Nerve-sparing Robot-assisted Radical Prostatectomy Research Articles

Long-Term Oncological Outcomes after Nerve-Sparing Robot-Assisted Radical Prostatectomy for High-Risk Localized Prostate Cancer: A Single-Center, Two-Arm Prospective Study.

To compare the oncological outcomes of patients with high-risk localized prostate cancer undergoing nerve-sparing and non-nerve-sparing robot-assisted radical prostatectomy (RARP). Between November 2002 and December 2018, we prospectively recorded the data of patients undergoing RARP for high-risk localized prostate cancer (PCa) at our tertiary referral center. NSS (nerve-sparing surgery) was carefully offered on the basis of the preoperative clinical characteristics of the patients and an intraoperative assessment. The patients were stratified into two groups: nerve-sparing and non-nerve-sparing groups (yes/no). Radical prostatectomies were performed by 10 surgeons with a robot-assisted technique using a daVinci® surgical system. The primary oncological outcome evaluated was biochemical recurrence (BCR). The secondary oncological outcomes assessed were positive surgical margins (PSMs) and cancer-specific survival (CSS). A total of 779 patients were included in the study: 429 (55.1%) underwent NSS while 350 (44.9%) underwent non-NSS. After a mean (±SD) follow-up of 192 (±14) months, 328 (42.1%) patients developed BCR; no significant difference was found between the NSS and non-NSS groups (156 vs. 172; p = 0.09). Both our univariable and multivariable analyses found that the nerve-sparing approach was not a predictor of BCR (p > 0.05). Kaplan-Mayer survival curves for BCR showed no significant difference among the non-NSS, unilateral NSS, and bilateral NSS groups (log rank test = 0.6). PSMs were reported after RARPs for 254 (32.6%) patients, with no significant difference between the NSS and non-NSS group (143 vs. 111; p = 0.5). In the subgroup of 15 patients who died during the follow-up period, mean (±SD) CSS was 70.5 (±26.1) months, with no significant difference between the NSS and non-NSS groups (mean CSS: 70.3 vs. 70.7 months). NSS does not appear to negatively impact the oncological outcomes of patients with high-risk PCa. Randomized clinical trials are needed to confirm our promising findings.

Neurovascular Structure-Adjacent Frozen-Section Examination (NeuroSAFE) Technique of Nerve-Sparing Robot-Assisted Radical Prostatectomy (RARP) in Indian Scenario: Technique, Feasibility, and Early Outcomes.

Potency and urinary continence are adversely affected post-prostatectomy. The primary objective is oncological safety by ensuring negative surgical margins (NSM) and best functional recovery through nerve preservation in appropriate patients. NeuroSAFE technique of intra-operative frozen-section (IFS) analysis was devised for comprehensive assessment of surgical margins adjacent to the neurovascular tissue surface of the prostate. We analyzed our initial experience with this technique. Five NS-RARPs were performed utilizing the NeuroSAFE technique between October 2021 and February 2022. Patient demographics, disease stage, operative console time, post-operative complications, final histopathology, biochemical recurrence (BCR), erectile function, and urinary continence were recorded. The mean age of patients was 59.2 ± 1.3years. All had clinically organ-confined disease with ISUP grade ≤ 3. The mean operative time of NS-RARP with NeuroSAFE was 240 ± 21min and average NeuroSAFE time was 45 ± 3.8min. All patients had NSM on IFS. No patient had Clavien-Dindo grade > 1 complications. Margins were negative on final histopathology. No patient had BCR at 6 and 12weeks. Three patients were able to have sexual intercourse and only one patient required single precaution pad at 12weeks. NeuroSAFE is feasible and can ensure intra-operative oncological safety of the NS procedure. Moreover, it gives the opportunity to convert positive surgical margin to prognostically favorable NSM by secondary resection. Our initial experience which is the first in India is encouraging with favorable functional outcomes. Large prospective studies and longer follow-up are required specially to evaluate the oncological benefit.

Novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation and long-term outcomes for a single surgeon

Although novel techniques for avoiding incontinence during robot-assisted radical prostatectomy have been developed, long-term oncological outcomes are unknown. The objective of this study was to determine the long-term oncological outcomes and functional outcomes of novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation for a single surgeon. Data from 100 patients who underwent structure-preserving prostatectomies performed by a single surgeon were retrospectively analyzed. The median console time was 123 min. Bilateral nerve-sparing was performed in 43% of patients underwent, and 57% underwent unilateral nerve-sparing surgery. Most patients (96%) reached complete pad-zero urinary continence by one year after surgery. Satisfactory erectile function was achieved in 97% of patients who underwent bilateral nerve-sparing surgery, and 80% of patients who underwent unilateral nerve-sparing surgery. The surgical margin was positive for 25% of patients, and the biochemical recurrence-free rate at 5 years was 77%. The cancer-specific survival rate was 100% during the median follow-up period of 4.5 years. Clavien-Dindo grade III complications occurred in 1% of cases. The outcomes for novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation were similar to previously reported oncological outcomes, with satisfactory functional outcomes. This operative method may be useful for patients who are eligible for nerve-sparing surgery.

A transparent synthetic peptide hydrogel as a haemostatic agent in athermal nerve sparing robot-assisted radical prostatectomy: an observational study.

PuraStat® is a new synthetic haemostatic agent constituting peptides that self-assemble into sheets when exposed to ionic charges. The objective of this submission is to assess the perioperative, functional and user-reported outcomes of PuraStat® as an athermal topical haemostatic agent for use on the neurovascular bundle (NVB) in robot-assisted radical prostatectomy (RARP), and to inform further research into this developing field. Demographic and disease data for 29 consecutive patients undergoing RARP were recorded. PuraStat® was used as the primary haemostatic agent to the NVB, without thermal or suture haemostasis, unless necessary. Preoperative, 1-h postoperative and 24-h postoperative haemoglobin (Hb) were measured. Operative data including postoperative complications up to 30 days were noted. Urinary function, continence and erectile function (EF) were measured pre- and postoperatively with the International Prostate Symptom Score (IPSS), patient reporting of pad usage, and International Index of Erectile Function (IIEF)-5 respectively. A qualitative assessment of PuraStat® was made intraoperatively by the surgical assistant in the following categories: transparency, haemostatic efficacy, ready-to-use, handling, and overall satisfaction. Twenty-nine males aged between 49 and 75 years underwent a nerve-sparing RARP under a single surgeon for clinically significant prostate cancer with PuraStat® used as the primary haemostatic agent at the NVB. One patient required an additional haemostatic suture. The median prostate volume was 36 mL. Mean blood loss was 363 mL. The mean Hb at 1 and 24 h postoperative was 135.2 and 125.1 mg/dL. Median Hb change from 1-24 h postoperative was 11 mg/dL. No transfusions were required, and there were no postoperative complications. Urinary function and continence were preserved. EF in our series was lower than published data. Our observational study suggests that PuraStat® is a safe haemostatic agent in RARP with similar perioperative bleeding outcomes, comparable long-term urinary outcomes and a high level of intraoperative user satisfaction. The effects on EF requires further investigation. PuraStat® appears to be a useful therapeutic tool for the urologist performing RARPs.

Early and late urinary continence outcomes after unilateral and bilateral nerve-sparing robot-assisted radical prostatectomy: A retrospective multicentre cohort study in Japan (the MSUG94 group).

The impact of unilateral and bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (NS-RARP) procedures on continence and the time to continence recovery have not been established. We retrospectively reviewed a total of 2801 patients who underwent RARP in 9 institutions. Procedures were classified as NS or non-NS; NS procedures were further classified as unilateral or bilateral. The recovery of continence was analysed using propensity score matching method. The pad-free rates at 12months after surgery were higher in the NS group (95% confidence interval of odds ratio, 1.06-1.51). Pad-free rates at all time points within 12months of surgery did not significantly differ between the unilateral and bilateral NS groups. NS-RARP resulted in better urinary continence outcomes than non-NS-RARP in the first 12months after surgery. Urinary recovery rates did not significantly differ between unilateral and bilateral NS-RARP.

