A0407 Selective digital rectal examination in the PSA–mpMRI era: diagnostic yield, rapid learning curve, and educational implications

Objective. To analyze the learning curves of the different stages of robotic-assisted laparoscopic hysterectomy. Design. Retrospective analysis. Design Classification. Canadian Task Force classification II-2. Setting. Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. Patient Intervention. Women receiving robotic-assisted total and subtotal laparoscopic hysterectomies for benign conditions from May 1, 2013, to August 31, 2015. Measurements and Main Results. The mean age, body mass index (BMI), and uterine weight were 46.44 ± 5.31 years, 23.97 ± 4.75 kg/m2, and 435.48 ± 250.62 g, respectively. The most rapid learning curve was obtained for the main surgery console stage; eight experiences were required to achieve duration stability, and the time spent in this stage did not violate the control rules. The docking stage required 14 experiences to achieve duration stability, and the suture stage was the most difficult to master, requiring 26 experiences. BMI did not considerably affect the duration of the three stages. The uterine weight and the presence of adhesion did not substantially affect the main surgery console time. Conclusion. Different stages of robotic-assisted laparoscopic hysterectomy have different learning curves. The main surgery console stage has the most rapid learning curve, whereas the suture stage has the slowest learning curve.

Double-balloon enteroscopy: ready for prime time?

Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study

Laparoscopic bladder augmentation has been limited because of the extensive suturing required. The use of robot-assisted laparoscopic (RAL) procedures may circumvent this limitation and allow more efficient suturing. The purpose of the study is to define the techniques and the potential pitfalls in performing RAL bladder augmentation in an animal model. Ten swine underwent RAL bladder augmentation using 20 cm of ileum. In five animals, the bowel anastomosis was performed intracorporeally. In the others, the bowel ends were externalized through one of the ports, and a free-hand bowel anastomosis was performed. The operative time was recorded. The anastomoses were evaluated for patency and leakage. The mean procedure time was 6 hours 44 minutes (range 5 hours 50 min-8 hours 5 min) with a rapid learning curve. We identified minor technical modifications that were helpful, such as placement of "hitch stitches," irrigation of the isolated bowel loop extracorporeally, and leaving the bladder wall attachment intact to maintain bladder suspension. Leakage at the bowel-bowel anastomosis occurred in one animal with use of a stapling technique. Because this could be a potentially fatal complication, we altered our technique to perform the bowel-bowel anastomosis outside the peritoneal cavity. Subsequently, there was no further incidences of bowel leakage, and all anastomoses were patent. The mean bowel-bowel anastomosis time was equivalent to using the two techniques. Leakage at the bowel-bladder anastomosis was seen in two animals, both occurring early in the series. RAL bladder augmentation can be safely and efficiently performed. There is a rapid learning curve. We identified minor technical modifications in techniques to help reduce operative time and potential complications. We recommend performing the bowel-bowel anastomosis outside the peritoneum to avoid the risk of leakage. Leakage at the bowel-bladder anastomosis may occur but can be managed with simple catheter drainage.

Procidentia is one of complications of pregnancy and childbirth. The challenge of treatment is to preserve fertility if needed and to find effective methods with rapid learning curve. Our technique—Isam technique—fulfills these needs with a short hospital stay, very low risk of complications and relapse, a rapid learning curve as well, and no need for long contraceptive methods after operation.

