Robotic Console Research Articles

Robotic parathyroidectomy is a feasible technique for primary hyperparathyroidism

PurposeFocused parathyroidectomy is the gold standard treatment modality for primary hyperparathyroidism, which allows accurate preoperative localization. Robotic parathyroidectomy has emerged as a feasible procedure for focused parathyroidectomy. This study aimed to report the experiences of gasless robotic transaxillary parathyroidectomy for primary hyperparathyroidism in a single center.MethodsWe assessed the data obtained from patients who underwent gasless robotic parathyroidectomy with the transaxillary approach between December 2013 and August 2022 and were diagnosed with primary hyperparathyroidism at our institute. The data included clinical, biochemical, and pathological features and operation time.ResultsOf the 12 patients, 11 were women and one was a man. The median age of the patients was 44.5 years (range: 15–65 years). The median preoperative maximum mass diameters on ultrasonography and neck computed tomography were 1.2 ± 0.5 and 1.1 ± 0.6 cm, respectively. The median size of the postoperative maximum mass diameter in gross pathology was 1.3 ± 0.4 cm. The location of the enlarged parathyroid was left superior in five patients, right inferior in four, left inferior in three, and no right superior in one. In the final pathological examination, all cases were parathyroid adenomas. Only one case experienced a postoperative bleeding complication. At six months from surgery, average of an axillary scar length was 5.85 cm, and an average width was 0.21 cm. The mean operative time was 113 ± 48 min. The mean robot docking and console times were 9 ± 5 and 47 ± 52 min, respectively.ConclusionsRobotic transaxillary parathyroidectomy is a feasible technique in select patients with primary hyperparathyroidism and preoperatively localized disease. The gasless robotic transaxillary approach provides procedural safety as well as superior cosmetic results without a neck scar.

First-in-human real-time AI-assisted instrument deocclusion during augmented reality robotic surgery.

The integration of Augmented Reality (AR) into daily surgical practice is withheld by the correct registration of pre-operative data. This includes intelligent 3D model superposition whilst simultaneously handling real and virtual occlusions caused by the AR overlay. Occlusions can negatively impact surgical safety and as such deteriorate rather than improve surgical care. Robotic surgery is particularly suited to tackle these integration challenges in a stepwise approach as the robotic console allows for different inputs to be displayed in parallel to the surgeon. Nevertheless, real-time de-occlusion requires extensive computational resources which further complicates clinical integration. This work tackles the problem of instrument occlusion and presents, to the authors' best knowledge, the first-in-human on edge deployment of a real-time binary segmentation pipeline during three robot-assisted surgeries: partial nephrectomy, migrated endovascular stent removal, and liver metastasectomy. To this end, a state-of-the-art real-time segmentation and 3D model pipeline was implemented and presented to the surgeon during live surgery. The pipeline allows real-time binary segmentation of 37 non-organic surgical items, which are never occluded during AR. The application features real-time manual 3D model manipulation for correct soft tissue alignment. The proposed pipeline can contribute towards surgical safety, ergonomics, and acceptance of AR in minimally invasive surgery.

Robotic-assisted laparoscopy in pediatric surgical oncology: a narrative review.

Robotic surgical oncology in children calls for experienced surgeons in minimally invasive surgery (MIS) and a solid oncological background. The aim of this review was to analyze the current state of robotic-assisted laparoscopy in pediatric tumor resection, assess the necessary framework of minimally invasive surgical oncology and describe future developments of the robotic technology. A literature search of the MEDLINE/PubMed database was conducted, using the terms "robotic surgery", "pediatric" or "children" and "oncology" or "tumor". All relevant English-language studies published between 2008 and 2022 were reviewed. Although concerns have been raised regarding the use of MIS in surgical oncology, current literature reports similar oncological outcome if surgeons comply with the oncologic principles. The benefits of MIS have been established for robotic surgery in adult studies, including a shorter time to adjuvant chemotherapy. Surgical feasibility should be assessed based on tumor characteristics, preoperative imaging focusing on vascular involvement and surgeon's experience until clear guidelines are issued. The difficulties in establishing eligibility criteria for robotic resection of pediatric tumors lie in the great variability of indications, heterogeneity in tumor histology with their own surgical specificities, and wide range of age and weight, as shown by the literature review we performed. Between 2008 and 2022, 31 studies reported 171 cases with three studies including at least ten patients. The most reported procedure was adrenalectomy (41 cases). Current research in pediatric surgical oncology focuses on intraoperative locoregional treatment, improved vision with fluorescence and dyed-loaded specific probes and the many possibilities of enhancement software using the robotic console. The robotic technology allows the surgeon to push the boundaries of conventional laparoscopy. Specific surgical guidelines are necessary.

