Introduction Of Robot-assisted Surgery Research Articles

Training and education of operating room nurses in robot-assisted surgery: a systematic review.

With the introduction of robot-assisted surgery, the role and responsibility of the operating room nurses have been expanded. The surgical team for robotic-assisted surgery depends on the ability of the operating room nurses to operate and handle the robotic system before, during, and after procedures. However, operating room nurses must acquire the necessary competencies for robotic-assisted surgery. We performed a systematic review using the databases MEDLINE and EMBASE to review the evidence on educating and training operating room nurses in robot-assisted surgery. Studies describing operating room nurses' training and team-training with operating room nurses for robot-assisted surgery were included. The Medical Education Research Study Quality Instrument (MERSQI) and the Newcastle-Ottawa Scale-Education (NOS-E) were used to evaluate the quality of the included studies. We identified 3351 potential studies and included 16 in the final synthesis. Nine studies focused on team-training in robot-assisted surgery: four focused solely on training for operating room nurses, and only three on operating room nurses as first assistants in robot-assisted surgery. Most studies examined team-training in RAS, including OR nurses, focused on emergency situations and conversion to an open procedure. Only a few studies addressed other competencies relevant to OR nurses in RAS. No randomized controlled trials were identified. Only a few studies used pre- and post-testing, and only one examined clinical outcomes. The quality assessment of the included studies was moderate to low, with a median MERSQI score of 10.3 and a median NOS-E score of 2. There is sparse research on the education of operating room nurses in robot-assisted surgery, and the literature emphasizes the training of surgeons. More research is needed to develop evidence-based training for operating room nurses in robot-assisted surgery.

Inpainting surgical occlusion from laparoscopic video sequences for robot-assisted interventions.

Medical technology for minimally invasive surgery has undergone a paradigm shift with the introduction of robot-assisted surgery. However, it is very difficult to track the position of the surgical tools in a surgical scene, so it is crucial to accurately detect and identify surgical tools. This task can be aided by deep learning-based semantic segmentation of surgical video frames. Furthermore, due to the limited working and viewing areas of these surgical instruments, there is a higher chance of complications from tissue injuries (e.g., tissue scars and tears). With the aid of digital inpainting algorithms, we present an application that uses image segmentation to remove surgical instruments from laparoscopic/endoscopic video. We employ a modified U-Net architecture (U-NetPlus) to segment the surgical instruments. It consists of a redesigned decoder and a pre-trained VGG11 or VGG16 encoder. The decoder was modified by substituting an up-sampling operation based on nearest-neighbor interpolation for the transposed convolution operation. Furthermore, these interpolation weights do not need to be learned to perform upsampling, which eliminates the artifacts generated by the transposed convolution. In addition, we use a very fast and adaptable data augmentation technique to further enhance performance. The instrument segmentation mask is filled in (i.e., inpainted) by the tool removal algorithms using the previously acquired tool segmentation masks and either previous instrument-containing frames or instrument-free reference frames. We have shown the effectiveness of the proposed surgical tool segmentation/removal algorithms on a robotic instrument dataset from the MICCAI 2015 and 2017 EndoVis Challenge. We report a 90.20% DICE for binary segmentation, a 76.26% DICE for instrument part segmentation, and a 46.07% DICE for instrument type (i.e., all instruments) segmentation on the MICCAI 2017 challenge dataset using our U-NetPlus architecture, outperforming the results of earlier techniques used and tested on these data. In addition, we demonstrated the successful execution of the tool removal algorithm from surgical tool-free videos that contained moving surgical tools that were generated artificially. Our application successfully separates and eliminates the surgical tool to reveal a view of the background tissue that was otherwise hidden by the tool, producing results that are visually similar to the actual data.

The RoboCOS Study: Development of an international core outcome set for the comprehensive evaluation of patient, surgeon, organisational and population level impacts of robotic assisted surgery.