PurposeThe purpose of this study was to determine the learning curve for total operative time using a novel cutting guide positioning robotic assistant for total knee arthroplasty (raTKA). Additionally, we compared complications and final limb alignment between raTKA and manual TKA (mTKA), as well as accuracy to plan for raTKA cases.MethodsWe performed a retrospective cohort study on a series of patients (n = 180) that underwent raTKA (n = 90) using the ROSA Total Knee System or mTKA (n = 90) by one of three high-volume (> 200 cases per year) orthopaedic surgeons between December 2019 and September 2020, with minimum three-month follow-up. To evaluate the learning curve surgical times and postoperative complications were reviewed.ResultsThe cumulative summation analysis for total operative time revealed a change point of 10, 6, and 11 cases for each of three surgeons, suggesting a rapid learning curve. There was a significant difference in total operative times between the learning raTKA and both the mastered raTKA and mTKA groups (p = 0.001) for all three surgeons combined. Postoperative complications were minimal in all groups. The proportion of outliers for the final hip-knee-ankle angle compared to planned was 5.2% (3/58) for the mastered raTKA compared to 24.1% (19/79) for mTKA (p = 0.003). The absolute mean difference between the validated and planned resections for all angles evaluated was < 1 degree for the mastered raTKA cases.ConclusionAs the digital age of medicine continues to develop, advanced technologies may disrupt the industry, but should not disrupt the care provided. This cutting guide positioning robotic system can be integrated relatively quickly with a rapid initial learning curve (6-11 cases) for operative times, similar 90-day complication rates, and improved component positioning compared to mTKA. Proficiency of the system requires additional analysis, but it can be expected to improve over time.Level of evidenceLevel III Retrospective Therapeutic Cohort Study.

Robotic-assisted total knee arthroplasty (RA-TKA) has gained popularity for its potential ability to improve surgical precision and patient outcomes, despite concerns about its long learning curve and increased operative times. The aim of this study is to evaluate the learning curve of the ROSA® Knee System, the relationship between each phase of the learning curve and the accuracy of the robotic system in femoral component size and knee alignment prediction. A single surgeon retrospective analysis of total operative time (TOT) and total robotic time was conducted. The first 60 cases of RA-TKA performed between July 2023 and March 2024 were included. Six (10%) patients were excluded due to incomplete surgical reports. A cumulative sum analysis was used to identify the learning and proficiency phases of the surgeon's learning curve. Moreover, femoral component size prediction accuracy and the difference between planned and achieved knee alignment were analyzed. The projected learning curve showed a significant reduction in TOT after 10 cases, with mean time decreasing from 62.6 ± 7.92 min in the learning phase to 49.9 ± 8.10 min in the proficiency phase (p = 0.0008). The robotic procedure accounted for 48% and 42% of the TOT in the learning and proficiency phases, respectively. Prediction in femoral component size was accurate in 92.6% of cases. The difference between planned and achieved knee alignment was not statistically significant (1.1° ± 0.9°). The ROSA® Knee System allows a rapid learning curve in RA-TKA, with a significant reduction in operative time after the first 10 cases. An experienced orthopaedic surgeon specialized in knee arthroplasty can quickly reach a proficiency phase, maintaining high accuracy in alignment and femoral component sizing. These findings suggest that the ROSA® system is an effective and reliable tool for CR RA-TKA, offering precise and reproducible outcomes. IV.

Robotic-assisted partial nephrectomy (RAPN) is a standard approach for nephron-sparing surgery. The Hugo-RAS system is an emerging platform, but data on its outcomes and learning curve are limited. This study evaluates the safety, efficacy, and learning curve of RAPN using Hugo-RAS in a high-volume laparoscopic center. We analyzed 42 consecutive RAPN cases performed with the Hugo-RAS system from May 2023 to October 2024. Perioperative outcomes, renal function, and the learning curve were assessed. The primary endpoint was the "trifecta" (warm ischemia time <25 min, negative surgical margins, and no major complications). Learning curve analysis used Cumulative Sum Control Chart (CUSUM) methodology. The median console time was 88 minutes (IQR: 74-107), with a docking time of 5 minutes (IQR: 240-420s). The trifecta rate was 83.3%, and no conversions occurred. Docking proficiency was achieved by the 5th case, while console time proficiency was reached after 7-8 cases. Tumor complexity did not significantly impact surgical time (p = 0.781) but was associated with longer warm ischemia time (p = 0.0037). The Hugo-RAS system allows for safe and effective RAPN with a rapid learning curve. Surgeons adapt quickly, achieving proficiency within a short number of cases. Further studies are needed to validate long-term outcomes and broader applicability.