Comparing pentafecta outcomes between nerve sparing and non nerve sparing robot-assisted radical prostatectomy in a propensity score-matched study

Pentafecta (continence, potency, cancer control, free surgical margins, and no complications) is an important outcome of prostatectomy. Our objective was to assess the pentafecta achievement between nerve-spring and non-nerve-sparing robot-assisted radical prostatectomy (RARP) in a large single-center cohort. The study included 1674 patients treated with RARP between August 2009 and November 2022 to assess the clinical outcomes. Cox regression analyses were performed to evaluate the prognostic significance of RARP for pentafecta achievement, and 1:1 propensity score matching (PSM) was performed between the nerve-sparing and non-nerve-sparing to test the validity of the results. Pentafecta definition included continence, which was defined as the use of zero pads; potency, which was defined as the ability to achieve and maintain satisfactory erections or ones firm enough for sexual activity and sexual intercourse. The biochemical recurrence rate was defined as two consecutive PSA levels > 0.2 ng/mL after RARP; 90-day Clavien–Dindo complications ≤ 3a; and a negative surgical pathologic margin. The median follow-up period was 61.3 months (IQR 6–159 months). A multivariate Cox regression analysis demonstrated that pentafecta achievement was significantly associated with nerve-sparing (NS) approach (1188 patients) (OR 4.16; 95% CI 2.51–6.9), p < 0.001), unilateral nerve preservation (983 patients) (OR 3.83; 95% CI 2.31–6.37, p < 0.001) and bilateral nerve preservation (205 patients) (OR 7.43; 95% CI 4.14–13.36, p < 0.001). After propensity matching, pentafecta achievement rates in the NS (476 patients) and non-NS (476 patients) groups were 72 (15.1%) and 19 (4%), respectively. (p < 0.001). NS in RARP offers a superior advantage in pentafecta achievement compared with non-NS RARP. This validation study provides the pentafecta outcome after RARP associated with nerve-sparing in clinical practice.

PE027 - Artificial intelligence 3D augmented reality guided intraoperative biopsy helps to improve oncological safety during nerve-sparing robotic-assisted radical prostatectomy

PE027 - Artificial intelligence 3D augmented reality guided intraoperative biopsy helps to improve oncological safety during nerve-sparing robotic-assisted radical prostatectomy

Three-dimensional automatic artificial intelligence driven augmented-reality selective biopsy during nerve-sparing robot-assisted radical prostatectomy: A feasibility and accuracy study

ObjectiveTo evaluate the accuracy of our new three-dimensional (3D) automatic augmented reality (AAR) system guided by artificial intelligence in the identification of tumour's location at the level of the preserved neurovascular bundle (NVB) at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy. MethodsIn this prospective study, we enrolled patients with prostate cancer (clinical stages cT1c–3, cN0, and cM0) with a positive index lesion at target biopsy, suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging. Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital (Orbassano, Turin, Italy), from December 2020 to December 2021. At the end of extirpative phase, thanks to our new AAR artificial intelligence driven system, the virtual prostate 3D model allowed to identify the tumour's location at the level of the preserved NVB and to perform a selective excisional biopsy, sparing the remaining portion of the bundle. Perioperative and postoperative data were evaluated, especially focusing on the positive surgical margin (PSM) rates, potency, continence recovery, and biochemical recurrence. ResultsThirty-four patients were enrolled. In 15 (44.1%) cases, the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging (Wheeler grade L2) while in 19 (55.9%) cases extracapsular extension was detected (Wheeler grade L3). 3D AAR guided biopsies were negative in all pathological tumour stage 2 (pT2) patients while they revealed the presence of cancer in 14 cases in the pT3 cohort (14/16; 87.5%). PSM rates were 0% and 7.1% in the pathological stages pT2 and pT3 (<3 mm, Gleason score 3), respectively. ConclusionWith the proposed 3D AAR system, it is possible to correctly identify the lesion's location on the NVB in 87.5% of pT3 patients and perform a 3D-guided tailored nerve-sparing even in locally advanced diseases, without compromising the oncological safety in terms of PSM rates.

Predicting Surgical Experience After Robotic Nerve-sparing Radical Prostatectomy Simulation Using a Machine Learning-based Multimodal Analysis of Objective Performance Metrics.