Increase in robot assisted operating room efficiency: A quality improvement study

Pyeloplasties are time-sensitive, and the most common robot assisted intervention performed in pediatric urology. Early intervention is intended to avoid permanent loss of renal function with negative long-term effects if surgery is delayed when indicated. A need to increase capacity has become a premium value in patient care. Our aim was to reduce operative time, providing value by reducing total robotic console time in robot assisted pyeloplasty (RP) cases. We hypothesized that process improvement and supply management during RP leads to a significant reduction in operative time. Intraoperative surgical workflow was reviewed and routine tasks performed during the various sections were selected with the goal of reducing Operating room inactivity. We focused on robotic arm activity, and total operative time to assess our outcomes. Our intervention was to standardize an OR staff task list, a priori supply inventory procurement for each anticipated major step in the case, confirmed prior to each major step. Baseline RP duration data for a single Pediatric Urologist were identified and recorded before any interventions. A clinical standard work (CSW) was developed based on optimization of equipment/supplies for the RP procedure, compartmentalized into the 8 key steps for RP. These major steps included: patient positioning, docking, retroperitoneal and ureteral dissection, hitch stitch, pyelotomy, stent placement, and anastomosis. Balancing measures included percentage trainee console use, preparatory time, and OR block start/end time. Baseline data for RP cases performed between 11/2020 and 2/2022 were automatically extracted from charts and analyzed using AdaptX (Seattle, WA). Post-intervention was between 3/2022 to 3/2023. Mann-WhitneyU was used for continuous variables for non-parametric distribution. 37 patients underwent RP during the study period. 15 cases were performed prior to intervention and 22 post intervention Total console time prior to intervention was 152 vs 109min after intervention (p=0.0002). Dual instrument inactivity was reduced from 13.1% to 7.1% (p<0.0001). Dual consoles were used in 40% vs ∼69% pre-vs post-intervention, respectively (p=0.5000). No difference in patient age distribution between groups was seen (p=0.1498). Trainee operative time did not differ statistically pre- and post-intervention (63.0 vs 48.6%, p=0.0871). Decreasing surgical lapses and standardizing intraoperative tasks can result in more efficient case completion, potentially increasing OR capacity.

Fluorescence guidance during robotic resection of bladder wall endometriosis: case report and technique.

The application of indocyanine green (ICG) has recently been reported to aid in the resection of endometriosis in the bladder wall and/or involving the ureters. A symptomatic 41-year-old patient with dysmenorrhea and pollakisuria was referred to our tertiary center. Imaging revealed a 1.5-2cm intramural endometriotic nodule in the posterior bladder wall. She was planned for robotic resection of the endometriotic nodule, under ICG guidance, together with a hysterectomy. After placement of double-J ureteral stents and clamping the bladder, perforation of the bladder mucosa could be avoided whilst performing a circumferential resection of the nodule. By clamping the bladder catheter after instillation of ICG, both the bladder wall thickness and ureters could be visualized with near-infrared imaging during robotic resection of the endometriotic nodule and hysterectomy. With the surgical approach described here, endometriotic nodules/tissue can be removed precisely with enlarged vision at the robot console, safely, and completely without damaging adjacent tissues.