Total knee arthroplasty (TKA) is widely used to manage severe knee osteoarthritis. However, conventional TKA (C-TKA) often leaves patients dissatisfied due to suboptimal alignment and soft-tissue balance. Robotic-assisted TKA (RA-TKA), particularly with imageless systems like the NAVIO Surgical System, promises enhanced accuracy and improved outcomes. This study aims to validate the accuracy of RA-TKA in achieving functional alignment (FA) and to explore the learning curve associated with this technique. A retrospective analysis included 101 patients undergoing RA-TKA with the NAVIO system from July 2021 to April 2024. Data on alignment angles, gap balance, and surgical times were analyzed. Patients were categorized by preoperative coronal alignment (valgus, neutral, and varus), with subgroups within the varus category. Accuracy was defined as deviations ≤3° for alignment and ≤1mm for gap balance. Learning curve trends were analyzed using segmented regression. The study demonstrated a mean alignment error of 1.18° (±1.21) and a gap balance accuracy of 84%, with no significant differences across knee morphologies. The RA-TKA system achieved an overall implant alignment accuracy rate of 95%. Varus knees with greater deformities (>6°) showed comparable or superior accuracy to less severe cases. Surgical time averaged 72.3min (±5.6), with significant reductions observed after the first 11 cases, reflecting procedural efficiency improvements without compromising accuracy. The RA-TKA reliably achieves precise FA across diverse knee morphologies with a rapid learning curve. Future studies should evaluate long-term outcomes and implant survivorship to confirm these promising findings. IV.

Learning curve of robotic living donor Nephrectomy: Results from a high-volume transplantation center

Catheter ablation is a cornerstone in managing patients with symptomatic, drug-refractory atrial fibrillation (AF), and while effective, traditional thermal ablation techniques are associated with rare but significant complications due to a non-selective thermal energy transfer to all biologic tissues. Pulsed field ablation (PFA) offers a non-thermal approach, targeting myocardial tissue selectively while sparing adjacent structures. The PulseSelect system is a novel PFA platform, and this analysis examines the procedural outcomes, acute complications, and the learning curve associated with introduction of the PulseSelect system in six European centers. The One Shot to Pulmonary Vein Isolation (1STOP) project prospectively included 131 patients with paroxysmal or persistent AF treated with the PulseSelect system across six centers. Procedural data, patient characteristics, and acute outcomes were summarized. Additionally, sedation protocols, fluoroscopic times, and acute success rates were reported. Patients (mean age 61.7 ± 9.7 years; 31.3% female) had predominantly paroxysmal AF (80.9%). Median procedural and fluoroscopy times were 55.0 and 16.0 min, respectively. General anesthesia was used in 75.5% of cases, while in the remaining 24.5% moderate sedation protocols allowed procedures (even in 15.1% without an anesthesiologist). Acute PVI success was 100%, and no major complications were observed. A short learning curve was noted, with significant reductions in procedural times after the initial 2-3 cases at each center. The PulseSelect system showed short procedural times, with a rapid learning curve, thus leading with high procedural efficiency. In 1 out of 4 cases general anesthesia was not applied, and no major complications were observed.

Learning curve for combined reconstruction of the anterolateral and anterior cruciate ligaments: a report of 108 cases with a single surgeon

