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Meneghetti I, Sighinolfi MC, Dibitetto F, Collins JW, Mosillo L, Catalano C, Rocco B, De Dominicis M, De Maria M. Partial nephrectomy series using Versius robotic surgical system: technique and outcomes of an initial experience. J Robot Surg 2024; 18:73. [PMID: 38349425 DOI: 10.1007/s11701-024-01843-8] [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: 11/20/2023] [Accepted: 01/21/2024] [Indexed: 02/15/2024]
Abstract
Partial nephrectomy (PN) represents a procedure where the use of a robot has further enabled successful completion of this complex surgery. The results of this procedure using Versius Robotic Surgical System (VRSS) still need to be evaluated. Our working group described the technique and reported the initial results of a series of PN using VRSS. We presented our setting, surgical technique and outcomes for PN, using VRSS. Between 2022 and 2023, 15 patients underwent PN performed by two surgeons in two different centers. Fifteen patients underwent PN. The median lesion size identified on preoperative imaging was 4 (IQR 2.3-5) cm. Median PADUA score was 8 (IQR 7-9). Two procedures were converted to radical nephrectomy for enhanced oncological disease control. Of the 13 nephrectomies that were completed as partial, 7 were performed clampless and 6 with warm ischemia clamping. Median clamping time was 10 (IQR 9-11) minutes. No procedure was converted to open. Median blood loss was 200 (IQR 100-250) mL. Median total operative time was 105 (IQR 100-110) minutes. Median console time was 75 (IQR 66-80) minutes. Median set-up time was 13 (IQR 12-14) minutes. No intraoperative complications were reported. The median hospitalization time was 4 (IQR 3.5-4) days. None of the patients were transfused and none of the patients required readmission. In a pathology report, one patient had a positive surgical margin. Our initial experience suggests that performing PN using VRSS is feasible with good short-term outcomes.
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Affiliation(s)
| | | | - Francesco Dibitetto
- Department of Urology, Uroclinic Casa di Cura Nuova Villa Claudia, Rome, Italy
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
- Division of Uro-oncology, University College London Hospital, London, UK
- CMR Surgical, Cambridge, UK
| | - Luca Mosillo
- Department of Urology, Apuane Hospital, Massa, Italy
| | | | - Bernardo Rocco
- Department of Urology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Mauro De Dominicis
- Department of Urology, Uroclinic Casa di Cura Nuova Villa Claudia, Rome, Italy
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De Maria M, Meneghetti I, Mosillo L, Collins JW, Catalano C. Versius robotic surgical system: case series of 18 robot-assisted radical prostatectomies. BJU Int 2024; 133:197-205. [PMID: 37604773 DOI: 10.1111/bju.16156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVE To present the results of the first series of patients treated with robot-assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost-effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach. PATIENTS AND METHODS Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3-month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set-up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set-up and operating times to optimise utilisation of the Versius system. RESULTS The median (interquartile range [IQR]) set-up time was 8.5 (7-10) min. The median (IQR) console time was 201 (170-242) min. The median (IQR) operative time was 213 (186-266) min. The median (IQR) total surgery time was 226 (201-277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17-20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra- or postoperative complications at the 1-month follow-up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75-5) days, and the transurethral catheter was removed after a mean (range) of 8 (7-14) days. Continence at 2 months was achieved in 72.2% of the patients. CONCLUSIONS Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set-up enables a rapid docking approach and efficient completion of the surgery.
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Affiliation(s)
| | | | - Luca Mosillo
- Urology Department, Ospedale Apuane, Massa, Italy
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Invention, University College London, London, UK
- Division of Uro-Oncology, University College London Hospital, London, UK
- Associate Medical Director, CMR Surgical, Cambridge, UK
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Patel V, Saikali S, Moschovas MC, Patel E, Satava R, Dasgupta P, Dohler M, Collins JW, Albala D, Marescaux J. Technical and ethical considerations in telesurgery. J Robot Surg 2024; 18:40. [PMID: 38231309 DOI: 10.1007/s11701-023-01797-3] [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: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
Telesurgery, a cutting-edge field at the intersection of medicine and technology, holds immense promise for enhancing surgical capabilities, extending medical care, and improving patient outcomes. In this scenario, this article explores the landscape of technical and ethical considerations that highlight the advancement and adoption of telesurgery. Network considerations are crucial for ensuring seamless and low-latency communication between remote surgeons and robotic systems, while technical challenges encompass system reliability, latency reduction, and the integration of emerging technologies like artificial intelligence and 5G networks. Therefore, this article also explores the critical role of network infrastructure, highlighting the necessity for low-latency, high-bandwidth, secure and private connections to ensure patient safety and surgical precision. Moreover, ethical considerations in telesurgery include patient consent, data security, and the potential for remote surgical interventions to distance surgeons from their patients. Legal and regulatory frameworks require refinement to accommodate the unique aspects of telesurgery, including liability, licensure, and reimbursement. Our article presents a comprehensive analysis of the current state of telesurgery technology and its potential while critically examining the challenges that must be navigated for its widespread adoption.
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Affiliation(s)
- Vipul Patel
- AdventHealth Global Robotics Institute, Celebration, FL, USA
- University of Central Florida (UCF), Orlando, FL, USA
| | - Shady Saikali
- AdventHealth Global Robotics Institute, Celebration, FL, USA.
| | - Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, Celebration, FL, USA
- University of Central Florida (UCF), Orlando, FL, USA
| | - Ela Patel
- Stanford University, Stanford, CA, 94305, USA
| | | | - Prokar Dasgupta
- MRC Centre for Transplantation, Department of Urology, King's Health Partners, King's College London, London, UK
| | - Mischa Dohler
- Advanced Technology Group, Ericsson Inc., Santa Clara, CA, 95054, USA
| | - Justin W Collins
- Division of Uro-Oncology, University College London Hospital, London, UK
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
- CMR Surgical, Cambridge, UK
| | - David Albala
- Downstate Health Sciences University, Syracuse, NY, USA
- Department of Urology, Crouse Hospital, Syracuse, NY, USA
| | - Jacques Marescaux
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Boal MWE, Anastasiou D, Tesfai F, Ghamrawi W, Mazomenos E, Curtis N, Collins JW, Sridhar A, Kelly J, Stoyanov D, Francis NK. Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review. Br J Surg 2024; 111:znad331. [PMID: 37951600 PMCID: PMC10771126 DOI: 10.1093/bjs/znad331] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/14/2023]
Abstract
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.
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Affiliation(s)
- Matthew W E Boal
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
| | - Dimitrios Anastasiou
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Freweini Tesfai
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
| | - Walaa Ghamrawi
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
| | - Evangelos Mazomenos
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Nathan Curtis
- Department of General Surgey, Dorset County Hospital NHS Foundation Trust, Dorchester, UK
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Ashwin Sridhar
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - John Kelly
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Computer Science, UCL, London, UK
| | - Nader K Francis
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- Yeovil District Hospital, Somerset Foundation NHS Trust, Yeovil, Somerset, UK
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Bjerrum F, Collins JW, Butterworth J, Slack M, Konge L. Competency assessment for the Versius surgical robot: a validity investigation study of a virtual reality simulator-based test. Surg Endosc 2023; 37:7464-7471. [PMID: 37400688 DOI: 10.1007/s00464-023-10221-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/04/2022] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND When introducing new equipment like robotic surgical systems, it is essential to ensure that surgeons have the basic skills before operating on patients. The objective was to investigate the validity evidence for a competency-based test for basic robotic surgical skills using the Versius® trainer. METHODS We recruited medical students, residents, and surgeons which were classified based on data on clinical experience with the Versius system as either novices (0 min), intermediates (1-1000 min), or experienced (> 1000 min). All participants completed three rounds of eight basic exercises on the Versius trainer, where the first was used for familiarization and the final two for data analysis. The simulator automatically recorded data. Validity evidence was summarized using Messick's framework, and the contrasting groups' standard-setting method was used to define pass/fail levels. RESULTS 40 participants completed the three rounds of exercises. The discriminatory abilities of all parameters were tested, and five exercises including relevant parameters were selected to be part of the final test. 26 of 30 parameters could differentiate between novices and experienced surgeons but none of the parameters could discriminate between the intermediate and experienced surgeons. Test-retest reliability analysis using Pearson's r or Spearman's rho showed only 13 of 30 parameters had moderate or higher reliability. Non-compensatory pass/fail levels were defined for each exercise and showed that all novices failed all the exercises and that most experienced surgeons either passed or nearly passed all five exercises. CONCLUSION We identified relevant parameters for five exercises that could be used to assess basic robotic skills for the Versius robotic system and defined a credible pass/fail level. This is the first step in developing a proficiency-based training program for the Versius system.
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Affiliation(s)
- Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark.
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark.
- Copenhagen Academy for Medical Education and Simulation (CAMES), Ryesgade 53B, 4th floor, 2100, Copenhagen, Denmark.
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Division of Uro-Oncology, University College London Hospital, London, UK
- CMR Surgical Ltd, Cambridge, UK
| | | | - Mark Slack
- CMR Surgical Ltd, Cambridge, UK
- Clinical School, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, The University of Copenhagen, Copenhagen, Denmark
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Burke JR, Fleming CA, King M, El-Sayed C, Bolton WS, Munsch C, Harji D, Bach SP, Collins JW. Utilising an accelerated Delphi process to develop consensus on the requirement and components of a pre-procedural core robotic surgery curriculum. J Robot Surg 2023; 17:1443-1455. [PMID: 36757562 PMCID: PMC9909133 DOI: 10.1007/s11701-022-01518-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/31/2022] [Indexed: 02/10/2023]
Abstract
Robot-assisted surgery (RAS) continues to grow globally. Despite this, in the UK and Ireland, it is estimated that over 70% of surgical trainees across all specialities have no access to robot-assisted surgical training (RAST). This study aimed to provide educational stakeholders guidance on a pre-procedural core robotic surgery curriculum (PPCRC) from the perspective of the end user; the surgical trainee. The study was conducted in four Phases: P1: a steering group was formed to review current literature and summarise the evidence, P2: Pan-Specialty Trainee Panel Virtual Classroom Discussion, P3: Accelerated Delphi Process and P4: Formulation of Recommendations. Forty-three surgeons in training representing all surgical specialties and training levels contributed to the three round Delphi process. 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. There was 100% response from all three rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of > 0.8. There was 97.7% agreement that a standardised PPCRC would be advantageous to training and that, independent of speciality, there should be a common approach (95.5% agreement). Consensus was reached in multiple areas: 1. Experience and Exposure, 2. Access and context, 3. Curriculum Components, 4 Target Groups and Delivery, 5. Objective Metrics, Benchmarking and Assessment. Using the Delphi methodology, we achieved multispecialty consensus among trainees to develop and reach content validation for the requirements and components of a PPCRC. This guidance will benefit from further validation following implementation.
