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Article of the week: Robotic surgery training methods: take your pick

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 of Dr. Goh discussing standardized robotic surgery training methods.

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

Comparative assessment of three standardized robotic surgery training methods

Andrew J. Hung, Isuru S. Jayaratna, Kara Teruya, Mihir M. Desai, Inderbir S. Gill and Alvin C. Goh*

USC Institute of Urology, Hillard and Roclyn Herzog Center for Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, and *Department of Urology, Methodist Institute for Technology, Innovation and Education, The Methodist Hospital, Houston, TX, USA

OBJECTIVES

• To evaluate three standardized robotic surgery training methods, inanimate, virtual reality and in vivo, for their construct validity.

• To explore the concept of cross-method validity, where the relative performance of each method is compared.

MATERIALS AND METHODS

• Robotic surgical skills were prospectively assessed in 49 participating surgeons who were classified as follows: ‘novice/trainee’: urology residents, previous experience <30 cases (n = 38) and ‘experts’: faculty surgeons, previous experience ≥30 cases (n = 11).

• Three standardized, validated training methods were used: (i) structured inanimate tasks; (ii) virtual reality exercises on the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA, USA); and (iii) a standardized robotic surgical task in a live porcine model with performance graded by the Global Evaluative Assessment of Robotic Skills (GEARS) tool.

• A Kruskal–Wallis test was used to evaluate performance differences between novices and experts (construct validity).

• Spearman’s correlation coefficient (ρ) was used to measure the association of performance across inanimate, simulation and in vivo methods (cross-method validity).

RESULTS

• Novice and expert surgeons had previously performed a median (range) of 0 (0–20) and 300 (30–2000) robotic cases, respectively (P < 0.001).

• Construct validity: experts consistently outperformed residents with all three methods (P < 0.001).

• Cross-method validity: overall performance of inanimate tasks significantly correlated with virtual reality robotic performance (ρ = −0.7, P < 0.001) and in vivo robotic performance based on GEARS (ρ = −0.8, P < 0.0001).

• Virtual reality performance and in vivo tissue performance were also found to be strongly correlated (ρ = 0.6, P < 0.001).

CONCLUSIONS

• We propose the novel concept of cross-method validity, which may provide a method of evaluating the relative value of various forms of skills education and assessment.

• We externally confirmed the construct validity of each featured training tool.

 

Read Previous Articles of the Week

 

Editorial: Three robotic surgery training methods: is there a clear winner?

All training adds value. A craft-based specialty such as surgery has always recognised this. The advent of advanced minimally invasive surgical technology and techniques has provided both new challenges and new opportunities for surgical performance and for the delivery of training. Conceptually, we have moved from the Halstedian model of ‘See one, do one, teach one’ [1] to an environment where skills are acquired away from the operating room in simulator, inanimate and in vivo (animal) laboratory training sessions. Increased scrutiny of credentialling and medico-legal aspects of robotic surgery have reinforced the importance of training and have led to a number of papers outlining pathways to facilitate this [2, 3].

In the present paper, Hung et al. evaluate the construct validity of three standardised training methods (inanimate, simulator and in vivo) and also compare the three different platforms for cross-method training value. As others have shown, the latest generation of robotic surgery simulators have high face, content and construct validity [4, 5] and the present paper confirms the value of both inanimate and simulator training for novice surgeons. In addition, the authors confirmed the construct validity of a simple in vivo exercise using the daVinci© surgical system by demonstrating that experts outperformed novices. Using Spearman’s rank correlation coefficient, the authors compared the three training methods under evaluation and concluded that they were strongly correlated for construct validity between exert and novice surgeons. While construct validation of these exercises may be established, are they useful for experts? Until realistic virtual reality surgical simulations are available, only a novice, an inexperienced or an occasional robot-assisted surgeon may benefit from virtual reality exercises.

What are we therefore to conclude from this? For certain, the advent of excellent surgical simulators and structured inanimate exercises has provided tools for novice surgeons to acquire console skills in a safe and structured environment. This will enhance their operating performance and reduce aspects of the learning curve such as operating time; however, the lack of availability of in vivo training opportunities greatly limits the applicability of this method of surgical training. In many countries (including Australia and the UK), this type of training is illegal or not available. The robotic surgery industry has strongly recommended that in vivo training should be undertaken in one of their official training facilities before surgeons are given the credentials to use this technology; however, even in the USA where most of these facilities are located, key leaders within the AUA have called for the awarding of credentials for robotic surgery ‘not to be an industry driven process, but one that is a result of a standardized, competency based, peer evaluation system’ [2]. Notably, the current AUA Standard Operating Practices (guidelines) for the awarding of credentials for robotic surgery list in vivo training as being optional.

