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Worldwide Live Robotic Surgery 24-Hour Event 2015

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For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

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In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards  held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

KI studio

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

 

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

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Article of the Week: A Novel Interface for the Telementoring of Robotic Surgery

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

A Novel Interface for the Telementoring of Robotic Surgery

Daniel H. Shin, Leonard Dalag, Raed A. Azhar, Michael Santomauro, Raj SatkunasivamCharles Metcalfe, Matthew Dunn, Andre Berger, Hooman Djaladat, Mike Nguyen, Mihir M. Desai, Monish Aron, Inderbir S. Gill and Andrew J. Hung

 

University of Southern California Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

 

OBJECTIVE

To prospectively evaluate the feasibility and safety of a novel, second-generation telementoring interface (Connect; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot.

MATERIALS AND METHODS

Robotic surgery trainees were mentored during portions of robot-assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in-room mentoring or remote mentoring using Connect. While viewing two-dimensional, real-time video of the surgical field, remote mentors delivered verbal and visual counsel, using two-way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi-factorial Likert-based survey. The Mann–Whitney and t-tests were used to determine statistical differences.

RESULTS

We enrolled 55 mentored surgical cases (29 in-room, 26 remote). Perioperative variables of operative time and blood loss were similar between in-room and remote mentored cases. Robotic skills assessment showed no significant difference (P > 0.05). Mentors preferred remote over in-room telestration (P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer (P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in-room mentored case; no intraoperative injuries were reported during remote sessions.

CONCLUSIONS

In a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology.

Editorial: Robotic Networks – delivering empowerment through integration

Intuitive’s latest version of Connect for the Da Vinci Si model allows surgeons to communicate remotely via a laptop or personal computer, direct to the surgeon’s console. It has one-way video from the console to the remote mentor and bi-directional audio and telestration (drawing), replicating the successful strategy employed in many industries to develop networks, to share expertise and knowledge. The study published by Shin et al. [1] in this issue of BJUI is a technical proof of concept study and is an important first step to realising the potential of robotic networks. The study describes the application of Connect on a local area network (LAN), which is a network that interconnects computers in a limited geographical area such as a hospital, whereas a wide access network (WAN) is a computer network spanning regions, countries or even the world. The next logical advance for Connect is to study connections between different institutions, states and even internationally between countries. Connections between two UK NHS trusts have been successfully trialled, with plans for formal connections between hospitals in Sweden and the UK underway.

Minimally invasive surgery using video technologies has greatly improved opportunities for surgical learning. Telementoring has existed in various forms for >20 years and has been shown to have a positive impact on outcomes [2]. In a study by Påhlsson et al. [3], telementoring delivered by a high-volume surgeon at a tertiary hospital to a low-volume rural hospital, increased their cannulation rate in endoscopic retrograde cholangiopancreatography from 85% (one of the lowest in the country) to 99% (highest success rate).

While robotic surgery continues to evolve quickly, it remains an expensive service with required investment in surgeons’ learning curves in both established and new techniques. Maximum value is realised once the team is experienced, efficient and outcomes are optimised. Even between tertiary centres of excellence there are different skill sets. Successful collaborative approaches to training have potential to steepen learning curves. With Connect robotic trainers will have the additional option to disseminate their knowledge from a distance, without the need for mentor or mentee to travel.

Current healthcare WANs between hospitals can enable secure, quality assured connections over national and international networks. Connect will have a role in LANs [1]; however, studying telementoring across larger networks will probably define its beneficial effects on the learning curve. Connections between centres with the largest difference in skill sets are likely to show the greatest impacts.

Robotic networks are likely to exist in various forms and telementoring could be complemented by supplementary services delivered over both local and wide access networks. Future potential services over a LAN include real-time multi-disciplinary teams with direct communication from the console to the radiologists and histopathologists.

Simulators have been used in industries outside healthcare, such as the aviation industry, to measure both proficiency and technical skill learning. Although robotic surgical simulation has not yet reached a stage where it replicates all aspects of robotic surgical procedures, it currently has potential to accelerate trainees along their learning curve outside the operating room and thus contribute to patient safety. Simulators greatest future value may be aligned with the data and feedback that robotic networks will provide, replicating the roles of airport control centres and flight simulators. With better understanding of surgical learning curves and the ability to score and differentiate between performance levels [4], data collected via networks may also have a future role in regulation of surgery (Fig. 1).

