METHODS

A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared.

RESULTS

A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis.

CONCLUSION

We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.

Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison

BACKGROUND

Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is surging worldwide. Aim of the study was to perform a multicentric cost-analysis of RARC by comparing the gross cost of the intervention across hospitals in four different European countries.

METHODS

Patients who underwent RARC + ICUD were recruited from eleven European centers in four European countries (Belgium, France, Netherlands, and UK) between 2015 and 2020. Costs were divided into six parts: cost for hospital stay, cost for ICU stay, cost for surgical theater occupation, cost for transfusion, cost for robotic instruments, and cost for stapling instruments. These costs were individually assessed for each patient.

RESULTS

A total of 490 patients were included. Median operative time was 300(270-360) minutes and median hospital length-of-stay was 11(8-15) days. The average total cost of RARC was 14.794€ (95%CI 14.300-15.200€). A significant difference was found for the total cost, as well as the various subcosts abovementioned, between the four included countries. Different sets and types of robotic instruments were used by each center, leading to a difference in cost of robotic instrumentation. Nearly 84% of costs of RARC were due to hospital stay (42%), ICU stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments.

CONCLUSION

Costs and subcosts of RARC + ICUD vary significantly across European countries and are mainly dependent of hospital length-of-stay and operative time rather than robotic instrumentation. Decreasing length-of-stay and reducing operative time could help to decrease the cost of RARC and make it more widely accessible.

Biochemical and Radiological Factors for Prognostication of Traumatic Brain Injury: An Institutional Experience

Introduction Traumatic brain injury (TBI) necessitates identifying patients at risk of fatal outcomes. Classic biomarkers used clinically today in other organ systems are quantitative in nature. This aspect largely restricts the prognostic ability of a theoretical quantitative brain biomarker. This study aimed to explore biochemical markers and imaging findings reflecting the severity of cerebral damage to predict outcomes. Methodology In this study, 61 TBI cases with moderate to severe brain injury were prospectively observed, and various indices including random blood sugar (RBS), hemoglobin, international normalized ratio (INR), lactate dehydrogenase (LDH), cortisol, and CT findings were assessed. Glasgow Outcome Scores (GOS) determined the outcomes. Statistical analysis was carried out to assess correlations.  Results The mean RBS level of those who did not survive was 259.58 mg/dL, whereas in those who survived the value was 158.48 mg/dL. Analysis indicated that patients with high RBS value on admission had a higher risk of mortality (p=0.000). We noted that the mean serum cortisol levesl on both Days 1 and 5 were higher in patients who died and were able to establish a statistically significant correlation between both the values and outcome. A statistically significant negative correlation between Day 1 and Day 5 serum LDH levels and outcomes was evident from our study (p=0.000 for both). Among the components of the Rotterdam score, the presence of intraventricular hemorrhage (IVH) in the CT scan had a significant association with unfavorable outcomes (p=0.01) while midline shift was significantly associated with a low GCS (p=0.04). Conclusion Biochemical markers such as INR, RBS, serum cortisol, and LDH at admission can serve as valuable indicators of prognosis in TBI patients. Furthermore, a persistent increase in LDH and cortisol levels between Days 1 and 5, along with the Glasgow Coma Scale and Rotterdam Scoring system, are good predictors of mortality.

PYY (3-36) protects against high fat feeding induced changes of pancreatic islet and intestinal hormone content and morphometry

BACKGROUND

Prolonged high fat feeding negatively impacts pancreatic and intestinal morphology. In this regard, direct effects of PYY(3-36) on intestinal cell and pancreatic islet morphometry are yet to be fully explored in the setting of obesity.

METHODS

We examined the influence of 21-days twice daily treatment with PYY(3-36) on these parameters in mice fed a high fat diet (HFD).

RESULTS

PYY(3-36) treatment decreased food intake, body weight and circulating glucose in HFD mice. In terms of intestinal morphology, crypt depth was restored to control levels by PYY(3-36), with an additional enlargement of villi length. PYY(3-36) also reversed HFD-induced decreases of ileal PYY, and especially GLP-1, content. HFD increased numbers of PYY and GIP positive ileal cells, with PYY(3-36) fully reversing the effect on PYY cell detection. There were no obvious differences in the overall number of GLP-1 positive ileal cells in all mice, barring PYY(3-36) marginally decreasing GLP-1 villi cell immunoreactivity. Within pancreatic islets, PYY(3-36) significantly decreased alpha-cell area, whilst islet, beta-, PYY- and delta-cell areas remained unchanged. However, PYY(3-36) increased the percentage of beta-cells while also reducing percentage alpha-cell area. This was related to PYY(3-36)-induced reductions of beta-cell proliferation and apoptosis frequencies. Co-localisation of islet PYY with glucagon or somatostatin was elevated by PYY(3-36), with GLP-1/glucagon co-visualisation increased when compared to lean controls.

CONCLUSION

PYY(3-36) exerts protective effects on pancreatic and intestinal morphology in HFD mice linked to elevated ileal GLP-1 content.

GENERAL SIGNIFICANCE

These observations highlight mechanisms linked to the metabolic and weight reducing benefits of PYY(3-36).

Do perioperative blood transfusions impact oncological outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion? Results from a large multi-institutional registry

BACKGROUND

Blood transfusions (BT) have been associated with adverse oncologic outcomes in multiple malignancies including open radical cystectomy (ORC) for urothelial carcinoma of the bladder (UCB). Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) delivers similar oncologic outcomes compared to ORC, yet with lower blood loss and reduced transfusions. However, the impact of BT after robotic cystectomy is still unknown.

METHODS

This is a multicenter study including patients treated for UCB with RARC and ICUD in 15 academic institutions, between January 2015 and January 2022. BT were administered during surgery (intraoperative blood transfusions, iBT) or during the first 30 days after surgery (post-operative blood transfusions, pBT). The association of iBT and pBT with recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) were evaluated by univariate and multivariate regression analysis.