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Affiliation(s)
- Joshua Richard Burke
- The Association of Surgeons in Training, Royal College of Surgeons of England, London, England, UK
- Robotics and Digital Surgery Initiative, Royal College of Surgeons of England, London, England
- Leeds Institute Medical Research, University of Leeds, Leeds, UK
| | - Christina A. Fleming
- The Association of Surgeons in Training, Royal College of Surgeons of England, London, England, UK
- The Royal College of Surgeons, Dublin, Ireland
| | - Martin King
- The Association of Surgeons in Training, Royal College of Surgeons of England, London, England, UK
- Craigavon Area Hospital, Craigavon, Northern Ireland
| | - Charlotte El-Sayed
- Technology Enhanced Learning Directorate of Innovation, Digital and Transformation, Health Education England, London, England
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | | | - Chris Munsch
- Technology Enhanced Learning Directorate of Innovation, Digital and Transformation, Health Education England, London, England
| | - Deena Harji
- Robotics and Digital Surgery Initiative, Royal College of Surgeons of England, London, England
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon P. Bach
- Robotics and Digital Surgery Initiative, Royal College of Surgeons of England, London, England
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Justin W. Collins
- University College London, Division of Surgery and Interventional Science, Research Department of Targeted Intervention, London, UK
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), UK, University College London, London, UK
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Haque TF, Hui A, You J, Ma R, Nguyen JH, Lei X, Cen S, Aron M, Collins JW, Djaladat H, Ghazi A, Yates KA, Abreu AL, Daneshmand S, Desai MM, Goh AC, Hu JC, Lebastchi AH, Lendvay TS, Porter J, Schuckman AK, Sotelo R, Sundaram CP, Gill IS, Hung AJ. Reply by Authors. Urol Pract 2022; 9:541. [PMID: 37145829 DOI: 10.1097/upj.0000000000000344.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Taseen F Haque
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Alvin Hui
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Jonathan You
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Runzhuo Ma
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Jessica H Nguyen
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Xiaomeng Lei
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven Cen
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Monish Aron
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Justin W Collins
- Division of Uro-oncology, University College London Hospital, London, UK
| | - Hooman Djaladat
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Ahmed Ghazi
- Urology Department, University of Rochester, Rochester, New York
| | - Kenneth A Yates
- Rossier School of Education, University of Southern California, Los Angeles, California
| | - Andre L Abreu
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Siamak Daneshmand
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Mihir M Desai
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Alvin C Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Amir H Lebastchi
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Thomas S Lendvay
- Department of Urology, University of Washington, Seattle, Washington
| | | | - Anne K Schuckman
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Rene Sotelo
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | | | - Inderbir S Gill
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
| | - Andrew J Hung
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California
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Jamjoom AA, Jamjoom AM, Thomas JP, Palmisciano P, Kerr K, Collins JW, Vayena E, Stoyanov D, Marcus HJ. Autonomous surgical robotic systems and the liability dilemma. Front Surg 2022; 9:1015367. [PMID: 36277285 PMCID: PMC9580336 DOI: 10.3389/fsurg.2022.1015367] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAdvances in machine learning and robotics have allowed the development of increasingly autonomous robotic systems which are able to make decisions and learn from experience. This distribution of decision-making away from human supervision poses a legal challenge for determining liability.MethodsThe iRobotSurgeon survey aimed to explore public opinion towards the issue of liability with robotic surgical systems. The survey included five hypothetical scenarios where a patient comes to harm and the respondent needs to determine who they believe is most responsible: the surgeon, the robot manufacturer, the hospital, or another party.ResultsA total of 2,191 completed surveys were gathered evaluating 10,955 individual scenario responses from 78 countries spanning 6 continents. The survey demonstrated a pattern in which participants were sensitive to shifts from fully surgeon-controlled scenarios to scenarios in which robotic systems played a larger role in decision-making such that surgeons were blamed less. However, there was a limit to this shift with human surgeons still being ascribed blame in scenarios of autonomous robotic systems where humans had no role in decision-making. Importantly, there was no clear consensus among respondents where to allocate blame in the case of harm occurring from a fully autonomous system.ConclusionsThe iRobotSurgeon Survey demonstrated a dilemma among respondents on who to blame when harm is caused by a fully autonomous surgical robotic system. Importantly, it also showed that the surgeon is ascribed blame even when they have had no role in decision-making which adds weight to concerns that human operators could act as “moral crumple zones” and bear the brunt of legal responsibility when a complex autonomous system causes harm.
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Affiliation(s)
- Aimun A.B. Jamjoom
- Centre for Clinical Brain Sciences, Edinburgh University, Edinburgh, United Kingdom
- Correspondence: Aimun A.B. Jamjoom
| | - Ammer M.A. Jamjoom
- Department of Trauma and Orthopaedic Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Jeffrey P. Thomas
- Department of Management, London School of Economics, London, United Kingdom
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma and Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Karen Kerr
- Digital Surgery, Medtronic Ltd, London, United Kingdom
| | - Justin W. Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, United Kingdom
| | - Effy Vayena
- Institute of Translational Medicine, ETH Zurich, Zurich, Switzerland
| | - Danail Stoyanov
- Digital Surgery, Medtronic Ltd, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, United Kingdom
| | - Hani J. Marcus
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, United Kingdom
- Division of Neurosurgery, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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Lam K, Abràmoff MD, Balibrea JM, Bishop SM, Brady RR, Callcut RA, Chand M, Collins JW, Diener MK, Eisenmann M, Fermont K, Neto MG, Hager GD, Hinchliffe RJ, Horgan A, Jannin P, Langerman A, Logishetty K, Mahadik A, Maier-Hein L, Antona EM, Mascagni P, Mathew RK, Müller-Stich BP, Neumuth T, Nickel F, Park A, Pellino G, Rudzicz F, Shah S, Slack M, Smith MJ, Soomro N, Speidel S, Stoyanov D, Tilney HS, Wagner M, Darzi A, Kinross JM, Purkayastha S. A Delphi consensus statement for digital surgery. NPJ Digit Med 2022; 5:100. [PMID: 35854145 PMCID: PMC9296639 DOI: 10.1038/s41746-022-00641-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/24/2022] [Indexed: 12/13/2022] Open
Abstract
The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term ‘digital surgery’. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients.
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Affiliation(s)
- Kyle Lam
- Department of Surgery and Cancer, Imperial College, London, UK.,Institute of Global Health Innovation, Imperial College London, London, UK
| | - Michael D Abràmoff
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA.,Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, USA
| | - José M Balibrea
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | | | - Richard R Brady
- Newcastle Centre for Bowel Disease Research Hub, Newcastle University, Newcastle, UK.,Department of Colorectal Surgery, Newcastle Hospitals, Newcastle, UK
| | | | - Manish Chand
- Department of Surgery and Interventional Sciences, University College London, London, UK
| | - Justin W Collins
- CMR Surgical Limited, Cambridge, UK.,Department of Surgery and Interventional Sciences, University College London, London, UK
| | - Markus K Diener
- Department of General and Visceral Surgery, University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Matthias Eisenmann
- Division of Computer Assisted Medical Interventions (CAMI), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kelly Fermont
- Solicitor of the Senior Courts of England and Wales, Independent Researcher, Bristol, UK
| | - Manoel Galvao Neto
- Endovitta Institute, Sao Paulo, Brazil.,FMABC Medical School, Santo Andre, Brazil
| | - Gregory D Hager
- The Malone Center for Engineering in Healthcare, The Johns Hopkins University, Baltimore, MD, USA.,Department of Computer Science, The Johns Hopkins University, Baltimore, MD, USA
| | | | - Alan Horgan
- Department of Colorectal Surgery, Newcastle Hospitals, Newcastle, UK
| | - Pierre Jannin
- LTSI, Inserm UMR 1099, University of Rennes 1, Rennes, France
| | - Alexander Langerman
- Otolaryngology, Head & Neck Surgery and Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - Lena Maier-Hein
- Division of Computer Assisted Medical Interventions (CAMI), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany.,LKSK Institute of St. Michael's Hospital, Toronto, ON, Canada
| | | | - Pietro Mascagni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,ICube, University of Strasbourg, Strasbourg, France
| | - Ryan K Mathew
- School of Medicine, University of Leeds, Leeds, UK.,Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Tumor Diseases, Heidelberg, Germany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery (ICCAS), Universität Leipzig, Leipzig, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Adrian Park
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, Annapolis, MD, USA
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, ON, Canada.,Vector Institute for Artificial Intelligence, Toronto, ON, Canada.,Unity Health Toronto, Toronto, ON, Canada.,Surgical Safety Technologies Inc, Toronto, ON, Canada
| | - Sam Shah
- Faculty of Future Health, College of Medicine and Dentistry, Ulster University, Birmingham, UK
| | - Mark Slack
- CMR Surgical Limited, Cambridge, UK.,Department of Urogynaecology, Addenbrooke's Hospital, Cambridge, UK.,University of Cambridge, Cambridge, UK
| | - Myles J Smith
- The Royal Marsden Hospital, London, UK.,Institute of Cancer Research, London, UK
| | - Naeem Soomro
- Department of Urology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stefanie Speidel
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,Centre for Tactile Internet with Human-in-the-Loop (CeTI), TU Dresden, Dresden, Germany
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Henry S Tilney
- Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Martin Wagner
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Tumor Diseases, Heidelberg, Germany
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College, London, UK.,Institute of Global Health Innovation, Imperial College London, London, UK
| | - James M Kinross
- Department of Surgery and Cancer, Imperial College, London, UK.