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Figure 1. Potential effect of robotic networks on identifying suboptimal technique and improving patient outcomes. (*Connect and Simulation diagrams by Intuitive Surgical).

International robotic networks will help achieve balance between the continual cycle of optimisation and standardisation of robotic surgical techniques. Standardised live surgery broadcast from home institutions [5] could support and promote both telementoring and the benefits of standardised surgical techniques [5, 6]. Standardisation is critical to developing cohesive networks with better understanding between mentors and mentees. It also aids identification of the ‘hazard’ steps in complex multistep procedures, enabling strategies to avoid the associated complications [6].

Sharing of expertise requires shared goals. In highly competitive healthcare systems where hospitals compete in attracting patients, there is inherent resistance to sharing. Connect enables interaction between mentor and mentee and once hard endpoints are identified and the beneficial effects of sharing are studied, new thinking in robotic surgery is likely. If benefits to surgical outcomes and improved safety using Connect are confirmed, both legal and reimbursement issues will probably be resolved.

In conclusion, change is driven on varying scales from local discussion, to national and international opinion and debate. While Connect will undoubtedly enhance communication between surgeons, it is the development of WANs, connecting the centres with the biggest differences in skill sets, which may deliver the greatest improvements. Collaboration via robotic networks has the potential to not only enable but to drive advancement in multiple areas of robotic surgery through the sharing of knowledge, innovations and expertise, resulting in continuous incremental improvement.

Justin Collins, Consultant Urologists, Olof AkreConsultant Urologists, Benjamin Challacombe*, Consultant Urologists, Omer Karim, Consultant Urologists and Peter Wiklund, Professor
Department of Urology, Karolinska University HospitalStockholm, Sweden, *Department of Surgery and Cancer, Kings College, Guys Hospital, London, and Department of Urology, Wexham Park Hospital, Slough, UK

 

References

 

1 Shin DH, Dalag L, Azhar Raed A et al. A novel interface for the telementoring of robotic surgery. BJU Int 2014; [Epub ahead of print]. DOI: 10.1111/bju.12985.

 

2 Challacombe B, Kandaswamy R, Dasgupta P, Mamode N. Telementoring facilitates independent hand-assisted laparoscopic living donor nephrectomy. Transplant Proc 2005;37:6136. 

 

 

4 Bonrath EM, Zevin B, Dedy NJ, Grantcharov TP. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg 2013;100:10808.

 

5 Collins JW, Akre O, Wiklund PN. Re: Walter Artibani, Vincenzo Ficarra, Ben J. Challacombe et al. EAU Policy on Live Surgery Events. Eur Urol 2014; 66: 8797. Eur Urol 2014; 66: e1212.

 

6 Collins JW, Tyritzis S, Nyberg T et al. Robot-assisted radical cystectomy – description of an evolved approach to radical cystectomy. Eur Urol 2013;64:65463.

 

Here comes the sun

BJUI-on-the-beach

Sun, sea, sand and stones: BJUI on the beach.

Welcome to this month’s BJUI and whether you are relaxing on a sun-drenched beach or villa somewhere having a hard-earned break, or back at your hospital covering for everyone else having their time off, we hope you will enjoy another fantastic issue. After an action packed BAUS meeting with important trial results, innovation, social media and the BJUI fully to the fore, this is a great moment to update yourself on what is hot in urology. This is probably the time of year when most urologists have a little extra time to take the BJUI out of its cover or open up the iPad and dig a little deeper into the articles, and we do not think you will be disappointed with this issue, which certainly has something for everyone.

In the ‘Article of the Month’, we feature an important paper from Egypt [1] examining factors associated with effective delayed primary repair of pelvic fractures that are associated with a urethral injury. Do be careful whilst you are travelling around the world, as most of the injuries in this paper were due to road traffic accidents. They reported 76/86 successful outcomes over a 7-year period. When a range of preoperative variables was assessed, four had particular significance for successful treatment outcomes. The paper really highlights that in the current urological world of robotics, laparoscopy and endourology, in some conditions traditional open surgery with delicate and precise tissue handling and real attention to surgical detail are the key components of a successful outcome.