RESULTS

A total of 635 patients were included in the study. Overall, 35/635 patients (5.51%) received iBT while 70/635 (11.0%) received pBT. After a mean follow-up of 23±18 months, 116 patients (18.3%) had died, including 96 (15.1%) from bladder cancer. Recurrence occurred in 146 patients (23%). iBT were associated with decreased RFS, CSS and OS (P<0.001) on univariate Cox analysis. After adjusting for clinicopathologic covariates, iBT were associated only with the risk of recurrence (HR: 1.7; 95% CI, 1.0-2.8, P=0.04). pBT were not significantly associated to RFS, CSS or OS on univariate and multivariate Cox regression models (P>0.05).

CONCLUSIONS

In the present study, patients treated by RARC with ICUD for UCB have a higher risk of recurrence after iBT, yet no significant association with CSS and OS was found. pBT are not associated with worse oncological prognosis.

fMRI BOLD and MEG theta power reflect complementary aspects of activity during lexicosemantic decision in adolescents with ASD

Neuroimaging studies of autism spectrum disorder (ASD) have been predominantly unimodal. While many fMRI studies have reported atypical activity patterns for diverse tasks, the MEG literature in ASD remains comparatively small. Our group recently reported atypically increased event-related theta power in individuals with ASD during lexicosemantic processing. The current multimodal study examined the relationship between fMRI BOLD signal and anatomically-constrained MEG (aMEG) theta power. Thirty-three adolescents with ASD and 23 typically developing (TD) peers took part in both fMRI and MEG scans, during which they distinguished between standard words (SW), animal words (AW), and pseudowords (PW). Regions-of-interest (ROIs) were derived based on task effects detected in BOLD signal and aMEG theta power. BOLD signal and theta power were extracted for each ROI and word condition. Compared to TD participants, increased theta power in the ASD group was found across several time windows and regions including left fusiform and inferior frontal, as well as right angular and anterior cingulate gyri, whereas BOLD signal was significantly increased in the ASD group only in right anterior cingulate gyrus. No significant correlations were observed between BOLD signal and theta power. Findings suggest that the common interpretation of increases in BOLD signal and theta power as 'activation' require careful differentiation, as these reflect largely distinct aspects of regional brain activity. Some group differences in dynamic neural processing detected with aMEG that are likely relevant for lexical processing may be obscured by the hemodynamic signal source and low temporal resolution of fMRI.

Virtual classroom proficiency-based progression for robotic surgery training (VROBOT): a randomised, prospective, cross-over, effectiveness study

Robotic surgery training has lacked evidence-based standardisation. We aimed to determine the effectiveness of adjunctive interactive virtual classroom training (VCT) in concordance with the self-directed Fundamentals of Robotic Surgery (FRS) curriculum. The virtual classroom is comprised of a studio with multiple audio–visual inputs to which participants can connect remotely via the BARCO weConnect platform. Eleven novice surgical trainees were randomly allocated to two training groups (A and B). In week 1, both groups completed a robotic skills induction. In week 2, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week 3, the groups received the alternate intervention. The primary outcome was measured using the validated robotic-objective structured assessment of technical skills (R-OSAT) at the end of week 2 (time-point 1) and 3 (time-point 2). All participants completed the training curriculum and were included in the final analyses. At time-point 1, Group A achieved a statistically significant greater mean proficiency score compared to Group B (44.80 vs 35.33 points, p = 0.006). At time-point 2, there was no significant difference in mean proficiency score in Group A from time-point 1. In contrast, Group B, who received further adjunctive VCT showed significant improvement in mean proficiency by 9.67 points from time-point 1 (95% CI 5.18–14.15, p = 0.003). VCT is an effective, accessible training adjunct to self-directed robotic skills training. With the steep learning curve in robotic surgery training, VCT offers interactive, expert-led learning and can increase training effectiveness and accessibility.

Gesture Recognition in Robotic Surgery With Multimodal Attention

Automatically recognising surgical gestures from surgical data is an important building block of automated activity recognition and analytics, technical skill assessment, intra-operative assistance and eventually robotic automation. The complexity of articulated instrument trajectories and the inherent variability due to surgical style and patient anatomy make analysis and fine-grained segmentation of surgical motion patterns from robot kinematics alone very difficult. Surgical video provides crucial information from the surgical site with context for the kinematic data and the interaction between the instruments and tissue. Yet sensor fusion between the robot data and surgical video stream is non-trivial because the data have different frequency, dimensions and discriminative capability. In this paper, we integrate multimodal attention mechanisms in a two-stream temporal convolutional network to compute relevance scores and weight kinematic and visual feature representations dynamically in time, aiming to aid multimodal network training and achieve effective sensor fusion. We report the results of our system on the JIGSAWS benchmark dataset and on a new in vivo dataset of suturing segments from robotic prostatectomy procedures. Our results are promising and obtain multimodal prediction sequences with higher accuracy and better temporal structure than corresponding unimodal solutions. Visualization of attention scores also gives physically interpretable insights on network understanding of strengths and weaknesses of each sensor.

Feasibility and safety of radical prostatectomy for oligo-metastatic prostate cancer: the Testing Radical prostatectomy in men with prostate cancer and oligo-Metastases to the bone (TRoMbone) trial

OBJECTIVES

To test the feasibility of randomisation to radical prostatectomy (RP) plus pelvic lymphadenectomy in addition to standard-of-care (SOC) systemic therapy in men with newly diagnosed oligo-metastatic prostate cancer.