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10
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Fuchs HF, Collins JW, Babic B, DuCoin C, Meireles OR, Grimminger PP, Read M, Abbas A, Sallum R, Müller-Stich BP, Perez D, Biebl M, Egberts JH, van Hillegersberg R, Bruns CJ. Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study. Dis Esophagus 2022; 35:6348318. [PMID: 34382061 DOI: 10.1093/dote/doab055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/29/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology. METHODS Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental. RESULTS All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE. CONCLUSION The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | - Benjamin Babic
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | | | | | | | | | | | | | - Daniel Perez
- Department of Surgery, University of Hamburg, Hamburg, Germany
| | | | | | | | - Christiane J Bruns
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
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11
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Vedula SS, Ghazi A, Collins JW, Pugh C, Stefanidis D, Meireles O, Hung AJ, Schwaitzberg S, Levy JS, Sachdeva AK. Artificial Intelligence Methods and Artificial Intelligence-Enabled Metrics for Surgical Education: A Multidisciplinary Consensus. J Am Coll Surg 2022; 234:1181-1192. [PMID: 35703817 PMCID: PMC10634198 DOI: 10.1097/xcs.0000000000000190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Artificial intelligence (AI) methods and AI-enabled metrics hold tremendous potential to advance surgical education. Our objective was to generate consensus guidance on specific needs for AI methods and AI-enabled metrics for surgical education. STUDY DESIGN The study included a systematic literature search, a virtual conference, and a 3-round Delphi survey of 40 representative multidisciplinary stakeholders with domain expertise selected through purposeful sampling. The accelerated Delphi process was completed within 10 days. The survey covered overall utility, anticipated future (10-year time horizon), and applications for surgical training, assessment, and feedback. Consensus was agreement among 80% or more respondents. We coded survey questions into 11 themes and descriptively analyzed the responses. RESULTS The respondents included surgeons (40%), engineers (15%), affiliates of industry (27.5%), professional societies (7.5%), regulatory agencies (7.5%), and a lawyer (2.5%). The survey included 155 questions; consensus was achieved on 136 (87.7%). The panel listed 6 deliverables each for AI-enhanced learning curve analytics and surgical skill assessment. For feedback, the panel identified 10 priority deliverables spanning 2-year (n = 2), 5-year (n = 4), and 10-year (n = 4) timeframes. Within 2 years, the panel expects development of methods to recognize anatomy in images of the surgical field and to provide surgeons with performance feedback immediately after an operation. The panel also identified 5 essential that should be included in operative performance reports for surgeons. CONCLUSIONS The Delphi panel consensus provides a specific, bold, and forward-looking roadmap for AI methods and AI-enabled metrics for surgical education.
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Affiliation(s)
- S Swaroop Vedula
- From the Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD (Vedula)
| | - Ahmed Ghazi
- the Department of Urology, University of Rochester Medical Center, Rochester, NY (Ghazi)
| | - Justin W Collins
- the Division of Surgery and Interventional Science, Research Department of Targeted Intervention and Wellcome/Engineering and Physical Sciences Research Council Center for Interventional and Surgical Sciences, University College London, London, UK (Collins)
| | - Carla Pugh
- the Department of Surgery, Stanford University, Stanford, CA (Pugh)
| | | | - Ozanan Meireles
- the Department of Surgery, Massachusetts General Hospital, Boston, MA (Meireles)
| | - Andrew J Hung
- the Artificial Intelligence Center at University of Southern California Urology, Department of Urology, University of Southern California, Los Angeles, CA (Hung)
| | | | - Jeffrey S Levy
- Institute for Surgical Excellence, Washington, DC (Levy)
| | - Ajit K Sachdeva
- Division of Education, American College of Surgeons, Chicago, IL (Sachdeva)
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12
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Nathan A, Fricker M, Georgi M, Patel S, Hang MK, Asif A, Sinha A, Mullins W, Shea J, Hanna N, Monks M, Peprah D, Sharma A, Ninkovic-Hall G, Lamb BW, Kelly J, Sridhar A, Collins JW. Virtual Interactive Surgical Skills Classroom: A Parallel-group, Non-inferiority, Adjudicator-blinded, Randomised Controlled Trial (VIRTUAL). J Surg Educ 2022; 79:791-801. [PMID: 34857499 DOI: 10.1016/j.jsurg.2021.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/05/2021] [Accepted: 11/06/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Arjun Nathan
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.
| | - Monty Fricker
- School of Medicine, Newcastle University, Newcastle, United Kingdom
| | - Maria Georgi
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Sonam Patel
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Man Kien Hang
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Aqua Asif
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Amil Sinha
- School of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - William Mullins
- School of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jessie Shea
- School of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nancy Hanna
- School of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Massimo Monks
- Department of Surgery, North Middlesex University Hospitals NHS Foundation Trust, London, United Kingdom
| | - David Peprah
- Department of Surgery, North Middlesex University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Akash Sharma
- Department of Radiology, Imperial College London, London, United Kingdom
| | - George Ninkovic-Hall
- Department of Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Benjamin W Lamb
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ashwin Sridhar
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Justin W Collins
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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13
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Marcus HJ, Khan DZ, Borg A, Buchfelder M, Cetas JS, Collins JW, Dorward NL, Fleseriu M, Gurnell M, Javadpour M, Jones PS, Koh CH, Layard Horsfall H, Mamelak AN, Mortini P, Muirhead W, Oyesiku NM, Schwartz TH, Sinha S, Stoyanov D, Syro LV, Tsermoulas G, Williams A, Winder MJ, Zada G, Laws ER. Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection. Pituitary 2021; 24:839-853. [PMID: 34231079 PMCID: PMC8259776 DOI: 10.1007/s11102-021-01162-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Surgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice. METHODS A mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached. RESULTS There was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured. CONCLUSIONS Through an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed "core" steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The "optional" steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.
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Affiliation(s)
- Hani J Marcus
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| | - Danyal Z Khan
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Anouk Borg
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Justin S Cetas
- Department of Neurosurgery, Oregon Health & Science University, Portland, USA
| | - Justin W Collins
- Department of Uro-Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil L Dorward
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Maria Fleseriu
- Department of Neurosurgery, Oregon Health & Science University, Portland, USA
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, USA
| | - Mark Gurnell
- Division of Clinical Endocrinology & NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Mohsen Javadpour
- Department of Neurosurgery, National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Chan Hee Koh
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Hugo Layard Horsfall
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Adam N Mamelak
- Department of Neurosurgery and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Pietro Mortini
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - William Muirhead
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Nelson M Oyesiku
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine (Endocrinology), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, USA
| | - Saurabh Sinha
- Department of Neurosurgery, Royal Hallamshire Hospital & Sheffield Children's Hospital, Sheffield, UK
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Luis V Syro
- Department of Neurosurgery, Hospital Pablo Tobon Uribe and Clinica Medellin-Grupo Quirónsalud, Medellin, Colombia
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Adam Williams
- Department of Neurosurgery, Southmead Hospital Bristol, Bristol, UK
| | - Mark J Winder
- Department of Neurosurgery, St Vincent's Public and Private Hospitals, Sydney, Australia
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, BTM 4, 60 Fenwood Road, Boston, USA
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14
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Chen IHA, Ghazi A, Sridhar A, Stoyanov D, Slack M, Kelly JD, Collins JW. Evolving robotic surgery training and improving patient safety, with the integration of novel technologies. World J Urol 2021; 39:2883-2893. [PMID: 33156361 PMCID: PMC8405494 DOI: 10.1007/s00345-020-03467-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/21/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- I-Hsuan Alan Chen
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.
- Department of Surgery, Division of Urology, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying District, Kaohsiung, 81362, Taiwan.
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK.
| | - Ahmed Ghazi
- Department of Urology, Simulation Innovation Laboratory, University of Rochester, New York, USA
| | - Ashwin Sridhar
- Division of Uro-Oncology, University College London Hospital, London, UK
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | | | - John D Kelly
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Division of Uro-Oncology, University College London Hospital, London, UK
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK.
- Division of Uro-Oncology, University College London Hospital, London, UK.
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15
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Mottrie A, Mazzone E, Wiklund P, Graefen M, Collins JW, De Groote R, Dell’Oglio P, Puliatti S, Gallagher AG. Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative. BJU Int 2021; 128:103-111. [PMID: 33251703 PMCID: PMC8359192 DOI: 10.1111/bju.15311] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To develop and seek consensus from procedure experts on the metrics that best characterise a reference robot-assisted radical prostatectomy (RARP) and determine if the metrics distinguished between the objectively assessed RARP performance of experienced and novice urologists, as identifying objective performance metrics for surgical training in robotic surgery is imperative for patient safety. MATERIALS AND METHODS In Study 1, the metrics, i.e. 12 phases of the procedure, 81 steps, 245 errors and 110 critical errors for a reference RARP were developed and then presented to an international Delphi panel of 19 experienced urologists. In Study 2, 12 very experienced surgeons (VES) who had performed >500 RARPs and 12 novice urology surgeons performed a RARP, which was video recorded and assessed by two experienced urologists blinded as to subject and group. Percentage agreement between experienced urologists for the Delphi meeting and Mann-Whitney U- and Kruskal-Wallis tests were used for construct validation of the newly identified RARP metrics. RESULTS At the Delphi panel, consensus was reached on the appropriateness of the metrics for a reference RARP. In Study 2, the results showed that the VES performed ~4% more procedure steps and made 72% fewer procedure errors than the novices (P = 0.027). Phases VIIa and VIIb (i.e. neurovascular bundle dissection) best discriminated between the VES and novices. LIMITATIONS VES whose performance was in the bottom half of their group demonstrated considerable error variability and made five-times as many errors as the other half of the group (P = 0.006). CONCLUSIONS The international Delphi panel reached high-level consensus on the RARP metrics that reliably distinguished between the objectively scored procedure performance of VES and novices. Reliable and valid performance metrics of RARP are imperative for effective and quality assured surgical training.