Our view is that although all training has value, there is not enough evidence that in vivo training (particularly on an animal with a rudimentary prostate), which requires international travel and considerable expense, adds sufficient value to be mandatory in any credentialling process. In fact, we have dropped the requirement to complete in vivo training from our requirements at major robotic surgery centres in Australia in favour of structured Mini-Fellowship training [6]. Hung et al. have confirmed what we already knew, which is that all training adds value; however it is likely that only simulator and inanimate training adds enough value to be incorporated into standardised training in robotic surgery.

The multi-disciplinary ‘Fundamentals of Robotic Surgery’ (FRS) curriculum being created by Dr Richard Satava and associates is working on psychomotor skills tasks that include inanimate models as well as corresponding virtual reality exercises. Multi-institutional validation of the FRS or similar curricula will allow the establishment of training milestones and proficiency benchmarks. We must continue to strive for further development of robotic and surgical simulation to change the training paradigm so that surgical training does not need to be at the expense, however minor, of increased operating time or adverse patient outcome.

Declan G. Murphy* and Chandru P. Sundaram
*Peter MacCallum Cancer Centre, Division of Cancer Surgery, University of Melbourne, Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, Melbourne, Australia, and Department of Urology, Indiana University, Indianapolis, IN, USA

References

  1. Halsted WS. The training of the surgeon. Bull Johns Hop Hosp 1904; XV: 8
  2. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialingJ Urol 2011;185: 1191–1197
  3. Zorn KC, Gautam G, Shalhav AL et al. Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeonsJ Urol 2009; 182: 1126–1132
  4. Finnegan KT, Meraney AM, Staff I, Shichman SJ. da Vinci Skills Simulator construct validation study: correlation of prior robotic experience with overall score and time score simulator performanceUrology 2012; 80: 330–335
  5. Abboudi H, Khan MS, Aboumarzouk O et al. Current status of validation for robotic surgery simulators – a systematic reviewBJU Int 2013; 111: 194–205
  6. Melbourne Uro-Oncology Training Program. Robotic surgery training. Available at: https://www.declanmurphy.com.au/training. Accessed 28 February 2013

Video: Take three: assessing robotic surgery training methods

Comparative assessment of three standardized robotic surgery training methods

Andrew J. Hung, Isuru S. Jayaratna, Kara Teruya, Mihir M. Desai, Inderbir S. Gill and Alvin C. Goh*

USC Institute of Urology, Hillard and Roclyn Herzog Center for Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, and *Department of Urology, Methodist Institute for Technology, Innovation and Education, The Methodist Hospital, Houston, TX, USA

OBJECTIVES

• To evaluate three standardized robotic surgery training methods, inanimate, virtual reality and in vivo, for their construct validity.

• To explore the concept of cross-method validity, where the relative performance of each method is compared.

MATERIALS AND METHODS

• Robotic surgical skills were prospectively assessed in 49 participating surgeons who were classified as follows: ‘novice/trainee’: urology residents, previous experience <30 cases (n = 38) and ‘experts’: faculty surgeons, previous experience ≥30 cases (n = 11).

• Three standardized, validated training methods were used: (i) structured inanimate tasks; (ii) virtual reality exercises on the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA, USA); and (iii) a standardized robotic surgical task in a live porcine model with performance graded by the Global Evaluative Assessment of Robotic Skills (GEARS) tool.

• A Kruskal–Wallis test was used to evaluate performance differences between novices and experts (construct validity).

• Spearman’s correlation coefficient (ρ) was used to measure the association of performance across inanimate, simulation and in vivo methods (cross-method validity).

RESULTS

• Novice and expert surgeons had previously performed a median (range) of 0 (0–20) and 300 (30–2000) robotic cases, respectively (P < 0.001).

• Construct validity: experts consistently outperformed residents with all three methods (P < 0.001).

• Cross-method validity: overall performance of inanimate tasks significantly correlated with virtual reality robotic performance (ρ = −0.7, P < 0.001) and in vivo robotic performance based on GEARS (ρ = −0.8, P < 0.0001).