PATIENTS AND METHODS

A prospective, randomised, non-blinded, feasibility clinical trial with an embedded QuinteT Recruitment Intervention (QRI) to optimise recruitment was conducted in nine nationwide tertiary care centres undertaking high-volume robotic surgery. We aimed to randomise 50 men with synchronous oligo-metastatic prostate cancer within an 18-month recruitment period to SOC systemic therapy vs SOC plus RP (intervention arm). The main outcome measures were: ability to randomise patients, optimised by a QRI; EuroQoL five Dimensions five Levels (EQ-5D-5L) questionnaires to capture quality-of-life (QoL) data at baseline and 3 months post-randomisation; routine clinicopathological assessment to capture adverse events and prostate-specific antigen in both arms, plus standard perioperative parameters in the surgical arm.

RESULTS

A total of 51 men were randomised within 14 months (one was subsequently deemed ineligible), with 60-83% accrual rate in centres that recruited at least two patients. All patients completed the trial follow-up; one patient in the intervention arm subsequently did not undergo the surgical intervention and one in the SOC arm refused all therapies. The QRI positively impacted recruitment. QoL data showed similarly high functioning in both study arms. Surgery for men with oligo-metastatic prostate cancer was found to be safe and had similar impact on early functional outcomes as surgery for standard indication.

CONCLUSION

It is feasible to randomise men with synchronous oligo-metastatic prostate cancer to a surgical intervention in addition to standard systemic therapies. While surgery appeared safe with no substantial impact on QoL in this feasibility study, a large randomised controlled trial is now warranted to examine treatment effectiveness of this additional component in the multimodality management of oligo-metastatic prostate cancer.

Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial

IMPORTANCE

Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.

OBJECTIVES

To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.

INTERVENTIONS

Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.

RESULTS

Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).

CONCLUSIONS AND RELEVANCE

Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410.

Virtual Interactive Surgical Skills Classroom: A Parallel-group, Non-inferiority, Adjudicator-blinded, Randomised Controlled Trial (VIRTUAL)

OBJECTIVE

This study evaluated the efficacy of virtual classroom training (VCT) in comparison to face-to-face training (FFT) and non-interactive computer-based learning (CBL) for basic surgical skills training.

DESIGN

This was a parallel-group, non-inferiority, prospective randomised controlled trial with three intervention groups conducted in 2021. There were three intervention groups with allocation ratio 1:1:1. Outcome adjudicators were blinded to intervention assignment. Interventions consisted of 90-minute training sessions. VCT was delivered via the BARCO weConnect platform, FFT was provided in-person by expert instructors and CBL was carried out by participants independently. The primary outcome was post-intervention Objective Structured Assessment of Technical Skills score, adjudicated by two experts and adjusted for baseline proficiency. The assessed task was to place three interrupted sutures with hand-tied knots.

SETTING

This multicentre study recruited from five medical schools in London.

PARTICIPANTS

Inclusion criteria were medical student status and access to a personal computer and smartphone. One hundred fifty-nine eligible individuals applied online. Seventy-two participants were randomly selected and stratified by subjective and objective suturing experience prior to permuted block randomization.

RESULTS

Twenty-four participants were allocated to each intervention, all were analysed per-protocol. The sample was 65.3% female with mean age 21.3 (SD 2.1). VCT was non-inferior to FFT (adjusted difference 0.44, 95% CI: -0.54 to 1.75, delta 0.675), VCT was superior to CBL (adjusted difference 1.69, 95% CI: 0.41-2.96) and FFT was superior to CBL (adjusted difference 1.25, 95% CI: 0.20-2.29). The costs per-attendee associated with VCT, FFT and CBL were £22.15, £39.69 and £16.33 respectively. Instructor hours used per student for VCT and FFT were 0.25 and 0.75, respectively.

CONCLUSIONS

VCT provides greater accessibility and resource efficiency compared to FFT, with similar educational benefit. VCT has the potential to improve global availability and accessibility of surgical skills training.

Learning Curve Analysis for Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section Scientific Working Group

Background

The utilisation of robot-assisted radical cystectomy with intracorporeal reconstruction (iRARC) has increased in recent years. Little is known about the length of the learning curve (LC) for this procedure.

Objective

To study the length of the LC for iRARC in terms of 90-d major complications (MC90; Clavien-Dindo grade ≥3), 90-d overall complications (OC90, Clavien-Dindo grades 1–5), operating time (OT), estimated blood loss (EBL), and length of hospital stay (LOS).

Design, setting, and participants

This was a retrospective analysis of all consecutive iRARC cases from nine European high-volume hospitals with ≥100 cases. All patients had bladder cancer for which iRARC was performed, with an ileal conduit or neobladder as the urinary diversion.

Outcome measurements and statistical analysis

Outcome parameters used as a proxy for LC length were the number of consecutive cases needed to reach a plateau level in two-piece mixed-effects models for MC90, OC90, OT, EBL, and LOS.

Results and limitations

A total of 2186 patients undergoing iRARC between 2003 and 2018were included. The plateau levels for MC90 and OC90 were reached after 137 cases (95% confidence interval [CI] 80–193) and 97 cases (95% CI 41–154), respectively. The mean MC90 rate at the plateau was 14% (95% CI 7–21%). The plateau level was reached after 75 cases (95% CI 65–86) for OT, 88 cases (95% CI 70–106) for EBL, and 198 cases (95% CI 130–266) for LOS. A major limitation of the study is the difference in the balance of urinary diversion types between centres.

Conclusions

This multicentre retrospective analysis for the iRARC LC among nine European centres showed that 137 consecutive cases were needed to reach a stable MC90 rate.

Patient summary

We carried out a multicentre analysis of the surgical learning curve for robot-assisted removal of the bladder and bladder reconstruction in patients with bladder cancer. We found that 137 consecutive cases were needed to reach a stable rate of serious complications.