The introduction of robot-assisted surgery is costly and requires whole system transformation, which makes the assessment of benefits (or drawbacks) complex. To date, there has been little agreement on which outcomes should be used in this regard. The aim of the RoboCOS study was to develop a core outcome set for the evaluation of robot-assisted surgery that would account for its impact on the whole system. Identification of a long-list of potentially relevant outcomes through systematic review of trials and health technology assessments; interviews with individuals from a range of stakeholder groups (surgeons, service managers, policy makers and evaluators) and a focus group with patients and public; prioritisation of outcomes via a 2-round online international Delphi survey; consensus meeting. 721 outcomes were extracted from the systematic reviews, interviews and focus group which were conceptualised into 83 different outcome domains across four distinct levels (patient, surgeon, organisation and population) for inclusion in the international Delphi prioritisation survey (128 completed both rounds). The consensus meeting led to the agreement of a 10-item core outcome set including outcomes at: patient level (treatment effectiveness; overall quality of life; disease-specific quality of life; complications (including mortality); surgeon level (precision/accuracy; visualisation); organisation (equipment failure; standardisation of operative quality; cost-effectiveness); and population (equity of access). The RoboCOS core outcome set, which includes the outcomes of importance to all stakeholders, is recommended for use in all future evaluations of robot-assisted surgery to ensure relevant and comparable reporting of outcomes.

Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections

BackgroundMany centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center.MethodsSingle center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010–February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications.ResultsAmong 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100–500] to 150 ml [IQR 50–300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001).ConclusionThe introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value.Graphical

Robot-assisted ex vivo neobladder reconstruction: preliminary results of surgical skill evaluation

PurposeAdvanced developments in the medical field have gradually increased the public demand for surgical skill evaluation. However, this assessment always depends on the direct observation of experienced surgeons, which is time-consuming and variable. The introduction of robot-assisted surgery provides a new possibility for this evaluation paradigm. This paper aims at evaluating surgeon performance automatically with novel evaluation metrics based on different surgical data.MethodsUrologists (n=10) from a hospital were requested to perform a simplified neobladder reconstruction on an ex vivo setup twice with different camera modalities (n=2) randomly. They were divided into novices and experts (n=5, respectively) according to their experience in robot-assisted surgeries. Different performance metrics (n=2) are proposed to achieve the surgical skill evaluation, considering both instruments and endoscope. Also, nonparametric tests are adopted to check if there are significant differences when evaluating surgeons performance.ResultsWhen grouping according to four stages of neobladder reconstruction, statistically significant differences can be appreciated in phase 1 (p=0.0284) and phase 2 (p=0.01953) with normalized time-related metrics and camera movement-related metrics, respectively. On the other hand, considering experience grouping shows that both metrics are able to highlight statistically significant differences between novice and expert performances in the control protocol. It also shows that the camera-related performance of experts is significantly different (p=0.003153) when handling the endoscope manually and when it is automatic.ConclusionSurgical skill evaluation, using the approach in this paper, can effectively measure surgical procedures of surgeons with different experience. Preliminary results demonstrate that different surgical data can be fully utilized to improve the reliability of surgical evaluation. It also demonstrates its versatility and potential in the quantitative assessment of various surgical operations.

Introduction of robot-assisted surgery in gynecology

Introduction of robot-assisted surgery in gynecology

Advantages and disadvantages of main surgical approaches for robot-assisted radical prostatectomy

The introduction of robotic-assisted surgery into clinical practice has opened up new possibilities for the surgical treatment of urological patients. Robot-assisted radical prostatectomy (RARP) is one of the most commonly performed robot-assisted surgery. The review is devoted to the main surgical approaches for RARP. An analysis of publications on this topic was carried out using the search engines of the scientific databases PubMed, Medscape, Google Scholar, eLibrary when writing the article The article presents an overview of the advantages and disadvantages of the existing four access options for RARP: anterior, perineal, lateral and posterior, as well as oncological and functional outcomes of operations. It has been shown that a surgeon with different approaches can choose the most suitable one for a given clinical situation, focusing on the stage of the disease, the patients age, anatomical features of the prostate gland, the state of the patients erectile function, and the history of operations on the abdominal cavity and pelvic organs.