Robot-assisted ileocystoplasty for the treatment of adult neurogenic bladder: A video demonstration and outcomes

Abstract Ileocystoplasty is one of the treatment options in the armamentarium for the management of adults with neurogenic bladder dysfunction, after failure of less invasive treatment alternatives, such as intravesical onabotulinum toxin A injection therapy and sacral neuromodulation. It has traditionally been performed as open surgery and can be associated with significant morbidity, especially in the early postoperative period.[1] Complications associated with open ileocystoplasty include prolonged postoperative ileus, wound infections, and pain. Performing robot-assisted ileocystoplasty can reduce the morbidity associated with open surgery[2] and has been shown to be safe and feasible in experienced hands,[3] although it may be associated with increased operative duration because of its learning curve. Our technique of robot-assisted ileocystoplasty and early postoperative outcomes is demonstrated in this video (Supplemental Digital Content, http://links.lww.com/CURRUROL/A47). Robotic console time was 180 minutes, with minimal blood loss. Eight-hourly catheter aspiration and flushes were performed to manage the mucus in the urine. There were no metabolic acidosis or electrolyte derangements postoperatively. The patient was discharged on postoperative day 5. Postoperative cystogram at week 2 showed no leak and the patient is doing well at 1 year postoperatively. Robotic ileocystoplasty is safe and feasible and can reduce the morbidity associated with open surgery with good outcomes.

Identifying barriers to resident robotic console time in a general surgery residency through a targeted needs assessment.

Robotic-assisted general surgery is experiencing exponential growth. Despite our institution's high volume, residents often graduate with inadequate console experience. Our aim was to identify the educational needs of residents and perceived barriers to residents' console time from both attendings and residents. Separate surveys were created and distributed to robotic surgery faculty and general surgery residents at our institution. Questions were a variety of modalities and focused on the robotic surgery experience at our institution, including barriers to resident console time from both attending surgeon and resident perspectives. Although residents' interest in robotic surgery exceeded that of open and laparoscopic surgery, confidence in their robotic skills was low compared to the other modalities. The top barriers to participating in robotic cases according to residents included minimal or no previous console time with the attending, lack of simulator time, and being required to perform bedside assistant duties. Faculty reported resident preparedness, prior robotic skill demonstration, simulator time, case complexity, and their own confidence as significant factors influencing resident console time. Using these results, we concluded that the design and implementation of a formal robotic surgery curriculum should incorporate simulation-based opportunities for residents to practice their skills, improve confidence, and increase console experience. In addition, simulation opportunities for faculty should also be considered to allow for improvement and maintenance of robotic surgical skills.

Robotic Anterior Resection for Rectosigmoid Colon Cancer using Single Port Access.

Single-port laparoscopic surgery (SPLS) and a robotic surgical system have recently been included in contemporary colorectal surgical practice. 1-4 SPLS may result in better cosmetic outcomes, reduced postoperative incisional pain, fewer incisional hernias, minimal organ damage, and fewer wound complications. 2,5 However, SPLS for left-sided colorectal cancer is a challenging technique, even for experienced laparoscopic colorectal surgeons, owing to the difficulty of constructing instrument triangulation and using endo-staplers in the pelvic cavity from a single umbilical port with adequate distal margins. The Da Vinci Si Single-Site ® system (Intuitive Surgical, Sunnyvale, CA) was specifically developed to overcome SPLS limitations. Since the robotic instruments are crossed at the port site, but the software "reassigns" them to the surgeon's hand on the robotic console, the platform can easily create instrument triangulation while minimizing external robotic arm collisions. 6-8 Due to the lack of wrist articulation, the limited range of motion of the semi-rigid robotic instruments, and the limited choice of instruments, the Single-Site ® platform has not yet been widely utilized for colorectal diseases. A novel robotic technique, the da Vinci SP ® system (Intuitive Surgical, Sunnyvale, CA, USA), was designed for single-site surgery. This platform has a robotic arm with a high degree of freedom that is introduced directly into the peritoneal cavity through a single incision. The benefits of the single-port da Vinci robot platform include a holographic display of the instrument location, wristed articulation and flexible elbows, a console-controlled camera, and three-dimensional optics. This robotic system for single-port access can perform lymph node dissection around the inferior mesenteric artery using 4-arm wrist articulation while preserving the autonomic nerves during left-sided colorectal cancer surgery.

Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery-A Review of Current Concepts and Perspectives.

The devastating impact of a circumflex coronary artery (CX) injury during mitral valve (MV) surgery is well reported. Despite significant improvements in preoperative risk assessment, intraoperative diagnosis and perioperative treatment strategies of CX injury during MV surgery, recent reports re-emphasize the variability in presentation, the unpredictable mechanisms of injury and the conflicting evidence regarding perioperative management. The progressive transition from conventional sternotomy access to minimally invasive surgical and transcatheter (TC) interventions for MV disease are associated with significant learning curves and require additional single-shaft and robotic console suture manipulation skills with special attentiveness to the potential risk of CX injury. The introduction of hybrid theatres that facilitate single stage surgical and TC interventions also provides new intraoperative diagnostic and therapeutic options without transporting unstable patients for percutaneous coronary intervention (PCI) assessment. By utilizing a MeSH terms-based PubMed search, a total of 89 patients with CX injury that occurred during MV surgery was identified from 49 reports between 1967 and 2022. MV surgery was performed by conventional sternotomy (n = 76, 85.4%), endoscopic (n = 12, 13.4%) and robotic access (n = 1, 1.1%), with 35 injuries (39.3%) resulting in total CX occlusion. Rescue PCI was utilized in 40 patients (44.9%). This manuscript provides a systematic overview of all available historic and contemporary reports on CX injury during MV surgery, outlines recent refinements in CX injury mechanisms, describes current MV surgery associated CX injury prevention and diagnosis and treatment strategies and highlights important MV procedural aspects that may minimize the risk and consequences of CX injury.

Validation of a multidisciplinary virtual reality (VR) robotic surgical curriculum.

The objective is to identify whether trainees demonstrate improvement in a standardized knot-tying task as assessed by Global Evaluative Assessment of Robotic Skills (GEARS) score after completion of a virtual reality (VR) robotic curriculum. An IRB-exempt prospective study was conducted with surgical trainees from August 2021 to February 2023. Participants initially performed a baseline robotic suturing task in which they were instructed to tie interrupted square knots in 10min. Participants then completed a virtual reality simulation curriculum involving 23 exercises until they achieved 90% proficiency on all tasks. Participants then repeated the suturing task. Pre- and post-curriculum suturing tasks were recorded, de-identified, and scored by expert graders using a GEARS score. Trainees from three academic centers were invited to participate. Medical students (MS1-MS3) and surgical residents from gynecology, urology, and general surgery were invited to participate. Twenty-five trainees completed the pre-curriculum suturing task, the VR curriculum, and the post-curriculum suturing task. Trainees demonstrated significant improvement in their post-test GEARS score by 2.43 points (p < 0.05) and were able to tie three additional knots within 10min after completion of the curriculum (p < 0.05). Trainees also demonstrated a faster time to complete first knot (114s improvement, p < 0.05) after completion of the curriculum. All participants agreed or strongly agreed that completion of the robotic curriculum helped them feel more comfortable using the robotic console, and improved their robotic surgical skills. Surgical trainees and medical students with limited prior robotic surgical experience demonstrated objective improvement after completion of a standardized VR curriculum.

Residents perform better technically, have less stress and workload, and prefer robotic to laparoscopic technique during inanimate simulation.