Negative mpMRI Rules Out Extra-Prostatic Extension in Prostate Cancer before Robot-Assisted Radical Prostatectomy

Background: The accuracy of multi-parametric MRI (mpMRI) in the pre-operative staging of prostate cancer (PCa) remains controversial. Objective: The purpose of this study was to evaluate the ability of mpMRI to accurately predict PCa extra-prostatic extension (EPE) on a side-specific basis using a risk-stratified 5-point Likert scale. This study also aimed to assess the influence of mpMRI scan quality on diagnostic accuracy. Patients and Methods: We included 124 men who underwent robot-assisted RP (RARP) as part of the NeuroSAFE PROOF study at our centre. Three radiologists retrospectively reviewed mpMRI blinded to RP pathology and assigned a Likert score (1-5) for EPE on each side of the prostate. Each scan was also ascribed a Prostate Imaging Quality (PI-QUAL) score for assessing the quality of the mpMRI scan, where 1 represents the poorest and 5 represents the best diagnostic quality. Outcome measurements and statistical analyses: Diagnostic performance is presented for the binary classification of EPE, including 95% confidence intervals and the area under the receiver operating characteristic curve (AUC). Results: A total of 231 lobes from 121 men (mean age 56.9 years) were evaluated. Of these, 39 men (32.2%), or 43 lobes (18.6%), had EPE. A Likert score ≥3 had a sensitivity (SE), specificity (SP), NPV, and PPV of 90.4%, 52.3%, 96%, and 29.9%, respectively, and the AUC was 0.82 (95% CI: 0.77-0.86). The AUC was 0.76 (95% CI: 0.64-0.88), 0.78 (0.72-0.84), and 0.92 (0.88-0.96) for biparametric scans, PI-QUAL 1-3, and PI-QUAL 4-5 scans, respectively. Conclusions: MRI can be used effectively by genitourinary radiologists to rule out EPE and help inform surgical planning for men undergoing RARP. EPE prediction was more reliable when the MRI scan was (a) multi-parametric and (b) of a higher image quality according to the PI-QUAL scoring system.

Components of a safe cystectomy service during coronavirus disease 2019 in a high-volume centre

Objective:

Delivery of a safe cystectomy service is a multidisciplinary exercise. In this article, we detail the measures implemented at our institution to deliver a cystectomy service for bladder cancer patients during coronavirus disease 2019 (COVID-19).

Methods:

A ‘one-stop’ enhanced recovery clinic had been established at our hospital, consisting of an anaesthetist, an exercise testing service, urinary diversion nurses, clinical nurse specialists and surgeons. During COVID-19, we modified these processes in order to continue to provide urgent cystectomy safely for bladder cancer. We collected patients’ outcomes prospectively measuring demographic characteristics, oncological and perioperative outcomes, the presence of COVID-19 symptoms and confirmed COVID-19 test results.

Results:

From March to May 2020, 25 patients underwent radical cystectomy for bladder cancer. Twenty-four procedures were performed with robotic assistance and one open as part of a research trial. We instituted modifications at various multidisciplinary steps, including patient selection, preoperative optimisation, enhanced recovery protocols, patient counselling and perioperative protocols. Thirty-day mortality was 0%. The 30-day rate of Clavien ⩾3 complications was 8%. Postoperatively, none of the patients developed COVID-19 based on World Health Organization criteria and testing.

Conclusion:

We safely delivered a complex cystectomy service during the peak of the COVID-19 pandemic without any COVID-19-related morbidity or mortality.

Level of evidence:

Level 2b.

248 Urethral Self-Insertion of a USB Cable as Sexual Experimentation: A Case Report

Introduction

The insertion of a foreign body in the urethra is an uncommon urological emergency. A wide variety of inserted objects have been described, presenting either asymptomatically or with lower abdominal discomfort and lower urinary tract symptoms. Sexual experimentation and gratification as well as mental disorders are considered the main underlying causes. The aim of this report is to present the case of a USB wire self-insertion and its challenging urological management.

Case Presentation

A 15-year-old male patient presented to his local Accident and Emergency department with gross haematuria following self-insertion of the knotted cable of a USB wire into his urethra in the context of sexual experimentation. Endoscopic approach via rigid cystoscopy and optical urethrotomy was not effective. A suprapubic catheter was inserted, and the patient was urgently transferred to our hospital for tertiary management.

Following radiological assessment to confirm the position of the wire, a longitudinal peno-scrotal incision over the palpable foreign body was made. Urethrotomy revealed the knotted cable in the proximal aspect of the penile urethra, which was cut and removed. Urethra was subsequently closed over a urethral catheter. Postoperative recovery was uneventful, and patient was discharged home with oral antibiotics. Urethral catheter was removed following normal fluoroscopic assessment of the urethra two weeks later.

Conclusions

The management of a foreign urethral body can be challenging and usually requires tertiary expertise to achieve optimal outcomes. Poor initial management could potentially lead to devastating long-term complications such as urethral strictures and fistulas.

Defining the morbidity of Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: adoption of the Comprehensive Complication Index

BACKGROUND & OBJECTIVE

The Clavien-Dindo Classification (CDC) only reports the post-operative complication of highest grade. It is thus of limited value for radical cystectomy after which patients usually experience multiple complications. The CCI is a novel scoring system which incorporates all post-operative events in one single value. To adopt the Comprehensive Complication Index (CCI) for the evaluation of complications in patients undergoing Robot-Assisted Radical Cystectomy (RARC) with Intra-Corporeal Urinary Diversion (ICUD) and explore its advantages in the analysis of the morbidity of RARC with ICUD.

PATIENTS AND METHODS

Multicentric cohort of 959 patients undergoing RARC+ICUD between 2015-2020, whose complications are encoded in local prospective registries. Post-operative complications at 30 days were assessed using both the CDC and CCI. The CCI was calculated using an online tool (assessurgery.com). Risk factors for overall, major complications (CDC≥III) and CCI were evaluated using uni- and multivariable logistic and linear regressions. To analyse the potential advantage of using the CCI in clinical trials, a sample size calculation of a hypothetic clinical trial was performed using as endpoint reduction of morbidity with either the CDC or CCI.