The impact of surgical learning curve on survival – reopening the door for minimally invasive surgery in the management of cervical cancer?

Minimally invasive surgery has been widely adopted in gynaecological oncology with a significant surge since 2010 associated with the introduction of robot-assisted surgery. Up until 2018, virtually all testimonials of minimally invasive surgery for cervical cancer indicated equal oncological outcomes compared with laparotomy. The unexpected results from the only randomised controlled trial (Ramirez et al. N Engl J Med 2018;379:1895–904) seriously challenge the use of minimally invasive surgery for cervical cancer. However, the lack of plausible explanations for the inferior survival has made it hard for many gynaecological oncologists to accept the results at face value. Suggested causes such as the use of intrauterine manipulators and intracorporeal colpotomy may to some extent account for the detrimental outcomes but as practice differs widely worldwide, none of these factors seem convincing. In the current paper by Baeten et al., a different aspect of novel surgical technologies has been explored (BJOG 2020; https://doi.org/10.1111/1471-0528.16399). The adoption of any new modality/technology is clearly associated with a learning curve and it is well known from surgery that procedural outcomes, such as operative time, improve with increasing case numbers. However, the potential impact of learning curve on hard outcomes such as survival has scarcely been reported. Baeten et al. convincingly demonstrate that a substantial number of robot-assisted radical hysterectomies are required to overcome an initial harm. The authors point out that the learning curve should be considered institutional; suggesting that an individual learning curve may benefit from previous experiences at the specific institution. Intriguingly, similar data have not been presented for endometrial cancer, which may be related to the higher complexity of radical hysterectomy for cervical cancer. Although no specific changes were made over time in the current study, a learning curve may include modifications of surgical routines based on early experiences. Which specific improvements during the learning curve account for the increased survival are unclear but reduction of complications that could delay adjuvant treatment may be one. The data presented by Baeten et al. signify a solid effort to elucidate the underlying cause of the outcomes from the LACC trial, especially as the trial was launched at a time when most surgeons had limited experience from laparoscopic/robotic radical hysterectomy. The study should raise the awareness of surgical learning curve in the context of survival in oncological surgery. It also brings us to the most important question – how do we avoid harming our patients when novel technologies are adopted? The authors suggest that centralisation and structured training represent two of the most important strategies to mitigate the effects of early errors. Interestingly, recent population-based studies from countries with high levels of centralisation do not corroborate the findings from the LACC trial (Alfonzo et al. Eur J Cancer 2019;29:1072–6; Jensen et al. Eur J Cancer 2020;128:47–56). Although the current study may reopen the door for robotic surgery in the management of cervical cancer, prospective randomised trials are needed to ensure its safety. The impact of surgical learning curve should be considered in any future trial exploring oncological safety for procedural interventions. HF is a proctor for Intuitive Surgical Inc. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation.

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease.

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Research as the gatekeeper: introduction ofrobotic-assisted surgery into the public sector.

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

A Comparison of the Clinical Outcomes in Uterine Cancer Surgery After the Introduction of Robotic-Assisted Surgery.

To compare the rates of intraoperative and postoperative complications of open and robotic-assisted surgery in the treatment of endometrial cancer. This retrospective study was performed at a single academic institution from January 2014 to February 2017 in the Department of Gynecology Oncology at Amrita Institute of Medical Science, Kerala, India. The study included patients with clinically early stage uterine malignancy undergoing open or robotic-assisted surgery. Data collected included clinicopathological factors, intraoperative data, length of hospital stay and intraoperative and postoperative (early and late and severity according to Clavien-Dindo classification). Morbidity was compared between two groups. The study included 128 patients, of whom 61 underwent open surgery and 67 underwent robotic-assisted surgery. Mean operative time (P = 0.112), mean estimated blood loss (P < 0.001), number of patients requiring blood transfusion (P < 0.001) and mean length of hospital stay (P < 0.001) were significantly lower in robotic group. None of the patients in robotic group experienced intraoperative hemorrhage (P = 0.010). The early postoperative complications, SSI (P < 0.001), infection (P = 0.002), and urinary complications (P = 0.030) and late postoperative complications lymphoedema (P = 0.002), vault-related complications (1.5% robotic vs. 6.6% open) and incisional hernia (none in robotic vs. 4.9% in open) were significantly lower in robotic group. Grade-II complications (Clavien-Dindo classification) were significantly lower in robotic group (P < 0.001). Robotic-assisted surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay.