Whilst you are eating and drinking more than usual over the summer, we have some food for thought on surgery and metabolic syndrome with one of our ‘Articles of the Week’. This paper contains an important message for all those performing bladder outflow surgery. This paper by Gacci et al. [2] from an international group of consecutive patients clearly shows that men with a waist circumference of >102 cm had a far higher risk of persistent symptoms after TURP or open prostatectomy. This was particularly true for storage symptoms in this group of men and should influence the consenting practice of all urologists carrying out this common surgery.

Make sure you are staying well hydrated on your beach this August, as the summer months often lead to increased numbers of patients presenting to emergency departments with acute ureteric colic, so it seems timely to focus on this area. To this end I would like to highlight one of our important ‘Guideline of Guidelines’ series featuring kidney stones [3] to add to the earlier ones on prostate cancer screening [4]and prostate cancer imaging [5]. This series serve to assimilate all of the major national and international guidelines into one easily digestible format with specific reference to the strength of evidence for each recommendation. Specifically, we look at the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. Quite how the recent surprising results of the SUSPEND (Spontaneous Urinary Stone Passage ENabled by Drugs) trial will impact on the use of medical expulsive therapy remains to be seen [6].

So whether you are sitting watching the sunset with a drink in your hand or quietly working in your home at night, please dig a little deeper into this month’s BJUI on paper, online or on tablet. It will not disappoint and might just change your future practice.

 

References

 

 

3 Ziemba JB, Matlaga BR. Guideline of guidelines: kidney stones. BJU Int 2015; 116: 1849

 

4 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 3235

 

5 Wollin DA, Makarov DV. Guideline of guidelines: prostate cancer imaging. BJU Int 2015; [Epub ahead of print]. DOI: 10.1111/bju.13104

 

 

Ben Challacombe
Associate Editor, BJUI 

 

Article of the Week: Robotic Surgery – Development Of A Standardised Training Curriculum

Every Week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development Of A Standardised Training Curriculum For Robotic Surgery: A Consensus Statement From An International Multidisciplinary Group Of Experts

Kamran Ahmed, Reenam Khan, Alexandre Mottrie1, Catherine Lovegrove, Ronny Abaza2, Rajesh Ahlawat3, Thomas Ahlering4, Goran Ahlgren5, Walter Artibani6, Eric Barret7, Xavier Cathelineau7, Ben Challacombe, Patrick Coloby8, Muhammad S. KhanJacques Hubert9, Maurice Stephan Michel10, Francesco Montorsi11, Declan Murphy12Joan Palou13, Vipul Patel14, Pierre-Thierry Piechaud15, Hendrik Van Poppel16, PascalRischmann17, Rafael Sanchez-Salas7, Stefan Siemer18, Michael Stoeckle18, Jens-Uwe Stolzenburg19, Jean-Etienne Terrier20, Joachim W. Thuroff21, Christophe Vaessen22, Henk G. Van Der Poel23, Ben Van Cleynenbreugel16, Alessandro Volpe 1,24, Christian Wagner25Peter Wiklund26, Timothy Wilson27, Manfred Wirth28, Jorn Witt26 and Prokar Dasgupta

 