With the widespread adoption of minimally invasive surgery, there is a growing need for surgical residents to be trained by a procedure-specific curriculum. This study aimed to evaluate the technical performance and feedback of surgical residents undergoing the robotic and laparoscopic hepaticojejunostomy (HJ) and gastrojejunostomy (GJ) biotissue modules. A total of 23 PGY-3 surgical residents participated in this study and performed the laparoscopic and robotic HJ and GJ drills, which were recorded and scored by two independent graders using the modified objective structured assessment of technical skills (OSATS). After completing each drill, all participants filled out the NASA Task Load Index (NASA-TLX), Borg Exertion Scale, and Edwards Arousal Rating Questionnaire. Twenty-two (95.7%) residents had already received fundamentals of laparoscopic surgery certification. Eighteen (78.3%) residents had robotic virtual simulation training and the median (range) number of robotic surgery console experience was 4 (0-30). In the HJ comparison of the six OSATS domains, the robotic system was superior in Gentleness (p = 0.031). In the GJ comparison, the robotic system was superior in Time and Motion (p < 0.001), Instrument Handling (p = 0.001), Flow of Operation (p = 0.002), Tissue Exposure (p = 0.013), and Summary (p < 0.001). Participants answered significantly higher demand scores for laparoscopy on all six facets of NASA-TLX for both HJ and GJ (p < 0.05). The Borg Level of Exertion was > 2 points higher for laparoscopic HJ and GJ (p < 0.001). Residents rated more Nervousness and Anxiety for laparoscopic compared to robotic (p < 0.05) HJ and GJ. Additionally, when asked to score preference for robotic and laparoscopic approach in terms of technique and ergonomics, residents scored robot as better (laparoscopy worse) for both HJ and GJ in both domains. The robotic surgical system provided a more favorable environment for trainees with less mental and physical burden for minimally invasive HJ and GJ curriculum.

Preoperative 3D model guidance for robotic-partial nephrecto- my: a case report of intraoperative vascular injury and its man- agement

Partial nephrectomy (PN) is increasingly used in the treatment of renal cell carcinoma and is now considered the “gold standard” treatment for T1 lesions. However, it is still considered a challenging procedure. Several imaging modalities have been tested to improve PN outcomes. One of the most intriguing is 3D reconstruction, which can be used for both preoperative planning and intraoperative decision making. In the following case, we describe an intraoperative vascular injury that occurred during robot-assisted PN (RAPN), despite accurate preoperative 3D-guided planning, and its management. The patient undergoing PN was 57 years old and had an incidental diagnosis of a 17 mm left-sided renal lesion located on the posterior surface of the kidney at the lower pole. Based on the CT scan, a virtual 3D reconstruction was obtained, which highlighted the presence of a saccular dilatation of the main artery. Selective clamping of a segmental artery feeding the posterior surface of the lower pole of the kidney was planned. The RENAL nephrometry and PADUA score were calculated with a value of 4p and 6, respectively. Despite a thorough preoperative planning, a lesion of the dilatation of the main artery was identified with a large bleeding which was managed by global clamping of the kidney followed by selective suturing. In conclusion, PN remains a challenging procedure even for experienced and skilled surgeons. The occurrence of intraoperative complications is not anecdotal. The introduction of the robotic console and new intraoperative tools such as 3D models have reduced the risk of adverse events, but their complete elimination is still utopian due to the extreme complexity of the procedure.