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Affiliation(s)
- Alexandre Mottrie
- Orsi AcademyMelleBelgium
- Department of UrologyOnze Lieve Vrouw Hospital (OLV)AalstBelgium
| | - Elio Mazzone
- Orsi AcademyMelleBelgium
- Department of UrologyOnze Lieve Vrouw Hospital (OLV)AalstBelgium
- Division of Oncology/Unit of UrologyURIL’Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San RaffaeleMilanItaly
- Vita‐Salute San Raffaele UniversityMilanItaly
| | - Peter Wiklund
- Department of UrologyKarolinska InstitutetStockholmSweden
- Department of UrologyIcahn School of Medicine at Mount Sinai Health SystemNew YorkNYUSA
| | - Markus Graefen
- Martini‐Klinik Prostate Cancer CenterUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Justin W. Collins
- Orsi AcademyMelleBelgium
- Department of Uro‐oncologyUniversity College London Hospital (UCLH)LondonUK
| | - Ruben De Groote
- Orsi AcademyMelleBelgium
- Department of UrologyOnze Lieve Vrouw Hospital (OLV)AalstBelgium
| | - Paolo Dell’Oglio
- Orsi AcademyMelleBelgium
- Department of UrologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Stefano Puliatti
- Orsi AcademyMelleBelgium
- Department of UrologyOnze Lieve Vrouw Hospital (OLV)AalstBelgium
- Department of UrologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Anthony G. Gallagher
- Orsi AcademyMelleBelgium
- Faculty of Life and Health SciencesUlster UniversityNorthern IrelandUK
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Collins JW, Marcus HJ, Ghazi A, Sridhar A, Hashimoto D, Hager G, Arezzo A, Jannin P, Maier-Hein L, Marz K, Valdastri P, Mori K, Elson D, Giannarou S, Slack M, Hares L, Beaulieu Y, Levy J, Laplante G, Ramadorai A, Jarc A, Andrews B, Garcia P, Neemuchwala H, Andrusaite A, Kimpe T, Hawkes D, Kelly JD, Stoyanov D. Ethical implications of AI in robotic surgical training: A Delphi consensus statement. Eur Urol Focus 2021; 8:613-622. [PMID: 33941503 DOI: 10.1016/j.euf.2021.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/02/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Justin W Collins
- University College London, Division of Surgery and Interventional Science, Research Department of Targeted Intervention; Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London; University College London Hospital, Division of Uro-oncology.
| | - Hani J Marcus
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London
| | - Ahmed Ghazi
- Simulation Innovation Laboratory, University of Rochester, USA
| | - Ashwin Sridhar
- University College London, Division of Surgery and Interventional Science, Research Department of Targeted Intervention; University College London Hospital, Division of Uro-oncology
| | - Daniel Hashimoto
- Surgical Artificial Intelligence and Innovation Laboratory, Massachusetts General Hospital, USA
| | - Gregory Hager
- Malone Center for engineering in healthcare, Department of Computer Science, John Hopkins University, Baltimore, USA
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Italy
| | | | - Lena Maier-Hein
- Deutsches Krebsforschungszentrum, Division of Computer Assisted Medical Interventions, Heidelberg, Germany
| | - Keno Marz
- Deutsches Krebsforschungszentrum, Division of Computer Assisted Medical Interventions, Heidelberg, Germany
| | - Pietro Valdastri
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, UK
| | - Kensaku Mori
- Director of Information Technology Center, Nagoya University, Japan
| | - Daniel Elson
- Hamlyn Centre for robotic surgery, Department of Surgery and cancer, Imperial College London, UK
| | - Stamatia Giannarou
- Hamlyn Centre for robotic surgery, Department of Surgery and cancer, Imperial College London, UK
| | - Mark Slack
- Honorary Senior Lecturer, University of Cambridge, Cambridge UK; CMO CMR Surgical, Cambridge, UK
| | - Luke Hares
- Chief technology director, CMR Surgical, Cambridge, UK
| | - Yanick Beaulieu
- Division of Cardiology and Critical Care, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada
| | - Jeff Levy
- Institute for Surgical Excellence, Philadelphia, USA
| | - Guy Laplante
- Director, Global Medical Affairs at Medtronic Minimally Invasive Therapies, Brampton, Canada
| | - Arvind Ramadorai
- Director, Digital-Assisted Surgery (DAS), Medtronic Surgical Robotics, North Haven, CT, USA
| | - Anthony Jarc
- Applied Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Ben Andrews
- Strategy, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | | | | | | | - Tom Kimpe
- BARCO NV - Healthcare division, Kortrijk, Belgium
| | - David Hawkes
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London
| | - John D Kelly
- University College London, Division of Surgery and Interventional Science, Research Department of Targeted Intervention; Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London; University College London Hospital, Division of Uro-oncology
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London
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17
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Collins JW, Ghazi A, Stoyanov D, Hung A, Coleman M, Cecil T, Ericsson A, Anvari M, Wang Y, Beaulieu Y, Haram N, Sridhar A, Marescaux J, Diana M, Marcus HJ, Levy J, Dasgupta P, Stefanidis D, Martino M, Feins R, Patel V, Slack M, Satava RM, Kelly JD. Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training. EUR UROL SUPPL 2020; 22:23-33. [PMID: 34337475 PMCID: PMC8317899 DOI: 10.1016/j.euros.2020.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.,Department of Uro-Oncology, University College London Hospital, London, UK.,Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - Ahmed Ghazi
- University of Rochester Medical Center, Rochester, NY, USA
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - Andrew Hung
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | - Tom Cecil
- Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Anders Ericsson
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Mehran Anvari
- Department of Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | | | - Yanick Beaulieu
- Division of Cardiology and Critical Care, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Nadine Haram
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ashwin Sridhar
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.,Department of Uro-Oncology, University College London Hospital, London, UK
| | - Jacques Marescaux
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Michele Diana
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Hani J Marcus
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - Jeffrey Levy
- Institute for Surgical Excellence, Philadelphia, PA, USA
| | - Prokar Dasgupta
- MRC Centre for Transplantation, Kings College London, London, UK
| | | | | | - Richard Feins
- Division of C Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Vipul Patel
- Global Robotics Institute, Celebration, FL, USA
| | - Mark Slack
- Department of Obstetrics and Gynaecology, Addenbrooke's Hospital, Cambridge, UK
| | | | - John D Kelly
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.,Department of Uro-Oncology, University College London Hospital, London, UK
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18
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Williams SB, Cumberbatch MG, Kamat AM, Jubber I, Kerr PS, McGrath JS, Djaladat H, Collins JW, Packiam VT, Steinberg GD, Lee E, Kassouf W, Black PC, Cerantola Y, Catto JW, Daneshmand S. Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis. Eur Urol 2020; 78:719-730. [DOI: 10.1016/j.eururo.2020.06.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 06/13/2020] [Indexed: 02/06/2023]
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19
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Ebbing J, Wiklund PN, Akre O, Carlsson S, Olsson MJ, Höijer J, Heimer M, Collins JW. Development and validation of non-guided bladder-neck and neurovascular-bundle dissection modules of the RobotiX-Mentor® full-procedure robotic-assisted radical prostatectomy virtual reality simulation. Int J Med Robot 2020; 17:e2195. [PMID: 33124140 PMCID: PMC7988553 DOI: 10.1002/rcs.2195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 01/15/2023]
Abstract
Background Full‐procedure virtual reality (VR) simulator training in robotic‐assisted radical prostatectomy (RARP) is a new tool in surgical education. Methods Description of the development of a VR RARP simulation model, (RobotiX‐Mentor®) including non‐guided bladder neck (ngBND) and neurovascular bundle dissection (ngNVBD) modules, and assessment of face, content, and construct validation of the ngBND and ngNVBD modules by robotic surgeons with different experience levels. Results Simulator and ngBND/ngNVBD modules were rated highly by all surgeons for realism and usability as training tool. In the ngBND‐task construct, validation was not achieved in task‐specific performance metrics. In the ngNVBD, task‐specific performance of the expert/intermediately experienced surgeons was significantly better than that of novices. Conclusions We proved face and content validity of simulator and both modules, and construct validity for generic metrics of the ngBND module and for generic and task‐specific metrics of the ngNVBD module.
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Affiliation(s)
- Jan Ebbing
- University Hospital Basel, Department of Urology, Basel, Switzerland.,Karolinska University Hospital, Department of Urology, Stockholm, Sweden
| | - Peter N Wiklund
- Karolinska University Hospital, Department of Urology, Stockholm, Sweden.,Karolinska Institutet, Department of Molecular Medicine and Surgery (MMK), Stockholm, Sweden.,Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY, USA
| | - Olof Akre
- Karolinska University Hospital, Department of Urology, Stockholm, Sweden.,Karolinska Institutet, Department of Molecular Medicine and Surgery (MMK), Stockholm, Sweden
| | - Stefan Carlsson
- Karolinska University Hospital, Department of Urology, Stockholm, Sweden.,Karolinska Institutet, Department of Molecular Medicine and Surgery (MMK), Stockholm, Sweden
| | - Mats J Olsson
- Karolinska University Hospital, Department of Urology, Stockholm, Sweden
| | - Jonas Höijer
- Karolinska Institutet, Unit of Biostatistics, Institute of Environmental Medicine (IMM), Stockholm, Sweden
| | - Maurice Heimer
- University Hospital Basel, Department of Urology, Basel, Switzerland.,Charité - University Hospital, Medical Department, Division of Nephrology, Berlin, Germany
| | - Justin W Collins
- Karolinska Institutet, Department of Molecular Medicine and Surgery (MMK), Stockholm, Sweden.,University College London Hospital, London, England
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20
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Brooks NA, Kokorovic A, McGrath JS, Kassouf W, Collins JW, Black PC, Douglas J, Djaladat H, Daneshmand S, Catto JWF, Kamat AM, Williams SB. Critical analysis of quality of life and cost-effectiveness of enhanced recovery after surgery (ERAS) for patient's undergoing urologic oncology surgery: a systematic review. World J Urol 2020; 40:1325-1342. [PMID: 32648071 DOI: 10.1007/s00345-020-03341-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 04/24/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols have been implemented across a variety of disciplines to improve outcomes. Herein we describe the impact of ERAS on quality of life (QOL) and cost for patients undergoing urologic oncology surgery. METHODS A systematic literature search using the MEDLINE, Scopus, Clinictrials.gov, and Cochrane Review databases for studies published between 1946 and 2020 was conducted. Articles were reviewed and assigned a risk of bias by two authors and were included if they addressed ERAS and either QOL or cost-effectiveness for patients undergoing urologic oncology surgery. RESULTS The literature search yielded a total of 682 studies after removing duplicates, of which 10 (1.5%) were included in the review. Nine articles addressed radical cystectomy, while one addressed ERAS and QOL for laparoscopic nephrectomy. Six publications assessed the impact of ERAS on QOL domains. Questionnaires used for assessment of QOL varied across studies, and timing of administration was heterogeneous. Overall, ERAS improved patient QOL during early phases of recovery within the realms of bowel function, physical/social/cognitive functioning, sleep and pain control. Costs were assessed in 4 retrospective studies including 3 conducted in the United States and one from China all addressing radical cystectomy. Studies demonstrated either decreased costs associated with ERAS as a result of decreased length of stay or no change in cost based on ERAS implementation. CONCLUSION While limited studies are published on the subject, ERAS implementation for radical cystectomy and laparoscopic nephrectomy improved patient-reported QOL during early phases of recovery. For radical cystectomy, there was a decreased or neutral overall financial cost associated with ERAS. Further studies assessing QOL and cost-effectiveness over the entire global period of care in a variety of urologic oncology surgeries are warranted.