Department of Urology, Medical Research Council (MRC) Centre for Transplantation, Kings College London, GuyHospital, London, UK, 1Department of Urology, OLV Vattikuti Robotic Surgery Institute, OLV Hospital, Aalst, Belgium, 2Department of Urology, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital Richard J Solove Research Institute, Columbus, OH, USA, 3Medanta The Medicity, Gurgaon, Haryana, India, 4Department of Urology, University of California, Irvine, Orange, CA, USA, 5Department of Urology, Lund University Hospital, Lund, Sweden, 6Urology Clinic, A.O.U.I. Verona, Verona, Italy, 7Department of Urology, Institut Mutualiste Montsouris, Paris, France, 8Service dUrologie, Centre Hospitalier Rene-Dubos, Cergy-Pontoise, France, 9Service dUrologie, CHRU Nancy, Vandoeeuvre-les-Nancy, France, 10University Hospital, Mannheim, Germany, 11Department of Urology, San Raffaele Scientic Institute, Milan, Italy, 12Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Vic., Australia, 13Department of Urology, Fundacio Puigvert, Universitat Autonoma de Barcelona, Barcelona, Spain, 14Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA, 15Clinique Saint-Augustin, Bordeaux, France, 16Department of Urology, University Hospital, KU Leuven, Leuven, Belgium, 17Service de Chirurgie Urologique, CHU Purpan, Toulouse, France, 18Klinik fur Urologie und Kinderurologie, Universitatsklinikum des Saarlandes, Homburg/Saar, Germany, 19Department of Urology, University of Leipzig, Leipzig, Germany, 20Department of Urology, Foch Hospital, Suresnes, France, 21Department of Urology, Ulm University Medical Center, Ulm, Germany, 22Service D’Urologie et de Transplantation Réno-Pancréatique, Hôpital Pitié-Salpêtrière, Paris, France, 23Department Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands, 24University of Eastern Piedmont, Novara, Italy, 25St. Antonius-Hospital Gronau, Gronau, Germany, 26Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden, 27Division of Urology, City of Hope, Duarte, CA, USA, and 28Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany

 

OBJECTIVES

To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented.

MATERIALS AND METHODS

An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points.

RESULTS

In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions.

CONCLUSION

This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room.

Editorial: Towards a Standardized Training Curriculum For Robotic Surgery

The work of the authors [1] towards robotic training and credentialing is much needed and should be applauded as increased scrutiny is being placed on complications associated with robotic surgery [2]. The authors held three separate meetings in 2012 and 2013 in which they identified themes, developed a training curriculum, and assessed expert agreement with their proposed curriculum. The authors’ [1]quantitative survey of 24 experts revealed that all ‘agreed’ or ‘agreed strongly’ with the proposed curriculum. The curriculum includes three areas, cognitive, psychomotor, and teamwork/communication skills, which we feel are vital for good outcomes [3]. As was noted, there are available ‘E-learning’ tools online from organisations such as the AUA and from Intuitive Surgical, and these can be further expanded and validated [4, 5]. The AUA also has recommendations for credentialing requirements that are available online.

We agree with the authors [1] that simulation should include inanimate models, which provide a good cost to benefit ratio. There are increasing numbers of inanimate models for the simulation of procedures, e.g. partial nephrectomy and pyeloplasty. One limitation of inanimate training is that the entire robotic surgical system is used and it may only be free for training on nights and weekends when the robotic systems are not being used clinically. Virtual reality simulators offer a more convenient way to become familiar with the robotic environment, but at a cost of ≈$100 000 (American dollars). Virtual reality simulation is predominantly used to develop skills for a junior trainee or a novice surgeon. However, procedure-specific and augmented-reality simulation is being developed and will greatly enhance robotic training.

The authors [1] should be applauded for offering a specific curriculum consisting of online training, an 8-day ‘discovery’ course for simulation and observation, and a 6-month fellowship for step-wise progression to ‘live’ surgical console time. As the authors note, credentialing should be based on competency and not on the number of cases logged or the duration of training alone. The duration of the fellowship should be based on the learning objectives and research/academic requirements.

In the USA, robotic surgical training is included during residency in urology and a fellowship may not be required if a graduating resident is proficient according to the programme directors’ assessment. For surgeons who have not been trained during residency, proctoring by an experienced surgeon is recommended by the AUA [5], after completing a structured robotic surgical curriculum as described in this article [1]. However, a validated curriculum and benchmarks for competency have not been established. The Fundamentals of Robotic Surgery (FRS) curriculum will be validated during the next year for a multidisciplinary curriculum with skills testing [6].

We also agree with the authors [1] that non-technical skills such as trouble-shooting, teamwork, leadership, and communication are critically important for preventing adverse events. Many if not most complications occur due to failures in patient selection, trocar positioning, and bedside assisting. Also, many complications can be traced to ‘system’ problems rather than console performance. Robotic surgery requires a proficient team to ensure good outcomes.