RESULTS

Overall, 885 post-operative complications were reported in 507 patients (53%). The CCI improved the definition of post-operative morbidity in 22.6% of patients. Male sex and neobladder were associated to major complications and to a significant increase in CCI on adjusted regressions. In a hypothetical clinical trial, 80 patients would be needed to demonstrate a ten point reduction in CCI, compared to 186 needed to demonstrate an absolute risk reduction of 20% in overall morbidity using the CDC.

CONCLUSION

CCI improves the evaluation of post-operative morbidity by considering the cumulative aspect of complications compared to the CDC. Implementing the CCI for radical cystectomy would help reducing sample sizes in clinical trials.

Comparative Effectiveness Analyses of Salvage Prostatectomy and Salvage Radiotherapy Outcomes Following Focal or Whole-Gland Ablative Therapy (High-Intensity Focused Ultrasound, Cryotherapy or Electroporation) for Localised Prostate Cancer

AIMS

Ablative therapy, such as focal therapy, cryotherapy or electroporation, aims to treat clinically significant prostate cancer with reduced treatment-related toxicity. Up to a third of patients may require further local salvage treatment after ablative therapy failure. Limited descriptive, but no comparative, evidence exists between different salvage treatment outcomes. The aim of this study was to compare oncological and functional outcomes after salvage robot-assisted radical prostatectomy (SRARP) and salvage radiotherapy (SRT).

MATERIALS AND METHODS

Data were collected prospectively and retrospectively on 100 consecutive SRARP cases and 100 consecutive SRT cases after ablative therapy failure in a high-volume tertiary centre.

RESULTS

High-risk patients were over-represented in the SRARP group (66.0%) compared with the SRT group (48.0%) (P = 0.013). The median (interquartile range) follow-up after SRARP was 16.5 (10.0-30.0) months and 37.0 (18.5-64.0) months after SRT. SRT appeared to confer greater biochemical recurrence-free survival at 1, 2 and 3 years compared with SRARP in high-risk patients (year 3: 86.3% versus 66.0%), but biochemical recurrence-free survival was similar for intermediate-risk patients (year 3: 90.0% versus 75.6%). There was no statistical difference in pad-free continence at 12 and 24 months between SRARP (77.2 and 84.7%) and SRT (75.0 and 74.0%) (P = 0.724, 0.114). Erectile function was more likely to be preserved in men who underwent SRT. After SRT, cumulative bowel and urinary Radiation Therapy Oncology Group toxicity grade I were 25.0 and 45.0%, grade II were 11.0 and 11.0% and grade III or IV complications were 4.0 and 5.0%, respectively.

CONCLUSION

We report the first comparative analyses of salvage prostatectomy and radiotherapy following ablative therapy. Men with high-risk disease appear to have superior oncological outcomes after SRT; however, treatment allocation does not appear to influence oncological outcomes for men with intermediate-risk disease. Treatment allocation was associated with a different spectrum of toxicity profile. Our data may inform shared decision-making when considering salvage treatment following focal or whole-gland ablative therapy.

Defining Factors Associated with High-quality Surgery Following Radical Cystectomy: Analysis of the British Association of Urological Surgeons Cystectomy Audit

Background

Radical cystectomy (RC) is associated with high morbidity.

Objective

To evaluate healthcare and surgical factors associated with high-quality RC surgery.

Design setting and participants

Patients within the prospective British Association of Urological Surgeons (BAUS) registry between 2014 and 2017 were included in this study.

Outcome measurements and statistical analysis

High-quality surgery was defined using pathological (absence of positive surgical margins and a minimum of a level I lymph node dissection template with a minimum yield of ten or more lymph nodes), recovery (length of stay ≤10 d), and technical (intraoperative blood loss <500 ml for open and <300 ml for minimally invasive RC) variables. A multilevel hierarchical mixed-effect logistic regression model was utilised to determine the factors associated with the receipt of high-quality surgery and index admission mortality.

Results and limitations

A total of 4654 patients with a median age of 70.0 yr underwent RC by 152 surgeons at 78 UK hospitals. The median surgeon and hospital operating volumes were 23.0 and 47.0 cases, respectively. A total of 914 patients (19.6%) received high-quality surgery. The minimum annual surgeon volume and hospital volume of ≥20 RCs/surgeon/yr and ≥68 RCs/hospital/yr, respectively, were the thresholds determined to achieve better rates of high-quality RC. The mixed-effect logistic regression model found that recent surgery (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.11-1.34, p < 0.001), laparoscopic/robotic RC (OR: 1.85, 95% CI: 1.45-2.37, p < 0.001), and higher annual surgeon operating volume (23.1-33.0 cases [OR: 1.54, 95% CI: 1.16-2.05, p = 0.003]; ≥33.1 cases [OR: 1.64, 95% CI: 1.18-2.29, p = 0.003]) were independently associated with high-quality surgery. High-quality surgery was an independent predictor of lower index admission mortality (OR: 0.38, 95% CI: 0.16-0.87, p = 0.021).

Conclusions

We report that annual surgeon operating volume and use of minimally invasive RC were predictors of high-quality surgery. Patients receiving high-quality surgery were independently associated with lower index admission mortality. Our results support the role of centralisation of complex oncology and implementation of a quality assurance programme to improve the delivery of care.

Patient summary

In this registry study of patients treated with surgical excision of the urinary bladder for bladder cancer, we report that patients treated by a surgeon with a higher annual operative volume and a minimally invasive approach were associated with the receipt of high-quality surgery. Patients treated with high-quality surgery were more likely to be discharged alive following surgery.