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Affiliation(s)
- Nathan A Brooks
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Kokorovic
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John S McGrath
- Department of Urology, Royal Devon and Exeter NHS Trust, Exeter, UK
| | - Wassim Kassouf
- Department of Urology, McGill University Health Center, McGill, Montreal, QC, Canada
| | - Justin W Collins
- Department of Urology, University College London Hospital, London, UK
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - James Douglas
- Department of Urology, University Hospital of Southampton, Hampshire, UK
| | - Hooman Djaladat
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Siamak Daneshmand
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Williams
- Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
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21
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Vanlander AE, Mazzone E, Collins JW, Mottrie AM, Rogiers XM, van der Poel HG, Van Herzeele I, Satava RM, Gallagher AG. Orsi Consensus Meeting on European Robotic Training (OCERT): Results from the First Multispecialty Consensus Meeting on Training in Robot-assisted Surgery. Eur Urol 2020; 78:713-716. [PMID: 32089358 DOI: 10.1016/j.eururo.2020.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 11/07/2019] [Accepted: 02/05/2020] [Indexed: 01/22/2023]
Abstract
To improve patient outcomes in robotic surgery, robotic training and education need to be modernised and augmented. The skills and performance levels of trainees need to be objectively assessed before they operate on real patients. The main goal of the first Orsi Consensus Meeting on European Robotic Training (OCERT) was to establish the opinions of experts from different scientific societies on standardised robotic training pathways and training methodology. After a 2-d consensus conference, 36 experts identified 23 key statements allotted to three themes: training standardisation pathways, validation metrics, and implementation prerequisites and certification. After two rounds of Delphi voting, consensus was obtained for 22 of 23 questions among these three categories. Participants agreed that societies should drive and support the implementation of benchmarked training using validated proficiency-based pathways. All courses should deliver an internationally agreed curriculum with performance standards, be accredited by universities/professional societies, and, trainees should receive a certificate approved by professional societies and/or universities after successful completion of the robotic training courses. This OCERT meeting established a basis for bringing surgical robotic training out of the operating room by seeking input and consensus across surgical specialties for an objective, validated, and standardised training programme with transparent, metric-based training outcomes. PATIENT SUMMARY: The Orsi Consensus Meeting on European Robotic Training (OCERT) is an international, multidisciplinary, Delphi-panel study of scientific societies and experts focused on training in robotic surgery. The panel achieved consensus that standardised international training pathways should be the basis for a structured, validated, replicable, and certified approach to implementation of robotic technology.
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Affiliation(s)
- Aude E Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Elio Mazzone
- Orsi Academy, Melle, Belgium; Department of Urology, OLV, Aalst, Belgium; Division of Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Justin W Collins
- Orsi Academy, Melle, Belgium; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Xavier M Rogiers
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | | | - Anthony G Gallagher
- Orsi Academy, Melle, Belgium; Faculty of Life and Health Sciences, Ulster University, Belfast, Northern Ireland, UK
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22
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Larcher A, De Naeyer G, Turri F, Dell'Oglio P, Capitanio U, Collins JW, Wiklund P, Van Der Poel H, Montorsi F, Mottrie A. The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation. Eur Urol 2019; 75:1023-1031. [PMID: 30979635 DOI: 10.1016/j.eururo.2019.02.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/21/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND No validated training program for robot-assisted partial nephrectomy (RAPN) exists. OBJECTIVE To define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN). DESIGN, SETTING, AND PARTICIPANTS A modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS To define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann-Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence. RESULTS AND LIMITATIONS Consensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p>0.05). Conversely, operative time was longer after cRAPN (p<0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p<0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety. CONCLUSIONS The European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program. PATIENT SUMMARY Patients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.
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Affiliation(s)
- Alessandro Larcher
- Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.
| | - Geert De Naeyer
- Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Filippo Turri
- ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Paolo Dell'Oglio
- Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Umberto Capitanio
- Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Justin W Collins
- ORSI Academy, Melle, Belgium; Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Department of Urology, Icahn School of Medicine at Mt Sinai, New York, NY, USA
| | - Henk Van Der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Francesco Montorsi
- Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
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23
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Rusch P, Ind T, Kimmig R, Maggioni A, Ponce J, Zanagnolo V, Coronado PJ, Verguts J, Lambaudie E, Falconer H, Collins JW, Verheijen RHM. Recommendations for a standardised educational program in robot assisted gynaecological surgery: Consensus from the Society of European Robotic Gynaecological Surgery (SERGS). Facts Views Vis Obgyn 2019; 11:29-41. [PMID: 31695855 PMCID: PMC6822956] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery. METHODS A Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education. RESULTS On review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons. CONCLUSIONS Consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery.
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Affiliation(s)
- P Rusch
- Department of Obstetrics and Gynaecology, University Hospital Duisburg-Essen; Hufelandstr. 55, 45147 Essen, Germany. .
| | - T Ind
- Department of Gynaecological Oncology, The Royal Marsden, London, UK;,St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London,
| | - R Kimmig
- Department of Obstetrics and Gynaecology, University Hospital Duisburg-Essen; Hufelandstr. 55, 45147 Essen, Germany. .
| | - A Maggioni
- Division of Gynaecology, European Institute of Oncology, Via Ripamonti, 435,
20141 Milano, Italy. .
| | - J Ponce
- Department of Gynaecological Oncology, Hospital Universitari de Bellvitge, c/ Feixa Llarga, sn, 08907 L’ Hospitalet de Llobregat. Barcelona, Spain.
| | - V Zanagnolo
- Division of Gynaecology, European Institute of Oncology, Via Ripamonti, 435,
20141 Milano, Italy. .
| | - PJ Coronado
- Department of Gynaecological Oncology, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Avda. de Séneca, 2, Ciudad Universitaria, 28040 Madrid, Spain.
| | - J Verguts
- Division of Gynaecology, European Institute of Oncology, Via Ripamonti, 435,
20141 Milano, Italy. . ;,Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000 Leuven, Belgium;,Department of
Obstetrics and Gynaecology, Jessa Hospital, 3500 Hasselt, Belgium,
| | - E Lambaudie
- Department of Gynaecologic Oncology, Centre de Lutte Contre le Cancer Oscar Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France;,Aix Marseille Université, Site Timone, Timone 27, boulevard Jean Moulin, 13385 Marseille cedex 5, France.
| | - H Falconer
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/University Hospital, 171 76 Stockholm, Sweden.
| | - JW Collins
- Department of Urology, Karolinska University Hospital, Karolinska Universitetssjukhuset, Solna, D1:01 171 76 Stockholm, Sweden.
| | - RHM Verheijen
- Department of Gynaecological Oncology, UMCU Cancer Center,
University Medical Center, Utrecht, Netherlands.
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Leow JJ, Bedke J, Chamie K, Collins JW, Daneshmand S, Grivas P, Heidenreich A, Messing EM, Royce TJ, Sankin AI, Schoenberg MP, Shipley WU, Villers A, Efstathiou JA, Bellmunt J, Stenzl A. SIU–ICUD consultation on bladder cancer: treatment of muscle-invasive bladder cancer. World J Urol 2019; 37:61-83. [DOI: 10.1007/s00345-018-2606-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/12/2018] [Indexed: 01/09/2023] Open
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Collins JW, Levy J, Stefanidis D, Gallagher A, Coleman M, Cecil T, Ericsson A, Mottrie A, Wiklund P, Ahmed K, Pratschke J, Casali G, Ghazi A, Gomez M, Hung A, Arnold A, Dunning J, Martino M, Vaz C, Friedman E, Baste JM, Bergamaschi R, Feins R, Earle D, Pusic M, Montgomery O, Pugh C, Satava RM. Utilising the Delphi Process to Develop a Proficiency-based Progression Train-the-trainer Course for Robotic Surgery Training. Eur Urol 2019; 75:775-785. [PMID: 30665812 DOI: 10.1016/j.eururo.2018.12.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 10/26/2018] [Accepted: 12/28/2018] [Indexed: 01/14/2023]
Abstract
CONTEXT As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. OBJECTIVE To provide guidance on an optimised "train-the-trainer" (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training. EVIDENCE ACQUISITION The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. 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 that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90. CONCLUSIONS Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation. PATIENT SUMMARY As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised "train-the trainer" curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts' knowledge of surgical training.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden; Orsi Academy, Melle, Belgium.
| | - Jeffrey Levy
- Institute for Surgical Excellence, Philadelphia, PA, USA
| | | | - Anthony Gallagher
- College of Medicine and Health, University College Cork, Ireland; Faculty of Life and Health Sciences, Ulster University, UK
| | | | - Tom Cecil
- Hampshire Hospitals NHS Foundation Trust, UK
| | - Anders Ericsson
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Alexandre Mottrie
- Orsi Academy, Melle, Belgium; Department of Urology, OLV, Aalst, Belgium
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Kamran Ahmed
- MRC Centre for Transplantation, King's College London, UK
| | | | | | - Ahmed Ghazi
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Andrew Hung
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Anne Arnold
- American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Joel Dunning
- James Cook University Hospital, Middlesbrough, UK
| | | | | | - Eric Friedman
- Aviation Safety Inspector, Federal Aviation Administration, Washington, DC, USA
| | - Jean-Marc Baste
- Department of Cardio-thoracic Surgery, Rouen University Hospital, Rouen, France
| | | | - Richard Feins
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - David Earle
- New England Hernia Center, Chelmsford, MA, USA
| | | | - Owen Montgomery
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Carla Pugh
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Hosseini A, Dey L, Laurin O, Adding C, Hoijer J, Ebbing J, Collins JW. Ureteric stricture rates and management after robot-assisted radical cystectomy: a single-centre observational study. Scand J Urol 2018; 52:244-248. [DOI: 10.1080/21681805.2018.1465462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Abolfazl Hosseini
- Department of Urology, Karolinska Institutet, Karolinskavagen, Stockholm, Sweden
| | - Linda Dey
- Department of Urology, Karolinska Institutet, Karolinskavagen, Stockholm, Sweden
| | - Oscar Laurin
- Department of Urology, Karolinska Institutet, Karolinskavagen, Stockholm, Sweden
| | - Cristofer Adding
- Department of Urology, Karolinska Institutet, Karolinskavagen, Stockholm, Sweden
| | - Jonas Hoijer
- Department of Biostatistics, Centre for Occupational and Environmental Medicine, Stockholm, Sweden
| | - Jan Ebbing
- Department of Urology, University of Basel Medical School, Basel, Switzerland
| | - Justin W. Collins
- Department of Urology, Karolinska Institutet, Karolinskavagen, Stockholm, Sweden
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Abstract
Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.