Machine learning methods have emerged as objective tools to evaluate operative performance in urological procedures. Our objectives were to establish machine learning-based methods for predicting surgeon caseload for nerve-sparing robot-assisted radical prostatectomy using our validated hydrogel-based simulation platform and identify potential metrics of surgical expertise. Video, robotic kinematics, and force sensor data were collected from 35 board-certified urologists at the 2022 American Urological Association conference. Video was annotated for surgical gestures. Objective performance indicators were derived from robotic system kinematic data. Force metrics were calculated from hydrogel model integrated sensors. Data were fitted to 3 supervised machine learning models-logistic regression, support vector machine, and k-nearest neighbors-which were used to predict procedure-specific learning curve proficiency. Recursive feature elimination was used to optimize the best performing model. Logistic regression predicted caseload with the highest AUC score for 5/7 possible data combinations (force, 64%; objective performance indicators + gestures, 94%; objective performance indicators + force, 90%; gestures + force, 93%; objective performance indicators + gestures + force, 94%). Support vector machine predicted the highest AUC score for objective performance indicators (82%) and gestures (94%). Logistic regression with recursive feature elimination was the most effective model reaching 96% AUC in predicting case-specific experience. Most contributory features were identified across all model types. We have created a machine learning-based algorithm utilizing a novel combination of objective performance indicators, gesture analysis, and integrated force metrics to predict surgical experience, capable of discriminating between surgeons with low or high robot-assisted radical prostatectomy caseload with 96% AUC in a standardized, simulation-based environment.

Measuring thermal spread during bipolar cauterizing using an experimental pneumoperitoneum and thermal sensors.

During nerve-sparing robot-assisted radical prostatectomy (RARP) bipolar electrocoagulation is often used but its use is controversial for the possible thermal damage of neurovascular bundles. Aim of the study was to evaluate the spatial-temporal thermal distribution in the tissue and the correlation with the electrosurgery-induced tissue damage in a controlled, CO2-rich environment modelling the laparoscopy conditions.. We manufactured a sealed plexiglass chamber (SPC) equipped with sensors to reproduce experimentally the environmental conditions of pneumoperitoneum during RARP. We evaluated in 64 pig musculofascial tissues (PMTs) of approximately 3 cm3 × 3 cm3 × 2 cm3 the spatial-temporal thermal distribution in the tissue and the correlation with the electrosurgery-induced tissue damage in a controlled CO2-rich environment modeling the laparoscopy conditions. Critical heat spread of bipolar cauterizing during surgical procedure was assessed by the employment of a compact thermal camera (C2) with a small core sensor (60 × 80 microbolometer array in the range 7-14 μm). Bipolar instruments used at 30 W showed a thermal spread area of 18 mm2 when applied for 2 s and 28 mm2 when applied for 4 s. At 60 W, bipolar instruments showed a mean thermal spread and 19 mm2 when applied for 2 s; and 21 mm2 when applied for 4 s. Finally, histopathological analysis showed that thermal damage is distributed predominantly on the surface rather than in depth. The application of these results is very interesting for the definition of an accurate use of bipolar cautery during nerve-sparing RARP. It demonstrates the feasibility of using miniaturized thermal sensors, thus addressing the potential for next developments regarding the design of thermal endoscopic devices for robotic use.

Nerve-sparing robot-assisted radical prostatectomy with the HUGO™ robot-assisted surgery system using the 'Aalst technique'.

Nerve-sparing robot-assisted radical prostatectomy with the HUGO™ robot-assisted surgery system using the 'Aalst technique'.

Effects of different surgical modalities for nerve-sparing robot-assisted radical prostatectomy on postoperative erectile function: a systematic review and one-arm meta-analysis

ABSTRACT Maintaining erectile function is an important quality of life issue for patients with localized prostate cancer treated with robotic-assisted radical prostatectomy (RARP). However, most existing studies are retrospective and inherently weak and cannot conclude which NS approach is most effective in restoring function in patients. We therefore performed a consistent and objective assessment of sexual function outcomes in RARP using different nerve-sparing methods to optimize postoperative outcomes. A systematic review and meta-analysis was performed based on PRISMA and STROBE statement criteria. Statistical analysis was performed using StataMP software version 14. The Newcastle-Ottawa scale was used to assess the risk of bias. This single-arm meta-analysis included 3 randomized controlled trials and 14 cohort studies with a total of 3756 patients. Our meta-analysis found that patients had the highest efficiency rate of 0.86 (0.78, 0.93) after the NS technique using the retrograde method. Overall, there are significant differences between RARP NS techniques and outcomes, and the ideal technical strategy to optimize outcomes remains controversial. However, there is consensus on the importance of careful separation, dissection of the NVB, reduction of traction and thermal injury, and preservation of the fascia around the prostate. We still need more well-designed randomized controlled trials with videos describing the details of the different surgical techniques before they can be replicated.