Urethral self-insertion of a USB cable as sexual experimentation: A case report

The insertion of a foreign body into the urethra is a delicate matter that may prevent patients from presenting promptly. It can have serious long-term implications. Sexual experimentation and gratification, as well as underlying mental disorders, are considered the main causes of retained foreign bodies in the urethra and bladder. Management varies depending on the shape and size of the object, and the mechanism of insertion. Here we describe the case of a 15-year-old boy who self-inserted a USB wire into his proximal urethra. Manual and endoscopic attempts at removal were unsuccessful. A peno-scrotal urethrostomy was performed.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p &lt; 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

283 Salvage Versus Primary Robot-Assisted Radical Prostatectomy: A Propensity-Matched Comparative Effectiveness Study from A High-Volume Tertiary Centre

Aim

Salvage Robot-Assisted Radical Prostatectomy (sRARP) is a potential treatment option for locally recurrent Prostate Cancer after non-surgical primary treatment. There are minimal data comparing outcomes between propensity-matched salvage and primary Robot-Assisted Radical Prostatectomy (RARP). We compare perioperative, oncological, and functional outcomes of sRARP with primary RARP and between sRARP post-whole and focal gland therapy.

Method

1:1 propensity-matched comparison of 146 sRARP with primary RARP from a cohort of 3,852 consecutive patients from a high-volume tertiary centre.

Results

There were no significant differences in patient characteristics between the salvage and primary RARP groups. Grade III-V Clavien-Dindo complication rates were 1.3% and 0% in the salvage and primary groups, respectively (p = 0.310). Median (IQR) follow-up was 16 (10,30) and 21 (13,33) months in the salvage and primary groups, respectively. BCR rates were 30.8% and 13.7% in the salvage and primary groups, respectively (p &lt; 0.001). Pad-free continence rates were 79.1% and 85.4% at two years in the salvage and primary groups, respectively (p = 0.160). ED rates were 95.2% and 77.4% in the salvage and primary groups, respectively (p &lt; 0.001). Comparing the whole gland and focal gland groups, BCR rates were 33.3% and 29.1%, respectively (p = 0.687), pad-free continence rates were 66% and 89.3%, respectively (p = 0.001), and ED rates were 98.3% and 93%, respectively (p = 0.145).

Conclusions

SRARP has similar perioperative but inferior oncological outcomes to primary RARP. Continence rates are similar to primary RARP, but potency is worse. Perioperative and oncological outcomes of sRARP after focal gland therapy are similar but continence outcomes are superior compared to sRARP after whole gland therapy.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

1420 ViRtual prOficiency Based prOgression for Robotic Training (VROBOT): A Prospective Cohort Study Protocol

Introduction

Robotic surgery is an evolving field that requires specialist training. Historically, robotic surgery training has lacked standardisation. Recently, training centres have introduced proficiency-based modules and curriculums to certify and progress the skills of novice robotic surgeons. However, training tends to be self-directed and non-interactive. Limited interactive teaching does exist but can be inaccessible and expensive. We aim to validate the effectiveness of the current Fundamentals of Robotic Surgery (FRS) training curriculum with the addition of interactive virtual classroom teaching.

Method

16 novice surgical trainees will be assigned to two training groups. The interventions will be implemented following a one-week robotic skills induction. Both groups will receive access to the FRS curriculum for one week. The intervention group will additionally receive virtual classroom robotic skills training. The primary outcome will be the objective performance scores after training using a synthetic model based on task errors, time taken and contact pressure. In week 3, each group will receive the alternate intervention and objective performance scores will be measured to determine the trajectory of scores.

Results

Significant objective performance improvement following the intervention will be indicative of intervention quality.

Conclusions

This will be the first feasibility study evaluating the efficacy of interactive virtual robotic surgery training. It will determine the effect size of virtual classroom training on the development of basic robotic surgical skills in addition to the proficiency-based FRS curriculum. The findings will assist the development and implementation of further resource-efficient virtual robotic surgical skills training programs.

Continuing acetylsalicylic acid during Robotic-Assisted Radical Cystectomy with intracorporeal urinary diversion does not increase hemorrhagic complications: results from a large multicentric cohort

OBJECTIVES

To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart.

METHODS

Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist.

RESULTS

640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions.

CONCLUSIONS

Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

INTRODUCTION

Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

METHODS

A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

RESULTS

Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

CONCLUSIONS

Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P &lt; 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

Virtual Interactive Surgical Skills Classroom: Protocol for a Parallel-Group, Noninferiority, Adjudicator-Blinded, Randomized Controlled Trial (VIRTUAL)

Background

Traditional face-to-face training (FFT) for basic surgical skills is inaccessible and resource-intensive. Noninteractive computer-based learning is more economical but less educationally beneficial. Virtual classroom training (VCT) is a novel method that permits distanced interactive expert instruction. VCT may optimize resources and increase accessibility.

Objective

We aim to investigate whether VCT is superior to computer-based learning and noninferior to FFT in improving proficiency in basic surgical skills.

Methods

This is a protocol for a parallel-group, noninferiority, randomized controlled trial. A sample of 72 undergraduates will be recruited from 5 medical schools in London. Participants will be stratified by subjective and objective suturing experience level and allocated to 3 intervention groups at a 1:1:1 ratio. VCT will be delivered using the BARCO weConnect software, and FFT will be provided by expert instructors. Optimal student-to-teacher ratios of 12:1 for VCT and 4:1 for FFT will be maintained. The assessed task will be interrupted suturing with hand-tied knots.

Results

The primary outcome will be the postintervention Objective Structured Assessment of Technical Skills score, adjudicated by 2 experts blinded to the study and adjusted for baseline proficiency. The noninferiority margin (δ) will be defined using historical data.