• Virtual reality performance and in vivo tissue performance were also found to be strongly correlated (ρ = 0.6, P < 0.001).

CONCLUSIONS

• We propose the novel concept of cross-method validity, which may provide a method of evaluating the relative value of various forms of skills education and assessment.

• We externally confirmed the construct validity of each featured training tool.

Technological Innovation in the BJUI

Time waits for no man St. Marher, 1225

Urology is arguably the leading technology driven surgical specialty. This is no accident. As surgeons we have always looked towards minimal invasion to reduce the trauma of access to our patients. One would have thought that the advent of drugs for BPH and OAB would perhaps reduce our hunger for technology. On the contrary, many urologists have moved on to effective alternatives to TURP such as HoLEP and having learnt the lessons from previous unproven over enthusiasm, relied on the results of high quality randomised trials before accepting the results.

The BJUI has a long history of publishing innovative manuscripts in the fields of basic science, imaging and therapeutics. We aim to bring the readership entire new paradigms in surgical diagnostics and treatment. Indeed while we enjoy #ERUS13 in sunny Stockholm, the autumn sunshine reminds us of the role played by robotics in the steady rise of technological innovation. This “sub specialty” has become so prominent that the EAU are soon accepting ERUS and its committee as an integral part of the European Association of Urology. The randomised trials, meta analysis and health technology assessments are gradually appearing in contemporary literature such that it is no longer true to say that robotics is just a fad backed up by little or poor evidence. Robotics remains one of the most highly cited parts of the BJUI and therefore together with laparoscopy has its own dedicated section. We were pleased to publish the novel method of suprapubic catheterisation as an alternative to the urethral route after robotic prostatectomy [1] which led to much conversation on the BJUI twitter page. Our readers ultimately decide whether to adopt a particular technique or technology and are now able to vote via the BJUI Poll.

Last month, Mahesh Desai demonstrated microPCNL in London. The technology is truly breathtaking. It is hard to believe that light and image transmission as well as stone disintegration can be effectively achieved via a needle so thin! We almost stopped doing robotics and were thinking of re-training to become stone surgeons. Mahesh and his team went on to back up the technology with a randomised comparison against flexible ureterorenoscopy [2]. It should come as no surprise that such an article should come from the sub-continent where stone disease is endemic.

And the technological innovations in the BJUI continue. This month we present three rather different articles for your reading pleasure. The first is an international collaboration demonstrating the ideal dose and safety of photodynamic TOOKAD therapy (a light-activated vascular occluding agent) in localised prostate cancer. Nearly 80% of patients had negative biopsies at 6 months [3]. Next we evaluate the role of PET CT in bladder cancer patients undergoing cystectomy. With almost a 20% greater pickup than standard imaging, we may be able to save a number of patients a morbid operation in the presence of metastasis. Advanced imaging may also allow better stratification of patients for neo-adjuvant chemotherapy [4]. Finally, we have an exciting paper from Iran on the use of endometrial derived stem cells for creating bladder replacements and alternatives to meshes in prolapse surgery. The immuno and scanning electron micrographic images in this paper are just stunning [5].

The BJUI intends to continue leading technological innovation in urology. We will bring our readers early phase safety data on new technologies in addition to long-term results to truly judge their efficacy and durability. We hope you enjoy reading, citing and interacting with these articles online at bjui.org and ultimately translate them to your own clinical practice.

Prokar Dasgupta, Editor in Chief, BJUI
Ben Challacombe, Associate Editor, BJUI
King’s Health Partners

References

  1. Ghani KR, Trinh Q-D, Sammon JD et al. Percutaneous suprapubic tube bladder drainage after robot-assisted radical prostatectomy: a step-by-step guide. BJU Int 2013; 112: 703–705
  2. Sabnis RB, Ganesamoni R, Doshi A, Ganpule AP, Jagtap J, Desai MR. Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013; 112: 355–361
  3. Azzouzi A-R, Barret E, Moore CM. TOOKAD® Soluble vascular-targeted photodynamic (VTP) therapy: determination of optimal treatment conditions and assessment of effects in patients with localised prostate cancer. BJU Int 2013; 112: 766–774
  4. Mertens LS, Fioole-Bruining A, Vegt E, Vogel WV, van Rhijn BW, Horenblas S. Impact of 18F-fluorodeoxyglucose (FDG)-positron-emission tomography/computed tomography (PET/CT) on management of patients with carcinoma invading bladder muscle. BJU Int 2013; 112: 729–734
  5. Shoae-Hassani A, Sharif S, Seifalian AM, Mortazavi-Tabatabaei SA, Rezaie S, Verdi J. Endometrial stem cell differentiation into smooth muscle cell: a novel approach for bladder tissue engineering in women. BJU Int 2013; 112: 854–863
Original publication of this editorial can be found at: doi 10.1111/bju.12431BJUI 2013; 112: 707.