V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE”

You have accessJournal of UrologyCME1 Apr 2023V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE” Marco Paciotti, Carlo Andrea Bravi, Mottaran Angelo, Luigi Nocera, Luca Sarchi, Rui Farinha, Adele Piro, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Frederiek D'Hondt, Geert De Naeyer, Aalst, Belgium, Ruben De Groote, and Alexandre Mottrie Marco PaciottiMarco Paciotti More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Mottaran AngeloMottaran Angelo More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Rui FarinhaRui Farinha More articles by this author , Adele PiroAdele Piro More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Frederiek D'HondtFrederiek D'Hondt More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Aalst Aalst More articles by this author , Belgium Belgium More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The HUGO™ RAS is a competitor for leadership in the field of robotic surgery. However, concerns remain about the ease of use of this device by new adopters. We performed the first robot-assisted radical prostatectomy (RARP) procedure in Europe with Hugo RAS. In this video, we described our surgical technique for bilateral nerve-sparing (NS) RARP performed using this novel platform. We also reported surgical setting and outcomes of our case series. METHODS: The procedure shown in the video was performed by an experienced robotic surgeon (AM) using HUGO RAS in March 2022. This robotic platform consists of four independent arm carts, novel design hand controllers and an open console. We described a RARP performed according the “Aalst technique”, including useful surgical tips. Moreover, we reported perioperative, pathological and short-term functional outcomes of consecutive patients affected by low- or intermediate-risk prostate cancer (PCa) who underwent NS RARP with HUGO RAS between February and October 2022 at our Center. RESULTS: Patients were in Trendelemburg position. One eleven-mm endoscope port was placed on the midline above the umbilicus, while other three 8 mm robotic ports were placed on a transversal line 5 cm below the optic port. Two laparoscopic ports were positioned in the right hemi-abdomen. Three arm carts were docked from the left of the operative bed, and one from the right. RARP was performed with a trans-peritoneal, anterior approach following validated metrics. Some of the specific characteristics our of technique, described in the video, are: sparing of the median umbilical ligament, postero-lateral approach to the bladder neck, antero-lateral release of the neurovascular bundles, dissection of the apex according to the “collar technique”, posterior muscolofascial reconstruction incorporated into urethrovesical anastomosis. Overall, 76 patients affected by low- or intermediate-risk PCa underwent RARP with HUGO RAS using this technique. In every case, all the steps of the procedure were completed. No intraoperative complication was recorded. Full outcomes are reported in the video. CONCLUSIONS: In this video, we described a step-by-step NS RARP performed according to our technique using the novel HUGO RAS. We provided useful tips to perform critical phases of the procedure. Experienced surgeons were able to easily perform all the surgeries with optimal perioperative, pathological, and functional outcomes. Therefore, we showed that surgical experience can be easily transferred to this novel platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Carlo Andrea Bravi More articles by this author Mottaran Angelo More articles by this author Luigi Nocera More articles by this author Luca Sarchi More articles by this author Rui Farinha More articles by this author Adele Piro More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Frederiek D'Hondt More articles by this author Geert De Naeyer More articles by this author Aalst More articles by this author Belgium More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

PD30-01 USING MACHINE LEARNING TO CLASSIFY PROCEDURE-SPECIFIC SURGICAL EXPERIENCE BASED ON SURGICAL GESTURE RECOGNITION IN A RADICAL PROSTATECTOMY SIMULATION