Minimally invasive robot-assisted gastric bypass after open Mason reduction gastroplasty

The introduction of robot-assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This article describes the experiences with aconversion surgery from acomplicated open Mason gastroplasty to aRoux en Y gastric bypass using the da Vinci Xi robotic system. A29-year-old female patient underwent aMason reduction gastroplasty by laparotomy in 1995 (body mass index BMI 53.2 kg/m2). The course was complicated with arevision due to abscess formation and subsequent secondary healing. In 1996 an open revision of the gastroplasty due to persisting gastroesophageal reflux disease and outlet stenosis with dilatation of the outlet and an open cholecystectomy for cholecystolithiasis were performed . Abdominoplasty was performed for skin flaps in 2001 after the patient had lost 68 kg in weight. The patient presented at our hospital because of insufficient weight reduction even with weight gain since 2001 and treatment-refractive gastroesophageal reflux with adhesion problems. Clinical examination revealed normal scar tissue formation with no indications for an incisional hernia. The BMI was 48.2 kg/m2 with a body weight of 124 kg. The surgery was performed using ada Vinci Xi robotic system after access via a blunt dissection with the introduction of two trocars and adhesiolysis. The gastric pouch was created using Echelon 60 mm cartridges via an additional trocar. The gastroenterostomy was constructed with a150 cm alimentary loop and a60 cm biliodigestive loop resulting in aRoux en Ybypass. The operating time was 224 min. The postoperative course was uneventful. Enteral nutrition was resumed on day 2 and the patient was discharged from the hospital 4days postoperation. This preliminary experience suggests that robotic revisional surgery can be performed safely even after complicated bariatric operations.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

BackgroundThe implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.ObjectivesTo (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.DesignRealist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.FindingsThe introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.ConclusionsOur research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.LimitationsThis study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.Future workFuture research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Robotic-assisted laparoscopic nephrectomy.

The introduction of robot-assisted surgery has helped practitioners implement laparoscopic approached to complex retroperitoneal and renal surgery. Urologists are now more frequently completing surgeries such as radical nephroureterectomy, radical nephrectomy with IVC thrombectomy, and retroperitoneal lymphadentectomy via a laparoscopic approach than ever before. This review discusses the rational of the above surgeries as well as a technical step-by-step description of our robotic nephroureterectomy surgical approach.

Current status of robot-assisted surgery.

The introduction of robot-assisted surgery, and specifically the da Vinci Surgical System, is one of the biggest breakthroughs in surgery since the introduction of anaesthesia, and represents the most significant advancement in minimally invasive surgery of this decade. One of the first surgical uses of the robot was in orthopaedics, neurosurgery, and cardiac surgery. However, it was the use in urology, and particularly in prostate surgery, that led to its widespread popularity. Robotic surgery, is also widely used in other surgical specialties including general surgery, gynaecology, and head and neck surgery. In this article, we reviewed the current applications of robot-assisted surgery in different surgical specialties with an emphasis on urology. Clinical results as compared with traditional open and/or laparoscopic surgery and a glimpse into the future development of robotics were also discussed. A short introduction of the emerging areas of robotic surgery were also briefly reviewed. Despite the increasing popularity of robotic surgery, except in robot-assisted radical prostatectomy, there is no unequivocal evidence to show its superiority over traditional laparoscopic surgery in other surgical procedures. Further trials are eagerly awaited to ascertain the long-term results and potential benefits of robotic surgery.