Currently, there are no uniform credentialing requirements to practice robotic surgery in the USA or many other countries. A validated robotic training curriculum with competency-based assessments is essential and can be integrated into residency programmes where robotic technology is readily available. Where robotic surgical volume is inadequate, fellowship programmes can provide the needed training. A validated competency-based approach offers the hope of better patient outcomes and the continued acceptance of new technologies such as robotic surgery.

Clinton D. Bahler and Chandru P. Sundaram
Department of Urology, Indiana University, Indianapolis, IN, USA

 

References

 

 

2 Alemzadeh H, Iyer RK, Raman J. Safety Implications of Robotic Surgery: Analysis of Recalls and Adverse Event Reports of da Vinci Surgical Systems. The Society of Thoracic Surgeons Annual Meeting2014; Orlando, Florida. Available at: https://www.sts.org/sites/default/les/documents/pdf/annmtg/2014AM/50AM_MonJan27.pdf. Accessed February 2015.

 

3 Bahler CD, Sundaram CP. Training in Robotic surgery: simulatorssurgery, and credentialing. Urol Clin North Am 2014; 41: 5819.

 

4 The American Urological Association. E-Learning: Urologic Robotic Surgery Course. The American Urological Association Education and Research, Inc, 2012. Available at: https://www.auanet.org/education/modules/robotic-surgery/. Accessed April 2014.

 

5 The American Urological Association. Standard Operating Practices (SOPS) for Urologic Robotic Surgery. The American Urological Association, 2013. Available at: https://www.auanet.org/common/pdf/about/SOP-Urologic-Robotic-Surgery.pdf. Accessed April 2014.

 

 

 

Article of the Week: An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison between robot-assisted, laparoscopic and open approaches

Oussama Elhage*, Ben Challacombe*, Adam Shortland‡ and Prokar Dasgupta*
§*The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, Medical Research Council (MRC) Centre for Transplantation, King’s College London, One Small Step Laboratory, and §MRC Centre for Transplantation & National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre, King’s College London, King’s Health Partners, Guy’s Hospital, London, UK

 

OBJECTIVES

To evaluate, in a simulated suturing task, individual surgeons’ performance using three surgical approaches: open, laparoscopic and robot-assisted.

SUBJECTS AND METHODS

Six urological surgeons made an in vitro simulated vesico-urethral anastomosis. All surgeons performed the simulated suturing task using all three surgical approaches (open, laparoscopic and robot-assisted). The time taken to perform each task was recorded. Participants were evaluated for perceived discomfort using the self-reporting Borg scale. Errors made by surgeons were quantified by studying the video recording of the tasks. Anastomosis quality was quantified using scores for knot security, symmetry of suture, position of suture and apposition of anastomosis.

RESULTS

The time taken to complete the task by the laparoscopic approach was on average 221 s, compared with 55 s for the open approach and 116 s for the robot-assisted approach (anova, P < 0.005). The number of errors and the level of self-reported discomfort were highest for the laparoscopic approach (anova, P < 0.005). Limitations of the present study include the small sample size and variation in prior surgical experience of the participants.

CONCLUSIONS

In an in vitro model of anastomosis surgery, robot-assisted surgery combines the accuracy of open surgery while causing lesser surgeon discomfort than laparoscopy and maintaining minimal access.

Editorial: Conventional laparoscopic surgery – more pain, no gain!

Advances in surgical technology have revolutionized the way surgery is performed today. Conventional laparoscopic surgery dominated the surgical paradigm for several decades, until robot-assisted surgery created the next giant leap. In the pressent article, Elhage et al. [1] compare and correlate physical stress and surgical performances among three modes of a standardized surgical step. Their study shows the obvious physical strain and technical limitations faced while performing conventional laparoscopic surgery, subsequently leading to compromised surgical outcomes. The physical impact of conventional laparoscopic surgery has been well documented through surgeon feedback as well as ergonomic assessment [2, 3]. Various studies have reported that higher physical stress, associated with ergonomic limitations, is experienced when performing conventional laparoscopy compared to the comfort and ease of robot-assisted surgery, as highlighted in the present study. Increased workload has also been associated with performance errors, with a steep learning curve needed to achieve surgical excellence during conventional laparoscopy [4].