Conclusions

This study will serve as a comprehensive appraisal of the suitability of virtual basic surgical skills classroom training as an alternative to FFT. Our findings will assist the development and implementation of further resource-efficient, accessible, virtual basic surgical skills training programs during the COVID-19 pandemic and in the future.

Trial Registration

International Standard Randomized Controlled Trial Number ISRCTN12448098; https://www.isrctn.com/ISRCTN12448098

International Registered Report Identifier (IRRID)

PRR1-10.2196/28671

Recovery of health-related quality of life in patients undergoing robot-assisted radical cystectomy with intracorporeal diversion

OBJECTIVE

To report the health-related quality of life (HRQoL) after robot-assisted radical cystectomy and intracorporeal urinary diversion (iRARC), and to identify factors impacting on return to baseline.

PATIENTS AND METHODS

Consecutive patients undergoing iRARC between January 2016 and December 2017 completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item core (EORTC-QLQ-C30) and EORTC-QLQ-Muscle-Invasive Bladder Cancer Module (EORTC-QLQ-BLM30) questionnaires before surgery and had a minimum of 12 months follow-up postoperatively.

RESULTS

A total of 76 patients met the inclusion criteria at 12 months. Neobladder (NB) cases (n = 24) were younger (57.0 vs 71.0 years, P < 0.001) and fitter than ileal conduit (IC) cases (n = 52), and had higher physical (100.0 vs 93.3, P = 0.039) and sexual functioning (66.7 vs 50.0, P = 0.013) scores at baseline. Longitudinal analysis of the EORTC-QLQ-C30 showed that physical (NB: 93.3 vs 100.0, P = 0.020; IC: 80.0 vs 93.3, P < 0.001) and role functioning scores (NB: 83.3 vs 100.0, P = 0.010; IC: 83.3 vs 100.0, P = 0.017) decreased and fatigue score (NB: 22.2 vs 11.1, P = 0.026; IC: 33.3 vs 22.2, P = 0.008) increased at 3 months in both diversion groups. Scores returned to baseline at 6 months except physical functioning score in IC patients that remained below baseline until 12 months (86.7 vs 93.3, P = 0.012). The global HRQoL score did not show significant change postoperatively in both groups. A major 90-day Clavien-Dindo complication was a significant predictor (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.02-0.62; P = 0.012) of deteriorated global HRQoL score at 3 months, while occurrence of a late complication (OR 0.14, 95% CI 0.03-0.65; P = 0.013) was a predictor of deteriorated global HRQoL score at 12 months. Longitudinal analysis of the EORTC-QLQ-BLM30 showed that urinary problems (NB: 14.3 vs 38.3, P < 0.001; IC: 5.6 vs 19.1, P < 0.001) and future perspective (NB: 33.3 vs 44.4, P = 0.004; IC: 22.2 vs 44.4, P < 0.001) scores were better than baseline at 3 months. Sexual function deteriorated significantly at 3 months (NB: 8.3 vs 66.7, P < 0.001; IC: 4.2 vs 50.0, P < 0.001) and then showed improvement at 12 months but was still below baseline (NB: 33.3 vs 66.7, P = 0.001; IC: 25.0 vs 50.0, P < 0.001). Involvement in penile rehabilitation was shown to be a significant predictor (β 18.62, 95% CI 6.06-30.45; P = 0.005) of higher sexual function score at 12 months.

CONCLUSION

While most functional domains and symptoms scales recover to or exceed baseline within 6 months of iRARC, physical function remains below baseline in IC patients up to 12 months. Global HRQoL is preserved for both types of urinary diversion; however, postoperative complications seem to be the main driving factor for global HRQoL. Sexual function is adversely affected after iRARC suggesting that structured rehabilitation of sexual function should be an integral part of the RC pathway.

Salvage Versus Primary Robot-assisted Radical Prostatectomy: A Propensity-matched Comparative Effectiveness Study from a High-volume Tertiary Centre

Background

Salvage robot-assisted radical prostatectomy (sRARP) is a potential treatment option for locally recurrent prostate cancer (PCa) after nonsurgical primary treatment. There are minimal data comparing outcomes between propensity-matched sRARP and primary robot-assisted radical prostatectomy (RARP).

Objective

The primary objective is to compare perioperative, oncological, and functional outcomes of sRARP with primary RARP, and the secondary is to compare outcomes between sRARP after whole and focal gland therapy.

Design, setting, and participants

A 1:1 propensity-matched comparison was carried out of 135 sRARP cases with primary RARP cases from a cohort of 3852 consecutive patients from a high-volume tertiary centre.

Outcome measurements and statistical analysis

Perioperative, oncological, and functional outcomes including complication rates, positive surgical margins, biochemical recurrence (BCR), continence, and erectile dysfunction (ED) were retrospectively collected.

Results and limitations

There were no significant differences in patient characteristics between sRARP and primary RARP groups. In the salvage and primary groups, median (interquartile range) follow-up periods were 521 (304–951) and 638 (394–951) d, grade III–V Clavien-Dindo complication rates were 1.5% and 0% (p = 0.310), BCR rates were 31.9% and 14.1% (p < 0.001) at the last follow-up, pad-free continence rates were 78.8% and 84.3% at 2 yr (p = 0.337), and ED rates were 94.8% and 76.3% (p < 0.001), respectively. Comparing the whole and focal gland groups, BCR rates were 36.7% and 29.1% (p = 0.687) at follow-up, pad-free continence rates were 53.1% and 89.3% at 2 yr (p < 0.001), and ED rates were 98% and 93% (p = 0.214), respectively.

Conclusions

Salvage RARP has similar perioperative outcomes to primary RARP with inferior potency rates. Post–focal therapy sRARP has similar recurrence and continence rates to primary RARP. Post–whole gland therapy, complication, and recurrence rates are higher, and there is a higher risk of urinary incontinence.