Development of a Classification System for Live Surgical Feedback

Live feedback in the operating room is essential in surgical training. Despite the role this feedback plays in developing surgical skills, an accepted methodology to characterize the salient features of feedback has not been defined. To quantify the intraoperative feedback provided to trainees during live surgical cases and propose a standardized deconstruction for feedback. In this qualitative study using a mixed methods analysis, surgeons at a single academic tertiary care hospital were audio and video recorded in the operating room from April to October 2022. Urological residents, fellows, and faculty attending surgeons involved in robotic teaching cases during which trainees had active control of the robotic console for at least some portion of a surgery were eligible to voluntarily participate. Feedback was time stamped and transcribed verbatim. An iterative coding process was performed using recordings and transcript data until recurring themes emerged. Feedback in audiovisual recorded surgery. The primary outcomes were the reliability and generalizability of a feedback classification system in characterizing surgical feedback. Secondary outcomes included assessing the utility of our system. In 29 surgical procedures that were recorded and analyzed, 4 attending surgeons, 6 minimally invasive surgery fellows, and 5 residents (postgraduate years, 3-5) were involved. For the reliability of the system, 3 trained raters achieved moderate to substantial interrater reliability in coding cases using 5 types of triggers, 6 types of feedback, and 9 types of responses (prevalence-adjusted and bias-adjusted κ range: a 0.56 [95% CI, 0.45-0.68] minimum for triggers to a 0.99 [95% CI, 0.97-1.00] maximum for feedback and responses). For the generalizability of the system, 6 types of surgical procedures and 3711 instances of feedback were analyzed and coded with types of triggers, feedback, and responses. Significant differences in triggers, feedback, and responses reflected surgeon experience level and surgical task being performed. For example, as a response, attending surgeons took over for safety concerns more often for fellows than residents (prevalence rate ratio [RR], 3.97 [95% CI, 3.12-4.82]; P = .002), and suturing involved more errors that triggered feedback than dissection (RR, 1.65 [95% CI, 1.03-3.33]; P = .007). For the utility of the system, different combinations of trainer feedback had associations with rates of different trainee responses. For example, technical feedback with a visual component was associated with an increased rate of trainee behavioral change or verbal acknowledgment responses (RR, 1.11 [95% CI, 1.03-1.20]; P = .02). These findings suggest that identifying different types of triggers, feedback, and responses may be a feasible and reliable method for classifying surgical feedback across several robotic procedures. Outcomes suggest that a system that can be generalized across surgical specialties and for trainees of different experience levels may help galvanize novel surgical education strategies.

Is Robotic Console Time a Surrogate for Resident Operative Autonomy?

Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy. Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed. A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores. Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

Prior Robotic Console Expertise May Improve Basic Skills at the New Hugo RAS Simulator: Results from a Cohort Trial and Implications for Skill Transference Across Platforms

BackgroundRobot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator. ObjectiveThis study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator. Design, setting, and participantsWe present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons. InterventionAll participants underwent a hands-on “pick and place” exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded. Outcome measurements and statistical analysisMetrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console). Results and limitationsAll participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower (p < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34–45) compared with both naïve participants (61 s, IQR 53–71) and laparoscopists (93 s, IQR 53–162). The overall score of the exercise decreased with age (p = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups (p = 0.006). Neither gender (p = 0.7) nor videogame use (p = 0.9) correlated significantly with the metrics. ConclusionsThis is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue. Patient summaryIn the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform.

Intentional enterotomies: validation of a novel robotic surgery training exercise.

While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick's validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.

Muscle fatigue and physical discomfort reported by surgeons performing robotic-assisted surgery: a multinational survey.

Robotic surgery has revolutionized surgical procedures and has provided many advantages over traditional laparoscopic and open surgeries. Despite the benefits, there are concerns about the physical discomfort and injuries that may be experienced by surgeons during robotic surgeries. This study aimed to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. A questionnaire was created and sent to 1000 robotic surgeons worldwide, with a response rate of 30.9%. The questionnaire consisted of thirty-seven multiple-choice questions, three short answer questions, and one multiple-option question pertaining to the surgeon's workload as well as their level of discomfort while and after performing surgery. The primary endpoint was to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. Secondary endpoints were to highlight any correlation between age group, BMI, hours of operation, workout regimen, and significant pain levels. The results showed that the most common muscle groups implicated in physical pain and discomfort were the neck, shoulders, and back, with many of the surgeons attributing their muscular fatigue and discomfort to the ergonomic design of the surgeon console. Despite the level of surgeon comfort the robotic console provides when compared to other conventional forms of surgery, the findings suggest the need for better ergonomic practices during robotic surgeries to minimize physical discomfort and injuries for surgeons.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

V05-06 3D AUGMENTED REALITY TECHNOLOGY FOR IDENTIFICATION OF NEOPLASTIC VENOUS THROMBUS DURING ROBOTIC RADICAL NEPHRECTOMY FOR RCC