Focal Therapy and Prostate Cancer

The International Task Force on Prostate Cancer defines focal therapy (FT) for prostate cancer (PCa) as the therapy that "selectively ablates known disease and preserves existing functions, with the overall objective of minimizing lifetime morbidity without compromising life expectancy". FT for the treatment of PCa has been called the "male lumpectomy", an analogue to women's breast lumpectomy for the treatment of breast cancer. Radical prostatectomy continues to be the most frequently performed treatment for localized PCa, as anatomic knowledge and several technical advances, i.e. the introduction of robotic assisted surgery, have led to successful oncological outcome and lower rates of post-treatment morbidity. However, a proportion of patients still experiences a no negligible sexual, urinary, and bowel morbidity. Although the rationale of active surveillance for low-risk PCa (PSA <10 ng/mL, Gleason grade 6 or less, and clinical stage T1c-T2a) is sound, only few of newly diagnosed patients elect this approach. Thus, in the recent years the concept of a "subtotal therapy" gained the interest of some urological schools. The aim of this paper is to review the existing literature in order to provide the status of art on FT for PCa. The manuscript will focus on the characteristics of the target population, on the pre-operative evaluation to localise disease, as well as on perioperative, functional, and disease-control following focal therapy.

We can’t afford to be laggards

It seems unlikely that a month can go by without an insightful article or commentary in the specialty or lay press focused on robots and the subsequent costs, benefits and potential harm in urological surgery. Those interested in diffusion of innovation theory will continue to have a field day dissecting the characteristics of the early adopters, the early and late majority as well as the laggards (which likely will include most of us in Canada). The enablers for the early adopters of robotic-assisted surgery are obvious given the impressive technology and, particularly, the market forces. The barriers are arguably more complex, including the knowledge gap around perceived benefit, the compatibility with attaining and maintaining competing skill sets and, of course, the reality of fiscal responsibility. Global dissemination and reinvention of robotic-assisted surgery seem destined to creep along given the vagaries in cost of quality issues surrounding its flagship, robotic assisted laparoscopic prostatectomy (RALP). Multiple prospective observational studies, as well as population-based evaluations of outcomes across surgical approaches, hint at superior perioperative outcomes for RALP.1 However, the questionable evidence from these studies has raised a call for higher research standards and a re-focusing on quality and comparative efficacy of all treatment approaches for prostate cancer.2,3 Still, the issues facing us around this technology adoption are not going away soon: most of us will recall that the Third Law of Robotics is that “a robot must protect its own existence” (with all due credit to those who have first alluded to Isaac Asimov in this discussion). Dramatic changes in technology have inspired educational innovation as well as debate in urological surgery. One could argue that a certain “learning curve” had been attained in most academic programs addressing the conversion and balance of open and pure laparoscopic surgery to suit the needs of residents. The introduction of robotic-assisted surgery will be more difficult to juggle. These educational concerns will have been naturally addressed in the United States due to more rapid adoption of robots outside of training centres with an unintended, although perhaps fortuitous, centralization of surgical care.3 The substantially slower adoption of robotic technology in other countries, particularly in Canada, will not facilitate this transition as easily. These issues are highlighted by two articles in this issue of the CUAJ which survey both trainees and educators in Canadian programs.4,5 The respondents of these relatively small studies confirm a perceived variability in teaching and evaluation of technical skills in general, and intimate at misgivings around robotic experiences specifically. Although these observations are limited in scope and time, it would seem apparent that these issues need to be proactively addressed with a national dialogue. The Royal College of Physicians and Surgeons of Canada Objectives in Training (the benchmark for our educational standards) lists open prostatectomy as an “A” procedure, one that the trainee should be expert at completing independently, as compared to a laparoscopic prostatectomy which is listed as a “C” procedure. To be fair, these have been last updated in 2009 (an eternity it seems in technology advances) and undoubtedly the specialty committee in urology has been struggling with these training issues involving minimally invasive surgery in Canadian programs. However, given the rapidly moving target that is prostate cancer and the real need to improve the quality of our collective care, we need clear direction from our surgical and educational leaders. How do we best construct apposite and consistent guidelines for technical training, simulation and credentialing in a way that ensures trainees can attain, and maintain, their skills for the realities of practice now and in the future landscape of operative urology? In this, we can ill afford to be laggards.