Patient summary

We report the largest propensity-matched comparison of salvage robot-assisted radical prostatectomy (RARP) after focal and whole gland therapy. Salvage RARP is a feasible procedure for the treatment of locally recurrent prostate cancer in high-volume centres; however, patients should be counselled appropriately as to the different outcomes.

Ethical implications of AI in robotic surgical training: A Delphi consensus statement

CONTEXT

As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them.

OBJECTIVES

To provide ethical guidance on developing narrow AI applications for surgical training curricula. We define standardised approaches to developing AI driven applications in surgical training that address current recognised ethical implications of utilising AI on surgical data. We aim to describe an ethical approach based on the current evidence, understanding of AI and available technologies, by seeking consensus from an expert committee.

EVIDENCE ACQUISITION

The project was carried out in 3 phases: (1) A steering group was formed to review the literature and summarize current evidence. (2) A larger expert panel convened and discussed the ethical implications of AI application based on the current evidence. A survey was created, with input from panel members. (3) Thirdly, panel-based consensus findings were determined using an online Delphi process to formulate guidance. 30 experts in AI implementation and/or training including clinicians, academics and industry contributed. The Delphi process underwent 3 rounds. Additions to the second and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement.

EVIDENCE SYNTHESIS

There was 100% response from all 3 rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of >0.8. There was 100% consensus that there is currently a lack of guidance on the utilisation of AI in the setting of robotic surgical training. Consensus was reached in multiple areas, including: 1. Data protection and privacy; 2. Reproducibility and transparency; 3. Predictive analytics; 4. Inherent biases; 5. Areas of training most likely to benefit from AI.

CONCLUSIONS

Using the Delphi methodology, we achieved international consensus among experts to develop and reach content validation for guidance on ethical implications of AI in surgical training. Providing an ethical foundation for launching narrow AI applications in surgical training. This guidance will require further validation.

PATIENT SUMMARY

As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them.In this paper we provide guidance on ethical implications of AI in surgical training.

V12 VIRTUAL: Virtual InteRacTive sUrgicAl skiLls classroom – A Randomized Controlled Trial Proposal

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction and feedback. They may optimise resources and increase accessibility, facilitating larger-scale training whilst producing a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will receive virtual classroom training. The assessed task will be to place three interrupted sutures with hand tied knots. Pre- and post-intervention Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will be measured. Feasibility and accessibility will also be assessed.

Results

Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine relative performance.

Conclusion

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual BSS classroom training as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient virtual BSS training programs during the COVID-19 pandemic and in the future.

Classification and standardized reporting of percutaneous nephrolithotomy (PCNL): International Alliance of Urolithiasis (IAU) Consensus Statements

BACKGROUND

The aim of this study was to reach a consensus in the classification and standardized reporting for the different types of PCNLs.

METHODS

The RAND/UCLA appropriateness methodology was used to reach a consensus. Thirty-two statements were formulated reviewing the literature on guidelines and consensus on PCNLs, and included procedure specific details, outcome measurements and a classification for PCNLs. Experts were invited to two rounds of input, the first enabled independent modifications of the proposed statements and provided the option to add statements. The second round facilitated scoring of all statements. Each statement was discussed in the third round to decide which statements to include. Any suggestion or disagreement was debated and discussed to reach a consensual agreement.

RESULTS

Twenty-five recommendations were identified to provide standardized reporting of procedure and outcomes. Consensual scoring above 80% were strongly agreed upon by the panel. The top treatment related outcomes were size of sheath used (99.1%) and position for PCNL (93.5%). The highest ranked Outcome Measures included definition of postoperative hospital length of stay (94.4%) and estimated blood loss (93.5%).

CONCLUSIONS

The consensus statements will be useful to clarify operative technique, in the design of clinical trials and standardized reporting, and presentation of results to compare outcomes of different types of PCNLs.

Classification and Standardized Reporting of Percutaneous Nephrolithotomy (PCNL): International Alliance of Urolithiasis (IAU) consensus statements

BACKGROUND

To reach a consensus in the classification and standardized reporting for the different types of PCNLs.

METHODS

The RAND/UCLA appropriateness methodology was used to reach a consensus. Thirty-two statements were formulated reviewing the literature on guidelines and consensus on PCNLs, and included procedure specific details, outcome measurements and a classification for PCNLs. Experts were invited to two rounds of input, the first enabled independent modifications of the proposed statements and provided the option to add statements. The second round facilitated scoring of all statements. Each statement was discussed in the third round to decide which statements to include. Any suggestion or disagreement was debated and discussed to reach a consensual agreement.

RESULTS

Twenty-five recommendations were identified to provide standardised reporting of procedure and outcomes. Consensual scoring above 80% were strongly agreed upon by the panel. The top treatment related outcomes were size of sheath used (99.1%) and position for PCNL (93.5%). The highest ranked Outcome Measures included definition of post-operative hospital length of stay (94.4%) and estimated blood loss (93.5%).

CONCLUSIONS

The consensus statements will be useful to clarify operative technique, in the design of clinical trials and standardized reporting, and presentation of results to compare outcomes of different types of PCNLs.

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training

Context

The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence acquisition

This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence synthesis

There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions

Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient summary

Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group

Objectives

To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians.

Patients and Methods

We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) after surgery were calculated using the non‐parametric Aalen‐Johansen estimator.

Results

A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30‐ and 90‐day rate for high‐grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre‐ and postoperative variables, age ≥80 years was not an independent predictor of high‐grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non‐cancer‐related 90‐day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12‐month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001).

Conclusions

The minimally invasive approach to RARC with ICUD for bladder cancer in well‐selected elderly patients (aged ≥80 years) achieved a tolerable high‐grade complication rate; the 90‐day postoperative mortality rate was driven by cancer progression and the non‐cancer‐related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer‐related vs treatment‐related risks and benefits.