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Affiliation(s)
- Stavros Ioannis Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Nils Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
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Dumond JB, Collins JW, Cottrell ML, Trezza CR, Prince H, Sykes C, Torrice C, White N, Malone S, Wang R, Patterson KB, Sharpless NE, Forrest A. p16 INK4a , a Senescence Marker, Influences Tenofovir/Emtricitabine Metabolite Disposition in HIV-Infected Subjects. CPT Pharmacometrics Syst Pharmacol 2016; 6:120-127. [PMID: 28019088 PMCID: PMC5321809 DOI: 10.1002/psp4.12150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/07/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022]
Abstract
The goal of this study was to explore the relationships between tenofovir (TFV) and emtricitabine (FTC) disposition and markers of biologic aging, such as the frailty phenotype and p16INK4a gene expression. Chronologic age is often explored in population pharmacokinetic (PK) analyses, and can be uninformative in capturing the impact of aging on physiology, particularly in human immunodeficiency virus (HIV)‐infected patients. Ninety‐one HIV‐infected participants provided samples to quantify plasma concentrations of TFV/FTC, as well as peripheral blood mononuclear cell (PBMC) samples for intracellular metabolite concentrations; 12 participants provided 11 samples, and 79 participants provided 4 samples, over a dosing interval. Nonlinear mixed effects modeling of TFV/FTC and their metabolites suggests a relationship between TFV/FTC metabolite clearance (CL) from PBMCs and the expression of p16INK4a, a marker of cellular senescence. This novel approach to quantifying the influence of aging on PKs provides rationale for further work investigating the relationships between senescence and nucleoside phosphorylation and transport.
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Affiliation(s)
- J B Dumond
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J W Collins
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M L Cottrell
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C R Trezza
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hma Prince
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C Sykes
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C Torrice
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - N White
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - S Malone
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R Wang
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - K B Patterson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - N E Sharpless
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - A Forrest
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Collins JW, Hosseini A, Adding C, Nyberg T, Koupparis A, Rowe E, Perry M, Issa R, Schumacher MC, Wijburg C, Canda AE, Balbay M, Decaestecker K, Schwentner C, Stenzl A, Edeling S, Pokupić S, D'Hondt F, Mottrie A, Wiklund PN. Early Recurrence Patterns Following Totally Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section (ERUS) Scientific Working Group. Eur Urol 2016; 71:723-726. [PMID: 27816299 DOI: 10.1016/j.eururo.2016.10.030] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
Recurrence following radical cystectomy often occurs early, with >80% of recurrences occurring within the first 2 yr. Debate remains as to whether robot-assisted radical cystectomy (RARC) negatively impacts early recurrence patterns because of inadequate resection or pneumoperitoneum. We report early recurrence patterns among 717 patients who underwent RARC with intracorporeal urinary diversion at nine different institutions with a minimum follow-up of 12 mo. Clinical, pathologic, radiologic, and survival data at the latest follow-up were collected. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method, and Cox regression models were built to assess variables associated with recurrence. RFS at 3, 12, and 24 mo was 95.9%, 80.2%, and 74.6% respectively. Distant recurrences most frequently occurred in the bones, lungs, and liver, and pelvic lymph nodes were the commonest site of local recurrence. We identified five patients (0.7%) with peritoneal carcinomatosis and two patients (0.3%) with metastasis at the port site (wound site). We conclude that unusual recurrence patterns were not identified in this multi-institutional series and that recurrence patterns appear similar to those in open radical cystectomy series. PATIENT SUMMARY In this multi-institutional study, bladder cancer recurrences following robotic surgery are described. Early recurrence rates and locations appear to be similar to those for open radical cystectomy series.
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Affiliation(s)
| | | | | | | | | | | | | | - Rami Issa
- St. Georges Hospital London, London, UK
| | | | - Carl Wijburg
- Carl Wijburg, Rijnstate, Arnhem, The Netherlands
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Collins JW, Patel H, Adding C, Annerstedt M, Dasgupta P, Khan SM, Artibani W, Gaston R, Piechaud T, Catto JW, Koupparis A, Rowe E, Perry M, Issa R, McGrath J, Kelly J, Schumacher M, Wijburg C, Canda AE, Balbay MD, Decaestecker K, Schwentner C, Stenzl A, Edeling S, Pokupić S, Stockle M, Siemer S, Sanchez-Salas R, Cathelineau X, Weston R, Johnson M, D'Hondt F, Mottrie A, Hosseini A, Wiklund PN. Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View. Eur Urol 2016; 70:649-660. [PMID: 27234997 DOI: 10.1016/j.eururo.2016.05.020] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/12/2016] [Indexed: 12/17/2022]
Abstract
CONTEXT Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials. OBJECTIVE To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients. EVIDENCE ACQUISITION The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee. EVIDENCE SYNTHESIS Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation. CONCLUSIONS This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs. PATIENT SUMMARY There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.
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Affiliation(s)
- Justin W Collins
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Hiten Patel
- Department of Urology, University Hospital of Northern Norway, Tromsø, Norway
| | - Christofer Adding
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Walter Artibani
- Department of Urology, Verona University Hospital, Verona, Italy
| | | | | | - James W Catto
- Department of Urology, Sheffield University Hospital, Sheffield, UK
| | | | - Edward Rowe
- Department of Urology, Bristol Urological Institute, Bristol, UK
| | | | - Rami Issa
- Department of Urology, St Georges, London, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter Hospital, Exeter, UK
| | | | | | - Carl Wijburg
- Department of Urology, Rijnstate, Arnhem, Netherlands
| | | | - Meviana D Balbay
- Department of Urology, Memorial Sisli Hospital, Istanbul, Turkey
| | | | | | - Arnulf Stenzl
- Department of Urology, University of Tuebingen, Tubingen, Germany
| | | | - Sasa Pokupić
- Department of Urology, Da Vinci Zentrum, Hanover, Germany
| | - Michael Stockle
- Department of Urology, Universittatsklinikum des Saarlandes, Homburg, Germany
| | - Stefan Siemer
- Department of Urology, Universittatsklinikum des Saarlandes, Homburg, Germany
| | | | | | - Robin Weston
- Department of Urology, Royal Liverpool Hospital, Liverpool, UK
| | - Mark Johnson
- Department of Urology, Newcastle upon Tyne Hospitals, Newcastle, UK
| | | | | | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Peter N Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
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Collins JW, Adding C, Hosseini A, Nyberg T, Pini G, Dey L, Wiklund PN. Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service. Scand J Urol 2015; 50:39-46. [PMID: 26313582 DOI: 10.3109/21681805.2015.1076514] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service. MATERIALS AND METHODS Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection. RESULTS Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade. CONCLUSIONS Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.
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Affiliation(s)
- Justin W Collins
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Christofer Adding
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Abolfazl Hosseini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Tommy Nyberg
- b 2 Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet , Stockholm, Sweden
| | - Giovannalberto Pini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Linda Dey
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Peter N Wiklund
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
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Chan KG, Guru K, Wiklund P, Catto J, Yuh B, Novara G, Murphy DG, Al-Tartir T, Collins JW, Zhumkhawala A, Wilson TG. Robot-assisted radical cystectomy and urinary diversion: technical recommendations from the Pasadena Consensus Panel. Eur Urol 2015; 67:423-31. [PMID: 25595099 DOI: 10.1016/j.eururo.2014.12.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes. OBJECTIVE To review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS The Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3-4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received. SURGICAL PROCEDURE The consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Preoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented. RESULTS AND LIMITATIONS Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. CONCLUSIONS Refinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound. PATIENT SUMMARY We summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.
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Collins JW, Sooriakumaran P, Sanchez-Salas R, Ahonen R, Nyberg T, Wiklund NP, Hosseini A. Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience. Indian J Urol 2014; 30:307-13. [PMID: 25097318 PMCID: PMC4120219 DOI: 10.4103/0970-1591.134251] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Introduction: The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation. Materials and Methods: Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates. Results: The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women. Conclusions: Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - P Sooriakumaran
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden ; Department of Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - R Sanchez-Salas
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - R Ahonen
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - T Nyberg
- Department of Oncology and Pathology, Section of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - N P Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - A Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
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Affiliation(s)
- Justin W. Collins
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- St. Peter's Hospital; Chertsey
| | - Prasanna Sooriakumaran
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- Surgical Intervention Trials Unit; Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - N. Peter Wiklund
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
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Abstract
We performed a systematic literature review to assess the current status of a totally intracorporeal robot-assisted radical cystectomy (RARC) approach. The current 'gold standard' for radical cystectomy remains open radical cystectomy. RARC has lagged behind robot-assisted prostatectomy in terms of adoption and perceived patient benefit, but there are indications that this is now changing. There have been several recently published large series of RARC, both with extracorporeal and with intracorporeal urinary diversions. The present review focuses on the totally intracorporeal approach. Radical cystectomy is complex surgery with several important outcome measures, including oncological and functional outcomes, complication rates, patient recovery and cost implications. We aim to answer the question of whether there are advantages to a totally intracorporeal robotic approach or whether we are simply making an already complex procedure more challenging with an associated increase in complication rates. We review the current status of both oncological and functional outcomes of totally intracorporeal RARC compared with standard RARC with extraperitoneal urinary diversion and with open radical cystectomy, and assess the associated short- and long-term complication rates. We also review aspects in training and research that have affected the uptake of RARC. Additionally we evaluate how current technology is contributing to the future development of this surgical technique.
