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Zuluaga L, Rich JM, Gupta R, Pedraza A, Ucpinar B, Okhawere KE, Saini I, Dwivedi P, Patel D, Zaytoun O, Menon M, Tewari A, Badani KK. AI-powered real-time annotations during urologic surgery: The future of training and quality metrics. Urol Oncol 2024; 42:57-66. [PMID: 38142209 DOI: 10.1016/j.urolonc.2023.11.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/23/2023] [Accepted: 11/02/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION AND OBJECTIVE Real-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time. SUMMARY BACKGROUND DATA While AI models possess the capability to generate automated annotations based on a collection of video images, the real-time implementation of such technology in urological robotic surgery to aid surgeon and training staff it is still pending to be studied. METHODS We conducted an educational symposium, which broadcasted 2 live procedures, a robotic-assisted radical prostatectomy (RARP) and a robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones. This was achieved through trained algorithms, conventional video recognition, and novel Video Transfer Network technology which captures clips in full context, enabling automatic recognition and surgical mapping in real-time. RESULTS Real-time AI annotations for procedure #1, RARP, are found in Table 1. The safety milestone annotations included the apical safety maneuver and deliberate views of structures such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound, temporary clip application and removal, hemostatic powder application, and notable hemorrhage. CONCLUSIONS For the first time, surgical intelligence successfully showcased real-time AI annotations of 2 separate urologic robotic procedures during a live telecast. These annotations may provide the technological framework for send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support, leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes, and support training and education.
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Affiliation(s)
- Laura Zuluaga
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY.
| | - Jordan Miller Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Raghav Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Adriana Pedraza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Burak Ucpinar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Indu Saini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Priyanka Dwivedi
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Dhruti Patel
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Osama Zaytoun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Mani Menon
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Ashutosh Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
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Okhawere KE, Rich JM, Beksac AT, Zuluaga L, Saini I, Ucpinar B, Levieddin J, Joel IT, Deluxe A, Stifelman MD, Crivellaro S, Abaza R, Eun DD, Bhandari A, Hemal AK, Porter J, Mansour A, Pierorazio PM, Zaytoun O, Badani KK. Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity. J Laparoendosc Adv Surg Tech A 2023; 33:835-840. [PMID: 37339434 DOI: 10.1089/lap.2023.0142] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.
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Affiliation(s)
- Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jordan Miller Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alp Tuna Beksac
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura Zuluaga
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Indu Saini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Burak Ucpinar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Levieddin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Iretiayo T Joel
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Radiology, University College Hospital, Ibadan, Nigeria
| | - Anthony Deluxe
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael D Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Simone Crivellaro
- Department of Urology, University of Illinois, Chicago, Illinois, USA
| | | | - Daniel D Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, Pennsylvania, USA
| | - Akshay Bhandari
- Division of Urology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James Porter
- Department of Urology, Swedish Medical Center, Seattle, Washington, USA
| | - Ahmed Mansour
- Department of Urology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Phillip M Pierorazio