You have accessJournal of UrologyCME1 Apr 2023PD30-01 USING MACHINE LEARNING TO CLASSIFY PROCEDURE-SPECIFIC SURGICAL EXPERIENCE BASED ON SURGICAL GESTURE RECOGNITION IN A RADICAL PROSTATECTOMY SIMULATION Nathan Schuler, Lauren Shepard, Tyler Holler, Patrick Saba, and Ahmed Ghazi Nathan SchulerNathan Schuler More articles by this author , Lauren ShepardLauren Shepard More articles by this author , Tyler HollerTyler Holler More articles by this author , Patrick SabaPatrick Saba More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003316.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Effectiveness of nerve sparing robot assisted radical prostatectomy (NS-RARP) is mainly based on recovery of postoperative erectile function. Previously, robotic kinematic data differentiated surgical expertise in suturing tasks and predicted continence rates. Using a validated realistic NS-RARP simulation with embedded sensors measuring torque on neurovascular bundles (NVB), our objective was to apply machine learning algorithms to classify surgical experience based on pure surgical gesture data inputs. METHODS: 50 certified urologists with average robotic case volumes (RV) of 1206 (range 100 - >5000) completed surveys and a NS-RARP simulation, during which video and force sensor data were collected. Videos were annotated for ten approved individual surgical gestures (e.g., cut, traction etc.) and aggregated based on instrument used and combinations of multiple gestures. Total force, average force, and number of force peak events were calculated. With a total of 33 inputs, output included total/NS-RARP case volume and NVB force data. Data was fit to a Gaussian Mixture model, then separated based on gesture utilization patterns. Tukey’s HSD test was used to determine significance in inter-group comparisons of RV and force metrics. RESULTS: Participants were clustered into 3 groupings based on mean total RV: 14 Super-Users (SU) (2221), 14 High Volume (HV) (1017), and 5 Low Volume (LV) (110) urologists (Figure 1). Significant differences were found between SU and HV for both Robotic case (p=0.03) and RARP volumes (p=0.008). Gesture pattern comparisons showed significant differences between SU vs HV and HV v LV in 64% and 30% of gesture inputs respectively. Force sensor comparisons showed significant differences in Total Force and Force Peak events between SU vs LV (p=0.014; p=0.021) and HV vs LV (p=0.021; p=0.046) groups. No significant differences in forces between SU and HV were found. CONCLUSIONS: This machine learning algorithm successfully categorized surgical experience into caseload and force applied, based solely on gesture inputs within a realistic simulated NS-RARP task. Differences in gestures differentiated HV from SU urologists, alluding to potential for targeted areas of improvement in gesture patterns, even for HV surgeons. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e830 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Schuler More articles by this author Lauren Shepard More articles by this author Tyler Holler More articles by this author Patrick Saba More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP26-11 PROJECT SURGICAL RADAR: MASTERY REGISTRY OF OBJECTIVE PERFORMANCE INDICATORS DURING A REALISTIC NERVE-SPARING ROBOTIC RADICAL PROSTATECTOMY SIMULATION

You have accessJournal of UrologyCME1 Apr 2023MP26-11 PROJECT SURGICAL RADAR: MASTERY REGISTRY OF OBJECTIVE PERFORMANCE INDICATORS DURING A REALISTIC NERVE-SPARING ROBOTIC RADICAL PROSTATECTOMY SIMULATION Nathan Schuler, Lauren Shepard, Andrea Smith, Sue Kulason, Andrew Yee, and Ahmed Ghazi Nathan SchulerNathan Schuler More articles by this author , Lauren ShepardLauren Shepard More articles by this author , Andrea SmithAndrea Smith More articles by this author , Sue KulasonSue Kulason More articles by this author , Andrew YeeAndrew Yee More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy (NS-RARP) ranges from 8% to 49% even by high-volume surgeons with no consensus on granular tasks that result in the best potency. Studies found robotic kinematic data to correlate with select RARP clinical outcomes. We analyzed Objective Performance Indicators (OPIs) from a mastery registry of high-volume urologists performing a NS-RARP simulation to identify which metrics can predict operative expertise. METHODS: Thirty urologists (avg. RARP volume=734) performed a NS-RARP on a validated, realistic, hydrogel model with force sensors embedded in the neurovascular bundle (NVB). Robotic kinematic (51 OPIs) and force (number of force peaks, variability, average and total force) data were collected. These OPIs were mapped to broader technical skill categories and used to build logistic regression classifiers that predict the probability of case volume and force data. Data was fit to a Gaussian Mixture model, then separated based on OPIs. Tukey’s HSD test was used to determine significance in inter-group comparisons of overall robotic, RARP volume and force metrics RESULTS: Urologists were clustered into 3 groups based on mean total Overall robotic and RARP volume into 7 Super-Users (SU), 14 High Volume (HV), and 9 Low Volume (LV) surgeons (Figure 1a). OPIs were categorized into 3 broad categories: robotic efficiency, tool motion, and operative fluidity. A significant difference (<0.05) across groups was seen in 31 OPIs (18 across all 3 groups, 10 when comparing SU vs HV and HV vs LV, and 6 when comparing HV vs LV groups). Force metrics showed significant difference comparing SU and HV to LV (Figure 1a). A significant negative correlation was found between force metrics and robotic volume, RARP volume and 13 OPIs (5 robotic efficiency , 4 tool motion, and 4 operative fluidity OPIs) (Figure 1b). CONCLUSIONS: Experienced urologists demonstrated a higher incidence of operative fluidity and tool efficiency OPIs, which are also predictive of less force data applied to the NVB during the simulation. These specific actions specific to super users may improve surgical efficiencies through structured feedback. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e356 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Schuler More articles by this author Lauren Shepard More articles by this author Andrea Smith More articles by this author Sue Kulason More articles by this author Andrew Yee More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

Advanced Reconstruction of Vesicourethral Support May Improve Urinary Continence and Quality of Life After Non-nerve-sparing Robot-assisted Radical Prostatectomy.