Currently, the use of robot-assisted surgery is on the rise, as an alternative to both open and conventional laparoscopic surgery across the developed world, despite its obvious economic limitations. Better ergonomics during robot-assisted surgery will increase the comfort of the surgeon, but the future of surgery may easily be linked to the improvements experienced by all of us in the automobile industry. Developments, from manual gear-clutch control to automatic speed control and the luxury of adaptive cruise control today, make us safe drivers with minimal physical stress. The concept of adaptive cruise control, which adjusts the speed of a vehicle in relation to its surroundings, sounds similar to the leap from manual camera control during conventional laparoscopy to console-based control during camera navigation in robot-assisted surgery. With advances in the speed and size of computers, pneumatic-based joint mechanics and mindfulness meditation on the horizon, it will not be long before surgeons will sit back and watch the marvel of the machine. Surgeons just need to learn to hold on to their seats!

Syed J. Raza*, Khurshid A. Guru† anRobert P. Huben†
*Fellow, †Endowed Professor of Urologic Oncology, Department of Urology and A.T.L.A.S (Applied Technology Laboratory for Advanced Surgery) Program, Roswell Park Cancer Institute, Buffalo, NY, USA

 

References

 

2 Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic and robotic surgery.

J Robotic Surg 2012; 6: 65–723 Hubert N, Gilles M, Desbrosses K, Meyer JP, Felblinger J, Hubert J. Ergonomic assessment of the surgeon’s physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot 2013; 9:142–147

4 Yurko YY, Scerbo MW, Prabhu AS, Acker CE, Stefanidis D. Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool. Simul Healthc 2010; 5: 267–271

 

Article of the Week: RA-RPLND – Technique and Initial Case Series of 18 Patients

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Tim Dudderidge discussing his paper. 

If you only have time to read one article this week, it should be this one.

Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients

Scott M. Cheney, Paul E. Andrews, Bradley C. Leibovich* and Erik P. Castle

Mayo Clinic Arizona Department of Urology, Phoenix, AZ, and *Mayo Clinic Rochester Department of Urology, Rochester, MN, USA

OBJECTIVE

To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for non-seminomatous germ cell tumours (NSGCT) and paratesticular rhabdomyosarcoma (RMS) at our institution.

PATIENTS AND METHODS

Between March 2008 and May 2013, 17 patients underwent RA-RPLND for NSGCT and one for paratesticular RMS. Data were collected retrospectively on patient demographics, preoperative tumour characteristics, and perioperative outcomes including open conversion rate, lymph node (LN) yield, rate of positive LNs, operative time, estimated blood loss (EBL), and length of stay (LOS). Perioperative outcomes were compared between patients receiving primary RA-RPLND vs post-chemotherapy RA-RPLND. Medium-term outcomes of tumour recurrence rate and maintenance of antegrade ejaculation were recorded.

RESULTS

RA-RPLND was completed robotically in 15 of 18 (83%) patients. LNs were positive in eight of 18 patients (44%). The mean LN yield was 22 LNs. For cases completed robotically, the mean operative time was 329 min, EBL was 103 mL, and LOS was 2.4 days. At a mean (range) follow-up of 22 (1–58) months, there were no retroperitoneal recurrences and two of 17 (12%) patients with NSGCT had pulmonary recurrences. Antegrade ejaculation was maintained in 91% of patients with a nerve-sparing approach. Patients receiving primary RA-RPLND had shorter operative times compared with those post-chemotherapy (311 vs 369 min, P = 0.03). There was no significant difference in LN yield (22 vs 18 LNs, P = 0.34), EBL (100 vs 313 mL, P = 0.13), or LOS (2.75 vs 2.2 days, P = 0.36).

CONCLUSION

This initial selected case series of RA-RPLND shows that the procedure is safe, reproducible, and feasible for stage I–IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.

Editorial: RPLND – Open Surgery’s Next Challenger Is Ready To Enter The Ring

By Tim Dudderidge

The da Vinci surgical system delivers the benefits of laparoscopic surgery with an easier and more precise human–tissue interface than conventional laparoscopic instruments. Nearly all major uro-oncological procedures are being performed robotically. In this issue of BJUI, Cheney et al. [1] present their technique and initial experience of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for patients with primary and post-chemotherapy non-seminoma germ cell tumours. Quality indicators for RA-RPLND include adequate clearance of the desired surgical field, satisfactory lymph node yield, acceptable perioperative morbidity and length of stay, as well as longer-term functional and oncological outcomes. So how well does RA-RPLND stand up to scrutiny?