- Division of Urology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Osama Zaytoun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Ucpinar B, Rich JM, Okhawere KE, Razdan S, Zaytoun O, Zuluaga L, Saini I, Stifelman MD, Abaza R, Eun DD, Bhandari A, Hemal AK, Porter J, Crivellero S, Mansour A, Pierorazio PM, Badani KK. Robot-assisted partial nephrectomy for complex renal tumors: Analysis of a large multi-institutional database. Urol Oncol 2023:S1078-1439(23)00189-8. [PMID: 37316415 DOI: 10.1016/j.urolonc.2023.05.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/25/2023] [Accepted: 05/18/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Highly complex renal masses pose a challenge to urologic surgeons' ability to perform robotic partial nephrectomy (RPN). Given the increased utilization of the robotic approach for small renal masses, we sought to characterize the outcomes and determine the safety and feasibility of RPN for complex renal masses from our large multi-institutional cohort. METHODS We performed a retrospective analysis of patients with R.E.N.A.L. Nephrometry Scores ≥10 who underwent RPN in our multi-institutional cohort (N = 372). Baseline demographic, clinical and tumor related characteristics were evaluated with the primary endpoint of trifecta achievement (defined as negative surgical margin, no major complications, and warm ischemia time ≤25 min). Relationships between variables were assessed using the chi-square test of independence, Fisher exact test, Mann-Whitney U test, and Kruskal Wallis test. Logistic regression was used to evaluate the relationship between baseline characteristics and trifecta achievement. RESULTS Of 372 patients in the study, mean age was 58 years, and median BMI was 30.49 kg/m2. The median tumor size was 4.3 cm (3.0-5.9 cm). Most of the patients had R.E.N.A.L. scores of 10 (n = 253; 67.01%). Overall, trifecta was achieved in 72.04% of patients. Stratifying intraoperative and postoperative outcomes by R.E.N.A.L. scores, there was no significant difference in trifecta achievement, operative time, warm ischemia time (WIT), open conversion, major complication, or positive margin rates. Length of hospital stay was significantly longer for higher R.E.N.A.L. scores (median days 2 vs. 1, P = 0.012). Multivariate analyses for factors associated with trifecta achievement concluded that age and baseline eGFR were independently associated with trifecta achievement. CONCLUSION RPN is a safe and reproducible procedure for complex tumors with R.E.N.A.L. Nephrometry scores ≥10. Our results suggest excellent rates of trifecta achievement and short-term functional outcomes when performed by experienced surgeons. Long-term oncological and functional evaluation are needed to further support this conclusion.
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Affiliation(s)
- Burak Ucpinar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jordan Miller Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Osama Zaytoun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura Zuluaga
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Indu Saini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Ronney Abaza
- Department of Urology, Central Ohio Urology Group, Columbus, OH
| | - Daniel D Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, PA
| | - Akshay Bhandari
- Division of Urology, Mount Sinai Medical Center, Miami Beach, FL
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC
| | - James Porter
- Department of Urology, Swedish Urology, Seattle, WA
| | | | - Ahmed Mansour
- Department of Urology, University of Texas Health Science Center, San Antonio, TX
| | | | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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Greilich PE, Virella CD, Rich JM, Kurada M, Roberts K, Warren JF, Harford WV. Remifentanil versus meperidine for monitored anesthesia care: a comparison study in older patients undergoing ambulatory colonoscopy. Anesth Analg 2001; 92:80-4. [PMID: 11133605 DOI: 10.1097/00000539-200101000-00016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Colonoscopy is one of the most frequently performed outpatient procedures in the United States. This study was designed to test the hypothesis that a remifentanil infusion would be superior to boluses of meperidine in older patients undergoing ambulatory colonoscopy. One hundred ASA physical status I-IV patients undergoing colonoscopy were randomized in this double-blinded study to receive either remifentanil infusions (n = 49) or titrated boluses of meperidine (n = 51). Patient tolerance was assessed using physiologic variables and side effects associated with opioid analgesia. Verbal pain/anxiety and patient/operator satisfaction were also assessed. As a group, the physiologic characteristics demonstrated no significant differences in the response to the colonoscopy procedure. Although the patient and operator satisfaction surveys were similar between groups, the incidences of tachycardia, hypotension, and nausea were less and the adjusted verbal pain and anxiety scores were more in the Remifentanil group compared with the Meperidine group. This study demonstrates that remifentanil and meperidine were equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider. The differences in the pharmakinetics of remifentanil and meperidine most likely account for the differences noted between the two treatment groups. IMPLICATIONS Remifentanil infusions and meperidine boluses are equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider.
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Affiliation(s)
- P E Greilich
- University of Texas Southwestern Medical Center-Dallas, USA.