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Collins JW, Tyritzis S, Nyberg T, Schumacher MC, Laurin O, Adding C, Jonsson M, Khazaeli D, Steineck G, Wiklund P, Hosseini A. Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder - what is the effect of the learning curve on outcomes? BJU Int 2013; 113:100-7. [PMID: 24053710 DOI: 10.1111/bju.12347] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect of the learning curve on operative, postoperative, and pathological outcomes of the first 67 totally intracorporeal robot-assisted radical cystectomies (RARCs) with neobladders performed by two lead surgeons at Karolinska University Hospital. PATIENTS AND METHODS Between December 2003 and October 2012, 67 patients (61 men and six women) underwent RARC with orthotopic urinary diversion by two main surgeons. Data were collected prospectively on patient demographics, peri- and postoperative outcomes including operation times, conversion rates, blood loss, complication rates, pathological data and length of stay (LOS) for these 67 consecutive patients. The two surgeons operated on 47 and 20 patients, respectively. The patients were divided into sequential groups of 10 in each individual surgeon's series and assessed for effect of the learning curve. RESULTS Patient demographics and clinical characteristics were similar in both surgeons' groups. The overall total operation times trended down in both surgeons' series from a median time of 565 min in the first group of 10 cases, to a median of 345 min in the last group for surgeon A (P < 0.001) and 413 to 385 min for surgeon B (not statistically significant). Risk of conversion to open surgery also decreased with a 30% conversion rate in the first group to zero in latter groups (P < 0.01). Overall complications decreased as the learning curve progressed from 70% in the first group to 30% in the later groups (P < 0.05), although major complications were not statistically different when compared between the groups. Patient demographics did not change over time. The mean estimated blood loss was unchanged across groups with increasing experience. The pathological staging, mean total lymph node yield and number of positive margins were also unchanged across groups. There was a decrease in LOS from a mean of 19 days in the first group to a mean (range) of 9 (4-78) days in the later groups, although the median LOS was unchanged and therefore not statistically significant. CONCLUSIONS Totally intracorporeal RARC with intracorporeal neobladder is a complex procedure, but it can be performed safely, with a structured approach, at a high-volume established robotic surgery centre without compromising perioperative and pathological outcomes during the learning curve for surgeons. An experienced robotic team and mentor can impact the learning curve of a new surgeon in the same centre resulting in decreased operation times early in their personal series, reducing conversion rates and complication rates.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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Collins JW, Tyritzis S, Nyberg T, Schumacher M, Laurin O, Khazaeli D, Adding C, Jonsson MN, Hosseini A, Wiklund NP. Robot-assisted radical cystectomy: description of an evolved approach to radical cystectomy. Eur Urol 2013; 64:654-63. [PMID: 23769588 DOI: 10.1016/j.eururo.2013.05.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/05/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery. OBJECTIVE We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women. DESIGN, SETTING, AND PARTICIPANTS Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC. SURGICAL PROCEDURE We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis. RESULTS AND LIMITATIONS RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤ pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥ 3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥ 3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr. CONCLUSIONS Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.
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Abstract
BACKGROUND Historically, a reduced serum sodium concentration has been used to diagnose absorption of electrolyte-free irrigating fluid during transurethral resection of the prostate (TURP). In bipolar TURP, the irrigating solution contains electrolytes, thus invalidating the serum sodium method. In this study, we investigated whether glucose can be used to diagnose the absorption of irrigating fluid during TURP procedures. METHODS The serum glucose and sodium concentrations were measured in 250 patients undergoing monopolar TURP using either 1.5% glycine or 5% glucose for urinary bladder irrigation. The glucose kinetics was analyzed in 10 volunteers receiving a 30-min infusion of 20 mL/kg of acetated Ringer's solution with 1% glucose. These data were then used in computer simulations of different absorption patterns that were summarized in a nomogram for the relationship between the glucose level and administered fluid volume. RESULTS There was a statistically significant inverse linear relationship between the decrease in serum sodium and the increase in glucose levels after absorption of 5% glucose during TURP (r(2) = 0.80). The glucose concentration increased, from 4.6 (sd 0.4) to 8.3 (0.9) mmol/L, during the experimental infusions. Regardless of the absorption pattern, all simulations indicated that the uptake of 1 L of fluid containing 1% glucose corresponded to an increase in the glucose level of 3.7 (sd 1.6) mmol/L at the end of surgery, whereas 2 L yielded an increase of 6.9 (1.7) mmol/L. CONCLUSIONS In bipolar TURP, the addition of glucose to a concentration of 1% in the electrolyte-containing irrigation fluid can be used as a tracer of absorption that is comparable with measuring serum sodium after monopolar TURP.
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Affiliation(s)
- David Piros
- Department of Anesthesiology, Karolinska Institutet at Söder Hospital, S-118 83 Stockholm, Sweden.
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Abstract
OBJECTIVE To examine influences on neonatologists' decision-making regarding resuscitation of extremely premature infants. STUDY DESIGN A mailed survey of Illinois neonatologists evaluated influences on resuscitation. Personal and parentally opposed (that is, acting against parental wishes) gray zones of resuscitation were defined, with the lower limit (LL) the gestational age at or below which resuscitation would be consistently withheld and the upper limit (UL) above which resuscitation was mandatory. RESULT Among the 85 respondents, LL and UL of the personal and parentally opposed gray zones were median 22 and 25 weeks, respectively. Neonatologists with an UL personal gray zone <25 completed weeks were significantly more fearful of litigation, more likely to have received didactic/continuing medical education teaching, and less likely to always consider parents' opinions in resuscitation decisions. Neonatologists with an UL parentally opposed gray zone <25 completed weeks were more fearful of litigation. CONCLUSION Neonatologists perceive a 'gray zone' of resuscitative practices and should understand that external influences may affect their delivery room resuscitation practices.
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Affiliation(s)
- A R Weiss
- Pediatrics, Children's Memorial Hospital, Chicago, IL, USA.
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Collins JW, Macdermott S, Bradbrook RA, Drake B, Keeley FX, Timoney AG. The effect of the choice of irrigation fluid on cardiac stress during transurethral resection of the prostate: a comparison between 1.5% glycine and 5% glucose. J Urol 2007; 177:1369-73. [PMID: 17382734 DOI: 10.1016/j.juro.2006.11.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE Variable amounts of irrigation fluid are absorbed during transurethral prostate resection. Previous studies suggest that cardiac stress occurs as a result of transurethral prostate resection, possibly due to glycine absorption. We performed a prospective, blinded, randomized trial comparing 1.5% glycine with 5% glucose irrigating solution. We assessed whether glycine or glucose irrigation for transurethral prostate resection is associated with cardiotoxicity, as measured by troponin I and echocardiogram changes. MATERIALS AND METHODS Between December 2001 and March 2003, 250 patients were recruited. Changes in immediate postoperative vs preoperative echocardiogram and serum cardiac troponin I indicated perioperative myocardial stress. Intraoperative irrigating fluid absorption was measured with 1% ethanol as a marker. Operative details recorded were anesthesia type, resection time, resected tissue weight and temperature change. Blood loss was measured with transfusions considered. Postoperatively blood assessments included serum glycine assay. RESULTS Five patients (4%) in the glycine group and 3 (2%) in the glucose group had significantly increased troponin I after surgery. Of these men 1 per group had myocardial infarction and the remainder had transient ischemia. Logistic regression was used to identify factors associated with an unfavorable outcome, which was recorded as a significant increase in troponin I or ischemic changes on echocardiography. Increasing patient age and blood loss were associated with an unfavorable outcome (OR 1.84 and 1.24, respectively). We noted no significant differences in the 1.5% glycine and 5% glucose groups with regard to troponin I/echocardiogram. However, when the glycine assay was compared with adverse outcomes, an increased glycine assay was found to be associated with echocardiogram changes (p = 0.001) and with increased troponin I levels (relative risk 10.71). CONCLUSIONS Transurethral prostate resection has an effect on the myocardium perioperatively. Glycine absorption causes echocardiogram changes and it is associated with increased troponin I. Increasing patient age and blood loss are associated with myocardial insult. The risk of increased blood loss was accumulative with each unit lost. Unrecognized blood loss or glycine absorption may explain the increase in morbidity and mortality previously reported in patients who undergo transurethral prostate resection.
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Martland GT, Toner PG, Collins JW, Kinder RB, Shepherd NA. Ureteric obstruction due to prostatic implantation in the sigmoid colon: a unique late complication of ureterosigmoidostomy. Histopathology 2007; 50:800-2. [PMID: 17355276 DOI: 10.1111/j.1365-2559.2007.02644.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barrass BJR, Thurairaja R, Collins JW, Gillatt D, Persad RA. Optimal Nutrition Should Improve the Outcome and Costs of Radical Cystectomy. Urol Int 2006; 77:139-42. [PMID: 16888419 DOI: 10.1159/000093908] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 02/27/2006] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Nutritional support has been demonstrated to improve recovery from radical cystectomy, but is expensive and when used inappropriately may actually increase the costs and morbidity of surgery. We sought to establish national patterns of practice with regard to feeding following cystectomy in the UK. AIMS AND METHODS Following consultation with the specialist nutrition team, a questionnaire was designed to investigate the feeding strategy after cystectomy and dispatched by post to all UK urologists. RESULTS The majority (60%) of respondents employed a traditional strategy of resting the bowel and feeding orally after bowel recovery. A minority used either early total parenteral nutrition (TPN; 18.5%) or enteral nutrition (6.5%), but a larger proportion (29%) felt enteral nutrition was the 'optimal' feeding regime. Only 30% used guidelines and 52% felt trials would help to establish a nutrition strategy following cystectomy. CONCLUSION There is little evidence that TPN improves the outcome of cystectomy and it may actually increase morbidity and costs, whereas enteral nutrition may improve recovery. Despite this evidence TPN is widely used by urologists whereas enteral nutrition is used infrequently. Implementation of an evidence-based feeding regime after cystectomy is likely to reduce the morbidity and financial costs of cystectomy.