The aim of this study was to assess the learning curve of robotic-assisted hiatal hernia repair. Patients undergoing robotic-assisted hiatal hernia repair from May 2018 to April 2024 were retrospectively included. Clinical characteristics, operative times, and postoperative data were collected. A cumulative summation (CUSUM) analysis of operative times, adjusted for surgical complexity, was conducted. We selected 101 patients who underwent robotic-assisted hiatal hernia repair performed by three surgeons. The mean age was 65.7 ± 14.3 years, with 69 (68.3%) female patients. Adjusted operative times were calculated based on hernia type, age, sex, BMI, and American Society of Anesthesiologists (ASA) score. The CUSUM analysis estimated the learning curve to be between 15 and 21 cases. Only one minor intraoperative complication occurred. Postoperatively, 19 (18.8%) complications were observed, with only 3 (3.0%) classified as grade 3 according to the Clavien-Dindo classification. Complications were evenly distributed between the learning and post-learning phases. After a mean follow-up of 26.5 ± 18.0 months, 13 (12.9%) cases of recurrence were recorded, none of which required surgical revision. Experienced surgeons performing robotic-assisted hiatal hernia repair seem to have a rapid learning curve. A significant reduction in operative time was observed after 15 to 21 cases.

Diagnostic bronchoscopy has undergone two major paradigm shifts in the last 40 years. First, the advent of flexible bronchoscopy gave chest physicians improved access to the tracheobronchial tree with a rapid learning curve and greater patient comfort compared with rigid bronchoscopy. The second paradigm shift has evolved over the last 5 years with the proliferation of new technologies that have significantly enhanced the diagnostic capabilities of flexible bronchoscopy compared with traditional methods. At the forefront of these new technologies is endobronchial ultrasound. In its various forms, endobronchial ultrasound has improved diagnostic yield for pulmonary masses, nodules, intrathoracic adenopathy, and disease extent, thereby reducing the need for more invasive surgical interventions. Various navigational bronchoscopy systems have become available to increase flexible bronchoscope access to small peripheral pulmonary lesions. Furthermore, various modalities of airway assessment, including optical microscopic imaging technologies, may play significant roles in the diagnosis of a variety of pulmonary diseases in the future. Finally, the combination of new diagnostic bronchoscopy technologies and novel approaches in molecular analysis and biomarker assessment hold promise for enhanced diagnosis and personalized management of many pulmonary disorders. In this review, we provide a contemporary review of diagnostic bronchoscopy developments over the past decade.

Our study evaluated the efficacy and feasibility of left bundle branch area pacing (LBBAP) compared to right ventricular outflow tract septal pacing (RVOSP). We conducted a prospective, single-center, observational study involving 200 consecutive patients who required pacemaker implantation. The patients were divided into two groups (LBBAP and RVOSP), with 100 patients in each group. We aimed to compare the safety and efficacy, as well as the procedure and fluoroscopy times, between the two groups. Additionally, we aimed to describe the learning curve for the LBBAP group. The success and acute complication rates were similar (P = .56 vs. P = .65). The procedure time was longer in the LBBAP group compared to the RVOSP group (18 [13-28] vs. 11 [7-17] min; P < .001), while the fluoroscopy time was shorter in the LBBAP group compared to the RVOSP group (2.8 [1.3-3.7] vs. 3.1 [2-5.9] min; P = .02). The paced QRS interval was narrower in the LBBAP group (123.77 ± 10.25 vs. 159.79 ± 17.0 ms; P = .001). There were no significant differences in pacing parameters like R-wave sensing (9.6 ± 5.2 vs. 9.1 ± 4.7 mV; P = .91), bipolar impedance (685.9 ± 151.8 vs. 686.5 ± 158.6 Ω; P = .98), or pacing threshold (0.70 ± 0.29 vs. 0.64 ± 0.26 V @ 0.4 ms; P = .63). In the LBBAP group, both the procedure time (12 [10.5-15] vs. 32 [28.5-38.5] min; P < .001) and the fluoroscopy time (2 [1-4.6] vs. 5.1 [3.4-12] min; P < .01) were shorter in the last quartile (Q4) compared to the first quartile (Q1). The procedure time was similar between LBBAP Q4 and RVOSP (12 [10.5-15] vs. 11 [7-17] min; P = .33). LBBAP is as safe as RVOSP and achieves a narrower paced QRS compared to RVOSP. After a rapid learning curve, a shorter fluoroscopy time and a similar procedure time can be achieved.