Postoperative urinary incontinence (UI) after robot-assisted radical prostatectomy (RARP) has a significant impact on patients' quality of life (QOL). Several surgical techniques have been reported to improve postoperative UI. The aim of the study was to investigate the impact of advanced reconstruction of vesicourethral support (ARVUS) on urinary symptoms and QOL after non-nerve-sparing robot-assisted radical prostatectomy (RARP). Patients who underwent non-nerve-sparing RARP from October 2010 to October 2020 at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine were reviewed. Patients were divided into the ARVUS and non-ARVUS groups, and propensity score matching was performed. Patients were evaluated by the International Prostate Symptom Score (IPSS), Incontinence Modular Questionnaire Short Form (ICIQ-SF), QOL index, and number of pads used before and 1, 3, 6, and 12 months after RARP. The number of patients in the ARVUS and non-ARVUS group were 41 and 41, respectively. On cystography, the distance of the symphysis pubis to the bladder neck was significantly shorter (p<0.001) and the posterior urethrovesical angle was significantly smaller in the AUVUS group (p<0.001). In the ICIQ-SF, the ARVUS group was significantly better at 6 and 12 months postoperatively. In the IPSS, the ARVUS group was significantly better than the non-ARVUS group at 3 months postoperatively. In a multivariable analysis, membranous urethral length [odds ratio (OR)=3.44, p=0.015] and ARVUS (OR=2.72, p=0.046) were significant factors in achieving 0 pads and total ICIQ-SF Question 1 and 2 scores of ≤2 at 12 months postoperatively. ARVUS improved urinary symptoms and QOL. ARVUS seems to be a useful surgical procedure for non- nerve-sparing RARP.

Association of nerve-sparing grading in robotic radical prostatectomy and trifecta outcome.

To evaluate the neurovascular bundle preservation grades during robotic-assisted radical prostatectomy and compared to the trifecta combined outcome (oncologic control, continence, and sexual function) twelve months after the surgery. Cohort of patients who underwent nerve-sparing robotic-assisted radical prostatectomy had the neurovascular bundle preservation retrospectively graded from 0 to 8 according to the Hopkins subjective visual classification. Patients then were divided into two groups, according to the median of nerve-sparing grading: those with score six or high and those with score less than six. Main outcome was the trifecta combined outcome and secondary outcomes was the individual trifecta criteria (prospective analysis). A secondary analysis with groups divided according to pre-operatory SHIM score was made. One hundred robotic-assisted nerve-sparing radical prostatectomy were performed, of which 83 were included. There were 53 patients with grading greater than or equal to six (group 1) and 30 patients less than six (group 2). 66.6% patients (35/53) in group 1 had a trifecta combined outcome of compared to 33.3% (10/30) in group 2 (p = 0.017). Individually, the erectile function was higher in group 1 (73.6%) compared to group 2 (46.7%) (p = 0.014). Both the results of the combined endpoint trifecta and erection were also maintained in the group with preoperative SHIM ≥ 17. The grading of preservation of the neurovascular bundle in radical prostatectomy is related to a better combined trifecta outcome one year after surgery.

Free-hand, transrectal ultrasound-guided hydrodissection of the retroprostatic space during robot-assisted radical prostatectomy: Impact on the learning curve