You have accessJournal of UrologyCME1 Apr 2023V05-06 3D AUGMENTED REALITY TECHNOLOGY FOR IDENTIFICATION OF NEOPLASTIC VENOUS THROMBUS DURING ROBOTIC RADICAL NEPHRECTOMY FOR RCC Daniele Amparore, Federico Piramide, Enrico Checcucci, Alberto Piana, Gabriele Volpi, Paolo Verri, Michele Sica, Mariano Burgio, Giovanni Busacca, Martina Mandaletti, Andrea Bellin, Matteo Manfredi, Cristian Fiori, and Francesco Porpiglia Daniele AmparoreDaniele Amparore More articles by this author , Federico PiramideFederico Piramide More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Alberto PianaAlberto Piana More articles by this author , Gabriele VolpiGabriele Volpi More articles by this author , Paolo VerriPaolo Verri More articles by this author , Michele SicaMichele Sica More articles by this author , Mariano BurgioMariano Burgio More articles by this author , Giovanni BusaccaGiovanni Busacca More articles by this author , Martina MandalettiMartina Mandaletti More articles by this author , Andrea BellinAndrea Bellin More articles by this author , Matteo ManfrediMatteo Manfredi More articles by this author , Cristian FioriCristian Fiori More articles by this author , and Francesco PorpigliaFrancesco Porpiglia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Notwithstanding the increasing of earlier diagnosis, a 6% of renal cell carcinoma (RCC) patients still are diagnosed with a neoplastic thrombus at the level of renal vein or inferior vena cava (IVC). For many years those renal tumors have been treated with open surgery, but with the recent technological development (laparoscopic and robotic surgery) surgeons decided to embark in this challenging procedures with the aim of reducing morbidity and hospitalization without impairing the oncological and perioperative safety. To optimize the intraoperative outcomes a correct estimation of neoplastic thrombus location is essential both in planning the surgical strategy and during the procedure itself. Hence some ancillary technologies such intraoperative ultrasound have been tested to assist surgeon during the intervention. During these last years 3D Augmented reality (AR) guidance has been reported to be a useful tool to correctly identify renal tumor location and assist surgeon during the interventions, especially in case of endophytic or posterior masses, which are therefore “hidden” inside or behind the healthy parenchyma. With the aim to give a contribution in this field, we tested 3D AR guidance during robot-assisted radical nephrectomy (RARN) with tumor thrombi in renal vein and IVC. METHODS: This is a pilot study aiming to explore the safety and feasibility of 3D AR guidance during RARN for tumors with neoplastic thrombi (levels 0-I). From November 2020 all patients scheduled for RARN due to non-metastatic RCC with level 0-I venous thrombus were enrolled. All patients underwent a four-phase contrast-enhanced CT, in order to create the 3D models which were visualized as AR images inside the robotic console. During surgery, AR system was performed overlapping the 3D virtual model over the real anatomy in real time thanks the tile pro technology of Da Vinci Surgical Console. A dedicated assistant performed the hand-assisted overlapping using a 3D mouse. With the AR technology it was possible to hide some elements of the 3D virtual model, from the kidney parecnhyma to the caval wall, increasing the surgeon’s perception of the extension of the thrombus. Perioperative and pathological data were collected and analyzed. RESULTS: 5 patients were prospectively enrolled. Level 0 thrombus was recorded in 3 patients, two patient had level 1 thrombus. Mean lesions size was 75.6 (+21.3) mm. Mean operative time was 123 min (+15 min) with mean IVC clamping time of 9.4 min (+6.8). Mean Estimated blood loss were 750 ml (+150). During the intervention the AR system allowed the surgeon to precisely estimate the correct location of thrombus in all the cases, driving to a more awareness of the surgical strategy. Moreover, no intra- or postoperative complications (>2 according to Clavien-Dindo) were recorded. CONCLUSIONS: In our preliminary experience 3D AR guidance seem to be safe and feasible in correctly estimate the thrombus limits, and able to drive surgeon towards the correct surgical strategy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e425 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniele Amparore More articles by this author Federico Piramide More articles by this author Enrico Checcucci More articles by this author Alberto Piana More articles by this author Gabriele Volpi More articles by this author Paolo Verri More articles by this author Michele Sica More articles by this author Mariano Burgio More articles by this author Giovanni Busacca More articles by this author Martina Mandaletti More articles by this author Andrea Bellin More articles by this author Matteo Manfredi More articles by this author Cristian Fiori More articles by this author Francesco Porpiglia More articles by this author Expand All Advertisement PDF downloadLoading ...