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Collins JW, Macdermott S, Bradbrook RA, Keeley FX, Timoney AG. Is using ethanol-glycine irrigating fluid monitoring and 'good surgical practice' enough to prevent harmful absorption during transurethral resection of the prostate? BJU Int 2006; 97:1247-51. [PMID: 16686720 DOI: 10.1111/j.1464-410x.2006.06208.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [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: 11/29/2022]
Abstract
OBJECTIVE To evaluate the utility of using a tracer of 1% ethanol in 1.5% glycine for the early detection of irrigation fluid absorption during transurethral resection of the prostate (TURP). PATIENTS AND METHODS In all, 126 men undergoing TURP were irrigated with a solution of 1% ethanol and 1.5% glycine; their expired air was tested for ethanol every 20 min, and again at the end of the procedure. Maximum absorption by the breath-ethanol reading was compared with the serum concentration of absorbed glycine (analysed by anion-exchange chromatography). RESULTS Complete data on 120 men were assessed; 75% of the men absorbed irrigation fluid, with glycine levels above the normal range. The sodium levels tended to decrease with increasing glycine levels (Spearman's rank correlation coefficient, - 0.57; 120 men) and five men (4%) developed clinical features of the TUR syndrome. There was a weak correlation between breath-ethanol levels and serum glycine levels (Spearman's rank correlation coefficient, 0.54). The experience of the surgeon, the weight of the resected chips, and the operative duration were not significantly predictive of irrigation fluid absorption. CONCLUSIONS A rising breath-ethanol level indicates irrigation fluid absorption. However, irrigating fluid absorption is unpredictable, supporting the case for alternative, potentially safer irrigants.
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Affiliation(s)
- Justin W Collins
- Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK.
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Kogan MD, Singh GK, Lu MC, Collins JW, Alexander GR, Yu SM, Newacheck PW. Racial and Ethnic Disparities in Child Health in the Us: Does the Gap Widen with Increasing Age. Am J Epidemiol 2006. [DOI: 10.1093/aje/163.suppl_11.s13-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Collins JW, Macdermott S, Bradbrook RA, Keeley FX, Timoney AG. A comparison of the effect of 1.5% glycine and 5% glucose irrigants on plasma serum physiology and the incidence of transurethral resection syndrome during prostate resection. BJU Int 2005; 96:368-72. [PMID: 16042732 DOI: 10.1111/j.1464-410x.2005.05633.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [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: 11/29/2022]
Abstract
OBJECTIVE To examine changes in the pathophysiology and frequency of the transurethral resection (TUR) syndrome with two irrigation fluids, as variable amounts of irrigation fluid are absorbed during TUR of the prostate (TURP), and although polar solutes are required to prevent an effect on diathermy, the solutes may have effects when absorbed. PATIENTS AND METHODS Between December 2001 and March 2003, 250 patients were included in a prospective randomized trial comparing glycine 1.5% with 5% glucose irrigation fluids. We measured blood loss, fluid absorption, temperature change, biochemistry including a glycine assay, and peri-operative symptoms. Blood samples were taken immediately before and immediately, 5 and 24 h after TURP. Irrigating fluid absorption during TURP was measured with 1% ethanol as a marker and breath ethanol measurements. Operative details were recorded, including the type of anaesthesia (with or with no sedation), resection time and weight of resected tissue. Peri-operative symptoms were documented prospectively. TUR syndrome was defined as a serum sodium level of < or = 125 mmol/L with two or more associated symptoms or signs of TUR syndrome. RESULTS Five (2%) patients had TUR syndrome; all five were irrigated with glycine, although this difference was not statistically significant (P = 0.06). Of the five men, three had hypotension, four were tired, one was nauseous, two had parasthesia, two had 'uneasiness', one had blurred vision and two were confused; none had chest pain. There was a large variation between the groups in the level of glycine assayed immediately after TURP; a high glycine level was associated with the TUR syndrome (P = 0.01). There was no difference between the groups in levels of sodium, potassium, urea, creatinine, osmolality, calcium, haematocrit, albumin serum levels or peri-operative blood loss (defined as a change from before to after TURP in haemoglobin level, accounting for transfusions). CONCLUSIONS An increase in serum glycine was associated with TUR syndrome; there were large variations in the amounts of glycine absorbed, reaching levels many times the upper limit of normal. In other studies, glycine was reportedly toxic, and that the levels recorded were many times the upper limit of normal may have both immediate and long-term effects.
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David RJ, Collins JW, Prachand N, Dickerman M. 593: Neighborhood Poverty, Maternal Age and Infant Birth Weight among African-Americans in Chicago: A Maternal Life-Course Analysis. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R J David
- University of Illinois at Chicago, Chicago, IL 60612
| | - J W Collins
- University of Illinois at Chicago, Chicago, IL 60612
| | - N Prachand
- University of Illinois at Chicago, Chicago, IL 60612
| | - M Dickerman
- University of Illinois at Chicago, Chicago, IL 60612
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Abstract
OBJECTIVE To conduct an intervention trial of a "best practices" musculoskeletal injury prevention program designed to safely lift physically dependent nursing home residents. DESIGN A pre-post intervention trial and cost benefit analysis at six nursing homes from January 1995 through December 2000. The intervention was established in January 1998 and injury rates, injury related costs and benefits, and severity are compared for 36 months pre-intervention and 36 months post-intervention. PARTICIPANTS A dynamic cohort of all nursing staff (n = 1728) in six nursing homes during a six year study period. INTERVENTION "Best practices" musculoskeletal injury prevention program consisting of mechanical lifts and repositioning aids, a zero lift policy, and employee training on lift usage. MAIN OUTCOME MEASURES Injury incidence rates, workers' compensation costs, lost work day injury rates, restricted work day rates, and resident assaults on caregivers, annually from January 1995 through December 2000. RESULTS There was a significant reduction in resident handling injury incidence, workers' compensation costs, and lost workday injuries after the intervention. Adjusted rate ratios were 0.39 (95% confidence interval (CI) 0.29 to 0.55) for workers' compensation claims, 0.54 (95% CI 0.40 to 0.73) for Occupational Safety and Health Administration (OSHA) 200 logs, and 0.65 (95% CI 0.50 to 0.86) for first reports of employee injury. The initial investment of $158 556 for lifting equipment and worker training was recovered in less than three years based on post-intervention savings of $55 000 annually in workers' compensation costs. The rate of post-intervention assaults on caregivers during resident transfers was down 72%, 50%, and 30% based on workers' compensation, OSHA, and first reports of injury data, respectively. CONCLUSIONS The "best practices" prevention program significantly reduced injuries for full time and part time nurses in all age groups, all lengths of experience in all study sites.
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Affiliation(s)
- J W Collins
- Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Safety Research, Morgantown, West Virginia 26505, USA.
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Abstract
OBJECTIVE To assess the costs of flexible ureterorenoscopy. MATERIALS AND METHODS Data were collected prospectively for 100 cases using a new flexible ureteroscope (DUR8, Circon ACMI, Stamford, USA), including the indications for flexible ureterorenoscopy, use of laser probes, disposable instrumentation, and the cost and timing of ureteroscope repair. RESULTS Of the 100 procedures 68 were for stone disease, 21 for known or suspected transitional cell carcinoma (TCC), six were diagnostic only and five were for pelvi-ureteric junction obstruction. The ureteroscope was repaired after the 29th and 88th cases. The ability of the ureteroscope to deflect was maintained throughout. At the time of purchase the ureteroscope was listed at pound 15 000 and each repair/exchange currently costs pound 4200, thus the total expenditure on the ureteroscope was pound 23 400. Total expenditure on ancillary equipment was pound 28 727, of which pound 22 927 was on disposables and pound 5800 on 10 laser probes. CONCLUSION In this series the costs of the ancillary equipment exceeded the purchase and maintenance of the ureteroscope, and we expect this trend to continue in the long term. The advent of more durable ureteroscopes may ultimately reduce the frequency of costly repairs. The cost of disposables should be considered in planning the budget.
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Affiliation(s)
- J W Collins
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Abstract
PURPOSE OF REVIEW The tolerability of extracorporeal shock wave lithotripsy has led to an increase in the treatment of small, asymptomatic renal calculi, yet we know very little about the natural history of such stones or about the long-term effects of this treatment. The efficacy of extracorporeal shock wave lithotripsy has been called into question, especially for lower pole stones. Several recent clinical studies have addressed these issues as well as the natural history of residual stone fragments following extracorporeal shock wave lithotripsy. RECENT FINDINGS Preliminary results of a randomized controlled trial show that prophylactic extracorporeal shock wave lithotripsy for small, asymptomatic renal calyceal stones does not appear to offer any advantage to patients in terms of stone-free rates, quality of life, renal function, symptoms, or hospital admissions, nor does it appear to affect blood pressure. However, a policy of observation is associated with a greater risk of requiring more invasive procedures. Reports regarding the incidence of hypertension following extracorporeal shock wave lithotripsy are conflicting, as are reports regarding anatomical factors affecting the clearance of lower pole stones. Percutaneous removal appears to be superior to extracorporeal shock wave lithotripsy for the treatment of lower pole stones. SUMMARY Extracorporeal shock wave lithotripsy does not appear to improve the clinical outcome of patients with small, asymptomatic calyceal calculi. Longer follow-up is required to assess the validity of the preliminary findings and may shed light on the long-term effects of this technique on blood pressure and stone growth/recurrence. Anatomical factors affecting the clearance of lower pole stones require standardization and further study. Further in-vitro studies are required to study the kinetics of stone growth and the effects of urine composition, flow rate, and macromolecular components.
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Collins JW, Papacek E, Schulte NF, Drolet A. Differing postneonatal mortality rates of Mexican-American infants with United-States-born and Mexico-born mothers in Chicago. Ethn Dis 2002; 11:606-13. [PMID: 11763285] [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: 02/23/2023] Open
Abstract
OBJECTIVES This study sought to determine the relationship between maternal nativity and the postneonatal mortality rate of urban Mexican-American infants. DESIGN This is a population-based study. METHODS Stratified and logistic regression analyses were performed on a data set of 1992-1995 computerized birth-death records of all Mexican-American infants born to Chicago residents with appended 1990 United States Census income and 1995 Chicago Department of Public Health data. RESULTS In Chicago, Mexican-American infants (N = 10,599) of US-born mothers had a postneonatal mortality rate of 3.2/1,000 compared to 2.1/1,000 for infants (40,813) of Mexico-born mothers; relative risk (95% confidence interval) equaled 1.5 (1.0-2.3). The adjusted odds ratio of postneonatal mortality was 1.4 (1.1-1.9) for Mexican-American infants of US-born mothers. The mortality rate due to preventable causes (sudden infant death syndrome, homicides, non-intentional injuries, and infections) for Mexican-American infants of US-born mothers was twice that of infants of Mexico-born mothers; relative risk (95% confidence interval) equaled 2.2 (1.3-3.8); this nativity differential persisted in non-impoverished communities. CONCLUSION The postneonatal mortality rate of urban Mexican-American infants with US-born mothers exceeds that of infants with Mexico-born mothers. This nativity disparity is attributable to preventable causes.
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Affiliation(s)
- J W Collins
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois 60611, USA.
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