Aim of the current study is to describe our technique of hydrodissection (HD) of the retroprostatic space (RPS) performed between the Denonvillier's fascia (DF) and prostatic capsule (PC) and to evaluate its impact on the outcomes of nerve-sparing robot-assisted radical prostatectomy (nsRALP) during the learning-curve period. This randomized study enrolled 25 consecutive male patients with indication of nsRALP. The HD and the subsequent dissection of the seminal vesicles (SVs) and RPS was performed by a resident in learning curve for RALP; the residual portion of RALP was performed by an expert. The perioperative, oncologic and functional outcomes of 2 groups of patients (Group A: nsRALP after HD of the RPS and Group B: standard nsRALP without HD) were compared. Two analyses were performed, considering a per-protocol (PP) population regarding only randomized patients with correct HD and an Intention-To-Treat (ITT) population regarding all randomized patients. In 4/14 (29%) of patients of Group A the injected fluid was not intraoperatively identified in the expected plane. The groups were statistically homogeneous in relation to the baseline variables. A statistically significant difference was observed between the SVs/RPS dissection time and the SVs-related estimated blood loss in both analyses. A significantly higher rate of dry patients was observed in group A at 1 month after nsRALP. A statistically significant correlation was observed between the effective time of dissection of the SVs and the postoperative IIEF-5 drop. The transrectal ultrasound-guided transperineal HD seems useful for the preliminary development of the RPS during the learning curve period of nsRALP. It seems associated with less time and blood loss for the dissection of the SVs and RPS. Studies on larger cohorts are needed to draw more robust conclusions.

Development and clinical applicability of MRI-based 3D prostate models in the planning of nerve-sparing robot-assisted radical prostatectomy.

The interpretation of conventional MRI may be limited by the two-dimensional presentation of the images. To develop patient-specific MRI prostate-based virtual and three-dimensional (3D)-printed models. To assess the association between 3D imaging and the pathological outcome of RARP specimen. To assess the clinical applicability of 3D models to guide nerve-sparing robot-assisted radical prostatectomy (RARP). We created virtual 3D and 3D-printed 3D models of 20 prostate cancer patients retrospectively. A comparison was made between conventional MRI and 3D-reconstructed images. The concordance between tumour lesion location in 3D models and pathology reporting of RARP specimens was assessed. Seven urologists assessed the side-specific extent of nerve-sparing based on (1) conventional MR images, (2) virtual 3D models, and (3) 3D-printed models. Clinically relevant changes in nerve-sparing and the absolute agreement between observers was analyzed using the Chi-square test and intra-class correlation coefficient (ICC). The index lesion was correctly visualized in 19/20 (95%) 3D models and the expected location of extraprostatic extension was correctly visualized in all 3D models. Clinically relevant changes in the planned extent of nerve-sparing between MRI and virtual 3D models and MRI and 3D-printed models were found in 25% and 26%. The ICC of the planned extent of nerve-sparing between urologists was 0.40 (95% CI 0.28-0.55) for conventional MRI, 0.52 (95% CI 0.39-0.66) for virtual 3D models and 0.58 (95% CI 0.45-0.71) for 3D-printed models. 3D models of the MRI prostate to guide RARP could aid urologists in the planning of nerve-sparing surgery as shown by a higher inter-observer agreement.

New Possibilities in Heart Failure: The Effects of Tadalafil on Diastolic Function in Patients Undergoing Robot-Assisted Radical Prostatectomy

Inhibitors of phosphodiesterase type 5 (PDE5i) are the first-line treatment for erectile dysfunction and are also used to treat pulmonary hypertension. PDE5i impedes the breakdown of nitric oxide (NO)-driven cyclic guanosine monophosphate (cGMP) in smooth muscle cells of the vascular bed, acting as a potent vasodilator. In heart failure, cGMP signaling is altered. The modulation of cGMP has therefore emerged as a potential therapeutic option for heart failure. In this prospective observational study, we aim to investigate whether tadalafil, a long-acting PDE5i used for erectile dysfunction, could also improve diastolic function assessed by cardiac ultrasound. A total of 23 patients were enrolled, undergoing nerve-sparing robot-assisted radical prostatectomy for prostate cancer and treated with 20 mg tadalafil on alternate days to recover erectile function. All patients underwent tadalafil treatment for at least 6 months. Participants underwent a clinical and cardiac ultrasound with color Doppler assessment at baseline, after 3 months, and after 6 months. At 6 months, no significant difference was found apart from lower E/e’ ratio (7.4 ± 2.7 vs. 6.3 ± 1.3; p &lt; 0.03), peak velocity of TR jet (2.4 ± 0.2 vs. 2.1 ± 0.2; p &lt; 0.001), and PAPs (27.3 ± 3.6 vs. 22.9 ± 5.7; p &lt; 0.005). Our prospective study shows that 6 months of erectile dysfunction therapy for secondary to radical prostatectomy is associated with a favorable effect on diastolic function, improving the E/e’ ratio and peak velocity of the TR jet.