 

Step-by-Step: Percutaneous suprapubic tube bladder drainage in RARP

Percutaneous suprapubic tube bladder drainage after robot-assisted radical prostatectomy: a step-by-step guide

Khurshid R. Ghani, Quoc-Dien Trinh, Jesse D. Sammon, Wooju Jeong, Andrea Simone, Ali Dabaja, Stacey Dusik, James O. Peabody and Mani Menon

Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA

OBJECTIVE

• To describe our technique of maintaining bladder drainage after robot-assisted radical prostatectomy (RARP) using a percutaneous suprapubic tube (PST) in place of a urethral catheter.

METHODS

• A watertight anastomosis permits placement of the PST. Contraindications include morbid obesity, concomitant inguinal hernia mesh repair, anticoagulation therapy, limited hand dexterity in the patient, bladder neck reconstruction and extensive adhesiolysis at RARP.

• The necessary equipment includes a 14-F PST balloon catheter set, a three-way connector, a connecting tube, a suture passer, 1/0 polypropylene sutures on a CT1 needle, a sterile plastic button, adhesive and steri-strips.

RESULTS

• The important steps for PST placement are: Step 1: robot-assisted placement of a bladder wall anchor suture; Step 2: transferring the bladder wall suture to anterior abdominal skin; Step 3: guided placement of the PST under robotic vision; Step 4: securing the PST within the bladder and abdominal wall; Step 5. postoperative care: clamping the PST on postoperative day 5, recording each void and post-void residual urine volumes in a patient diary, removal of the PST on postoperative day 7 after 48 h of voiding with residual urine <100 mL per void.

CONCLUSION

• We provide a concise step-by-step guide for placement of a PST during RARP as well as important management aspects for the successful adoption of this technique.

The Best of British

We live in a world that is getting smaller mainly because of global friendship, the Internet and the ease of travel. The British contribution to this should be a matter of pride for every UK urologist. Many friends and colleagues say that the BJUI has gone global, a decision that was made during the editorship of Hugh Whitfield and promoted under John Fitzpatrick. It was the correct move and has allowed British urology to maintain its prominent position in the rapidly changing world of academic publishing.

During BAUS 2013 we wanted our readers to know that the B in BJUI remains vital to the journal. We continue to publish and promote the best papers from UK for the benefit our local and international audience.

So here is the Best of British virtual issue, a selection of the most cited papers from UK in the BJUI in 2012-13. There are articles from every part of the British Isles proving that geography is not a barrier to quality.

It came as a surprise to me that Functional urology is the most cited section of the BJUI. We have highlighted a controversial but real life follow-up of patients having Botulinum toxin A injections for overactive bladder (OAB), a multicentre trial of a mini-sling and the natural history of urinary symptoms amongst ketamine users.

This is complemented by a Translational Science paper on the inhibition of stretching-evoked ATP release from bladder mucosa by anticholinergic agents. High-quality basic research with rapid translation is becoming real, thanks to the growth of Biomedical Research Centres in UK and overseas. We want to publish the best science papers and make them relevant to surgeons through Science Made Simple, a section that explains why our readers should care about science in a “dummies” fashion. The term “autophagy” is set to become as important as apoptosis.

Urological oncology is the largest section of the BJUI. There is considerable interest in prostate biopsies through the transrectal and transperineal routes and attempts at better imaging through MRI and perhaps Histoscanning. The role of surgery in high-risk prostate cancer is of particular relevance to British urologists within multidisciplinary teams as a number of our patients have aggressive, palpable and locally advanced disease. It is becoming clear that robotics can achieve oncological outcomes as robust as open surgery even in these patients. The Robotics and laparoscopy section of the BJUI has some of our most cited papers. We have given it prominence by featuring beautiful illustrations of  these common and evolving procedures in a Step by Step fashion on the front cover of our paper journal. Finally, a randomised controlled study evaluating the effects of metformin and lifestyle intervention on patients with prostate cancer receiving androgen deprivation therapy, has an important message.