The technique employed by Cheney et al., placing the robot at the head of the patient, is unfamiliar to most urologists I suspect. It appears to offer excellent access to the retroperitoneum, but still requires a re-docking when performing full bilateral dissections. Whether this technique is superior to the lateral approach that I and others have used for modified dissections requires further study [2,3]. The lymph node yield was lower than that previously reported for open RPLND and while Cheney et al. [1] observe this may be due to the use of a modified template where appropriate, the absence of any in-field recurrences at a median of 22 months is perhaps the more reliable sign that there is oncological equivalence. Concerns that a true template dissection cannot be completed with a robot-assisted laparoscopic approach are probably unjustified in my opinion. The description of surgical technique by Cheney et al., including suture ligation and division of lumbar vessels, confirms that if a surgeon is minded to do so, a complete bilateral or modified template clearance can be completed.

The absence of significant complications in this series is impressive; however, there were three out of 18 conversions to open surgery. The mean length of stay of 2.4 days is close to the 3–4 days stay I would expect after an uncomplicated open RPLND in a young fit man. However, 1–2 night stays were seen in their later cases as they gained experience. Perhaps more importantly in a group of working age men, return to full physical activity within 3 weeks is possible [2].

As highlighted by Cheney et al. [1], minimally invasive primary RPLND has been previously reported both by laparoscopic and robotic approaches. Their larger series provides an important demonstration that the robotic approach facilitates the more complex undertaking of post-chemotherapy RPLND. Furthermore they show that except for operative time, all other outcomes were similar in primary and post-chemotherapy cases.

As an enthusiast for minimally invasive therapies, I of course welcome these results and think that along with other published and presented series, they provide sufficient evidence to consider a more formal evaluation of this approach. However, how feasible is the wider introduction of RA-RPLND? Despite having experience of robotics and working in a team performing around 30 RPLNDs a year, I was only able to identify five cases during a 1-year period suitable for a robotic approach. With experience this could have been a higher proportion, but it is fair to conclude that suitable cases in typical cancer centres would be limited in number. This is particularly so for the UK and other European countries, where primary RPLND is not used. Cheney et al. [1] had similarly low numbers each year and recruited their cohort of 18 cases over 5 years.

An international multicentre registry is arguably the best way to gather more information on the safety and completeness of template dissection RPLND. Existing registries, e.g. the BAUS complex operations database, have already provided valuable insights into the results of RPLND in the UK [4] and could be combined with other international RA-RPLND databases already being compiled (Erik Castle MD personal communication). Partnership of testicular cancer surgeons without robotic experience with experienced robotic surgeons may also facilitate the development of additional centres for development of this procedure. They will also aid optimal patient selection and help avoid incomplete template dissections, which may compromise the excellent cancer control we are now used to.

There are clear potential advantages with a minimally invasive approach to RPLND, not least of which are the avoidance of a laparotomy scar, the reduction of complications and an earlier return to normal activity. Cheney et al. [1] have shown that their technique is feasible, safe and effective in the medium term and their results justify wider consideration of the procedure for further study and improvement.

Tim Dudderidge

University Hospital Southampton, Southampton, UK

References

1 Cheney SM, Andrews PE, Leibovich BC, Castle EP. Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients. BJU Int 2015; 115: 114–20

2 Dudderidge T, Pandian S, Nott D. Technique and outcomes for robotic assisted post-chemotherapy retroperitoneal lymph node dissection (RPLND) in Stage 2 non-seminomatous germ cell tumour (NSGCT). BJU Int 2012; 110: 97

3 Dogra PN, Singh P, Saini AK, Regmi KS, Singh BG, Nayak B. Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor. Urol Ann 2013; 5: 223–6

4 Hayes M, O’Brien T, Fowler S, BAUS RPLND Group. Contemporary retroperitoneal lymph node dissection (RPLND) for testis cancer in the UK – a national study. J Urol 2014; 191 (Suppl.): e89–90

 

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