MP26-10 COULD FINGER ASSIGNMENT AT THE ROBOTIC CONSOLE IMPROVE SURGICAL EDUCATION AND ERGONOMICS OR CAUSE ANY ADVERSE EVENTS? A RANDOMIZED PROSPECTIVE BLINDED SIMULATION PILOT STUDY

You have accessJournal of UrologyCME1 Apr 2023MP26-10 COULD FINGER ASSIGNMENT AT THE ROBOTIC CONSOLE IMPROVE SURGICAL EDUCATION AND ERGONOMICS OR CAUSE ANY ADVERSE EVENTS? A RANDOMIZED PROSPECTIVE BLINDED SIMULATION PILOT STUDY Zachary M. Connelly, Moss Matthew, Kevin Morgan, Alex Fuselier, Tomas Paneque, Harrison Torres, Mohamed Ahmed, MN Rochester, and Nazih Khater Zachary M. ConnellyZachary M. Connelly More articles by this author , Moss MatthewMoss Matthew More articles by this author , Kevin MorganKevin Morgan More articles by this author , Alex FuselierAlex Fuselier More articles by this author , Tomas PanequeTomas Paneque More articles by this author , Harrison TorresHarrison Torres More articles by this author , Mohamed AhmedMohamed Ahmed More articles by this author , MN RochesterMN Rochester More articles by this author , and Nazih KhaterNazih Khater More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic surgery has become a standard approach in urology. Greater range of motion may be attributed to the EndoWrist instruments that provide 7 degrees of freedom. This allows surgeons to gain precision and have fewer surgical complications. To our knowledge, no prior studies support one way to handle the controls at the surgical console. In our experience, volunteers report discomfort during wrist manipulation while using the thumb and middle finger (1&3). We hypothesize that using the thumb and index finger (1&2) will allow superior surgical proficiency via the Da Vinci Skills Simulator. METHODS: After IRB approval, we recruited 42 medical students across all 4 years in one university-based medical center. Each volunteer was given a standardized orientation. Students were then randomly assigned to start with their thumb and index finger (1&2) or (1&3). Two standardized modules were used with metrics calculated upon completion. These include: score, total time, economy of motion, efficiency score, collisions, inaccurate puncture, wound approximation, out of view, and penalty subtotal. Statistical analysis of the metrics was calculated using SPSS. RESULTS: Three were found to have statistically significant differences between the finger placement of 1&3compared to 1&2 (Figure 1). The number of collisions, wound approximation, and penalty score were all significant where 1&3 had a lower score in each. The number of collisions was 5.6 less in the 1&3 finger placement (p= 0.017). The wound approximation was 0.2 points smaller when using the 1&3 placement (p = 0.001). Lastly, the penalty assigned was 6.42 points lower when using 1&3 (p= 0.023). The overall score (p= 0.615), total time (p= 0.385), out of view (p=0.462), and economy of motion (p= 0.184) were not significant from one another. CONCLUSIONS: Although finger placement did not affect the overall score of the completed simulation, instrument collisions and unnecessary wound complications may lead to adverse outcomes. This may be due to decreased comfort in hand position resulting in a more cautious surgical approach. Better understanding of how finger placement can lead to decreased ergonomics and increased complications may shape robotic training. Source of Funding: N/A © 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 Zachary M. Connelly More articles by this author Moss Matthew More articles by this author Kevin Morgan More articles by this author Alex Fuselier More articles by this author Tomas Paneque More articles by this author Harrison Torres More articles by this author Mohamed Ahmed More articles by this author MN Rochester More articles by this author Nazih Khater More articles by this author Expand All Advertisement PDF downloadLoading ...