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Rich JM. Preoperative echocardiography for noncardiac surgery. Ann Intern Med 1998; 128:324-5. [PMID: 9471946 DOI: 10.7326/0003-4819-128-4-199802150-00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Affiliation(s)
- J M Rich
- Anesthesiology and Pain Management Service, Dallas Department of Veterans Affairs Medical Center, Texas, USA.
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Macdonell RA, Rich JM, Cros D, Shahani BT, Ali HH. The Lambert-Eaton myasthenic syndrome: a cause of delayed recovery from general anesthesia. Arch Phys Med Rehabil 1992; 73:98-100. [PMID: 1729983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 70-year-old man required prolonged ventilation after surgery to remove a rectal neoplasm. The cause of the slow recovery from the effects of neuromuscular blocking agents used during his anesthetic was the Lambert-Eaton myasthenic syndrome (LEMS). Before surgery, he had no neuromuscular symptoms, even in retrospect. LEMS should be considered in the diagnosis of prolonged recovery from neuromuscular blockade, even in previously asymptomatic patients.
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Affiliation(s)
- R A Macdonell
- Clinical Neurophysiology Laboratory, Massachusetts General Hospital, Boston 02114
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Rich JM. Use of the ultrasound stethoscope blood flow detector for cannulation of a weakly palpable radial artery. Heart Lung 1984; 13:47-8. [PMID: 6229507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Rich JM. Biphasic respiratory depression from neurolept anesthesia. AANA J 1982; 50:472-5. [PMID: 7180369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The recovery of patients following neurolept or fentanyl/nitrous oxide anesthesia is extremely variable due to variations in drug dosage, biotransformation and excretion idiosyncracies among individuals. The respiratory depressant effects of fentanyl or fentanyl/droperidol can far outlast the analgesic duration and can recur after having dissipated. The level of consciousness and the quality of breathing can be misleading indicators of complete recovery from neurolept anesthesia. Respiratory rate has been observed to return to control levels when simultaneous response to CO2 rebreathing was reduced and resting PeCO2 was increased. Naloxone can be used in dosages which will help ensure adequate ventilation without attenuating postoperative analgesia.
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Rich JM, Leinfelder KF, Hershey HG. An in vitro study of cement retention as related to orthodontics. Angle Orthod 1975; 45:219-25. [PMID: 1096684 DOI: 10.1043/0003-3219(1975)045<0219:aivsoc>2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Rich JM, Cobb TC, Leighton RF. Percutaneous transfemoral coronary arteriography without systemic anticoagulation--a review of 648 consecutive procedures. Cathet Cardiovasc Diagn 1975; 1:275-81. [PMID: 1222424 DOI: 10.1002/ccd.1810010306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Experience with 648 consecutive percutaneous transfemoral coronary arteriograms and left ventriculograms performed in a teaching laboratory without the use of systemic anticoagulation during the procedure was reviewed. Only 1 death was felt to be related to a procedure, and this occurred 3 weeks after a myocardial infarction. There were 10 myocardial infarctions or emboli, 8 cerebral vascular accidents, and 7 femoral artery complications. Only 1 patient experienced a residual neurologic change following a procedure-related cerebral vascular accident, and this was a mild visual field defect. Clotting of the catheter without sequelae but necessitating procedural changes occurred in 10 instances. The transient nature of the neurologic deficits and the low mortality suggest that the emboli which occurred in these patients were small, possibly platelet-fibrin accumulations. It is postulated that with the use of careful technic larger emboli capable of producing myocardial infarction with shock or disabling cerebral vascular accidents can be prevented, even in a training situation. However, smaller embolic phenomena probably cannot be completely avoided by the use of careful technic, and it is for prevention of small emboli that systemic anticoagulation with heparin may be of value.
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Rich JM, Meisner MH, Fontana ME, Wooley CF. Electrophysiologic stress tests in man: sinoatrial node suppression and recovery. J Lab Clin Med 1971; 78:805-6. [PMID: 5128844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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