While a number of new modalities of resection such as blue light and narrow band imaging are emerging, good quality white light resection by experienced endoscopists must not be ignored. It is not just about resection, however; adjuvant intravesical gemciabine found its way into a systematic review in patients with non-muscle invasive disease.

The Upper urinary tract often suffers at the hands of the bladder and prostate but is equally important. We have highlighted systematic reviews of ureteroscopic and percutaneous management of upper tract urothelial carcinoma, its surgical management by other modalities and the changing trends in stone disease that will be of interest to our endourological colleagues.

We have introduced a new Surgical Education section and bring to your attention the first results from the BAUS SIMULATE project, which combines technical and non-technical skills. This will be of great importance to every British trainee and indeed we are the international standard bearers in this field, thanks to your active participation.

We thoroughly enjoyed selecting this issue for your reading pleasure. A number of these articles have already been free downloads on www.bjui.org as articles of the week, and are now free to everyone as part of this virtual issue. They are further promoted internationally through our social media network and we are hoping to see a number of you at the BJUI SoMe course during BAUS.

Enjoy the highest quality, most cited articles from Britain. And be very proud, you deserve it!

Prof. Prokar Dasgupta, Editor in Chief, BJUI, Guy’s Hospital, King’s College London. @prokarurol

Scott Millar, Managing Editor, BJUI. @BJUIjournal

Creativity, Faster Horses, and Future Medicine

I was at an international cricket match, when during one of the very few lulls in the action I noticed a camera operator.  He was riding a Segway around the field in order to get close to the action and vary his angle for the viewers at home. After observing the function of this Segway-Human-Camera complex, it struck me that the only superfluous component in the system was the man with the beer gut and ill-fitting shorts.  All he did was point, focus, and zoom a camera. This can just as easily be done by a director in a control room, or even independently by a smart enough camera. It is not a stretch to imagine a computerized mobile field camera that can track a ball, and “intuitively” widen and tighten shots. The only thing keeping our man on the ground in employment is that at present, he is cheaper than the technology to replace him. His days are numbered. Taking the example of manufacturing, human workers are already replaced or reduced when lifting, welding, or assembling robots become as cost-effective as their flesh-based competitors.  Machines don’t fatigue, take breaks, or form unions, and so are an attractive alternative to, well, us.

With accelerating technology at declining cost, any job that is based around performing concrete tasks is at threat. Fast food restaurants are almost there, car wash services have been there for years, we only have pilots in aircraft because we don’t fully trust computers, and what next? Postal services? Car mechanics?

Lucky for us, doctors could never be replaced. Right?  Actually wrong. There are already electronic systems that in some situations make faster and more accurate diagnoses and management plans [https://www-03.ibm.com/innovation/us/watson/]. Perhaps the role of the physician will soon be giving a “human” face to explaining why the computer has ordered this course of treatment. That is, until technology can generate an adequately “human” face.

We may be relatively protected in surgery at present due to such things as appreciating variable tissue structures, making complex decisions based on unexpected findings, and adapting the surgical plan based on our understanding of the patient’s priorities. Technology will get there eventually. Even now it is conceivable that a computer could control an endoscope in the collecting system of a kidney, identify and then vaporize a stone as well as a human surgeon. A computer removing an organ is surely just further along this same scale.

The best protection we have is creativity. At present, computers have mastered managing vast quantities of data rapidly, and performing physical tasks within specific guidelines. We just cannot compete in this arena. Our advantage is in the abstract. We are still better at thinking of creative solutions, unexpected improvements, and more pleasant alternatives. A quote attributed to Henry Ford points out that if he had asked his customers what they wanted, they would have said “faster horses”. A binary brain would have worked tirelessly to give them this.

In the long term, doctors may only be researchers, generating ideas for computers to assimilate data on, but even then machines will be snapping at our heels. Why can’t a computer generate combinations of chemotherapeutic agents for a randomized trial? Even our last bastions of humanity, the arts, are not guaranteed safety. A computer can understand the mathematics of music, learn what is and is not palatable to the human ear, and “create” music. The same could be said of agreeable angles and architecture. One has to wonder, however long it takes, if the era of the human healer is approaching its end?

 

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

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Article of the week: Reality check: simulators are effective training tools for robotic surgery

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.

Current status of validation for robotic surgery simulators – a systematic review

Hamid Abboudi, Mohammed S. Khan, Omar Aboumarzouk*, Khurshid A. Guru†, Ben Challacombe, Prokar Dasgupta and Kamran Ahmed

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, *Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK, and †Department of Urology, Roswell Park Center for Robotic Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA

To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE®, EMBASE® and PsycINFO® databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; ‘expert’ and ‘novice’. Experts ranged in experience from 21–2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer®, ProMIS®, SimSurgery Educational Platform® (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial.Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

 

 

 

 

 

 

 

 

 

Read Previous Articles of the Week

Editorial: VR simulators can improve patient safety

You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

Procedure: Robot-assisted laparoscopic PN

A prospective comparison of surgical and pathological outcomes obtained after robot-assisted or pure laparoscopic partial nephrectomy in moderate to complex renal tumours: results from a French multicentre collaborative study

Alexandra Masson-Lecomte1,2,3, Karim Bensalah5,6, Elise Seringe2,3, Christophe Vaessen1,2, Alexandre de la Taille4,7, Nicolas Doumerc8,9, Pascal Rischmann8,9, Franck Bruyère10,11, Laurent Soustelle12,13, Stéphane Droupy12,13 and Morgan Rouprêt1,2

1Department of Urology, Pitié Salpétrière, Assistance Publique – Hôpitaux de Paris, Paris, 2Université Paris 6, Paris, 3Department of Statistics, Pitié Salpétrière, Assistance Publique – Hôpitaux de Paris, Paris, 4Department of Urology, Henri Mondor, Assistance Publique – Hôpitaux de Paris, Paris, 5Department of Urology, CHU de Reims, Reims, 6Université de Reims Champagnes-Ardenne, Marne, 7Université Paris-Est Creteil, Marne, 8Department of Urology, CHU Rangueil, Toulouse, 9Université Toulouse 3, Toulouse, 10Department of Urology, CHU Bretonneau, Tours, 11Université François-Rabelais, Tours, 12Department of Urology, CHU Caremeau, Nimes, 13Université Montpellier 1, Montpellier, France

OBJECTIVE

• To prospectively compare the surgical and pathological outcomes obtained with robot-assisted laparoscopic partial nephrectomy (RAPN) or laparoscopic PN (LPN) for renal cell carcinoma in a multicentre cohort.

PATIENTS AND METHODS

• Between 2007 and 2011, 265 nephron-sparing surgeries were performed at six French urology departments. The patients underwent either RAPN (n = 220) or LPN (n = 45) procedures.

• The operative data included operative duration, warm ischaemia time (WIT) and estimated blood loss (EBL). The postoperative outcomes included length of stay (LOS), creatinine variation (Modification of Diet in Renal Disease group), Clavien complications and pathological results.

• The complexity of the renal tumour was classified using the R.E.N.A.L. nephrometry scoring system. Student’s t-test and chi-squared tests were used to compare variables.

RESULTS

• The median follow-ups for the RAPN and LPN groups were 7 and 18 months, respectively (P < 0.001).

• Age and American Society of Anesthesiology score were significantly higher in the LPN group (P = 0.02 and P = 0.004, respectively).

• These variables were lower in the RAPN group: WIT [mean (SD) 20.4 (9.7) vs 24.3 (15.2) min; P = 0.03], operative duration [mean (SD) 168.1 (55.5) vs 199.7 (51.2) min; P < 0.001], operating room occupation time [mean (SD) 248.3 (66.7) vs 278.2 (71.3) min; P = 0.008], EBL [mean (SD) 244.8 (365.4) vs 268.3 (244.9) mL; P = 0.01], use of haemostatic agents [used in 78% of RAPNs and 100% of LPNs; P < 0.001] and LOS [mean (SD) 5.5 (4.3) vs 6.8 (3.2) days; P = 0.05).

• There were no significant differences between pre- and postoperative creatinine levels, pathology report or complication rates between the groups. The main limitation was due to the study’s non-randomised design.

CONCLUSION

• RAPN is not inferior to pure LPN for perioperative outcomes (i.e. EBL, operative duration, WIT, LOS). Only a randomised study with a longer follow-up can now provide further insight into oncological outcomes.

 

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